What happened
On July 31, 2021, an EMB-500 (Phenom 100), registration PR-DLM, was performing a flight from Congonhas (SBSP) to Barra Grande (SIRI) in Bahia, Brazil. The aircraft was carrying two pilots and one passenger.
Upon arrival at the destination, the crew performed an initial approach which resulted in a go-around. During a second attempt, the aircraft executed an unstable approach characterized by a low descent angle and excessive speed. The aircraft crossed the threshold at 15 feet, which was 12 knots above the planned VREF. Following touchdown, the aircraft failed to stop within the runway limits, traversing the entire length of the pavement and exiting through the opposite end. There were no injuries to the two crew members or the passenger, and the aircraft sustained no damage.
The investigation
CENIPA investigators examined the flight data and aircraft systems to determine the cause of the excursion. The investigation confirmed that the aircraft's braking systems, including the electronic Brake Control Unit (BCU) and the antiskid functionality, were operating correctly. Data indicated that while there were oscillations in hydraulic pressure, these were a result of the antiskid system preventing wheel lock-up and tire bursts, rather than a mechanical failure.
Investigators also evaluated the environmental and operational conditions. The runway at the private aerodrome was noted to be wet with some standing water and uneven pavement surfaces. Furthermore, the investigation looked into the crew's decision-making process, noting that the crew's desire to reach the programmed destination—driven by the passenger's intent—may have influenced their decision to proceed with the second landing attempt despite the unstable approach parameters.
Findings
- Inadequate command application, which resulted in a descent profile below the prescribed path and a touchdown speed exceeding VREF, delaying the start of effective braking.
- Flawed decision-making process, as the crew failed to effectively analyze or choose alternatives after the initial go-around, proceeding with a second attempt despite unstable parameters.
- Improper pilot attitude, where the crew did not actively dissuade the passenger's insistence on landing at the scheduled destination despite the prevailing conditions.
- Unstable approach parameters, including a low approach angle and excessive speed at the threshold.
- Environmental factors, specifically the wet and uneven condition of the runway surface, which may have contributed to the loss of braking effectiveness.
- Operational pressure, as the crew's decision-making was potentially influenced by the passenger's requirement to arrive at the destination.