Narrative:A Cessna 525 CitationJet CJ1 sustained substantial damage in a runway excursion accident on landing at Aruanã Airport, GO, Brazil. The seven persons on board sustained minor injuries. The occupants were on their way to a mass for former football player Fernandão who had died in a helicopter accident.
Aruaña Airport has a single 1280 m long runway. The airplane landed on runway 24 and travelled about 350 m from the end of the paved surface until it came to rest at a fence close to the GO-530 highway.
Probable Cause:
Contributing factors.
- Control skills - a contributor.
The pilot acted incorrectly on the handle of the auxiliary gear control, thinking that he was applying the emergency brake, making the braking of the aircraft impossible.
- Training - a contributor.
The activation of the incorrect lever for the emergency braking of the aircraft was due to insufficient training received by the pilot for the use of the system in question, thus compromising the proper management of the abnormal condition.
- Ergonomics Equipment (ergonomic characteristics) - a contributor.
The emergency brake actuator handle of the aircraft was located outside the pilot's sight field, which, together with the lack of knowledge about the correct lever to be activated for emergency braking, favored the pilot's automatic response in triggering the lever that was most adjusted and visually available on the panel - the emergency landing gear drive lever.
- Instruction - a contributor.
The instruction that the pilot received to operate the Cessna aircraft, model 525 did not emphasize in the theoretical phase the proper use of the emergency brake, nor contemplated training for the use of this system.
- Insufficient pilots experience - a contributor.
Despite having a lot of experience in aviation, the pilot was little experienced in the aircraft and still did not know basic functionalities like the use of the emergency brake and the engine shutdown through the evacuation checklist procedure.
Accident investigation:
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Investigating agency: | CENIPA Brazil |
Status: | Investigation completed |
Duration: | 5 years | Accident number: | A-109/CENIPA/2014 | Download report: | Final report
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Classification:
Runway excursion (overrun)
Sources:
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jornalopcao.com.br
Follow-up / safety actions
CENIPA issued 3 Safety Recommendations
Issued: 28-JUN-2019 | To: ANAC | A-109/CENIPA/2014 - 01 |
Disseminate the lessons learned in the present investigation, in order to alert the Brazilian civil aviation pilots and operators about the ergonomic characteristics of the Cessna 525 aircraft, in which the stick column blocks the visualization of the emergency brake handle and the plate with the inscription EMERG BREAK PULL" |
Issued: 28-JUN-2019 | To: ANAC | A-109/CENIPA/2014 - 02 |
Reevaluate the training requirements for Cessna 525 and similar aircraft, in order to provide the knowledge necessary for its safe operation. |
Issued: 28-JUN-2019 | To: ANAC | A-109/CENIPA/2014 - 03 |
Act in conjunction with the Aviation Schools and Training Centers certified for the Cessna 525, in order to increase the knowledge of the students on the use of the emergency brake. |
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Photos
Video, social media
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Goiânia-Santa Genoveva Airport, GO to Aruanã Airport, GO as the crow flies is 271 km (169 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.