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Last updated: 28 November 2021
Status:Final
Date:Thursday 14 November 2019
Time:ca 14:17
Type:Silhouette image of generic C550 model; specific model in this crash may look slightly different
Cessna 550 Citation II
Operator:José João Abdalla Filho
Registration: PT-LTJ
MSN: 550-0225
First flight: 1981
Total airframe hrs:6978
Cycles:6769
Crew:Fatalities: 1 / Occupants: 2
Passengers:Fatalities: 4 / Occupants: 8
Total:Fatalities: 5 / Occupants: 10
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:Maraú-Barra Grande Airport, BA (   Brazil)
Phase: Landing (LDG)
Nature:Private
Departure airport:Jundiaí Airport, SP (QDV/SDJD), Brazil
Destination airport:Maraú-Barra Grande Airport, BA (SIRI), Brazil
Narrative:
The Cessna 550 Citation II corporate jet took off from Jundiaí, Brazil, at 14:58 UTC on a private flight to an airstrip at the Kiaroa Eco-Luxury Resort at Barra Grande, Maraú, Brazil. The captain of the aircraft exercised the function of Pilot Flying (PF) and the copilot Pilot Monitoring (PM). This flight was the first landing at Barra Grande for the captain.
The en route part of the flight was uneventful and the aircraft joined the traffic circuit after crossing overhead at 1500 feet. On the downwind leg the captain took two photos of the runway. The downwind leg was extended to 4.5 nm. When turning to final approach, the aircraft was configured for landing. Also, the aircraft's Terrain Avoidance and Warning System (TAWS) had been silenced since the avionics system database did not contain information related to the Barra Grande Airport.
On final approach, at around 1,200ft, the flaps were selected down to 40° (full) at a speed of 136 KIAS.
The aircraft descended below the glide path and the airspeed had decreased to 106 knots when the copilot called out the airspeed and stated "Go around.". The captain then verified a.o. the position of the landing gear. When, the captain returned to look ahead, he noticed the aircraft was far below the ideal glide path and very close to the threshold of runway 11.
Immediately, he applied maximum power to the engines and pitched up the aircraft. Due to the delay in the acceleration of the engines, the aircraft continued to descend and it collided with a signpost. It then struck a ravine near the threshold of runway 11, causing the undercarriage to break. Then, the captain reduced the power of the engines to Idle and commanded the speed break on, forcing the aircraft to touch the runway.
The airplane slid along the runway, dragging the lower fuselage and the lower wing, until it slid off the left side. A fire erupted, that consumed most of the aircraft.

Probable Cause:

Contributing factors.:
- Control skills - a contributor.
The inadequate performance of the controls led the aircraft to make a path that was lower than the ideal. This condition had the consequence of touching the ground before the runway’s threshold.
- Attention - undetermined.
During the approach for landing, the commander divided his attention between the supervision of the copilot's activities and the performance of the aircraft's controls. Such circumstances may have impaired the flight management and limited the reaction time to correct the approach path.
- Attitude - undetermined.
The report that the commander took two photographs of the runway and of the Aerodrome with his cell phone, during the downwind leg, reflected an inadequate and complacent posture in relation to his primary tasks at that stage of the flight, which may have contributed to this occurrence.
- Communication - undetermined.
As reported by the commander, the low tone and intensity of voice used by the copilot during the conduct of callouts, associated with the lack of use of the head phones, limited his ability to receive information, which may have affected his performance in management of the flight.
- Crew Resource Management - a contributor.
The lack of proper use of CRM techniques, through the management of tasks on board, compromised the use of human resources available for the operation of the aircraft, to the point of preventing the adoption of an attitude (go-around procedure) that would avoid the accident, from the moment when the recommended parameters for a stabilized VFR approach are no longer present.
- Illusions - undetermined.
It is possible that the width of the runway, narrower than the normal for the pilots involved in the accident, caused the illusion that the aircraft was higher than expected, for that distance from the thrashold 11 of SIRI, to the point of influence the judgment of the approach path.
In addition, the fact that the pilot was surprised by the geography of the terrain (existence of dunes) and the coloring of the runway (asphalt and concrete), may have led to a false visual interpretation, which reflected in the evaluation of the parameters related to the approach path.
- Piloting judgment - a contributor.
The commander's inadequate assessment of the aircraft's position in relation to the final approach path and landing runway contributed to the aircraft touching the ground before the threshold.
- Perception - undetermined.
It is possible that a decrease in the crew's situational awareness level resulted in a delayed perception that the approach to landing was destabilized and made it impossible to correct the flight parameters in a timely manner to avoid touching the ground before the runway.
- Flight planning - undetermined.
It is possible that, during the preparation work for the flight, the pilots did not take into account the impossibility of using the perception and alarm system of proximity to the ground that equipped the aircraft, and the inexistence of a visual indicator system of approach path at the Aerodrome.
- Other / Physical sensory limitations – undetermined.
The impairment of the hearing ability of the aircraft commander, coupled with the lack of the use of head phones, may have interfered with the internal communication of the flight cabin, in the critical phase of the flight.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 1 year and 9 months
Accident number: A-144/CENIPA/2019
Download report: Final report

Classification:
Misjudgement of speed or altitiude
Undershoot/overshoot

Sources:
» g1.globo.com
» Criança vítima de acidente com aeronave que caiu no sul da Bahia morre em hospital de SP (g1.globo.com, 13-12-2019)
» Morre a 4ª vítima de acidente com aeronave executiva na Bahia (noticias.uol.com.br, 25-11-2019)


Follow-up / safety actions

CENIPA issued 4 Safety Recommendations

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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 Jundiaí Airport, SP to Maraú-Barra Grande Airport, BA as the crow flies is 1328 km (830 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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Citation II

  • 603 built
  • 49th loss
  • 17th fatal accident
  • 5th worst accident
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