What happened
On July 15, 2008, a Beechcraft BE-40, registration PT-WHF, was performing an IFR flight from Congonhas (SBSP) to São José dos Campos (SBSJ) to pick up passengers. The crew consisted of a captain and a co-pilot, who was in the initial stages of type training.
During the ILS approach to runway 15, the aircraft was flying below the required reference speed (VRef). As the aircraft reached the decision altitude, the captain took control of the aircraft to correct the glide path. During this maneuver, the captain applied a significant nose-down input while simultaneously reducing engine power. This aggressive correction caused the aircraft to lose airspeed and stall. The aircraft struck the ground with its right wingtip and right main landing gear approximately 50 meters before the runway threshold, before subsequently entering the runway. The impact caused severe damage to the wing, landing gear, and fuselage, and resulted in a fuel leak.
The investigation
CENIPA investigators examined the flight data, cockpit voice recorder (CVR), and radar images. The investigation focused on the crew's training status, the lack of a pre-flight briefing, and the execution of the approach. Investigators found that the co-pilot, acting as the pilot flying (PF), lacked fundamental instrument flight knowledge, and the captain's corrective actions directly contravened the company's Standard Operating Procedures (SOP). The investigation also revealed that both pilots had exceeded the legal timeframe for simulator training.
Findings
- Improper flight controls: The captain's aggressive nose-down input and power reduction caused the stall.
- Lack of coordination: There was a significant failure in cockpit resource management and coordination between the two pilots during the critical phase of the approach.
- Inadequate supervision: The company allowed a co-pilot in the initial stages of training to act as pilot flying without a qualified instructor on board.
- Training deficiencies: Both pilots had failed to complete required simulator training within the legally mandated period.
- Procedural omissions: The crew failed to conduct a proper flight briefing and did not follow the company's SOP regarding stabilized approaches and speed maintenance.
Safety action
Following the investigation, several safety recommendations were issued to the operator, including requirements that all training flights for new co-pilots be conducted by a qualified instructor and that all instructional briefings be strictly performed. CENIPA also recommended that ANAC evaluate control mechanisms to prevent air taxi companies from operating crews that do not comply with legal training standards.