Flight History
The aircraft, registration PR-AFA, departed Santos Dumont Airport (SBRJ) at 12:21 UTC on a transport flight to Santos Aerodrome (SBST) with two pilots and five passengers. The flight was under radar coverage by the approach control units of Rio de Janeiro and São Paulo, with no observed abnormalities. After being released for descent and approach, the crew contacted Santos Radio and reported their intention to perform the IFR ECHO 1 RWY 35 NDB approach. Later, they reported a go-around and intended to hold.
Accident Sequence
Observers on the ground at Santos Air Base and the Port of Santos reported seeing the aircraft flying over the runway at low altitude, then turning left after passing the departure end. They lost visual contact due to weather conditions. Moments later, the aircraft crashed. All seven occupants were killed.
Investigation Findings
The official investigation identified several factors contributing to the accident. The aircraft's trajectory and speed before impact suggested that it had climbed considerably before descending at an excessive speed, possibly due to exaggerated control inputs. The approach profile deviated from the prescribed ECHO 1 procedure, indicating a lack of adherence, potentially influenced by the captain's confidence from prior experiences. Self-pressure from the flight's routine may have reduced safety margins. Meteorological conditions were near minimums for the approach and below minimums for the circle-to-land procedure, but the conditions alone would not have been risky if the procedure had been followed correctly. The missed approach and weather conditions created a scenario conducive to spatial disorientation, evidenced by a large pitch-down angle, high speed, and engine power at impact. Crew coordination was hindered by the pilots' lack of experience working together and their different training backgrounds; the captain's assertive personality contrasted with the copilot's passivity. The copilot's voice analysis indicated fatigue and somnolence, despite compliance with duty time regulations. Lack of training in missed approach procedures for the CE 560XLS+ model may have increased cognitive load. Santos Radio did not provide current ceiling, visibility, or SIGMET information, which may have reduced the crew's situational awareness. The aircraft deviated from the planned airway and reported incorrect positions; the approach was flown at improper speeds. The captain's prior experience with FMS visual approaches may have fostered overconfidence. The crew's perception of weather conditions was likely inaccurate due to outdated METAR information. Weather prognostics and satellite imagery had indicated degrading conditions.