Narrative:
A Learjet 55C corporate jet was damaged in a runway excursion accident at Rio de Janeiro-Santos Dumont Airport (SDU). The aircraft ran off the end of runway 02R into the water of Guanabara Bay. The three occupants were not injured.
Approximately two minutes after takeoff from Santos Dumont Airport, the aircraft suffered a voltage drop in the electrical system.
This caused the sequential loss of functionality of various instruments and systems: TCAS, EHSI, EADI, RMI, altimeters and airspeed indicators.
The captain decided to return to the airport, in visual conditions, without declaring an emergency and, following the instructions of the approach controller, started descent to 3,000ft.
Upon reaching the cleared altitude, the pilots lost all communications with ATC. The aircraft was configured for approach and landing and as it aligned with runway 02R, most of the aircraft's instruments and systems became inoperative. The captain decided to continue the approach.
During the landing, the spoilers and reversers of the engines did not work and the aircraft did not show sufficient braking action and overran into Guanabara Bay.
Contributing Factors
1 Human Factor
1.1 Medical Aspect
It did not.
1.2 Psychological Aspect
1.2.1 Individual Information
a) Attention - contributed
The emotional state triggered by the crew in front of the emergency caused the attention to the landing to be fixed, so other important data such as the size of the runway were disregarded.
b) Attitude - contributed
The professional experience of the commander in aviation and in the aircraft itself contributed to overconfidence in his ability, leading him to believe that the decision was the most appropriate and safe for the situation.
c) Emotional state - contributed
The seizure of the crew was triggered by the presence of an unknown emergency, which may have interfered in the decision-making process to the point of not allowing, or even blocking, important data to be considered in the analysis of the situation and in the decision to persist in the landing .
d) Motivation - contributed
The commander persisted in completing the landing, even though there was the possibility of proceeding to the SBGL, thus configuring a compulsion to land. This behavior was possibly influenced by the emotional state experienced by the crew.
e) Perception - contributed
The nervousness of the crew due to the emergency caused a low situational awareness, making it difficult to identify and interpret the various occurrences of loss of functionality of most equipment and instruments.
The immediate decision to return in visual conditions to Santos Dumont airport and landing at this airport, even after the situation worsened, with the loss of functionality of most of the equipment and instruments on board, contributed to the lack of time for pilots to read the emergency section of the check list and correctly assess the situation. During the landing, it was identified that the aircraft would not stop on the runway, but the possibility of going around was not a considered alternative, which shows an inadequate analysis of the situation that contributed to an inadequate decision making.
1.2.2 Psychosocial Information
a) Communication - undetermined
The co-pilot did not explain to the captain his apprehension about the landing at Santos Dumont Airport, due to the reduced size of the runway for the situation, that is, he did not use the assertiveness to warn about a fact that, due to the circumstance experienced, was not being considered appropriately by the commander.
b) Team dynamics - contributed
It was identified that there was not a detailed breakdown of tasks in flight to ensure flight efficiency. The copilot, for example, took on the functions that he thought pertinent. This situation impaired the integration of the team, making it difficult to exchange information and collaboration to carry out the work.
1.2.3 Organizational information
a) Organizational culture - contributed
Due to the lack of standardized operating procedures and the low effectiveness of some training required, it was found that the organizational culture was permeated by informal attitudes, which did not value flight safety and, consequently, affected flight crew performance.
b) Training, Training and Training - contributed
Training is a process that aims at the efficient development of work by the individual. It is through it that habits of thought and action, skills, knowledge and attitudes that enable to carry out activities are improved. As the failure situation of both generators was not trained in the simulator, the crew did not have sufficient ability to correctly interpret the emergency situation.
c) Organization of work - contributed
There were no procedures implemented by the company for the duties that pertain to each function on board, so there is no standardization of the responsibilities to be performed in flight, which may interfere with the division of tasks between the crew in order to ensure that all cabin features are used more efficiently.
d) Organizational processes - indeterminate
The company adopted professional experience as the sole selection criterion. Although this criterion is important, it is not enough. In this way, the company also failed to consider the behaviors and skills appropriate to the culture, mission and organizational objectives, so that there was a cadre of pilots capable of performing their activity in accordance with the requirements of the function.
