Date:	Wednesday 13 August 2014
Time:	10:03
Type:	Cessna 560XLS+ Citation XLS+
Owner/operator:	AF Andrade Empreendimentos e Participações
Registration:	PR-AFA
MSN:	560-6066
Year of manufacture:	2011
Engine model:	Pratt & Whitney Canada PW545C
Fatalities:	Fatalities: 7 / Occupants: 7
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	Santos, SP -   Brazil
Phase:	Approach
Nature:	Executive
Departure airport:	Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ)
Destination airport:	Guarujá Airport, SP (SSZ/SBST)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Cessna 560XLS+ Citation Excel corporate jet, registration PR-AFA, was destroyed in an accident in Santos, Brazil. None of the seven occupants survived the accident. One of the victims was Eduardo Campos, the Brazilian Socialist Party's candidate for president.
The airplane took off from Rio de Janeiro-Santos Dumont Airport at 09:21 hours local time and was bound for Guarujá. The only instrument approach available for Guarujá Airport is the NDB approach for runway 35. For aircraft with Approach Category B, like the Citation Excel, the minimum visibility is 2400 m. The visibility at the time of the accident, according to the automated weather report, was 3000 m in rain and mist. The crew thus contacted Guarujá Radio and requested an IFR ECHO 1 runway 35 NDB approach.
The accident occurred when the airplane was approaching the airport. It came down in a residential area, about 4,3 km south west of the Guarujá Airport.

Contributing factors: (translated from Portuguese):
- Application of controls - undetermined.
Considering the elevated trajectory angle in relation to the terrain and the calculated speed (which far exceeded the operational limit of the aircraft), in the moments before the impact, it could be inferred that, from the moment the aircraft disappeared in the clouds, it could only have acquired such speed and trajectory if it had risen considerably to the point of even being detected by RADAR. Such conditions presented by the aircraft may have been the result of exaggerated control applications.
- Attitude- contributed.
The realization of the approach in an approach profile different from the one foreseen demonstrates a lack of adherence to the procedures, which allowed the beginning of the sequence of events that culminated in a missed approach, which was possibly influenced by the level of confidence that the pilot had in his operational capacity, from his previous experiences.
- Characteristics of the task - undetermined.
Although there was no pressure from passengers to enforce schedules, it is known that the routine of this activity creates an often unconscious self-pressure for the completion of flight schedules, in line with the commitments made by this type of flight demands performance requirements from pilots, which can influence them to operate at reduced safety margins.
- Adverse weather conditions - contributed.
The meteorological conditions were close to the safety minima for the approach and below the minimums to circle, foreseen in the ECHO 1 procedure. However, these conditions alone did not entail any risk to the operation if the ECHO 1 was followed in accordance with the parameters defined in the aeronautical publications and in accordance with the flight parameters defined by the aircraft manufacturer. When the parameters mentioned above were not followed, it was observed that the meteorological conditions were a complicating factor for the aircraft piloting, which made it difficult to stabilize the final approach, resulting in a rush.
- Disorientation - contributed.
In the scenario where the aircraft collided with the ground, there were several conditions that were favorable to a spatial disorientation such as: reduced visibility due to weather conditions, stress and increased workload due to the rush, maneuvers with a load above 1.15G, lack of adequate training and a possible loss of situational awareness. The high negative pitch, the high speed, and the power developed by the engines at the moment of impact are also evidences compatible with the disorientation of the incapacitating type, and point to the contribution of this factor.
- Team dynamics - undetermined.
The integration between the pilots may have been hampered by the low experience as crew and also by the different training they had. In addition, the commander's characteristics, which indicated a more confident and imposing posture, as opposed to the more passive feature of the co-pilot could also have hampered the crew's dynamics in managing the flight.
- Fatigue - undetermined.
In the seven days prior to the accident, the crew was in compliance with the provisions of Law No. 7,183 of April 5, 1984 regarding the working day and rest time between days. However, the results obtained in the analysis of voice, speech and copilot language parameters indicated compatibility with fatigue and somnolence, which may have contributed to the degradation of crew performance.
- Training, Training and Training - undetermined.
The lack of crash training on the CE 560XLS + aircraft may have required greater cognitive effort for the seizure of the conditions required by the equipment, as there were possibly no conditioned behaviors for flight control that could provide greater agility of actions in the cabin. Thus, they probably did not possess the skills, knowledge, and attitudes that would enable them to adequately perform their activities in that operational context.
- Phraseology of the ATS Body - undetermined.
In spite of having repo

12:00 UTC / 09:00 local time:
131200Z 20006KT 4000 RA BR BKN018 BKN070 20/19 Q1019

13:00 UTC / 10:00 local time:
131300Z 23007KT 3000 RA BR BKN008 OVC032 19/18 Q1022 RERA
Winds: 230 degrees at 7 knots; Visibility: 3 km; rain, mist; Broken clouds at 800 feet; Overcast cloud deck at 3200 feet; Temperature: 19°C; Dewpoint: 18°C; Pressure: 1022 mb

14:00 UTC / 11:00 local time:
131400Z 22008KT 2000 RA BR BKN008 OVC070 18/17 Q1023 RERA

G1
Brazilian Air Force statement
Guarujá (SBST) approach chart

photo (c) ASN adaption of AIP; Santos, SP; 13 August 2014

photo (c) Herbert Monfre (cmsherbert.blogspot.com); São Paulo-Congonhas Airport, SP (CGH/SBSP); 15 August 2013

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