Incident Overview

Date: Wednesday 13 August 2014
Aircraft Type: Cessna 560XLS+ Citation XLS+
Owner/operator: AF Andrade Empreendimentos e Participa‡?es
Registration Number: PR-AFA
Location: Santos, SP – ÿ Brazil
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 7 / Occupants: 7
Component Affected: Aircraft ? Cessna 560XLS+ Citation Excel corporate jetAircraft ? Cessna 560XLS+ Citation Excel corporate jet
Investigating Agency: CENIPACENIPA
Category: Accident
On September 1, 2023, at 09:21 hours local time, a Cessna 560XLS+ Citation Excel corporate jet, registration PR-AFA, crashed in a residential area near Guaruj  Airport, Brazil. Seven occupants were fatally injured. The aircraft was bound for Guaruj , and the flight path involved an approach category B (NDB) to runway 35. The initial report indicates an abrupt loss of altitude, likely due to a combination of factors including excessive speed and trajectory angle relative to terrain. The pilot, Eduardo Campos, the Brazilian Socialist Party candidate, was among the fatalities. Contributing factors included an application of controls that appeared to exceed the aircraft’s operational limits, a lack of adherence to established procedures, and a challenging atmospheric condition ? near-rain and mist ? which significantly reduced visibility. The pilot’s assessment of the situation suggests that the aircraft might have been accelerating to a point where it could only have achieved such speed and trajectory given the conditions. The aircraft’s trajectory angle, combined with the speed, created a situation where it could only have been initiated by a significant rise in altitude. Furthermore, the pilot’s acknowledgment of the approach profile deviation suggests a potential miscalculation of the situation. The pilot’s experience and the aircraft’s characteristics, particularly the approach profile, were potentially compromised by the pilot’s confidence in his operational capacity. Adverse weather conditions ? particularly the near-rain and mist ? exacerbated the situation, leading to a challenging approach. The pilot’s disorientation due to reduced visibility, workload, and maneuvers further contributed to the incident. The team dynamics, including the pilot’s experience level and the co-pilot’s characteristics, may have hampered crew coordination, and fatigue, due to the workload, contributed to the incident. The incident highlights the importance of adhering to established procedures and maintaining situational awareness in complex aviation scenarios.On September 1, 2023, at 09:21 hours local time, a Cessna 560XLS+ Citation Excel corporate jet, registration PR-AFA, crashed in a residential area near Guaruj  Airport, Brazil. Seven occupants were fatally injured. The aircraft was bound for Guaruj , and the flight path involved an approach category B (NDB) to runway 35. The initial report indicates an abrupt loss of altitude, likely due to a combination of factors including excessive speed and trajectory angle relative to terrain. The pilot, Eduardo Campos, the Brazilian Socialist Party candidate, was among the fatalities. Contributing factors included an application of controls that appeared to exceed the aircraft’s operational limits, a lack of adherence to established procedures, and a challenging atmospheric condition ? near-rain and mist ? which significantly reduced visibility. The pilot’s assessment of the situation suggests that the aircraft might have been accelerating to a point where it could only have achieved such speed and trajectory given the conditions. The aircraft’s trajectory angle, combined with the speed, created a situation where it could only have been initiated by a significant rise in altitude. Furthermore, the pilot’s acknowledgment of the approach profile deviation suggests a potential miscalculation of the situation. The pilot’s experience and the aircraft’s characteristics, particularly the approach profile, were potentially compromised by the pilot’s confidence in his operational capacity. Adverse weather conditions ? particularly the near-rain and mist ? exacerbated the situation, leading to a challenging approach. The pilot’s disorientation due to reduced visibility, workload, and maneuvers further contributed to the incident. The team dynamics, including the pilot’s experience level and the co-pilot’s characteristics, may have hampered crew coordination, and fatigue, due to the workload, contributed to the incident. The incident highlights the importance of adhering to established procedures and maintaining situational awareness in complex aviation scenarios.

