What happened
On August 12, 2010, a Learjet 55C, registration PT-LXO, departed from Santos Dumont Airport (SBRJ) in Rio de Janeiro, bound for Galeão Airport (SBGL). Shortly after takeoff, the flight crew experienced a rapid, sequential loss of several critical flight instruments and systems, including the TCAS, EHSI, EADI, RMI, altimeters, and airspeed indicators.
In response to the degradation of flight data, the commander decided to return to Santos Dumont under visual flight conditions. During the approach, the crew lost radio communications with Air Traffic Control (ATC). As the aircraft aligned with runway 02R, the failure of most onboard systems continued to progress. During the landing roll, the aircraft's spoilers and engine thrust reversers failed to deploy. Consequently, the aircraft could not decelerate sufficiently, overran the runway, and plunged into the waters of Guanabara Bay. All three occupants—the two pilots and one passenger—escaped the wreckage without injury, though the aircraft sustained severe damage and was declared a total loss.
The investigation
CENIPA's investigation focused on the chain of events leading to the loss of control on the ground. Investigators examined the sudden failure of multiple independent avionics and flight systems, the loss of communication with ATC, and the failure of deceleration devices (spoilers and reversers). The investigation also scrutinized the operator's training programs, maintenance oversight, and the standardization of cockpit procedures.
Findings
- The primary contributing factor was a lack of standardized operating procedures (SOPs) and inadequate Crew Resource Management (CRM) training, which hindered the crew's ability to manage the emergency effectively.
- Inadequate managerial supervision led to a failure in monitoring pilot performance during simulator and flight training, meaning critical deficiencies in the commander's handling of emergencies were not corrected.
- The operator's maintenance oversight was insufficient, with a lack of continuous analysis of maintenance services.
- An environment of low standardization was fostered by inadequate control over the updating of company manuals and a culture of informal operational actions.
- The crew's ability to manage the situation was further compromised by the loss of critical flight instruments and communication capabilities during the approach.