What happened
On May 18, 2013, a Cessna C500 (registration PT-LPZ) was performing a passenger flight from Sorocaba to Campo de Marte (SBMT) in São Paulo. During the final approach to runway 12, the aircraft crossed the threshold at a speed approximately 10 knots above the recommended VRef. The aircraft touched down approximately 1,000 meters from the threshold, significantly further down the runway than ideal.
During the landing roll, the pilot attempted to apply the emergency brakes but accidentally manipulated the emergency landing gear extension handle. This error prevented the aircraft from decelerating effectively. The aircraft subsequently veered left, striking a culvert in a grassy area, which caused the landing gear to fracture. The aircraft came to a stop approximately 41 meters from the opposite threshold with substantial damage to the airframe, including the fuselage, wings, and landing gear. All four occupants (two crew and two passengers) were uninjured.
The investigation
CENIPA's investigation focused on the sequence of events during the landing roll and the cockpit environment. Investigators examined the aircraft's technical logs and found that while the airworthiness certificate was valid, the aircraft's maintenance logs and flight logs were significantly outdated.
The investigation also analyzed the cockpit ergonomics. It was discovered that the emergency brake handle was positioned below the instrument panel in a location that was difficult to see. Furthermore, the emergency gear extension handle was located near the brake handle and was also colored red, which contributed to the pilot's error. Investigators noted that a manufacturer's service bulletin (SB 32-11) existed to improve the visibility and ergonomics of these controls, but it had not been implemented on PT-LPZ because it was not a mandatory modification.
Findings
- The pilot's inadvertent activation of the emergency gear release instead of the emergency brake was the primary error during the landing roll.
- The aircraft was operating near its maximum landing weight, which increased the required landing distance.
- The approach speed was higher than the manufacturer's recommended parameters.
- The touchdown point was too far down the runway, leaving insufficient distance to stop.
- There was a lack of adequate Cockpit Resource Management (CRM) and a failure to utilize aircraft manuals effectively.
- The pilot had limited experience specifically with this jet model.