What happened
On March 28, 1984, a Learjet operated by Líder Táxi Aéreo S/A, registration PE-LCN, departed Porto Alegre, Rio Grande do Sul, bound for Florianópolis, Santa Catarina. The flight carried two pilots and two passengers under Instrument Flight Rules (IFR). During the descent into Florianópolis, air traffic control instructed the crew to continue descending to Flight Level 100 while intercepting the 10-mile DME arc for runway 32 approach.
The pilot reported crossing Flight Level 110 at 18 miles out but failed to confirm interception of the DME arc as requested. When controllers asked again, the pilot stated they were on final approach. Control instructed the crew to perform a 360-degree turn on final due to traffic and to report position, but received no further response. The aircraft was later found completely destroyed in a mountainous jungle area near Serra do Capivari, Palhoça, well off the intended approach path.
The investigation
CENIPA examined flight data, wreckage, crew qualifications, and communications. The landing gear was down and locked, flaps at approximately 20 degrees, and the altimeter indicated 3,200 feet. The RMI showed a heading of 330 degrees. The co-pilot had severe psychological issues and financial distress, requiring sedatives to sleep. Both pilots lacked sufficient Omega navigation system training.
Findings
The accident resulted from multiple contributing factors:
- Procedural non-compliance: The pilot descended without authorization and ignored ATC instructions to report position on the DME arc.
- Navigation error: Lack of familiarity with the DME arc procedure led to incorrect trajectory execution. The crew likely initiated a turn too early, causing them to fly into terrain while attempting to intercept the final approach course.
- Pilot distraction: The co-pilot’s psychological state and use of sedatives may have impaired crew coordination.
- Communication breakdown: Failure to acknowledge ATC instructions prevented effective traffic separation and position monitoring.
Safety action
CENIPA recommended that Líder Táxi Aéreo S/A train pilots on correct DME arc procedures and strict adherence to ATC instructions. Additionally, rescue teams were instructed to properly document body positions before removal to aid future investigations.