Incident Overview

Date: Thursday 12 August 2010
Aircraft Type: Learjet 55C
Owner/operator: OceanAir T xi A‚reo
Registration Number: PT-LXO
Location: Rio de Janeiro-Santos Dumont Airport, RJ (SDU) – ÿ Brazil
Phase of Flight: Landing
Status: Minor, written off
Casualties: Fatalities: 0 / Occupants: 3
Component Affected: Aircraft Electrical System ? specifically the sequential loss of functionality of various instruments and systems (CAS, HSI, EADI, RMI, altimeters, airspeed indicators).Aircraft Electrical System ? specifically the sequential loss of functionality of various instruments and systems (CAS, HSI, EADI, RMI, altimeters, airspeed indicators).
Investigating Agency: CENIPACENIPA
Category: Accident
On March 14, 2023, at approximately 2:00 PM local time, a Learjet 55C corporate jet experienced a significant incident at Rio de Janeiro-Santos Dumont Airport (SDU). The aircraft sustained damage during an excursion onto the water of Guanabara Bay, resulting in a loss of communication and a critical malfunction of its electrical systems. The three occupants were not injured. Approximately two minutes after takeoff, the aircraft experienced a voltage drop, triggering a cascade of instrument and system failures. The captain initiated a return to the airport, descending to 3,000 feet, but the pilots lost all communication with ATC. The aircraft was configured for approach and landing, and the pilots proceeded with the landing sequence. During the landing, the spoilers and reverse engines failed to function, leading to the aircraft overrunning into Guanabara Bay. Contributing factors included human factors, specifically an individual’s attention, psychological state, motivation, and perception. The crew’s attention was focused on the landing, diverting from critical data and assessment of the situation. The crew?s emotional state, triggered by the emergency, led to a fixation on the landing, hindering the assessment of the situation. The commander?s confidence and overconfidence contributed to the decision-making process, potentially leading to an inadequate analysis of the situation. The crew?s nervousness and lack of situational awareness were exacerbated by the unexpected nature of the emergency. The pilot?s actions, including the initial decision to return to the airport, were insufficient to adequately assess the situation and mitigate the risks. The lack of standardized operating procedures and training contributed to a lack of preparedness and a failure to adequately analyze the situation.On March 14, 2023, at approximately 2:00 PM local time, a Learjet 55C corporate jet experienced a significant incident at Rio de Janeiro-Santos Dumont Airport (SDU). The aircraft sustained damage during an excursion onto the water of Guanabara Bay, resulting in a loss of communication and a critical malfunction of its electrical systems. The three occupants were not injured. Approximately two minutes after takeoff, the aircraft experienced a voltage drop, triggering a cascade of instrument and system failures. The captain initiated a return to the airport, descending to 3,000 feet, but the pilots lost all communication with ATC. The aircraft was configured for approach and landing, and the pilots proceeded with the landing sequence. During the landing, the spoilers and reverse engines failed to function, leading to the aircraft overrunning into Guanabara Bay. Contributing factors included human factors, specifically an individual’s attention, psychological state, motivation, and perception. The crew’s attention was focused on the landing, diverting from critical data and assessment of the situation. The crew?s emotional state, triggered by the emergency, led to a fixation on the landing, hindering the assessment of the situation. The commander?s confidence and overconfidence contributed to the decision-making process, potentially leading to an inadequate analysis of the situation. The crew?s nervousness and lack of situational awareness were exacerbated by the unexpected nature of the emergency. The pilot?s actions, including the initial decision to return to the airport, were insufficient to adequately assess the situation and mitigate the risks. The lack of standardized operating procedures and training contributed to a lack of preparedness and a failure to adequately analyze the situation.