1.3 Operational Aspect
1.3.1 Concerning the operation of the aircraft
a) Coordination of cabin - contributed
Inadequate management of cabin resources contributed to the pilots acting in an unmanned manner during the normal procedures and failing to resort to the emergency procedures established in the check list, which affected the coordination needed to identify the generator's power failure during the flight, and the decision to proceed to an aerodrome with a track of sufficient length.
b) Unawareness by the pilot - undetermined
A possible forgetting of the commander in turning on the generators during the starting sequence of the engines may have contributed to the batteries continuing to power the system and discharging during the flight.
c) Instruction - contributed
The captain's limitations in enunciating procedures in the English language contributed to his lack of assimilation of flight simulator training and to taking decisions based on his experience without consulting the emergency procedures section of the check list.
The lack of efficacy in the training provided to the company's pilots regarding CRM practices and the content of the Operartions Manual contributed to the pilots committing failures in the normal procedures that prevented the identification of the generators' power failure and did not resort to procedures provided for in the check list.
d) Pilot judgement - contributed
The adoption of procedures based on past experience led the captain to decide in advance on the visual return to SBRJ before carrying out a thorough examination of the available information and, as the situation worsened, to set the SBRJ landing option, without other alternatives being evaluated.
e) Aircraft maintenance - undetermined
An inadequate supervision of the services performed by the contracted maintenance company was such that the generator assembly failure was not identified by the application of the maintenance procedures established by the aircraft manufacturer during the inspections and services performed on the left generator.
The absence of a fault analysis system prevented the company from identifying that recurring failures of instruments and equipment could be due to the mismatch of the left generator.
Recurrent loaves in the electrical system, the hydraulic system and the reverse of the aircraft, without reliable corrective maintenance actions, led pilots to judge from past experience.
f) Management planning - contributed
The issuance of authorizations contained in the Operational Specifications (EO) incompatible with the operational complexity of the company meant that all the manuals, procedures and documents necessary for the implementation of an operational standardization within acceptable levels of safety were not developed.
The lack of Minimum Equipment Lists (MELs) developed by the company helped the crew to make their own decisions for continued flights in situations of system crashes and to develop an informal culture for the adoption of corrective maintenance actions.
The lack of specific procedures (SOP) influenced the quality of the content of the theoretical and practical training given to pilots due to the lack of definitions of the division of tasks within a standardized model that would facilitate the identification of emergency situations presented during the flight of the pilot. accident and better management of cabin resources.
g) Management oversight - contributed
Failure to measure and monitor the performance of pilots in in-flight training and in the simulator has contributed to the fact that difficulties encountered by the commander related to the accident were not corrected in time.
An inadequate updating of the manuals issued by the company contributed to the formation of an environment of low level of attention to standardization, as well as to the development of an operational culture based on informal actions.
There was no supervision and continued analysis of maintenance services.
1.3.2 Concerning ATS organs
Did not contribute
2 Material Factor
2.1 Concerning an aircraft
Did not contribute
2.2 Concerning ATS technology equipment and systems
Did not contribute
» Ocean Air diz que os três tripulantes de avião não tiveram ferimentos (G1,
12/08/2010)
| Status: | Accident investigation report completed and information captured |
| Date: | Thursday 12 August 2010 |
| Time: | 09:26 |
| Type: |  Learjet 55C |
| Operator: | OceanAir Táxi Aéreo |
| Registration: | PT-LXO |
| MSN: | 55C-135 |
| First flight: | 1988 |
| Engines: | 2 Garrett TFE731-3A-2B |
| Crew: | Fatalities: 0 / Occupants: 2 |
| Passengers: | Fatalities: 0 / Occupants: 1 |
| Total: | Fatalities: 0 / Occupants: 3 |
| Aircraft damage: | Minor |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | Rio de Janeiro-Santos Dumont Airport, RJ (SDU) ( Brazil)
|
| Phase: | Landing (LDG) |
| Nature: | Executive |
| Departure airport: | Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ), Brazil |
| Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ (GIG/SBGL), Brazil |
A Learjet 55C corporate jet was damaged in a runway excursion accident at Rio de Janeiro-Santos Dumont Airport (SDU). The aircraft ran off the end of runway 02R into the water of Guanabara Bay. The three occupants were not injured.
