Curitiba-Afonso Pena

The following findings were identified:
- The approach was considered stabilized;
- The required landing distance of 6,431t (1,960m) was compatible for the operation, since the LDA of runway 32 at SBFI was 7,201ft (2,195m);
- There was no evidence of malfunction of the aircraft brake system that could have caused the runway excursion;
- At the time of landing, the runway was wet with a significant amount of water on the pavement;
- The estimated deceleration corresponded to what would be expected on a very wet runway (> 3mm of water) with hydroplaning of the tires at higher speeds;
- The friction and macrotexture measurements had normal parameters and did not contribute to the aircraft's poor deceleration;
- The characteristics of the precipitation over threshold 14 associated with the large variations in wind direction and intensity were consistent with the windshear phenomenon, resulting from a microburst;
- The PR-TLZ sensors did not detect the occurrence of windshear during the landing approach;
- A sudden increase in the calibrated speed that peaked at 32kt altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, resulting in poor braking in the parts where the ground speed was lower;
- The speedbrakes were not extended during the run after landing, contrary to what was prevised in the AFM;
- The aircraft ran the full length of the runway, overpassed its limits and crashed into a ravine;
- There was a windshear alert issued about 30 seconds after the landing of the PRTLZ by an aircraft that was at the threshold 32;
- The aircraft had substantial damage; and
- The crewmembers and the passenger left unharmed.
Contributing factors:
- Control skills – undetermined
Despite the low contribution of the speedbrakes to the reduction of the landing distance, this device represents a deceleration resource through aerodynamic drag that should not be neglected, especially during landing on wet runways, and could have contributed to avoiding runway excursion.
- Adverse meteorological conditions – a contributor
The large variation in wind intensity peaked at 32 kt. This variation lasted 13 seconds and raised the indicated speed from 76 kt to 108 kt. Considering that the speed of 108 kt was very close to the VREF (111 KCAS), it can be stated that this phenomenon altered the aircraft's lift and, consequently, reduced the tires' grip on the ground, leading to poor braking.

Loss of control during initial climb in IMC conditions after the crew suffered a spatial disorientation. The following factors were identified:
- Weather conditions were not suitable for the completion of the flight,
- The crew failed to prepare the flight according to published procedures,
- The crew failed to follow the pre-takeoff checklist,
- The copilot did not have adequate training for this type of operation,
- The captain had emotional conditions that compromised flight operations,
- The relationship between both pilots was incompatible,
- The main attitude indicator was out of service since a week and the crew referred to the emergency attitude indicator,
- Because of poor flight preparation and non observation of the pre-takeoff checklist, the captain forgot to switch on the emergency attitude indicator prior to takeoff,
- At the time of the accident, the captain had accumulated 15 hours and 22 minutes of work without rest, which is against the law,
- The captain showed overconfidence and inflexibility which weakened his performances,
- Both pilots disagreed on operations,
- The visibility was poor due to the night and the ceiling at 300 feet above ground,
- The state of complacency of the organization was characterized by a culture adaptable to internal processes, without the adoption of formal rules for the operations division and the acceptance of operating conditions incompatible with security rules and protocols, which allowed the newly hired crew to feel free to act in disagreement with the standards and regulations in force at the time of the accident,
- Performing a sharp turn to the right in IMC conditions associated with a long working day and a lack of rest,
- The level of stress of the captain due to intense fatigue generated by a high workload and an insufficient rest period,
- Poor crew discipline,
- Poor judgment of the situation,
- Poor flight planning,
- Failures in the operator's organizational processes and lack of supervision of flight operations.

Double engine failure caused by a fuel exhaustion. It was determined that the crew did not prepare the flight according to procedures and took off with an insufficient fuel quantity on board.

Failure of both engines in flight due to fuel exhaustion. The following findings were identified:
- The crew failed to prepare the flight according to published procedures,
- The crew failed to check there was sufficient fuel in tanks prior to departure,
- The crew failed to follow the pre takeoff checklist,
- The captain showed excessive self confidence
- The captain exercised pressure on the copilot,
- The crew suffered fatigue due to an excessive period of work. At the time of the accident, the crew was overduty by three hours,
- The crew consumed alcohol beverages the night before the flight.