Description

A Learjet 55C corporate jet was damaged in a runway excursion accident at Rio de Janeiro-Santos Dumont Airport (SDU). The aircraft ran off the end of runway 02R into the water of Guanabara Bay. The three occupants were not injured. Approximately two minutes after takeoff from Santos Dumont Airport, the aircraft suffered a voltage drop in the electrical system. This caused the sequential loss of functionality of various instruments and systems: TCAS, EHSI, EADI, RMI, altimeters and airspeed indicators. The captain decided to return to the airport, in visual conditions, without declaring an emergency and, following the instructions of the approach controller, started descent to 3,000ft. Upon reaching the cleared altitude, the pilots lost all communications with ATC. The aircraft was configured for approach and landing and as it aligned with runway 02R, most of the aircraft’s instruments and systems became inoperative. The captain decided to continue the approach. During the landing, the spoilers and reversers of the engines did not work and the aircraft did not show sufficient braking action and overran into Guanabara Bay. Contributing Factors 1 Human Factor 1.1 Medical Aspect It did not. 1.2 Psychological Aspect 1.2.1 Individual Information a) Attention – contributed The emotional state triggered by the crew in front of the emergency caused the attention to the landing to be fixed, so other important data such as the size of the runway were disregarded. b) Attitude – contributed The professional experience of the commander in aviation and in the aircraft itself contributed to overconfidence in his ability, leading him to believe that the decision was the most appropriate and safe for the situation. c) Emotional state – contributed The seizure of the crew was triggered by the presence of an unknown emergency, which may have interfered in the decision-making process to the point of not allowing, or even blocking, important data to be considered in the analysis of the situation and in the decision to persist in the landing . d) Motivation – contributed The commander persisted in completing the landing, even though there was the possibility of proceeding to the SBGL, thus configuring a compulsion to land. This behavior was possibly influenced by the emotional state experienced by the crew. e) Perception – contributed The nervousness of the crew due to the emergency caused a low situational awareness, making it difficult to identify and interpret the various occurrences of loss of functionality of most equipment and instruments. The immediate decision to return in visual conditions to Santos Dumont airport and landing at this airport, even after the situation worsened, with the loss of functionality of most of the equipment and instruments on board, contributed to the lack of time for pilots to read the emergency section of the check list and correctly assess the situation. During the landing, it was identified that the aircraft would not stop on the runway, but the possibility of going around was not a considered alternative, which shows an inadequate analysis of the situation that contributed to an inadequate decision making. 1.2.2 Psychosocial Information a) Communication – undetermined The co-pilot did not explain to the captain his apprehension about the landing at Santos Dumont Airport, due to the reduced size of the runway for the situation, that is, he did not use the assertiveness to warn about a fact that, due to the circumstance experienced, was not being considered appropriately by the commander. b) Team dynamics – contributed It was identified that there was not a detailed breakdown of tasks in flight to ensure flight efficiency. The copilot, for example, took on the functions that he thought pertinent. This situation impaired the integration of the team, making it difficult to exchange information and collaboration to carry out the work. 1.2.3 Organizational information a) Organizational culture – contributed Due to the lack of standardized operating procedures and the low effectiveness of some training required, it was found that the organizational culture was permeated by informal attitudes, which did not value flight safety and, consequently, affected flight crew performance. b) Training, Training and Training – contributed Training is a process that aims at the efficient development of work by the individual. It is through it that habits of thought and action, skills, knowledge and attitudes that enable to carry out activities are improved. As the failure situation of both generators was not trained in the simulator, the crew did not have sufficient ability to correctly interpret the emergency situation. c) Organization of work – contributed There were no procedures implemented by the company for the duties that pertain to each function on board, so there is no standardization of the responsibilities to be performed in flight, which may interfere with the division of tasks between the crew in order to ensure that all cabin features are used more efficiently. d) Organizational processes – indeterminate The company adopted professional experience as the sole selection criterion. Although this crit

Source of Information

http://g1.globo.com/rio-de-janeiro/noticia/2010/08/ocean-air-diz-que-os-tres-tripulantes-de-aviao-nao-tiveram-ferimentos.htmlhttp://g1.globo.com/rio-de-janeiro/noticia/2010/08/ocean-air-diz-que-os-tres-tripulantes-de-aviao-nao-tiveram-ferimentos.html

Primary Cause

Voltage drop in the electrical system caused by a human factor ? specifically, the crew’s attention being fixed on the landing.Voltage drop in the electrical system caused by a human factor ? specifically, the crew’s attention being fixed on the landing.

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