What happened
On October 7, 2002, a Learjet 60, registration N5027Q, operated by DWIGGINS LLC, was performing a flight from Marília, Brazil, to Santa Cruz do Sul. The aircraft was carrying three crew members and two passengers. During the approach to runway 26 at Santa Cruz do Sul, the aircraft performed a low pass to determine wind direction. The crew then proceeded with an approach characterized by a high descent rate and a speed approximately 10 knots above the reference landing speed (Vref).
The aircraft touched down approximately 400 meters beyond the runway threshold. Despite the application of all available braking resources, the aircraft could not be stopped within the remaining runway length. The aircraft overran the pavement, crossed the opposite end of the runway, and collided laterally with an embankment located 50 meters from the runway edge, impacting a vehicle roadway. The impact caused severe damage to the cockpit, wings, and fuselage, rendering the aircraft a total loss. The co-pilot sustained fatal injuries, while the commander suffered serious injuries. The other crew members and passengers sustained minor injuries.
The investigation
CENIPA's investigation focused on the operational and human factors surrounding the landing. Investigators examined the aircraft's maintenance records, which showed the aircraft was relatively new and up to date. However, the investigation revealed significant discrepancies regarding crew qualifications. While the commander was properly rated, the co-pilot was operating the aircraft without the necessary type rating for the Learjet 60 and was flying with expired licenses. Additionally, the observer's medical certificate was invalid due to an incorrect validity period based on age.
Meteorological data indicated moderate rain and thunderstorms in the area, leaving the runway surface wet. The investigation also noted that the emergency brake had been engaged, which had deactivated the anti-skid system. Furthermore, the investigation found that the crew had not contacted the local aerodrome to verify weather conditions prior to arrival.
Findings
- Improper Approach Profile: The commander executed an unstable approach with excessive speed and a high descent rate.
- Inadequate Braking Performance: The wet runway conditions and the deactivation of the anti-skid system contributed to the inability to stop the aircraft.
- Lack of Crew Qualification: The co-pilot was not qualified for the aircraft type, and the crew lacked effective cockpit resource management (CRM) due to the lack of technical knowledge by the person in the right seat.
- Poor Operational Planning: The crew failed to plan for adverse weather or evaluate the required landing distance for a wet runway, which would have significantly increased the required runway length.
- Inadequate Decision Making: High levels of motivation led the crew to proceed with the landing despite the unstable approach and unfavorable environmental conditions.