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Last updated: 26 November 2021
Status:Final
Date:Wednesday 7 April 1999
Time:11:47
Type:Silhouette image of generic LJ24 model; specific model in this crash may look slightly different
Learjet 24D
Operator:Manacá Táxi Aéreo
Registration: PT-LEM
MSN: 24-270
First flight: 1973
Engines: 2 General Electric CJ610-6
Crew:Fatalities: 3 / Occupants: 3
Passengers:Fatalities: 2 / Occupants: 2
Total:Fatalities: 5 / Occupants: 5
Aircraft damage: Damaged beyond repair
Location:Ribeirão Preto-Leite Lopes Airport, SP (RAO) (   Brazil)
Phase: Landing (LDG)
Nature:Training
Departure airport:São Paulo-Congonhas Airport, SP (CGH/SBSP), Brazil
Destination airport:Ribeirão Preto-Leite Lopes Airport, SP (RAO/SBRP), Brazil
Narrative:
The Learjet operated on a training flight from São Paulo to Ribeirão Preto where the pilot was to conduct a revalidation of his pilot's license.
The flight crew conducted an NDB approach for a touch and go on runway 18 at Ribeirão Preto Airport. Just before touchdown, the aircraft banked right, causing the right hand wing tip tank to touch the runway. The pilot overcorrected, causing the aircraft to roll to the left to an inverted position. The aircraft impacted the runway and burst into flames.
It appeared that the pilot was used to flying Citation II jets and had very limited experience in Learjet 24D aircraft as copilot. Also, he had not flown for the last four months. The pilot's behavior showed excessive self-confidence, according to investigators.

Probable Cause:

Contributing Factors (translated from Portuguese):
a. Human Factor
Psychological - Contributed.
There was the participation of individual psychological variables in the pilot in command's performance , due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
b. Operational Factor
(1). Deficient Supervision - Contributed
There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
(2).Low Flight Experience in the Aircraft - Contributed
The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
(3). Deficient Cockpit Coordination - Contributed.
The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
(4). Deficient Application of Commands - Contributed.
The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
(5). Other Operational Aspects - Contributed
The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Accident number: final report
Download report: Final report

Classification:
Flightcrew un(der)qualified
Loss of control

Sources:
» DAC - Departamento de Aviação Civil


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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 São Paulo-Congonhas Airport, SP to Ribeirão Preto-Leite Lopes Airport, SP as the crow flies is 299 km (187 miles).
Accident location: Approximate; accuracy within a few kilometers.

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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Learjet 24

  • 259 built
  • 37th loss
  • 24th fatal accident
  • 4th worst accident
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