ASN Wikibase Occurrence # 264241
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| Date: | Sunday 16 October 2011 |
| Time: | 19:22 UTC |
| Type: |  Boeing 737-8EH |
| Owner/operator: | Gol Transportes Aéreos |
| Registration: | PR-GUL |
| MSN: | 35845/3785 |
| Year of manufacture: | 2011 |
| Fatalities: | Fatalities: 0 / Occupants: 101 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | São Paulo-Congonhas Airport, SP (CGH/SBSP) -
 Brazil
|
| Phase: | Take off |
| Nature: | Passenger - Scheduled |
| Departure airport: | São Paulo-Congonhas Airport, SP (CGH/SBSP) |
| Santos Dumont Airport, RJ (SBRJ) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
During the take-off run from Congonhas Airport, SP (SBSP), before reaching the rotation speed, the Engine alarm light came on, on the "Master Caution" panel, when both "Electronic Engine Control" (EEC) switched to mode "Alternate", and the Indicated Air Speed Disagree (IAS DISAGREE) was indicated.
Immediately after the landing gear was retracted, the Altitude Disagree (ALT DISAGREE) was indicated. The speed and altitude indications started to present significant differences in the different indicators, with a Stick Shaker warning, characterizing the stall condition.
The crew controlled the aircraft and declared an emergency for the Air Traffic Control (ATC), being transported by APP-SP to land at Campinas Airport (SBKP), which occurred safely.
Contributing Factors
1 Human Factor
1.1 Medical Aspect
Nothing to report.
1.2 Psychological Aspect
1.2.1 Individual Information
a) Attitude - contributed
There was complacency and over reliance on systems by the PF and PM in using the A/P and A/T following confirmation of the emergency;
b) Indications of stress - undetermined
The commander being checked (PF) was performing an activity imposed by the airline, which was not of his preference (acting on the air bridge);
c) Memory - contributed
The failure was presented in a different way from the way simulator training was conducted, making it more complex to perceive and understand;
d) Motivation - undetermined
Because he was not motivated to remain operating on the air bridge, it is possible that there was a decline in vigilance on the part of the PF, compromising his situational awareness (CS).
1.2.2 Psychosocial Information
Did not contribute.
1.2.3 Organizational Information
a) Work organization - contributed.
The complexity of the administrative and managerial structure of the company's maintenance bases, divided between Congonhas and Confins, generated some difficulty in communication, coordination and management of the various tasks to be performed by the company's maintenance sectors.
b) Formation, Capacitation and Training - contributed.
Several internal maintenance processes required the preparation of activity reports written in English language and, according to the professionals' reports, they were not trained by the company and sometimes they used translation tools from the internet to help understanding the information and acting in maintenance.
2 Operational Factor
2.1 Regarding the aircraft operation
a) Command application - contributed
After take-off the PF engaged the A/P and A/T, which had been disconnected on the take-off run, without considering the Airspeed and Altitude Disagree indications, which led the aircraft to a critical pitch attitude for that phase of the flight.
b) Adverse weather conditions - undetermined
The prevailing weather conditions were instrument flight conditions (IMC), a situation the crew encountered shortly after take-off at about 600ft AGL. It is possible that had the conditions been visual, the crew would have more quickly understood the situation the aircraft was in.
c) Cabin coordination - contributed
The tasks in the cockpit were not adequately managed and divided during the occurrence of the emergency as there was no clear division on who should fly the aircraft, keeping it under control and who should identify the fault, manage the emergency and liaise with the control agencies. The pilot in the right seat ended up accumulating several tasks at the same time, becoming overloaded and the jumpseat pilot also ended up helping out.
d) Instruction - undetermined
The Airspeed Unreliable emergency training was planned and was performed during the initial course in the flight simulator, however, the failure that occurred with the aircraft presented itself in a distinct and more complex way than it was trained in the simulator, which probably made it difficult for the crew to identify it correctly.
e) Piloting Judgment - contributed
After the landing gear retraction, already with the IAS DISAGREE indication, and the appearance of the Altitude Disagree - ALT DISAGREE indication in both PFDs, it was judged that it would be possible to maintain the normal procedures by engaging the A/P and A/T.
f) Aircraft Maintenance - contributed
It was found that the left ADM pneumatic hose was fitted but not correctly connected, which allowed it to be disconnected and air leak subsequently, resulting in incorrect information to the ADM and consequently to the PF instruments (altimeter and speedometer).
2.2 Regarding the ATS Organs
Did not contribute.
3 Material Factor
3.1 Concerning the aircraft
Did not contribute.
3.2Cerned with equipment and systems technology for ATS
Did not contribute.
Accident investigation:
 |
|
Sources:
1. http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/pt/pr_gul_16_10_11.pdf (CENIPA's Final Report)
2. http://g1.globo.com/jornal-da-globo/noticia/2011/12/controlador-de-voo-ajuda-evitar-tragedia-com-boeing-em-sao-paulo.html
3. https://www1.folha.uol.com.br/fsp/cotidian/14090-controlador-evita-tragedia-em-voo-apos-orientar-piloto.shtml
4. https://www.youtube.com/watch?v=qBprvkRin8g
5. https://youtu.be/dwavYjkYs10
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 20-Jun-2021 05:58 | Lucas.L | Added |
| 20-Jun-2021 06:08 | harro | Updated [Source, Embed code, Narrative, Accident report] |
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