What happened
On November 4, 2007, a Learjet 35A, registration PT-OVC, operated by Reali Táxi Aéreo Ltda., crashed into a residential neighborhood in the Casa Verde district of São Paulo. The aircraft had departed from Campo de Marte Airport (SBMT) bound for Santos Dumont Airport (SBRJ) under IFR flight rules.
Witnesses reported that during the takeoff roll, the aircraft performed normally. However, after rotation, the aircraft assumed an excessive pitch-up attitude, climbing to approximately 1,50 and then leveling its wings momentarily. Following this, the aircraft began a progressive right bank that eventually reached 90 degrees. The aircraft then entered a steep descent with the nose nearly vertical, impacting a residential area approximately one nautical mile northwest of the airfield. The impact and subsequent fire caused 8 fatalities, including the two crew members and six residents of the houses struck by the aircraft.
The investigation
CENIPA's investigation focused on the aircraft's configuration and the crew's performance during the pre-flight and takeoff phases. Investigators examined the fuel levels, noting that while the aircraft was within its maximum takeoff weight, there was a significant fuel imbalance. The investigation also reviewed the Cockpit Voice Recorder (CVR), which revealed that the crew failed to perform the required checklists during both the previous landing and the subsequent takeoff preparations. Furthermore, the investigation looked into the pilot's use of a mobile phone during the taxi phase and the lack of a takeoff briefing.
Findings
- The crew failed to perform the required checklists, which prevented the identification of critical errors.
- There was a significant fuel imbalance caused by the crew's attempt to correct fuel levels between the wings at an inappropriate time.
- The co-pilot was in the process of flight training and was performing his first jet type adaptation without sufficient simulator training.
- The pilot failed to supervise the co-pilot's cockpit preparations and did not conduct a takeoff briefing.
- The aircraft's fuel control panel design made it difficult to simultaneously monitor exact quantities in all tanks, contributing to potential misinterpretation.