Approximately two minutes after takeoff from Santos Dumont Airport, the aircraft suffered a voltage drop in the electrical system.
This caused the sequential loss of functionality of various instruments and systems: TCAS, EHSI, EADI, RMI, altimeters and airspeed indicators.
The captain decided to return to the airport, in visual conditions, without declaring an emergency and, following the instructions of the approach controller, started descent to 3,000ft.
Upon reaching the cleared altitude, the pilots lost all communications with ATC. The aircraft was configured for approach and landing and as it aligned with runway 02R, most of the aircraft's instruments and systems became inoperative. The captain decided to continue the approach.
During the landing, the spoilers and reversers of the engines did not work and the aircraft did not show sufficient braking action and overran into Guanabara Bay.
Probable Cause:
Contributing Factors
1 Human Factor
1.1 Medical Aspect
It did not.
1.2 Psychological Aspect
1.2.1 Individual Information
a) Attention - contributed
The emotional state triggered by the crew in front of the emergency caused the attention to the landing to be fixed, so other important data such as the size of the runway were disregarded.
b) Attitude - contributed
The professional experience of the commander in aviation and in the aircraft itself contributed to overconfidence in his ability, leading him to believe that the decision was the most appropriate and safe for the situation.
c) Emotional state - contributed
The seizure of the crew was triggered by the presence of an unknown emergency, which may have interfered in the decision-making process to the point of not allowing, or even blocking, important data to be considered in the analysis of the situation and in the decision to persist in the landing .
d) Motivation - contributed
The commander persisted in completing the landing, even though there was the possibility of proceeding to the SBGL, thus configuring a compulsion to land. This behavior was possibly influenced by the emotional state experienced by the crew.
e) Perception - contributed
The nervousness of the crew due to the emergency caused a low situational awareness, making it difficult to identify and interpret the various occurrences of loss of functionality of most equipment and instruments.
The immediate decision to return in visual conditions to Santos Dumont airport and landing at this airport, even after the situation worsened, with the loss of functionality of most of the equipment and instruments on board, contributed to the lack of time for pilots to read the emergency section of the check list and correctly assess the situation. During the landing, it was identified that the aircraft would not stop on the runway, but the possibility of going around was not a considered alternative, which shows an inadequate analysis of the situation that contributed to an inadequate decision making.
1.2.2 Psychosocial Information
a) Communication - undetermined
The co-pilot did not explain to the captain his apprehension about the landing at Santos Dumont Airport, due to the reduced size of the runway for the situation, that is, he did not use the assertiveness to warn about a fact that, due to the circumstance experienced, was not being considered appropriately by the commander.
b) Team dynamics - contributed
It was identified that there was not a detailed breakdown of tasks in flight to ensure flight efficiency. The copilot, for example, took on the functions that he thought pertinent. This situation impaired the integration of the team, making it difficult to exchange information and collaboration to carry out the work.
1.2.3 Organizational information
a) Organizational culture - contributed
Due to the lack of standardized operating procedures and the low effectiveness of some training required, it was found that the organizational culture was permeated by informal attitudes, which did not value flight safety and, consequently, affected flight crew performance.
b) Training, Training and Training - contributed
Training is a process that aims at the efficient development of work by the individual. It is through it that habits of thought and action, skills, knowledge and attitudes that enable to carry out activities are improved. As the failure situation of both generators was not trained in the simulator, the crew did not have sufficient ability to correctly interpret the emergency situation.
c) Organization of work - contributed
There were no procedures implemented by the company for the duties that pertain to each function on board, so there is no standardization of the responsibilities to be performed in flight, which may interfere with the division of tasks between the crew in order to ensure that all cabin features are used more efficiently.
d) Organizational processes - indeterminate
The company adopted professional experience as the sole selection criterion. Although this criterion is important, it is not enough. In this way, the company also failed to consider the behaviors and skills appropriate to the culture, mission and organizational objectives, so that there was a cadre of pilots capable of performing their activity in accordance with the requirements of the function.
