Learjet 35A – PT-LIH – Air Crash Data

Incident Overview

Date: Friday 15 March 1991

Aircraft Type: Learjet 35A

Owner/operator: L¡der T xi Areo

Registration Number: PT-LIH

Location: Uberlndia-Eduardo Gomes Airport, MG (UDI) – ÿ Brazil

Phase of Flight: Approach

Status: Destroyed, written off

Casualties: Fatalities: 0 / Occupants: 4

Component Affected: Aircraft Controls (Specifically, pilot’s actions and lack of proper control usage)Aircraft Controls (Specifically, pilot’s actions and lack of proper control usage)

Investigating Agency: CENIPACENIPA

Category: Accident

On August 8, 2023, a Learjet 35A incident occurred in S?o Paulo, Brazil, resulting in a catastrophic crash due to a confluence of factors. The aircraft, piloted by a co-pilot without a formal instructor’s qualification, took off from S?o Paulo (CGH) to pick up a patient in Uberlndia (UDI). Initial meteorological conditions were below minimum, with fog present, significantly impacting visibility and limiting the available runway options. The pilot initiated a series of maneuvers, including an approach, a visual approach, and a sharp turn, but ultimately resulted in a crash. Contributing factors included insufficient control, inadequate weather assessment, and a failure to properly utilize the aircraft’s controls. The co-pilot’s lack of qualified instruction, combined with the pilot’s actions, led to the incident. The incident was exacerbated by the adverse weather conditions, which reduced visibility and limited the available runway. The incident highlights a potential human factor ? psychological aspects ? and a failure to adequately assess the situation considering operational and weather limitations.On August 8, 2023, a Learjet 35A incident occurred in S?o Paulo, Brazil, resulting in a catastrophic crash due to a confluence of factors. The aircraft, piloted by a co-pilot without a formal instructor’s qualification, took off from S?o Paulo (CGH) to pick up a patient in Uberlndia (UDI). Initial meteorological conditions were below minimum, with fog present, significantly impacting visibility and limiting the available runway options. The pilot initiated a series of maneuvers, including an approach, a visual approach, and a sharp turn, but ultimately resulted in a crash. Contributing factors included insufficient control, inadequate weather assessment, and a failure to properly utilize the aircraft’s controls. The co-pilot’s lack of qualified instruction, combined with the pilot’s actions, led to the incident. The incident was exacerbated by the adverse weather conditions, which reduced visibility and limited the available runway. The incident highlights a potential human factor ? psychological aspects ? and a failure to adequately assess the situation considering operational and weather limitations.

Description

The Learjet 35A took off from S?o Paulo (CGH) for Uberlndia (UDI), to pick up a patient there. The co-pilot was pilot flying. It was his first flight on a Learjet without an instructor. This was against regulations since the co-pilot was not fully qualified yet and the captain was not qualified to act as an instructor. When arriving over Uberlndia, the meteorological conditions were below the minimums due to fog: 8/8 clouds at 100 m and a visibility of 200 m. Two approaches were attempted without success. They should have diverted to another airport, but a third attempt was made, probably because the crew felt pressure to accomplish the flight and pick up the patient. A visual approach was attempted at a low height. A sharp turn was flown during the turn to finals. With a large bank angle a left turn was made for runway 04. The airplane stalled and collided with the ground, skidding 300 m before coming to rest. CONCLUSION: Human Factor – Psychological Aspect – Contributed There was the participation of psychological variables, at individual and organizational level, that interfered in the crew’s performance, in relation to the need of landing in Uberlndia for the transportation of a patient. Operational Factor (1). Adverse Weather Conditions – Contributed The aerodrome had ceiling and visibility conditions below the minimum. (2). Disabled Application of Controls – Contributed The pilot did not use the aircraft controls properly, allowing it to stall and crash into the ground. (3). Cabin Coordination Weak – Undetermined There was an inadequate use of resources in the cabin intended for proper operation of the aircraft, as well as failure to comply with operating standards. (4). Disabled Judgement – Contributed There has been an inadequate assessment by the crew of the weather conditions. (5). Poor Planning – Contributed The flight preparation, with regard to the meteorological aspect, was inadequate. (6). Disabled Supervision – Contributed There was a deficiency in the supervision of the air activity, because a pilot with operational restrictions was climbed to fly with a commander who was not an instructor.

Primary Cause

Insufficient qualification of the co-pilot and pilot, coupled with adverse weather conditions and inadequate control leading to a crash.Insufficient qualification of the co-pilot and pilot, coupled with adverse weather conditions and inadequate control leading to a crash.

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