Incident Overview

Description
The Learjet 60 suffered a runway excursion on landing at Santa Cruz do Sul Airport, Brazil. The aircraft was owned by Dwiggins LLC and operated in Brazil by a crew of the American Virginia tobacco firm to evaluate the aircraft, as they were planning to acquire a Learjet 60. The flight departed Mar¡lia, Brazil, on a business flight with a captain, copilot and a pilot-in-training who was occupying the observer seat. The co-pilot, who would initially act only as an observer, didn’t have any amount of flight hours in the model that would qualify him for the type of flight and function he was performing. At the time of the accident, the weather conditions at the destination were light rain, and the runway was wet. The aircraft made a steep approach for landing and at a speed 10 kt higher than expected. The touch down on runway 26 was about 400 meters past the threshold. The landing was continued and, although every resource was used for braking, it ran off the end of the runway. It struck a ravine and a road located 50 meters from the end. The pilot suffered serious injuries, the co-pilot died, the other crewmember in training and passengers suffered minor injuries. Contributing Factors a. Human Factor (1) Physiological Did not contribute. (2) Psychological – Contributed Crewmembers’ overmotivation resulted in decreased situational alertness leading them to not perform a go-around, proceeding to the landing, disregarding the existing weather conditions, runway length, approach profile, and co-pilot operational capability. b. Material Factor Did not contribute. c. Operational Factor (1) Poor Judgment – Contributed The commander did not properly evaluate the consequences of a high speed approach, believing that, even though the first touchdown point was too long and too fast, he would be able to stop the aircraft within the runway limits. (2) Poor Planning – Contributed The crew did not plan adequately for a possible abnormality regarding the prevailing weather conditions, minimum runway limits required for landing, possible needs of going around, as well as did not consider the pilot’s inexperience in face of possible abnormalities, i.e., disregarded the importance of the landing briefing. (3) Flight Indiscipline – Contributed The use of a pilot without the proper documentation to occupy the function on board the aircraft. (4) Deficient Supervision – Contributed In the extent that the company management allowed an unqualified pilot to occupy the co-pilot function, without being properly qualified to adequately assist the captain. (5) Deficient Cockpit Coordination – Contributed There was inadequate cockpit resource management, since the pilot occupying the right seat was unaware of the equipment in question, in other words, he had no technical knowledge of the aircraft. (6) Deficient Application of Commands – Contributed By the inadequate runway and speed parameters, allowed by the commander when in final for landing, contributing for the aircraft to perform an unstabilized final approach. (7) Deficient Infrastructure – Undetermined It cannot be said that the lack of an aerodrome emergency plan is directly related as a determining factor in the aggravation of the injuries suffered by the crew members.
Primary Cause
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