ASN Wikibase Occurrence # 240816
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| Date: | Wednesday 26 August 2020 |
| Time: | |
| Type: |  Aero Boero AB-115 |
| Owner/operator: | Aeroclube de Guaratinguetá |
| Registration: | PP-GMC |
| MSN: | 303-B |
| Year of manufacture: | 1992 |
| Fatalities: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Guaratinguetá Aerodrome, SP (SBGW) -
 Brazil
|
| Phase: | Landing |
| Nature: | Training |
| Departure airport: | Guaratinguetá Airport, SP (GUJ/SBGW) |
| Guaratinguetá Airport, SP (GUJ/SBGW) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The aircraft took off from Guaratinguetá Aerodrome (SBGW), SP, in order to perform a local instruction flight, around 16:40 UTC, with two crew members on board. During the landing, at the moment of touchdown, the leg of the main right landing gear broke. The aircraft left the runway on the right side. The aircraft had substantial damage. The two crew members left unharmed.
Contributing factors.
- Control skills – a contributor.
During a “slipping” approach, the flaps were retracted from 45º to 30º, which reduced lift and caused the plane to perform a slope lower than normal.
- Crew Resource Management – a contributor.
The lack of communication between the pilots about the retraction of the flaps to 30º in the final approach denoted inefficiency in the use of the human resources available for the operation of the aircraft.
- Piloting judgment – a contributor.
The Flight Manual recommended landing with 45º of flaps, differently from what was provided by the instructor who performed the retraction on the final approach to 30º, denoting inadequate piloting judgment.
In addition, the IN believed that the lowest ramp was still within the acceptable limit, which is why he allowed the student to proceed to the final landing, which contributed to the outcome of this occurrence.
- Managerial oversight – undetermined.
It is likely that the risk management culture has not been fully implemented within the CIAC due to the time elapsed between the occurrence and the publication of the new requirements on the manual system and the guidance on the elaboration of an instructional program
Accident investigation:
 |
|
Sources:
CENIPA
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 02-Sep-2020 08:43 | harro | Added |
| 02-Oct-2022 17:42 | harro | Updated [Narrative, Accident report] |
Corrections or additions? ... Edit this accident description
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