5 fatalities

1999-04-07: Learjet 24 (PT-LEM) — Manacá Taxi Aéreo — Ribeirão Preto, Brazil

Ribeirão Preto, BrazilLanding (descent or approach)

On April 7, 1999, a Learjet 24 (registration PT-LEM) operated by Manacá Taxi Aéreo was involved in an aviation accident near Ribeirão Preto, Brazil during landing or approach. 5 people were killed. Investigators recorded the probable cause as: Contributing factors: individual psychological variables in the pilot-in-command (excess self-confidence, self-demand, dissimulation); co-pilot's permissiveness and insecurity; lack of adequate supervision by Manacá Táxi Aéreo (unqualified pilot, no recent… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781204453Data APIEditorial standards

During a training flight, an aircraft rolled right on final approach, struck a wing tip, overcorrected, crashed, and burned. All five occupants died.

Accident

A training flight operating between São Paulo-Congonhas and Ribeirão Preto-Leite Lopes Airport crashed during landing on runway 18. The aircraft, carrying five crew members including an instructor and pilots, was on final approach when, just before touchdown, it banked sharply to the right. The right wing tip struck the runway surface. The pilot-in-command overcorrected, causing the aircraft to go out of control. It came to rest 420 meters beyond the initial point of impact and caught fire. All five occupants were killed.

Investigation

Official findings identified multiple contributing factors. Individual psychological variables in the pilot-in-command's performance, such as excess self-confidence, self-demand, and dissimulation about his actual qualification for that type of flight, were cited. The co-pilot's personality with traits of permissiveness and insecurity allowed an unqualified pilot (with no employment link to Manacá Táxi Aéreo) to operate the aircraft. Inadequate supervision by Manacá Táxi Aéreo was noted, as it allowed a crew member who had not flown the aircraft type in one year, had no flights in four months, and lacked an employment relationship with the company. Organizational-level supervision failures included an incorrect license issued by the DAC, enabling its use for license revalidation in an aircraft for which the pilot was not qualified as commander. The sequence began with pilot errors due to lack of flight experience in the left-hand seat on that aircraft. Ineffective use of cockpit resources and interpersonal conflict from the co-pilot's intervention during final approach contributed. The pilot-in-command made excessive aileron corrections near landing. The pilot was qualified only as a co-pilot on the equipment but was issued a pilot license due to a typing error, making the operation irregular.

Probable cause

Contributing factors: individual psychological variables in the pilot-in-command (excess self-confidence, self-demand, dissimulation); co-pilot's permissiveness and insecurity; lack of adequate supervision by Manacá Táxi Aéreo (unqualified pilot, no recent flying, no employment); organizational supervision failure (incorrect license by DAC); pilot errors from lack of left-seat experience; inadequate cockpit resource management and interpersonal conflict; excessive aileron corrections; pilot qualification irregularity (typing error in license).