What happened
On July 23, 2012, a Cessna 525A, registration PP-MEO, departed from Comandante Rolim Adolfo Amaro Airport (SBJD) in Jundiaí, Brazil, bound for Fortaleza. While climbing through FL290, the aircraft experienced a loss of cabin pressure due to a leak in the main door pressure seal. The pilot in command (PIC) notified air traffic control and initiated an emergency descent to FL140, returning to the origin airport.
During the landing on runway 36, the aircraft utilized the entire available landing distance and overran the runway end by approximately five meters, damaging the runway lighting and the aircraft's right main tire. All three occupants—two crew members and one passenger—remained uninjured, though the aircraft sustained light damage.
The investigation
CENIPA's investigation focused on the crew's management of the depressurization and the subsequent landing performance. While the aircraft was certified for single-pilot operation, the investigation established that the occupant in the right seat was actively performing the duties of a Second in Command (SIC), including checklist execution and communications. However, this individual lacked the specific type rating for the Cessna 525A.
Investigators analyzed the Cockpit Voice Recorder (CVR) and found that the crew failed to follow the Airplane Flight Manual (AFM) procedures for a door seal failure, notably failing to use oxygen masks or perform the required door seal checklist. Furthermore, the investigation examined the pilot's braking technique. Although the pilot reported a brake failure, technical tests of the braking and anti-skid systems showed no malfunctions. Instead, the CVR revealed that the pilot delayed applying maximum braking effort until the very end of the runway, which was an inadequate technique for the available stopping distance.
Findings
- The crew's decision-making process was compromised by the pressure of the emergency.
- Ineffective cockpit coordination occurred because the pilot was managing high workloads while the acting SIC was not properly qualified for the aircraft type.
- The pilot's judgment regarding braking was flawed, as the delay in applying maximum braking pressure contributed to the overrun.
- The crew failed to execute the specific emergency checklists required for the pressure leak.
- The presence of an unqualified pilot performing SIC duties increased the pilot's workload during a critical phase of flight.