Description

A Cessna 560XLS+ Citation Excel corporate jet, registration PR-AFA, was destroyed in an accident in Santos, Brazil. None of the seven occupants survived the accident. One of the victims was Eduardo Campos, the Brazilian Socialist Party’s candidate for president. The airplane took off from Rio de Janeiro-Santos Dumont Airport at 09:21 hours local time and was bound for Guaruj . The only instrument approach available for Guaruj  Airport is the NDB approach for runway 35. For aircraft with Approach Category B, like the Citation Excel, the minimum visibility is 2400 m. The visibility at the time of the accident, according to the automated weather report, was 3000 m in rain and mist. The crew thus contacted Guaruj  Radio and requested an IFR ECHO 1 runway 35 NDB approach. The accident occurred when the airplane was approaching the airport. It came down in a residential area, about 4,3 km south west of the Guaruj  Airport. Contributing factors: (translated from Portuguese): – Application of controls – undetermined. Considering the elevated trajectory angle in relation to the terrain and the calculated speed (which far exceeded the operational limit of the aircraft), in the moments before the impact, it could be inferred that, from the moment the aircraft disappeared in the clouds, it could only have acquired such speed and trajectory if it had risen considerably to the point of even being detected by RADAR. Such conditions presented by the aircraft may have been the result of exaggerated control applications. – Attitude- contributed. The realization of the approach in an approach profile different from the one foreseen demonstrates a lack of adherence to the procedures, which allowed the beginning of the sequence of events that culminated in a missed approach, which was possibly influenced by the level of confidence that the pilot had in his operational capacity, from his previous experiences. – Characteristics of the task – undetermined. Although there was no pressure from passengers to enforce schedules, it is known that the routine of this activity creates an often unconscious self-pressure for the completion of flight schedules, in line with the commitments made by this type of flight demands performance requirements from pilots, which can influence them to operate at reduced safety margins. – Adverse weather conditions – contributed. The meteorological conditions were close to the safety minima for the approach and below the minimums to circle, foreseen in the ECHO 1 procedure. However, these conditions alone did not entail any risk to the operation if the ECHO 1 was followed in accordance with the parameters defined in the aeronautical publications and in accordance with the flight parameters defined by the aircraft manufacturer. When the parameters mentioned above were not followed, it was observed that the meteorological conditions were a complicating factor for the aircraft piloting, which made it difficult to stabilize the final approach, resulting in a rush. – Disorientation – contributed. In the scenario where the aircraft collided with the ground, there were several conditions that were favorable to a spatial disorientation such as: reduced visibility due to weather conditions, stress and increased workload due to the rush, maneuvers with a load above 1.15G, lack of adequate training and a possible loss of situational awareness. The high negative pitch, the high speed, and the power developed by the engines at the moment of impact are also evidences compatible with the disorientation of the incapacitating type, and point to the contribution of this factor. – Team dynamics – undetermined. The integration between the pilots may have been hampered by the low experience as crew and also by the different training they had. In addition, the commander’s characteristics, which indicated a more confident and imposing posture, as opposed to the more passive feature of the co-pilot could also have hampered the crew’s dynamics in managing the flight. – Fatigue – undetermined. In the seven days prior to the accident, the crew was in compliance with the provisions of Law No. 7,183 of April 5, 1984 regarding the working day and rest time between days. However, the results obtained in the analysis of voice, speech and copilot language parameters indicated compatibility with fatigue and somnolence, which may have contributed to the degradation of crew performance. – Training, Training and Training – undetermined. The lack of crash training on the CE 560XLS + aircraft may have required greater cognitive effort for the seizure of the conditions required by the equipment, as there were possibly no conditioned behaviors for flight control that could provide greater agility of actions in the cabin. Thus, they probably did not possess the skills, knowledge, and attitudes that would enable them to adequately perform their activities in that operational context. – Phraseology of the ATS Body – undetermined. In spite of having repo

Source of Information

http://g1.globo.com/sp/santos-regiao/noticia/2014/08/helicoptero-cai-sobre-academia-em-santos-no-litoral-de-sp.html, http://www.fab.mil.br/noticias/mostra/19519/NOTA-OFICIAL—Queda-de-aeronave-em-Santos-(SP), http://www.aisweb.aer.mil.br/download/?arquivo=14c6a57e-3de8-1030-95e7-72567f175e3ahttp://g1.globo.com/sp/santos-regiao/noticia/2014/08/helicoptero-cai-sobre-academia-em-santos-no-litoral-de-sp.html, http://www.fab.mil.br/noticias/mostra/19519/NOTA-OFICIAL—Queda-de-aeronave-em-Santos-(SP), http://www.aisweb.aer.mil.br/download/?arquivo=14c6a57e-3de8-1030-95e7-72567f175e3a

Primary Cause

Excessive speed and trajectory angle combined with challenging atmospheric conditions, leading to a loss of altitude and a potential miscalculation of the situation.Excessive speed and trajectory angle combined with challenging atmospheric conditions, leading to a loss of altitude and a potential miscalculation of the situation.

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