Incident Overview

Date: Sunday 23 March 2003
Aircraft Type: Mitsubishi Mu-300 Diamond IA
Owner/operator: Chubb do Brasil Companhia de Seguros
Registration Number: PT-LNN
Location: Santos Air Base, SP (SSZ) – ÿ Brazil
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 3
Component Affected: Aircraft ? Specifically, the aircraft’s control systems, navigation systems, and landing gear.Aircraft ? Specifically, the aircraft’s control systems, navigation systems, and landing gear.
Investigating Agency: CENIPACENIPA
Category: Accident
An aborted NDB descent resulted in a landing near the runway, leading to a catastrophic loss of control and subsequent sinking into the Canal de Bertioga. The pilot lost control, impacting the aircraft’s trajectory and causing it to exit the runway.An aborted NDB descent resulted in a landing near the runway, leading to a catastrophic loss of control and subsequent sinking into the Canal de Bertioga. The pilot lost control, impacting the aircraft’s trajectory and causing it to exit the runway.

Description

After an aborted NDB descent, the aircraft went around for a new attempt, reaching VFR conditions with runway 35 (asphalt, 1390 m long). There were large and medium cloud formations in the area. A tailwind landing was attempted. After landing, the pilot lost control and the aircraft went off the end of the runway. After crossing the concrete breakwater it ran into the Canal de Bertioga and sank, suffering serious damage. The occupants escaped unhurt. Contributing Factors: (translated from official report) 1 Human Factor 1.1 Medical Aspect Not searched. 1.2 Psychological Aspect Not searched. 1.2.1 Individual Information Nothing to report. 1.2.2 Psychosocial Information Nothing to report. 1.2.3 Organizational Information Nothing to report. 1.3 Operational Aspect 1.3.1 Concerning the operation of the aircraft a) Adverse weather conditions – contributed Heavy rain, low ceiling, around 800 feet, and visibility restrictions, approximately 2,500 meters, contributed to the occurrence. b) Forgetting the pilot – undetermined It is possible that the pilot forgot to use emergency brake features, which if used with discretion, could minimize the difficulties faced to stop the aircraft at the edge of the runway. c) Pilot Trial – contributed The crew judged that the present conditions would allow a safe landing at the aerodrome of Santos Air Base. d) Low pilot experience – undetermined The pilot and co-pilot had little experience of flying in the aircraft. It is likely that this contributed to the inadequate judgment of the landing conditions. e) Other – contributed In spite of the initiative to perform 360 degrees circle, to lose height, the pilot ended up positioned high and fast for the landing, which caused the touch down at 450 meters from the threshold of runway 35 and the exiting of the runway. 1.3.2 Concerning ATS Did not contribute. 2 Material Factor 2.1 Concerning the aircraft Did not contribute. 2.2 Concerning equipment and technology systems for ATS Did not contribute.

Primary Cause

Human Factor ? Specifically, pilot error and inadequate error handling.Human Factor ? Specifically, pilot error and inadequate error handling.

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