What happened
On November 14, 2019, a Cessna 550, registration PT-LTJ, was performing a private flight from Jundiaí, São Paulo, to Barra Grande Aerodrome in Maraú, Bahia. The aircraft was carrying two crewmembers and eight passengers.
During the final approach to runway 11, the aircraft struck a signpost and subsequently hit a ravine located before the runway threshold. The impact caused the main and auxiliary landing gear to collapse. Following the gear failure, the aircraft dragged along the runway for approximately 147 meters, causing the lower fuselage and wing to scrape the ground. The aircraft eventually veered off the left side of the runway and caught fire, which destroyed the airframe. The accident resulted in five fatalities (one crewmember and four passengers) and five serious injuries (one crewmember and four passengers).
The investigation
CENIPA's investigation examined the flight parameters, crew performance, and environmental conditions. Investigators found that while the weather was favorable and the aircraft was within weight and balance limits, the aircraft had taken off with a weight exceeding the limits specified in its operating manual.
The investigation also scrutinized the crew's cockpit environment. It was noted that the commander's attention was divided between monitoring the copilot and using a mobile phone to take photographs of the airfield during the wind leg. Furthermore, the investigation identified that the commander's hearing impairment, combined with the copilot's low vocal volume and the lack of headset use, hindered effective communication during the critical landing phase.
Findings
- Inadequate control skills led to an approach ramp that was lower than ideal, resulting in the aircraft touching the ground before the threshold.
- Failure to execute a go-around due to poor Crew Resource Management (CRM) prevented the crew from abandoning the unstable approach.
- Pilot distraction occurred as the commander took photographs of the aerodrome during the flight.
- Visual illusions caused by the runway's narrow width and the surrounding terrain (dunes and varying pavement colors) likely influenced the pilot's judgment of the approach slope.
- Impaired communication due to the commander's hearing loss and the lack of proper intercom usage.
Safety action
CENIPA issued several recommendations to the Brazilian National Civil Aviation Agency (ANAC), including:
- Implementing risk assessment procedures for operating turbojet aircraft at aerodromes lacking visual approach slope indicators or updated EGPWS databases.
- Improving medical inspection protocols for airmen with progressive health conditions that could impact flight safety.
- Disseminating lessons learned regarding the importance of stabilized approaches, correct flight planning, and adherence to CRM techniques.