Incident Summary
An ambulance flight operated between São Paulo-Congonhas Airport and Diamantina-Juscelino Kubitschek Airport experienced a runway overrun during landing. The aircraft, carrying two pilots and two doctors, was on a medical transport mission. After an unstabilized approach, the airplane touched down too far down runway 03 and was unable to stop within the remaining distance. It overran the runway, descended into a ravine, and came to rest.
Sequence of Events
According to the official investigation, the crew performed a wrong approach configuration, leading to a landing approximately 600 metres from the far end of runway 03. Given the landing distance available, the aircraft could not be brought to a stop before the runway threshold. The airplane subsequently departed the paved surface, went down a ravine, and sustained damage beyond economical repair.
Probable Cause and Contributing Factors
The probable cause of the accident was determined to be a wrong approach configuration on the part of the crew, which resulted in the airplane landing about 600 metres from the runway end, making it impossible to stop within the remaining distance.
Several contributing factors were identified. The two pilots were well-acquainted and frequently flew together, potentially leading to over-reliance on one another during the final phase of flight. This over-confidence may have caused the crew to neglect certain approach parameters. Lack of crew coordination was noted. Post-accident medical examinations indicated that the pilot-in-command (PF) might have been suffering from the effects of alcohol and fatigue, which could have impaired his alertness and reaction to warnings from the pilot monitoring (PM). Additionally, the crew decided to continue the landing despite an unstabilized approach, demonstrating poor judgment and inadequate situational awareness, as they failed to execute a go-around.
Aftermath
All four occupants exited the aircraft with minor injuries. The aircraft itself was damaged beyond repair. The investigation did not specify further details regarding the aircraft type, registration, or exact time of day.