What happened
On February 10, 2017, a Raytheon BAE125-800B, registration PT-OTC, operated by Líder Táxi Aéreo S.A., was performing a non-scheduled air taxi flight from Brasília to Congonhas Airport (SBSP), São Paulo. During the approach to Congonhas, the crew noticed that the left landing gear failed to indicate as locked in the extended position after following normal extension procedures.
After performing an approach and attempting to extend the gear via the emergency system—which also failed to provide a locked indication—the pilot in command decided to divert to Aeroporto Internacional Governador André Franco Montoro (SBGR) in Guarulhelos. During the landing roll at SBGR, the left landing gear retracted, causing the aircraft to veer off the left side of the runway into the adjacent grass area. The aircraft sustained substantial damage to the left wing leading edge, the left landing gear mechanism, and the tires. All three occupants—two pilots and one passenger—were uninjured.
The investigation
CENIPA's investigation focused on the mechanical failure of the landing gear and the crew's decision-making process. Investigators examined the aircraft's maintenance logs, which showed a discrepancy between the airframe flight hours and the maintenance records. The investigation also scrutinized the crew's use of the Quick Reference Handbook (QRH) and their adherence to Standard Operating Procedures (SOP) during the emergency.
Findings
- The primary cause of the excursion was the premature decision by the pilot in command to use the landing gear baulk override push button without first performing a full checklist review or evaluating the risks of gear retraction.
- The crew failed to follow the specific cautionary note in the QRH regarding the use of the override button, which can lead to unintended gear retraction.
- A lack of assertiveness from the second in command (SIC) prevented effective communication of the abnormal condition to the pilot in command.
- The crew's training and simulator experience did not adequately cover landing gear malfunctions occurring during the takeoff or approach segments.
- The pilot in command's motivation to complete the mission—as he was transporting a government official—contributed to a rushed decision-making process.
- The company's CRM training did not sufficiently address "planning continuity bias," leaving the crew less prepared for the pressure of maintaining the original flight plan during an emergency.