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Accident description
Last updated: 21 October 2017
Status:Final
Date:Wednesday 13 August 2014
Time:10:03
Type:Silhouette image of generic C56X model; specific model in this crash may look slightly different
Cessna 560XLS+ Citation XLS+
Operator:AF Andrade Empreendimentos e Participações
Registration: PR-AFA
C/n / msn: 560-6066
First flight: 2011
Engines: 2 Pratt & Whitney Canada PW545C
Crew:Fatalities: 2 / Occupants: 2
Passengers:Fatalities: 5 / Occupants: 5
Total:Fatalities: 7 / Occupants: 7
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location:Santos, SP (   Brazil)
Phase: Approach (APR)
Nature:Unknown
Departure airport:Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ), Brazil
Destination airport:Guarujá Airport, SP (SSZ/SBST), Brazil
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.

Probable Cause:

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 reported, in the first contact, that the aerodrome operated under instrument flight conditions, the messages transmitted to the aircraft by Rádio Santos did not present the conditions of ceiling, visibility and SIGMET, as foreseen in ICA 100-37. This may have contributed to a reduction in the level of situational awareness of the crew, since the last information accessed was probably the METAR of 11:00 am (UTC), which indicated conditions for visual operation of the aerodrome. In this way, pilots may have built a mental model on the weather conditions of SBST, in which they would be more favorable to the operation.
- Flight Discipline - contributed.
After coordinating its descent, PR-AFA made a left turn and, for no known reason, deviated from the W6 airway profile, descending below FL060. It then reported different positions from the actual ones until the moment it started a final approach. This approach differed from the trajectory of the final approach defined for the ECHO 1 procedure profile and was performed with different speed parameters than those recommended by the aircraft manufacturer. Such conditions have reduced the chances that the aircraft will fit into a stabilized final. The fact that the aircraft has overflown the runway followed by a curve at low altitude, with the weather conditions being below the minimum of the "go around" procedure; Instead of performing the rush profile provided for in the ECHO 1 procedure, also entailed risks to the operation and created favorable conditions for spatial disorientation.
- Memory - undetermined.
As the commander had already done visual approaches by the FMS on other occasions, the acquired working memory may have reinforced the safety in repeating it, even in another context, by the tendency of the human being to rely on previous successful experiences .
- Perception - undetermined.
An inaccurate perception of the pilots on the actual meteorological conditions that allowed the approach could have compromised the level of situational awareness and thus led the aircraft to an operating condition below the safety minima.
- Flight planning - undetermined.
The meteorological forecasts in the form of the TAF / GAMET code, valid at 12.00 (UTC) and available to the crew at the time the flight plan was passed in AIS-RJ, registered a possibility of degradation of visibility parameters and ceiling, due to the rain forecast associated with the humid mist, whose coverage included the duration of said flight, notably over the SBST area. The satellite image of 11:00 AM UTC and the SIGMET, valid from 10:30 AM (UTC), also showed a cold front in the Southeast region with a stratiform cloudiness band on SBST and prediction of convective nuclei with displacement To the northeast and with an average speed of 12kt. Despite the availability of such information, the crew may not have made a more accurate analysis showing a rapid degradation of the weather in the period between the take-off of SBRJ and the approach in SBST and thus may not have planned the flight in accordance with the conditions laid down by the meteorological service.
- Organizational processes - undetermined.
Despite having the C560 rating, required to operate the CE 560XLS + aircraft, none of the pilots were checked by contractors for their previous experience with this equipment and, as a result, no transition training and / or to operate the PR-AFA. The adoption of a formal system for the recruitment, selection, monitoring and evaluation of the professionals' performance could have identified the training needs for that type of aircraft.
- Support systems - undetermined.
Although the RBAC 61 required pilots to carry out flight instruction and proficiency testing to transition between CE 560XL family models, the need for specific training was only clarified in 04JUL2014, through the publication of the Supplementary Instruction of ANAC ( IS 61-004 Revision A). Until that date, such a need could only have been identified through consultation with the FAA FSB Report available only on the FAA website. In this context, PR-AFA pilots would only be subject to an assessment in EC 560XLS + on the occasion of their type revalidations, which would occur on the eve of their C560 qualifications, valid until October 2014 (commander ) And May 2015 (co-pilot). The fact that there was an authorization (C560) that was common to the operation of the C560 Citation, C560 Encore, C560 Encore +, CE 560XL, CE 560XLS or CE 560XLS + aircraft, did not allow the DCERTA system to refuse the pilot flight plan who did not have the proper training to operate one of those equipment. RBAC 67 contained physical and mental health requirements that were unclear, inducing physicians to use other publications to guide and subsidize their opinions and judgments about civil aviation personnel. The absence of such requirements, which should be adopted as acceptable minima for the pursuit of aerial activity, entailed the discretion of the physicians responsible for the judgments of the health inspections of the assessed personnel, and thus opened gaps that could allow non-fully qualified persons to perform functions In safety conditions below acceptable minimums.
- Task overload - undetermined.
Considering the possibility that the commander may have accumulated tasks as a consequence of a possible difficulty of the co-pilot to advise him at the beginning of the missed approach procedure, such accumulation may have exceeded his ability to manage them and thus have led to errors of piloting and / or spatial disorientation.

Accident investigation:
cover
Investigating agency: CENIPA
Status: Investigation completed
Duration: 1 year and 5 months
Accident number: A-134/CENIPA/2014
Download report: Final report

Classification:
Loss of control (presumed)

Sources:
» G1
» Brazilian Air Force statement
» Guarujá (SBST) approach chart

METAR Weather report:
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


Follow-up / safety actions

CENIPA issued 13 Safety Recommendations

Show all AD's and Safety Recommendations

Photos

photo of Cessna 560XLS+ Citation Excel PR-AFA
Accident location relative to NDB approach procedure
photo of Cessna 560XLS+ Citation Excel PR-AFA
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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 Rio de Janeiro-Santos Dumont Airport, RJ to Guarujá Airport, SP as the crow flies is 337 km (211 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 Excel

  • 908+ built
  • 2nd loss
  • The first fatal accident
  • The worst accident
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