What happened
On July 23, 2003, a Cessna Citation 551, registration PT-LME, was performing a repositioning flight from Lins to Sorocaba for maintenance purposes. The aircraft was carrying two pilots and one passenger. Upon approaching Sorocaba, the crew was informed by local radio that several aircraft without radios were operating in the traffic pattern for runway 36.
Seeking to avoid the traffic, the commander initially attempted an approach to the opposite runway, 18. However, after spotting an aircraft on the final for runway 36, the crew executed a go-around. During the subsequent maneuver to align with runway 36, the aircraft performed an unstabilized approach characterized by high sink rate and excessive speed. The aircraft touched down on the second half of the runway. Due to the high speed and the fact that the speed brakes were inoperative, the crew was unable to stop the aircraft within the remaining runway distance. The aircraft overran the pavement, descended a 20-meter embankment, and collided with a utility pole, trees, and residential structures. The impact resulted in one fatality (the commander), one injury (the co-pilot), and the total destruction of the aircraft.
The investigation
CENIPA's investigation focused on the sequence of events leading to the loss of control on the ground. Investigators examined the aircraft's mechanical state, finding that the speed brakes were indeed inoperative—a known discrepancy the crew was transporting the aircraft to repair. The investigation also reviewed the crew's performance, noting that no descent briefing or checklist review had been conducted prior to landing.
Analysis of the cockpit voice recorder (CVR) and witness accounts revealed significant issues with Crew Resource Management (CRM). The investigation established that the commander exercised an autocratic leadership style, which inhibited the co-pilot from effectively challenging the unstable approach or the decision-making process. Furthermore, the investigation found that while the left thrust reverser was functional, only the right reverser was deployed during the high-speed rollout.
Findings
- Unstabilized Approach: The aircraft performed a high and fast approach, failing to meet stabilized approach criteria.
- Inadequate Deceleration: The combination of excessive touchdown speed, the inoperative speed brakes, and the failure to utilize the left thrust reverser prevented the aircraft from stopping on the runway.
- Poor Crew Resource Management (CRM): The commander's autocratic behavior and the co-pilot's passive response led to a breakdown in coordination and situational awareness.
- Lack of Preparation: The crew failed to conduct a descent briefing or execute necessary checklists, which would have addressed the risks posed by the inoperative speed brakes and the runway length.
- Operational Decision Making: The commander's decision to attempt an approach to runway 18 despite known traffic on the opposite runway led to the initial go-around and subsequent unstable approach.