Accident Overview
An ambulance Learjet, operating a flight from São Paulo-Congonhas Airport to Uberlândia to pick up a patient, crashed while attempting a third approach. The aircraft struck the ground short of the runway threshold, resulting in serious injuries to all four occupants (two pilots and two doctors) and destruction of the aircraft.
Flight and Crew Details
The copilot was the pilot flying. This was his first flight on a Learjet without an instructor, which was against regulations because the copilot was not fully qualified. Additionally, the captain was not qualified to act as an instructor.
Weather Conditions
Upon arrival at Uberlândia, weather conditions were poor: a low ceiling at 100 meters (8/8 clouds), fog, and horizontal visibility less than 200 meters, which were below minimums. The flight took place at night.
Approach Attempts
The crew abandoned the first approach and initiated a go-around. A second approach was also abandoned. Rather than diverting to the alternate airport, the crew attempted a third approach, during which the aircraft struck the ground and crashed short of the runway.
Injuries and Damage
All four occupants were seriously injured. The aircraft was destroyed.
Probable Cause
The official investigation determined that the accident was the consequence of the combination of the following factors: poor flight preparation and planning, poor approach planning, wrong approach configuration, poor crew coordination, lack of visibility due to the night associated with below-minimums weather conditions, the crew failed to initiate a go-around and to divert to the alternate airport, poor crew resources management, non-observation of operational procedures, lack of supervision on part of the captain, and poor operational organization on part of the operator.