Accident Description
Following an uneventful flight from Florianópolis, the crew initiated an approach to São Paulo-Congonhas Airport Runway 35R. After touchdown, the aircraft was unable to stop within the remaining runway distance. It overran the end of the runway, descended an embankment, and collided with a fence, breaking into two sections. The passenger and the copilot sustained minor injuries, while the captain suffered serious injuries. The aircraft was destroyed.
Probable Cause Findings
The official investigation identified several factors that contributed to the accident. The commander exhibited overconfidence in himself and the aircraft, leading to a loss of critical risk discernment during the procedure. This was corroborated by the pilot's belief that he possessed extensive knowledge of the operation and the aircraft's responses. The investigation also inferred complacency on the part of the copilot, who felt uncomfortable but failed to make an incisive interference, believing the commander had performed high-speed approaches before and knew what he was doing.
The pilot failed to identify the touchdown location and remained unaware of the remaining runway length. He decided not to rush, demonstrating low situational awareness and a lack of awareness that impacted his reaction time. The crew did not properly assess available information, such as speed and runway length, leading to poor judgment and a failure to execute a missed approach.
The distance between crew members, exacerbated by the commander's overconfidence and the copilot's insecurity, resulted in the copilot lacking assertiveness in communicating concerns about excessive airspeed. The crew did not adopt effective crew resource management (CRM), failing to communicate assertively and share critical information before landing, allowing high speed to persist until touchdown. Despite adequate experience and training, the commander did not use available resources like speed brakes to reduce approach speed.
Variable wind direction and predominantly tailwind intensity equal to or greater than 10 knots contributed to excessive speed during landing.
The commander believed he could perform the approach and landing with speed above expectations.