ASN Wikibase Occurrence # 253812
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| Date: | Thursday 30 November 2017 |
| Time: | 08:37 UTC |
| Type: |  Airbus A320-232 |
| Owner/operator: | LATAM Brasil |
| Registration: | PR-MBG |
| MSN: | 1459 |
| Year of manufacture: | 2001 |
| Engine model: | IAE V2527-A5 |
| Fatalities: | Fatalities: 0 / Occupants: 155 |
| Aircraft damage: | Minor |
| Category: | Serious incident |
| Location: | Brasília-Presidente Juscelino Kubitschek International Airport, DF (BS -
 Brazil
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Santarém-Eduardo Gomes Airport, PA (STM/SBSN) |
| Brasília-Presidente Juscelino Kubitschek International Airport, DF (BSB/SBBR) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
LATAM Brasil Flight 3081, an Airbus A320, veered off the left side of the runway on landing at Brasília International Airport. It hit runway edge lights and damaged electrical boxes. The aircraft had minor damage.
At the time of the incident the airport operated under IMC, with the present weather showing a cloud ceiling at 500 feet (BKN005), heavy rain with thunderstorm (+ TSRA) and variable wind of 140º to 230º, with intensity from 10kt to 22kt (18010G22KT 140V230).
Contributing factors:
- Control skills – a contributor.
The reduction of the thrust levers to the IDLE position and the FLARE with approximately 80ft RA, associated with an inadequate rudder and aileron control contributed to the runway excursion.
- Attention – undetermined.
Given the scenario of the occurrence, there is a possibility that the level of attention required from the crew for the operation to be compromised, making it difficult to maintain good performance in a flight situation that required a higher degree of this executive function to act appropriately in the face of speed variation.
- Training – undetermined.
Although the flight condition without A / THR is part of the company's operational training, it is possible that the frequency with which it was officially performed by the crew did not guarantee safety in the execution of the procedure in a real flight, given the feeling of discomfort experienced by part of the crew.
- Adverse meteorological conditions – undetermined.
At the time of the occurrence, the weather conditions on the airfield were degraded, which may have contributed to the inappropriate judgment of the reduction of the thrust levers for IDLE and the beginning of FLARE with approximately 80ft RA.
- Emotional state – undetermined.
The feeling of discomfort with the aircraft configuration, reported by the crew, combined with the final context of the flight (weather degradation and missed approach), which increased the workload level, may have interfered with the crew's performance to the point of not assimilating correctly how circumstances could affect the operation.
- Fatigue – undetermined.
The conditions of susceptibility to fatigue present in the occurrence, associated with the degradation of performance demonstrated by the crew, denoted the possibility of a fatigue situation that impacted the crew's ability to assess and respond promptly to the work demands required to achieve a successful landing.
- Use of phraseology by ATS – undetermined.
On the second approach, at the time of landing authorization, data related to the direction and intensity of the wind were not included in the message passed by the TWR-BR. This information could contribute to assist in the decision to proceed with a possible go-around procedure, if the crew evaluated the extrapolation of the limits established by the company.
- Piloting judgment – a contributor.
The reduction of the thrust levers to IDLE and the start of FLARE with approximately 80ft RA indicated an inadequate assessment by the pilot of parameters related to the operation of the aircraft.
- Work organization – a contributor.
The company's schedule planning adopted for the period of the occurrence, a critical flight roster for the crew, in relation to fatigue, which favored a lowering of the level of physical and mental performance, putting at risk the ability to perform the operational activity safely.
- Perception – a contributor.
It was possible to observe a lowering of the crew's situational awareness level, since after landing they had no precision as to whether or not they left the runway. Such demotion is possible in view of the work context to which they were subjected during the flight of the occurrence.
- Decision-making process – a contributor.
The decision to proceed to the landing, on the second approach, in which there was a deterioration of meteorological conditions, showed an inaccurate assessment of the circumstances that would affect the operation, culminating in an off-axis landing.
It is worth mentioning that the lack of adequate rest is one of the factors that compromises the ability to solve problems and make appropriate decisions.
- Support systems – a contributor.
The technological support used by the company for flight scheduling allowed the extrapolation of internal rules, which aimed at more appropriate working hours, thus exposing crewmembers to situations that favored the degradation of their performance, both physical and mental.
The fatigue risk reporting mechanism offered by the company to its crewmembers, in this case, was not used, suggesting, still, the existence of flaws in its implementation and sedimentation process.
- Other – undetermined.
Influence of the environment: the position of the sun in relation to the horizon, making it difficult to adequately illuminate the field, associated with a cloud layer at 500ft, may have caused a glare of the pilots during the final approach phase for landing.
Accident investigation:
 |
|
Sources:
CENIPA
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 23-Apr-2021 12:54 | harro | Added |
| 23-Apr-2021 12:59 | harro | Updated [Time, Location, Narrative] |
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