What happened
On January 29, 2008, a Learjet 35 A, registration PT-LEB, operated by Voetur Táxi-Aéreo, was performing a multi-leg flight across Brazil. After departing Rio Branco, the aircraft proceeded to Cruzeiro do Sul (SBCZ) for its final leg of the day. During the approach to runway 10, the crew encountered a dense fog bank, locally known as "aru."
As the aircraft approached the runway, the pilot flying transferred control to the commander to facilitate better visibility from the left seat. Despite the visibility deteriorating, the crew continued the descent. Upon crossing the runway threshold at approximately 60 feet, the pilot lost visual contact with the ground, resulting in a hard landing. All eight occupants—two crew members and six passengers—remained uninjured, though the aircraft sustained significant damage to the landing gear, wing, and right wing tip tank.
The investigation
CENIPA's investigation focused on the cockpit environment and the crew's adherence to instrument approach procedures. Analysis of the Cockpit Voice Recorder (CVR) revealed significant cockpit coordination issues and a lack of effective monitoring. The investigation established that the crew descended below the Minimum Descent Altitude (MDA) of 1,150 feet without establishing visual contact with the runway.
Furthermore, the investigation noted that the commander had not undergone flight simulator training since 2001, and the co-pilot had not trained in a simulator since 1991. While the crew was aware of the adverse weather conditions, the investigation found that the pressure of a long duty day—exceeding 10 hours—and previous flight diversions due to weather may have influenced the decision to proceed with the landing.
Findings
- Flight Indiscipline: The crew deliberately descended below the established MDA without visual contact with the runway.
- Poor Crew Resource Management (CRM): There was a failure in cockpit coordination, specifically regarding the lack of effective call-outs and the failure of the pilot monitoring to alert the pilot flying to initiate a missed approach.
- Impaired Judgment: The crew made an inadequate assessment of the risks associated with continuing the approach after losing visual cues.
- Training Deficiencies: A lack of recent simulator training may have contributed to the decision not to execute a missed approach.
Safety action
Following the investigation, SERIPA VII issued several recommendations to the operator, including implementing educational programs on "Lost Approach Syndrome," CRM, and instrument approach profiles, as well as ensuring regular simulator training for all pilots. CENIPA also recommended that ANAC implement mechanisms to disseminate the lessons learned from this accident to prevent similar deviations from approach profiles.