Incident Overview

Date: Friday 6 April 1990
Aircraft Type: Learjet 25C
Owner/operator: Transam‚rica T xi A‚reo
Registration Number: PT-CMY
Location: Juiz De Fora-Francisco De Assis Airport, MG (JDF) – ÿ Brazil
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 2 / Occupants: 4
Component Affected: Learjet 25 AircraftLearjet 25 Aircraft
Category: Accident
The Learjet, carrying a cargo of bank notes and two passengers, experienced a catastrophic landing due to a combination of factors stemming from inadequate training, insufficient experience, and a failure to adequately assess and mitigate risks. The aircraft was overloaded, the runway was wet, and the pilot’s failure to perform calculations resulted in an excessive weight exceeding the runway’s length. The pilot’s decision to proceed with the approach despite the runway limitations led to a rapid deceleration, culminating in a significant embankment collapse and fire. The incident highlights a systemic failure encompassing insufficient training, inadequate supervision, and a disregard for established safety protocols, ultimately contributing to a significant loss of life and property.The Learjet, carrying a cargo of bank notes and two passengers, experienced a catastrophic landing due to a combination of factors stemming from inadequate training, insufficient experience, and a failure to adequately assess and mitigate risks. The aircraft was overloaded, the runway was wet, and the pilot’s failure to perform calculations resulted in an excessive weight exceeding the runway’s length. The pilot’s decision to proceed with the approach despite the runway limitations led to a rapid deceleration, culminating in a significant embankment collapse and fire. The incident highlights a systemic failure encompassing insufficient training, inadequate supervision, and a disregard for established safety protocols, ultimately contributing to a significant loss of life and property.

Description

The Learjet departed Santos Dumont Airport (SDU) at 14:40 for a flight to Juiz de Fora (JDF). The airplane carried a cargo of bank notes, accompanied by two passengers. On departure the Learjet was overloaded by 1568 lb (711 kg). On landing at Juiz de Fora it was even 2086 lb (946 kg) too heavy. This complicated the landing even further because the runway at Juiz de Fora was wet with standing water. Given the weight and runway conditions, the airplane needed a runway length of 3285 m. The runway was just 1303 m long. Because the pilot failed to make the necessary calculations, he continued the approach, not knowing that the runway length was insufficient for a safe landing. After touchdown the crew used the wheel brakes to decelerate. The spoilers did not extend. The Learjet overran the runway, fell down a 20 m high embankment and caught fire. It appeared that the captain had only little experience on Learjet 25 and the co-pilot, who was receiving line training, just had 9 hours on the type. CONCLUS?O: Fator Humano – Aspecto Psicol¢gico – Foi contribuinte para a ocorrˆncia do acidente devido …s falhas gerenciais ocorridas, foi permitido que uma aeronave fosse utilizada inadequadamente e que pilotos sem o treinamento e experiˆncia necess rios fossem escalados. Fator Operacional (1) Deficiente Instru‡?o – H  ind¡cios de que tenha contribu¡do. Face aos erros cometidos na condu‡?o do v“o, no que tange ao planejamento incorreto e deficiente, do n?o conhecimento ou desrespeito …s limita‡?es da aeronave, haja vista as condi‡?es existentes por ocasi?o do acidente, leva a crer que houve uma deficiente instru‡?o quando na fase de transi‡?o de outros equipamentos para este. N?o houve um acompanhamento adequado durante a evolu‡?o da instru‡?o ministrada ao aluno, devido ao n?o preenchimento das fichas de avalia‡?o de v“o. (2) Deficiente Coordena‡?o de Cabine – o co-piloto, ao participar da opera‡?o de pouso apenas como mero expectador, caracteriza, incontestavelmente, uma coordena‡?o deficiente entre os tripulantes. (3) Deficiente Julgamento – a determina‡?o em realizar o pouso dentro das condi‡?es existentes, no momento do acidente (pista molhada, excesso de peso, centro de gravidade fora dos limites etc), demonstra um julgamento totalmente deficiente por parte do comandante. (4) Deficiente Planejamento – foi o fator determinante para a ocorrˆncia do acidente, pois a falha nos c lculos de peso e balanceamento, bem como o carregamento incorreto, culminaram com a perda do controle na opera‡?o de pouso, j  que a aeronave excedia naquele momento a todos os limites de opera‡?o. (5) Deficiente Supervis?o – apesar de o comandante possuir larga experiˆncia de v“o, o n£mero de horas de v“o no tipo mostrou-se insuficiente para a fun‡?o de comandante, pois os dados colhidos por ocasi?o da investiga‡?o mostraram que o mesmo n?o possu¡a conhecimento t‚cnico necess rio, comprometendo suas decis?es como comandante. O co-piloto, por sua vez, ainda estava em forma‡?o. O que o piloto conhecia de concreto, com rela‡?o a miss?o que deveria executar, era apenas a rota a ser voada. Estes aspectos s?o compat¡veis com graves falhas de supervis?o e ausˆncia de doutrina de seguran‡a de v“o da empresa.

Primary Cause

Deficient Instruction (1) – Inadequate instruction and insufficient training led to a lack of understanding of operational limitations and potential hazards.Deficient Instruction (1) – Inadequate instruction and insufficient training led to a lack of understanding of operational limitations and potential hazards.

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