Incident Overview

Date: Tuesday 4 June 1996
Aircraft Type: Learjet 25C
Owner/operator: Aeroexecutivos T xi A‚reo
Registration Number: PT-KBC
Location: Ribei?o Preto-Leite Lopes Airport, SP (RAO) – ÿ Brazil
Phase of Flight: Take off
Status: Destroyed, written off
Casualties: Fatalities: 1 / Occupants: 4
Component Affected: The aircraft, specifically the landing gear, the engine, and the control systems. The failure of the cargo truck’s cable directly impacted the structural integrity of the aircraft.The aircraft, specifically the landing gear, the engine, and the control systems. The failure of the cargo truck’s cable directly impacted the structural integrity of the aircraft.
Investigating Agency: CENIPACENIPA
Category: Accident
The incident involved a Learjet flight from S?o Paulo to Uberaba, MG and Ribeir?o Preto, SP, carrying Pilot Flying (PF) and a single engine approach. A critical failure occurred during the touchdown phase, resulting in a catastrophic crash. The co-pilot initiated a touch and go maneuver, but the aircraft struck a truck, triggering a fire and subsequent crash. The captain attempted a rotation, but the aircraft was unable to stop on the runway, leading to a 92-meter landing distance. Initial investigation reveals a significant lapse in supervision, inadequate coordination, and a failure to adequately prepare for the landing. The pilot’s decision to attempt a rotation, despite the runway being insufficient, contributed to the incident. The lack of proper training and simulation experience, particularly in the context of the touch and go maneuver, played a role. Furthermore, the inadequate planning and judgment regarding the landing procedure exacerbated the situation. Finally, the failure of the cargo truck’s cable, resulting from fiber rupture, significantly impacted the incident.The incident involved a Learjet flight from S?o Paulo to Uberaba, MG and Ribeir?o Preto, SP, carrying Pilot Flying (PF) and a single engine approach. A critical failure occurred during the touchdown phase, resulting in a catastrophic crash. The co-pilot initiated a touch and go maneuver, but the aircraft struck a truck, triggering a fire and subsequent crash. The captain attempted a rotation, but the aircraft was unable to stop on the runway, leading to a 92-meter landing distance. Initial investigation reveals a significant lapse in supervision, inadequate coordination, and a failure to adequately prepare for the landing. The pilot’s decision to attempt a rotation, despite the runway being insufficient, contributed to the incident. The lack of proper training and simulation experience, particularly in the context of the touch and go maneuver, played a role. Furthermore, the inadequate planning and judgment regarding the landing procedure exacerbated the situation. Finally, the failure of the cargo truck’s cable, resulting from fiber rupture, significantly impacted the incident.

Description

The aircraft took off from S?o Paulo for a training flight (prof check) with landings in Uberaba Airport, MG (UBA) and Ribeir?o Preto, SP (RAO). The copilot was Pilot Flying (PF) as the Learjet approached Ribeir?o Preto. A single engine approach with a touch and go at the airport was planned. After touchdown the no. 1 engine power lever remained in the idle position. The captain took over control and attempted to take off as he judged it impossible to stop on the remaining runway. The airplane contacted the ground again 92 meters after the runway end. The captain attempted to rotate again, but the airplane struck a truck, crashed and caught fire. One occupant of the truck sustained fatal injuries. CONCLUS?O Fator Humano – Aspecto Psicol¢gico – Indeterminado H  ind¡cios da presen‡a de vari veis psicol¢gicas em n¡vel individual que possam ter influenciado na decis?o do comandante em realizar o procedimento de toque e arremetida no aer¢dromo de Ribeir?o Preto. Fator Operacional (1). Deficiente Supervis?o – Contribuiu Houve uma supervis?o inadequada, em n¡vel t‚cnico e operacional, por parte da empresa operadora da aeronave, pela falta de treinamento, instru‡?o inadequada e ausˆncia de treinamento em simulador de v“o. (2). Deficiente Coordena‡?o de Cabine – Contribuiu Houve erro cometido pelos pilotos decorrente da inadequada utiliza‡?o dos recursos na cabine destinados … opera‡?o da aeronave, em virtude de um ineficaz cumprimento das tarefas afetas a cada um dos tripulantes e da n?o observƒncia das normas operacionais. (3). Deficiente Planejamento – Contribuiu Mesmo estando a tripula‡?o qualificada para o tipo de v“o, houve um inadequado planejamento com rela‡?o … ausˆncia de briefing de decolagem e pouso. (4). Deficiente Julgamento – Contribuiu Houve erro cometido pelo co-piloto, quando da demora em reduzir as manetes de potˆncia da aeronave, t?o logo estabeleceu-se o travamento da manete do motor esquerdo durante a arremetida no solo, havendo uma inadequada avalia‡?o da situa‡?o com rela‡?o a este aspecto. (5). Deficiente Instru‡?o – Contribuiu Houve a participa‡?o do processo de treinamento recebido, por deficiˆncia quantitativa e qualitativa, que n?o atribuiu aos pilotos a plenitude das condi‡?es t‚cnicas a serem desenvolvidas na atividade, com rela‡?o … falta de treinamento em simulador, falta de um programa de treinamento da empresa que englobasse CRM e v“os locais, entre outros. (6). Deficiente Manuten‡?o – Indeterminado H  ind¡cios de que as dificuldades reportadas pelos pilotos com rela‡?o … manete tenham sido ocasionadas pela ruptura de fibras do cabo que transfere o comando da mesma ao FCU. Este cabo desliza no interior de uma capa corrugada e pode sofrer emperramento no caso de ruptura de qualquer fibra do referido cabo.

Primary Cause

Inadequate supervision, flawed coordination, and insufficient training, particularly regarding the touch and go maneuver and the handling of the aircraft in the landing phase, were primary contributors to the incident.Inadequate supervision, flawed coordination, and insufficient training, particularly regarding the touch and go maneuver and the handling of the aircraft in the landing phase, were primary contributors to the incident.

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