Incident Overview

Date: Sunday 4 February 1996
Aircraft Type: Cessna 500 Citation I
Owner/operator: T xi A‚reo Weston
Registration Number: PT-KPA
Location: Fazenda Matary, MA – ÿ Brazil
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 2
Component Affected: Citation aircraft – specifically, the aircraft’s control systems, flight management system, and throttle control.Citation aircraft – specifically, the aircraft’s control systems, flight management system, and throttle control.
Investigating Agency: CENIPACENIPA
Category: Accident
During a flight from Recife to Fazenda Matary with an intermediate stop at Imperatriz, a Citation aircraft experienced a significant incident. The instructor initiated a touch-and-go approach, setting flaps at 15 degrees and airspeed at 125 kts. Despite the airspeed being above normal, the instructor disregarded established procedures and proceeded with a full stop instead of a takeoff. The trainee observed the speed and intervened, advancing the throttles to initiate takeoff. The instructor’s overconfidence and failure to communicate his decision led to the aircraft exceeding the runway and subsequently catching fire. The incident highlights a combination of factors including excessive trust, impulsive judgment, and inadequate coordination.During a flight from Recife to Fazenda Matary with an intermediate stop at Imperatriz, a Citation aircraft experienced a significant incident. The instructor initiated a touch-and-go approach, setting flaps at 15 degrees and airspeed at 125 kts. Despite the airspeed being above normal, the instructor disregarded established procedures and proceeded with a full stop instead of a takeoff. The trainee observed the speed and intervened, advancing the throttles to initiate takeoff. The instructor’s overconfidence and failure to communicate his decision led to the aircraft exceeding the runway and subsequently catching fire. The incident highlights a combination of factors including excessive trust, impulsive judgment, and inadequate coordination.

Description

The Citation operated on a flight from Recife to Fazenda Matary with an intermediate stop at Imperatriz. On the last leg the instructor occupied the left seat and a training pilot occupied the right seat. While approaching Fazenda Matary, the instructor indicated that they would carry out a touch-and-go in order to observe the condition of the runway. Flaps were set at 15 degrees during the approach. The airspeed on finals was 125 kts, which is above the normal speed of 116 kts. After touchdown the instructor decided to make a full stop instead of a taking off again, but did not inform the training pilot. The training pilot observed the speed and noted that it fell below takeoff speed. With the end of the runway getting closer, he intervened and advanced the throttles for takeoff. The instructor thought the airplane still could be stopped on the runway. He took over control and retarded the throttles. The Citation overran the runway and caught fire. CONCLUS?O Fator Humano – Aspecto Psicol¢gico – Contribuiu Houve excesso de confian‡a, aliada a uma atitude impulsiva, por parte do instrutor, fazendo com que o mesmo estivesse convicto de que conseguiria pousar sem problemas, mesmo alterando o procedimento por ele j  estabelecido e n?o comunicando sua decis?o ao aluno. Fator Operacional (1). Deficiente Planejamento – Contribuiu O instrutor n?o planejou adequadamente o procedimento de pouso que decidiu realizar, contrariando o exposto em “briefing” anterior. (2). Deficiente Julgamento – Contribuiu Houve erro de julgamento do instrutor, decorrente da inadequada avalia‡?o de pouso normal com configura‡?o de flape em 15§ e velocidade cerca de 10kt acima da prevista, contrariando “briefing” anterior. (3). Deficiente Coordena‡?o de Cabine – Contribuiu O instrutor n?o informou ao aluno a sua decis?o de efetuar o pouso completo, sem arremetida, bem como n?o respondeu … solicita‡?o de iniciar a arremetida. O aluno acelerou os motores sem a autoriza‡?o do instrutor.

Primary Cause

Excessive trust, impulsive judgment, and inadequate coordination among the instructor.Excessive trust, impulsive judgment, and inadequate coordination among the instructor.

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