What happened
On February 4, 1996, a Cessna C-501 Citation I, registered PT-KPA, was performing a flight from Recife to Fazenda Matary, with a refueling stop in Imperatriz. The flight was being used for both passenger transport and flight instruction. During the approach to the private dirt runway at Fazenda Matary, the instructor, acting as the pilot flying, briefed the student pilot that the intention was to perform a touch-and-go landing to inspect the runway conditions using 15-degree flaps.
Upon touchdown, the instructor unilaterally decided to attempt a full stop instead of the briefed go-around. He deployed the speed brakes and began braking without informing the student. Noticing the lack of a go-around maneuver and the approaching end of the runway, the student pilot applied power to the engines to initiate a go-around. The instructor immediately responded by reducing power to idle, believing a full stop on the grass would be less hazardous than a go-around. The aircraft was unable to stop within the remaining runway distance, overran the threshold, struck obstacles, and caught fire after a fuel leak from the left wing. All three crew members escaped the wreckage uninjured.
The investigation
CENIPA's investigation focused on the breakdown of Crew Resource Management (CRM) and the decision-making process during the landing phase. Investigators examined the aircraft's maintenance records, which were found to be up to date, and the performance capabilities of the Cessna C-501 Citation I. While the aircraft's performance specifications suggested a stop was possible on the 950-meter runway under standard conditions, the actual approach was performed at a speed approximately 10 knots above the recommended Vref, with a non-standard flap configuration (15 degrees instead of full landing flaps).
Findings
- Improper Decision Making: The instructor demonstrated an impulsive attitude and an error in judgment by deviating from the established landing briefing without communicating the change to the student.
- Communication Failure: There was a significant breakdown in cockpit coordination; the instructor failed to respond to the student's queries and did not notify the crew of the change in landing intention.
- Conflicting Pilot Inputs: The student pilot's unauthorized application of power, intended to execute a go-around, directly conflicted with the instructor's attempt to reduce power for a full stop.
- Inadequate Planning: The landing was not properly planned for the specific configuration (15-degree flaps and higher approach speed) on a dirt runway surface.