What happened
On April 7, 1999, at approximately 11:47 AM, a Lear Jet 24D, registration PT-LEM, operated by Manacá Táxi Aéreo, crashed during a landing approach at Ribeirão Preto Airport (SBRP) in São Paulo, Brazil. The flight was being conducted as a check-flight to validate pilot technical certificates.
During the final stages of the approach to runway 18, the aircraft experienced a significant right wing dip, causing the right wingtip tank to contact the runway. In an attempt to correct the deviation, the pilot applied excessive control inputs in the opposite direction, which led to the left wingtip tank also striking the ground. The aircraft subsequently lost all control, flipped onto its back, and slid 4arg420 meters along the runway. The impact and subsequent friction ignited the aircraft's fuel, resulting in a massive fire. There were five fatalities among the occupants.
The investigation
CENIPA's investigation revealed a series of critical regulatory and operational failures. The pilot in command was not properly qualified to operate the aircraft in the left seat; while he held a technical certificate that erroneously listed him as a pilot, his actual qualification was limited to the co-pilot position for this specific aircraft type. Furthermore, the pilot had not flown this model in a command capacity before and had not flown any aircraft for four months.
The investigation also scrutinized the role of the co-pilot, who was found to have demonstrated a level of complacency by allowing an unqualified pilot to conduct the check-flight. Additionally, the investigation noted that the pilot's technical certificate contained a typographical error by the regulatory authority (DAC) that incorrectly granted him command privileges. The investigation also examined the aircraft's maintenance records, which were found to be adequate, and the airport's fire services, noting that while the airport's fire service was technically unavailable due to a NOTAM, local municipal units were present and responded to the scene.
Findings
- Improper Pilot Qualification: The pilot in command was operating the aircraft in the left seat without the necessary training or experience for that position in the Lear Jet 24D.
- Inadequate Control Inputs: The pilot utilized excessive and improper aileron commands during the final approach, which destabilized the aircraft.
- Regulatory Error: A typographical error in the pilot's technical certificate (CHT) led to an unauthorized expansion of his operational privileges.
- Lack of Supervision: The operator failed to ensure that only qualified personnel with a direct employment link to the company were performing check-flights.
- Human Factors: The pilot exhibited excessive self-confidence and a disregard for safety norms, while the co-pilot exhibited traits of insecurity and permissiveness.