What happened
On March 15, 1991, a Learjet 35A, registration PT-LIH, departed São Paulo (SBSP) for Uberlândia (SBUL) to perform an air ambulance mission. Upon arrival, the crew found that meteorological conditions at the destination were below the required minimums due to heavy fog.
After two unsuccessful IFR approach attempts, the crew initiated a go-around. During the second attempt, the pilot transitioned to a visual maneuver, attempting a short traffic pattern to intercept the final approach. While executing a steep left turn at low altitude with reduced engine power, the aircraft entered an aerodynamic stall. The left wing struck the ground near the threshold of runway 04, and the aircraft slid approximately 300 meters along the side of the runway. The impact resulted in serious injuries to the two crew members and light injuries to the two passengers. The aircraft was a total loss.
The investigation
CENIPA's investigation focused on the crew's decision-making and the aircraft's performance during the maneuver. Investigators found that the crew had departed São Paulo without verifying the weather conditions at the destination or at their alternate airports.
Technical analysis of the engines revealed that both were operating at low power during the accident; the left engine had ingested grass, and the right engine showed minor ingestion damage. The investigation also noted that the first officer, who was operating the aircraft in the left seat, was undergoing training and had documented difficulties operating this specific aircraft type. Furthermore, the company's training program lacked a systematic approach to instructor feedback and pilot evaluation.
Findings
- Inadequate flight planning: The crew failed to check weather conditions for the destination and alternates prior to departure.
- Poor decision-making: The crew attempted to land despite visibility and ceiling being below IFR minimums, driven by the perceived urgency of the medical mission.
- Improper aircraft handling: The pilot executed a steep turn at low speed and low power, which increased the stall speed beyond the aircraft's actual flying speed.
- Inadequate supervision and training: The commander allowed a pilot in training to occupy the left seat without being aware of the pilot's specific operational limitations, and the company lacked a standardized training and evaluation system.
- Lack of crew coordination: There was a failure in cockpit resource management and a failure to follow standard operating procedures during the go-around.