1.3 Operational Aspect
1.3.1 Concerning the operation of the aircraft
a) Coordination of cabin - contributed
Inadequate management of cabin resources contributed to the pilots acting in an unmanned manner during the normal procedures and failing to resort to the emergency procedures established in the check list, which affected the coordination needed to identify the generator's power failure during the flight, and the decision to proceed to an aerodrome with a track of sufficient length.
b) Unawareness by the pilot - undetermined
A possible forgetting of the commander in turning on the generators during the starting sequence of the engines may have contributed to the batteries continuing to power the system and discharging during the flight.
c) Instruction - contributed
The captain's limitations in enunciating procedures in the English language contributed to his lack of assimilation of flight simulator training and to taking decisions based on his experience without consulting the emergency procedures section of the check list.
The lack of efficacy in the training provided to the company's pilots regarding CRM practices and the content of the Operartions Manual contributed to the pilots committing failures in the normal procedures that prevented the identification of the generators' power failure and did not resort to procedures provided for in the check list.
d) Pilot judgement - contributed
The adoption of procedures based on past experience led the captain to decide in advance on the visual return to SBRJ before carrying out a thorough examination of the available information and, as the situation worsened, to set the SBRJ landing option, without other alternatives being evaluated.
e) Aircraft maintenance - undetermined
An inadequate supervision of the services performed by the contracted maintenance company was such that the generator assembly failure was not identified by the application of the maintenance procedures established by the aircraft manufacturer during the inspections and services performed on the left generator.
The absence of a fault analysis system prevented the company from identifying that recurring failures of instruments and equipment could be due to the mismatch of the left generator.
Recurrent loaves in the electrical system, the hydraulic system and the reverse of the aircraft, without reliable corrective maintenance actions, led pilots to judge from past experience.
f) Management planning - contributed
The issuance of authorizations contained in the Operational Specifications (EO) incompatible with the operational complexity of the company meant that all the manuals, procedures and documents necessary for the implementation of an operational standardization within acceptable levels of safety were not developed.
The lack of Minimum Equipment Lists (MELs) developed by the company helped the crew to make their own decisions for continued flights in situations of system crashes and to develop an informal culture for the adoption of corrective maintenance actions.
The lack of specific procedures (SOP) influenced the quality of the content of the theoretical and practical training given to pilots due to the lack of definitions of the division of tasks within a standardized model that would facilitate the identification of emergency situations presented during the flight of the pilot. accident and better management of cabin resources.
g) Management oversight - contributed
Failure to measure and monitor the performance of pilots in in-flight training and in the simulator has contributed to the fact that difficulties encountered by the commander related to the accident were not corrected in time.
An inadequate updating of the manuals issued by the company contributed to the formation of an environment of low level of attention to standardization, as well as to the development of an operational culture based on informal actions.
There was no supervision and continued analysis of maintenance services.
1.3.2 Concerning ATS organs
Did not contribute
2 Material Factor
2.1 Concerning an aircraft
Did not contribute
2.2 Concerning ATS technology equipment and systems
Did not contribute
Accident investigation:
 |
|
Classification:
Runway excursion (overrun)
Sources:
» Infraero press release 12/08/2010» Ocean Air diz que os três tripulantes de avião não tiveram ferimentos (G1,
12/08/2010)
Photos
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 Rio de Janeiro-Santos Dumont Airport, RJ to Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ as the crow flies is 14 km (9 miles).
Accident location: Exact; deduced from official accident report.
Distance from Rio de Janeiro-Santos Dumont Airport, RJ to Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ as the crow flies is 14 km (9 miles).
Accident location: Exact; deduced from 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.
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