What happened
On June 13, 2014, a Cessna 525, registration PP-PIM, was performing a flight from Goiânia to Cocalinho when the crew diverted to Aruanã Aerodrome (SWNH) in Goiás, Brazil. Upon landing on runway 24, the crew failed to successfully decelerate the aircraft. The aircraft overran the end of the runway, colliding with a perimeter fence and subsequently crashing into a ravine near a highway.
The accident resulted in one serious injury to the pilot and five minor injuries to the passengers and copilot. The aircraft sustained substantial structural damage.
The investigation
CENIPA's investigation focused on the failure of the braking process and the crew's response to the landing roll. Investigators found that while the normal braking system's performance was not definitively confirmed as failed, the emergency brake system was functional and available for use. However, the crew did not activate it.
The investigation revealed that the pilot, despite having extensive total flight experience, had only approximately 39 hours of experience specifically in the Cessna 525 model. Furthermore, the copilot was not rated for this aircraft type. The investigation also noted that a NOTAM was in effect at the time, prohibiting jet aircraft operations at the aerodrome due to potential foreign object debris (FOD), though the runway was found to be clean at the time of the accident.
Findings
- Inadequate training: The pilot's training for the Cessna 525 did not sufficiently emphasize the location or use of the emergency brake system.
- Ergonomic design: The emergency brake actuator handle was positioned such that it was obscured from the pilot's direct line of sight by the control column, leading the pilot to instinctively reach for the more visible landing gear lever.
- Pilot error: During the emergency, the pilot incorrectly manipulated the auxiliary gear control lever, believing it to be the emergency brake, which prevented effective deceleration.
- Insufficient type experience: The pilot's limited experience with this specific jet model contributed to the inability to manage the abnormal situation effectively.