Incident Overview

Date: Friday 15 August 1997
Aircraft Type: Cessna 550 Citation II
Owner/operator: Riana T xi A‚reo
Registration Number: PT-LML
Location: near Cocal do Sul, SC – ÿ Brazil
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 2
Component Affected: Aeronautical System ? Pressurization System ? Aircraft Control SystemsAeronautical System ? Pressurization System ? Aircraft Control Systems
Investigating Agency: CENIPACENIPA
Category: Accident
The incident involved a Citation aircraft experiencing a rapid decompression during takeoff, resulting in hypoxia and loss of consciousness among the pilots. The aircraft descended rapidly, reaching a significant altitude of approximately 1500 feet, before abruptly stopping. The pilots? subsequent slumped posture contributed to the spiral descent, ultimately leading to a loss of control and a subsequent breakup.The incident involved a Citation aircraft experiencing a rapid decompression during takeoff, resulting in hypoxia and loss of consciousness among the pilots. The aircraft descended rapidly, reaching a significant altitude of approximately 1500 feet, before abruptly stopping. The pilots? subsequent slumped posture contributed to the spiral descent, ultimately leading to a loss of control and a subsequent breakup.

Description

The crew probably forgot to verify the position of the pressurization mode selector prior to takeoff. The pressurization system was probably switched off as the Citation departed. Both pilots became hypoxic and passed out. At an altitude of about FL330 the one or both pilots probably slumped over the control column, causing the airplane to enter a descending left turn. The descent steepened and the airplane entered a spiral at a descent rate of 20.000 ft/min. It broke up at an altitude of 1500 feet. CONCLUS?O: Fator Humano – Aspecto Fisiol¢gico – Indeterminado  poss¡vel que a tripula‡?o tenha tido hip¢xia, em decorrˆncia de descompress?o lenta da aeronave, e que tal hip¢xia tenha causado perda da consciˆncia dos pilotos e conseqente perda de controle da aeronave. Fator Operacional (1). Esquecimento – Indeterminado  poss¡vel que a tripula‡?o tenha esquecido de ligar o seletor de pressuriza‡?o no cheque Before Take Off. (2). Deficiente Coordena‡?o de Cabine – Indeterminado  poss¡vel ter ocorrido um ineficaz gerenciamento das tarefas afetas a cada tripulante, falha ou confus?o na comunica‡?o que poderia ter contribu¡do para a perda de controle da aeronave ap¢s terem julgado ser necess rio a descida de emergˆncia. (3). Outros – Deficiˆncia na Realiza‡?o de Procedimento Padr?o – Indeterminado  poss¡vel que os pilotos tenham realizado o cheque Before Take Off inadequadamente ou tˆ-lo feito sem o aux¡lio do Check List. Fator Material – Indeterminado  poss¡vel que a luz de alarme cabine 10.000ft tenha falhado em v“o. No entanto, n?o se pode afirmar se houve tal falha, em decorrˆncia do estado dos destro‡os da aeronave n?o permitirem um exame mais profundo nesse sentido. Mesmo que tenha falhado no seu acendimento, tal falha pode ter se caracterizado tanto por deficiˆncia de material quanto por inadequada manuten‡?o, o que caracterizaria contribui‡?o do fator operacional. Outra possibilidade a ser considerada ‚ a falha da Air Cicle Machine, em decorrˆncia de deficiˆncia de projeto ou fabrica‡?o, o que poderia ter contribu¡do para a ocorrˆncia do acidente.

Primary Cause

Human Factor ? Physiological Aspect ? Indeterminate.Human Factor ? Physiological Aspect ? Indeterminate.

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