The following findings were identified:
- There was the participation of factors, with their own characteristics, that caused failures of attention, judgment and perceptual evaluation of distances and temporality. The qualitative training deficiency, the lack of cabin resource management and the low situational alert were significant contributing factors to the accident.
- PF has performed poorly in the use of the correct piloting technique in the combination of Speed x Ratio of Descent parameters.
- The instructor assigned by the company to supervise the acquisition of operational experience on route had not received specific instruction for the performance of this task. Technical and operational supervision was lacking.
- PF had good flight experience, but not in this type of aircraft. It was in the phase of acquiring operational experience in route. The inadequate action was also due to the little experience in the aircraft and in the circumstance of the operation, which required a quick correction close to the ground.
- The pilots did not adequately utilize the resources available in the cockpit for the proper operation of the aircraft. PF did not make the necessary corrections to modify the aircraft's trajectory, which was its assignment. The instructor (PNF), in turn, did not effectively correct or interfere with the PF flight, which would have been his responsibility since he was the supervisor of the operation. The pilots did not observe, yet, the technical-operational procedure foreseen in the Flight Operations Manual (MOV), regarding the GPWS warning. The crew did not observe that the warning determined an unsafe condition close to the touch. It was characterized an ineffective fulfillment of the tasks assigned to each crew member, besides the non-observance of the operational rules.
- On the IMC approach made, the PF varied the parameters, remaining high on the ramp. Upon reaching visual conditions, the PF increased the descent rate of the aircraft. The PNF, concerned with locating the runway, did not consider an inadequate PF correction.
- The PF, with the intention of reducing the drop ratio, did not apply correctly, in amplitude and in time, the power available in the engines. Near the touch, the PF increased the pitch angle, trying to reduce the drop ratio. Considering the low height (approximately 80 ft) and engine power (IDLE), the aircraft continued with a high rate of descent (approximately 1,800 ft/min), without the action taken by the PF altering its path. The PNF did not interfere in the application of the commands. Therefore, there was inadequate use of the aircraft commands by the crew members, in conditions for which they were qualified.
- The PF, even being alerted by the PNF about the low speed and high rate of descent, thought it was applying an adequate correction, however it kept the aircraft in an incompatible performance for landing. The PNF, despite having experience in flight and in the aircraft, showed a lack of knowledge of its limits regarding the point of irreversibility of an unsafe situation. The PNF was limited to alerting the PF about the situation, not guiding it on the correct way to make the corrections.
The PNF overestimated PF's capacity and did not take or try to take over the controls.
- The pilots were not aware of the maximum rate of descent during the touch for which the aircraft was certified, nor were they aware of the variation of that rate with respect to weight. The availability of the autopilot to the MDA could have minimized the ramp deviation observed.

The following findings were reported:
- Wrong approach configuration,
- Marginal weather conditions with limited visibility due to rain falls,
- The crew completed the landing with a tailwind component of 15-20 knots,
- The runway surface was wet,
- The runway length was 1,250 metres only,
- The aircraft landed too far down the runway, reducing the landing distance available,
- The braking action was poor because the runway surface was wet,
- The crew failed to initiate a go-around procedure.

The exact cause of the accident could not be determined with certainty. However, the following findings were reported:
- a. Human Factor
(1) Undetermined Physiological Aspect
Given the characteristics of the accident, which resulted in the destruction of the bodies, making it impossible to carry out examinations, it cannot be specified whether it contributed or not. However one cannot rule out the possibility that one of the crew members has been affected by a sudden illness (2nd Hypothesis of the Analysis).
(2) Psychological Aspect - Undetermined
It may have influenced, to the extent that the commander was operating an aircraft in which he had little experience and little knowledge, and which was demonstrated by the insecurity in the operation, reported to other pilots.
b. Material Factor
(1) Design Deficiency - Undetermined
Despite the information provided by representatives of Learjet Corp. who participated in the investigations, that the compensator engine ('pitch trim') with which this aircraft was equipped, had already undergone the modifications determined by the Federal Aviation Administration (FAA), one cannot help but wonder about a possible firing and locking of the 'pitch trim' engine in the extreme position (3rd Hypothesis of the Analysis). This aspect was hampered as the destruction suffered by the aircraft made a detailed analysis of the pitch trim system impossible.
c. Operational Factor
(1) Disabled Instruction - Contributed.
The commander and the co-pilot received a less than desired instruction, in quantitative and qualitative terms. As a result, the pilots did not acquire the full technical conditions necessary for the proper operation of the aircraft. The failure to perform the standard procedure to be followed in the emergency that led to the accident, i.e. the lowering of the landing gear, attests to the poor instruction given.
(2) Deficient Application of Controls: - Contributed
The pilots did not adjust the engine power properly after leveling and, after the aircraft started to abruptly descend, as a result, the 'overspeed' occurred, they could not avoid the loss of control.
(3) Weak Cockpit Coordination - Contributed.
The pilots made inadequate use of the aircraft's resources for its operation.
(4) Forgetfulness - Contributed.
This aspect is in accordance with the previous one, since the lowering of the undercarriage is part of the standard procedure to be performed in cases of overspeed.
(5) Little Flight Experience in the Aircraft - Contributed
The captain, despite having 6,500 hours of flight time, had already intended to fly another jet plane, but had flown little on Learjet. The other pilot, in turn, had had less experience in jet flying as a co-pilot, and in the Learjet, specifically, flew less than the commander.
As a result, when they were faced with an emergency that required rapid identification in order to take the necessary measures to remedy it, they lacked the necessary experience.
(6) Deficient Supervisor - contributed.
The air taxi company, to which the pilots belonged, was in a hurry to train this new crew. This resulted in inadequate operational training for the pilots, which demonstrates poor supervision of the company. The Civil Aviation System, through the regional body that deals directly with general aviation, failed to carry out proper oversight, as it did not detect the errors in the statements of instruction, and allowed the checks of the captain and the co-pilot to be carried out without reaching the minimum amount of flight hours and landings on that aircraft.