Accident
On a cargo flight from Rio de Janeiro-Santos Dumont Airport to Monte Carlos with intermediate stops in Juiz de Fora and Belo Horizonte, the aircraft departed at 1440 LT. On board were two pilots, two passengers, and a load of bank notes. Due to the crew's failure to prepare the flight according to procedures, the aircraft took off with a total weight exceeding the limit by more than 711 kilograms. Following inadequate flight and approach planning, the crew did not perform correct landing calculations. Upon arrival, the aircraft's total weight was 946 kilograms above the maximum landing weight.
The landing was attempted on wet runway 21. After touchdown, the spoilers did not deploy. Unable to stop within the remaining runway distance, the aircraft overran the runway, went down a 20-meter ravine, and came to rest, bursting into flames. The captain and one passenger were killed; the other pilot and the other passenger were injured. The aircraft was destroyed.
Investigation
The official investigation identified several contributing factors to the accident.
Probable Cause
The following contributing factors were identified:
- Human Factor - Psychological Aspect - It contributed to the occurrence of the accident due to managerial failures, allowing an aircraft to be used improperly and assigning pilots without the necessary training and experience.
- Deficient Instruction - There are indications that it contributed. Given the errors committed in conducting the flight, regarding incorrect and deficient planning, lack of knowledge or disregard for the limitations of the aircraft, considering the conditions existing at the time of the accident, it is believed that there was deficient instruction during the transition phase from other equipment to this one. There was inadequate follow-up during the instruction given to the student, due to the failure to complete the flight evaluation forms.
- Poor Cockpit Coordination - the copilot, by participating in the landing operation merely as a spectator, undeniably demonstrates poor coordination among the crew.
- Poor Judgment - the decision to perform the landing under the existing conditions at the time of the accident (wet runway, excess weight, center of gravity outside limits, etc.) demonstrates a completely deficient judgment on the part of the captain. At the time of the accident, runway 03/21 was 1,303 meters long and in light of the above elements, a distance of 3,285 meters was required for the plane to land.
- Poor Planning - this was the determining factor in the occurrence of the accident, as the failure in weight and balance calculations, as well as incorrect loading, culminated in the loss of control during the landing operation, since the aircraft exceeded all operational limits at that moment.
- Deficient Supervision - despite the commander having extensive flight experience, the number of flight hours on the aircraft type proved insufficient for the role of commander, as the data collected during the investigation showed that he did not possess the necessary technical knowledge, compromising his decisions as commander. The copilot, in turn, was still in training. What the pilot knew concretely, in relation to the mission he was to execute, was only the route to be flown. These aspects are consistent with serious supervision failures and the absence of flight safety doctrine in the company.