Incident Overview

Date: Monday 12 October 2009
Aircraft Type: Embraer EMB-500 Phenom 100
Owner/operator: Save Comercial e Importadora Ltda.
Registration Number: PP-AFM
Location: Angra dos Reis Airport, RJ – ÿ Brazil
Phase of Flight: Landing
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 4
Component Affected: The Phenom jet aircraft.The Phenom jet aircraft.
Investigating Agency: CENIPACENIPA
Category: Accident
The Phenom jet experienced a catastrophic runway excursion following landing on Runway 10 at Angra dos Reis Airport, Brazil, resulting in significant damage beyond repair. Contributing factors highlighted a confluence of operational and organizational issues, including pilot complacency, a disregard for established safety procedures, and a culture prioritizing expediency over risk assessment. The pilot?s decision to operate at an aerodrome with limited assessment of conditions, coupled with a willingness to yield to pressure from the boss, exacerbated the situation. Furthermore, the group?s culture of prioritizing the wishes of the aircraft owner, particularly in relation to jet-powered aircraft, played a crucial role in reinforcing the decision to proceed to landing with elevated weight and tailwind. The pilot?s limited flight experience further compounded the risks encountered during the landing run, leading to a degraded braking system and increased runway length required for stopping.The Phenom jet experienced a catastrophic runway excursion following landing on Runway 10 at Angra dos Reis Airport, Brazil, resulting in significant damage beyond repair. Contributing factors highlighted a confluence of operational and organizational issues, including pilot complacency, a disregard for established safety procedures, and a culture prioritizing expediency over risk assessment. The pilot?s decision to operate at an aerodrome with limited assessment of conditions, coupled with a willingness to yield to pressure from the boss, exacerbated the situation. Furthermore, the group?s culture of prioritizing the wishes of the aircraft owner, particularly in relation to jet-powered aircraft, played a crucial role in reinforcing the decision to proceed to landing with elevated weight and tailwind. The pilot?s limited flight experience further compounded the risks encountered during the landing run, leading to a degraded braking system and increased runway length required for stopping.

Description

The Phenom jet was damaged beyond repair when it suffered a runway excursion after landing on runway 10 at Angra dos Reis Airport, Brazil. Contributing Factors – Attitude – contributed The pilot considered the operation in Angra dos Reis unsafe, but operated the aircraft at that aerodrome several times, willingly yielding to the pressures of the boss. – Decision-making – contributed The crew proceeded to landing with tailwind and elevated aircraft weight, without considering the possibility of rushing or even using runway 28, which demonstrated that there was not an adequate assessment of the conditions involving the landing within the limits of the runway. – Culture of the working group – contributed The group’s culture of not performing a traffic circuit, nor landing on runway 28, especially in relation to jet-powered aircraft, reinforced the decision of the pilots to proceed to landing on the usual runway, considerably increasing the distance required to stop of the aircraft. In addition, the common practice among executive aviation pilots to yield to the wishes of the aircraft owner or the service contractor may have contributed to the complacent behavior of the crew. – External influences – indeterminate The possible pressure exerted by the owner to carry out the flights, as well as the need to maintain the job or the professional image, may have contributed to the complacency behavior of the crew on the issues that lead to the operation of aircraft under conditions below acceptable safety standards. – Organizational culture – contributed The culture of always fully fueling the aircraft regardless of the flight to be accomplished culminated in a landing weight above that required for the aircraft to stop within the runway boundaries. – Flight planning – contributed The flight planning did not consider that the takeoff weight of the aircraft would result in a landing weight above that required for the aircraft to stop within the runway boundary. – Little pilot experience – unspecified The pilots had only a few hours of flight time in the aircraft type of the accident, which contributed to the decrease in the perception of risk in the SDAG operation under those conditions. – Project – contributed The extrapolation of the pedal stroke and the consequent temporary disabling of the aircraft brake system at some point during the landing run degraded the braking of the aircraft and increased the length of runway necessary for the aircraft to stop after landing, despite that the performance chart of the aircraft indicated that the length of the runway was not sufficient for landing in those aircraft’s wind and weight conditions and aggravated the damage to the aircraft.

Source of Information

http://www.avcanada.ca/forums2/viewtopic.php?f=105&t=67732http://www.avcanada.ca/forums2/viewtopic.php?f=105&t=67732

Primary Cause

Pilot complacency and a disregard for established safety procedures, exacerbated by a culture prioritizing the wishes of the aircraft owner.Pilot complacency and a disregard for established safety procedures, exacerbated by a culture prioritizing the wishes of the aircraft owner.

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