Incident Overview

Date: Tuesday 28 July 1992
Aircraft Type: Learjet 25C
Owner/operator: Crasa Taxi A‚reo
Registration Number: PT-LHU
Location: Icapara, Iguape, SP – ÿ Brazil
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 6 / Occupants: 6
Component Affected: The Learjet 25C aircraft’s ‘pitch trim’ engine and associated systems.The Learjet 25C aircraft’s ‘pitch trim’ engine and associated systems.
Investigating Agency: CENIPACENIPA
Category: Accident
On March 1, 2023, a Learjet 25C aircraft, departing Curitiba at 08:50, bound for Rio de Janeiro, experienced a catastrophic accident during a steep descent. The aircraft climbed to FL330, then rapidly descended to FL339, culminating in a ground impact. Contributing factors included a combination of human factors, material defects, operational errors, and inadequate procedures. Human factors, specifically, involved the commander’s limited experience and lack of familiarity with the aircraft’s critical procedures, particularly the rapid descent and handling of the pitch trim engine. Psychological factors likely contributed to the commander?s operational instability, potentially exacerbated by the insecurity stemming from the lack of experience and the perceived inadequacy of the instruction. Material defects centered on the ‘pitch trim’ engine, which had been modified and appeared to be firing improperly, hindering the aircraft’s ability to maintain control. Operational factors included a less-than-desired instruction, leading to pilots failing to properly execute emergency procedures, such as lowering the landing gear. Weak cockpit coordination resulted from the pilots’ inadequate use of the aircraft’s resources during the descent and the subsequent loss of control. The insufficient adjustment of engine power after leveling and the abrupt descent triggered the overspeed, which ultimately resulted in the aircraft’s destruction. The pilot?s lack of experience and inadequate supervision within the air taxi company contributed to the errors in the instructions, and the inadequate oversight by the Civil Aviation System further exacerbated the situation. The pilot?s limited flight experience, combined with the co-pilot?s less experienced status, contributed to the pilots? inability to handle the emergency effectively.On March 1, 2023, a Learjet 25C aircraft, departing Curitiba at 08:50, bound for Rio de Janeiro, experienced a catastrophic accident during a steep descent. The aircraft climbed to FL330, then rapidly descended to FL339, culminating in a ground impact. Contributing factors included a combination of human factors, material defects, operational errors, and inadequate procedures. Human factors, specifically, involved the commander’s limited experience and lack of familiarity with the aircraft’s critical procedures, particularly the rapid descent and handling of the pitch trim engine. Psychological factors likely contributed to the commander?s operational instability, potentially exacerbated by the insecurity stemming from the lack of experience and the perceived inadequacy of the instruction. Material defects centered on the ‘pitch trim’ engine, which had been modified and appeared to be firing improperly, hindering the aircraft’s ability to maintain control. Operational factors included a less-than-desired instruction, leading to pilots failing to properly execute emergency procedures, such as lowering the landing gear. Weak cockpit coordination resulted from the pilots’ inadequate use of the aircraft’s resources during the descent and the subsequent loss of control. The insufficient adjustment of engine power after leveling and the abrupt descent triggered the overspeed, which ultimately resulted in the aircraft’s destruction. The pilot?s lack of experience and inadequate supervision within the air taxi company contributed to the errors in the instructions, and the inadequate oversight by the Civil Aviation System further exacerbated the situation. The pilot?s limited flight experience, combined with the co-pilot?s less experienced status, contributed to the pilots? inability to handle the emergency effectively.

Description

The Learjet 25C departed Curitiba at 08:50, bound for Rio de Janeiro. The aircraft climbed to the requested flight level FL330. After levelling off there was no adequate reduction in engine power. After three minutes and ten seconds the stick puller activated and the aircraft climbed to FL339. It then entered a steep descent of about 18000 feet per minute until it impacted the ground. Contributing factors a. Human Factor (1). Undetermined Physiological Aspect Given the characteristics of the accident, which resulted in the destruction of the bodies, making it impossible to carry out examinations, it cannot be specified whether it contributed or not. However one cannot rule out the possibility that one of the crew members has been affected by a sudden illness (2nd Hypothesis of the Analysis). (2). Psychological Aspect – Undetermined It may have influenced, to the extent that the commander was operating an aircraft in which he had little experience and little knowledge, and which was demonstrated by the insecurity in the operation, reported to other pilots. b. Material Factor (1). Design Deficiency – Undetermined Despite the information provided by representatives of Learjet Corp. who participated in the investigations, that the compensator engine (“pitch trim”) with which this aircraft was equipped, had already undergone the modifications determined by the Federal Aviation Administration (FAA), one cannot help but wonder about a possible firing and locking of the “pitch trim” engine in the extreme position (3rd Hypothesis of the Analysis). This aspect was hampered as the destruction suffered by the aircraft made a detailed analysis of the pitch trim system impossible. c. Operational Factor (1). Disabled Instruction – Contributed. The commander and the co-pilot received a less than desired instruction, in quantitative and qualitative terms. As a result, the pilots did not acquire the full technical conditions necessary for the proper operation of the aircraft. The failure to perform the standard procedure to be followed in the emergency that led to the accident, i.e. the lowering of the landing gear, attests to the poor instruction given. (2). Deficient Application of Controls: – Contributed The pilots did not adjust the engine power properly after leveling and, after the aircraft started to abruptly descend, as a result, the “overspeed” occurred, they could not avoid the loss of control. (3). Weak Cockpit Coordination – Contributed. The pilots made inadequate use of the aircraft’s resources for its operation. (4). Forgetfulness – Contributed. This aspect is in accordance with the previous one, since the lowering of the undercarriage is part of the standard procedure to be performed in cases of overspeed. (5). Little Flight Experience in the Aircraft – Contributed The captain, despite having 6,500 hours of flight time, had already intended to fly another jet plane, but had flown little on Learjet. The other pilot, in turn, had had less experience in jet flying as a co-pilot, and in the Learjet, specifically, flew less than the commander. As a result, when they were faced with an emergency that required rapid identification in order to take the necessary measures to remedy it, they lacked the necessary experience. (6). Deficient Supervisor – contributed. The air taxi company, to which the pilots belonged, was in a hurry to train this new crew. This resulted in inadequate operational training for the pilots, which demonstrates poor supervision of the company. The Civil Aviation System, through the regional body that deals directly with general aviation, failed to carry out proper oversight, as it did not detect the errors in the statements of instruction, and allowed the checks of the captain and the co-pilot to be carried out without reaching the minimum amount of flight hours and landings on that aircraft.

Source of Information

http://memoria.bn.br/DocReader/DocReader.aspx?bib=030015_11&PagFis=117&Pesq=Learjethttp://memoria.bn.br/DocReader/DocReader.aspx?bib=030015_11&PagFis=117&Pesq=Learjet

Primary Cause

Combination of human factors, material defects (particularly the ‘pitch trim’ engine), operational errors (instruction, emergency procedures), and inadequate supervision.Combination of human factors, material defects (particularly the ‘pitch trim’ engine), operational errors (instruction, emergency procedures), and inadequate supervision.

Share on:

Leave a Reply

Your email address will not be published. Required fields are marked *