ASN Wikibase Occurrence # 285950
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Date: | Wednesday 26 September 2018 |
Time: | 15:47 UTC |
Type: | Airbus A321-231 |
Owner/operator: | LATAM Brasil |
Registration: | PT-MXH |
MSN: | 4570 |
Year of manufacture: | 2011 |
Engine model: | IAE V2533-A5 |
Fatalities: | Fatalities: 0 / Occupants: 192 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | São Paulo-Guarulhos International Airport, SP (GRU/SBGR) -
Brazil
|
Phase: | Landing |
Nature: | Passenger - Scheduled |
Departure airport: | Fortaleza-Pinto Martins Airport, CE (FOR/SBFZ) |
Destination airport: | São Paulo-Guarulhos International Airport, SP (GRU/SBGR) |
Investigating agency: | CENIPA |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:The LATAM Brasil Airbus A321 was cleared for the IAC RNAV (GNSS) Y approach procedure for runway 27L at São Paulo-Guarulhos International Airport (GRU).
However, the aircraft performed the IAC RNAV (GNSS) Y procedure for runway 27R and landing on runway 27R.
The landing occurred normally and the aircraft proceeded to the apron.
Contributing factors.
- Attention - undetermined.
It is possible that there had been a decrease in the crew's attention levels, as well as a decrease in the controllers' attention levels regarding the standardization of phraseology, since the weather conditions at the moment of the occurrence were favorable to visual flight, together with the small amount of traffic in the TMA-SP.
- Communication - contributed.
The fact that the readback was not fully done, and that the ATS did not question the runway in use, allowed the flight profile to be done to the incorrect runway.
- Cabin coordination - undetermined.
The fact that none of the pilots realized that the aircraft was programmed to perform a different procedure than the one authorized by the ATS may have resulted from a failure in the distribution of tasks among the crew members, since no concern was observed with verifying the information provided by the ATS.
- Crew phrasing - contributed.
The fact that none of the messages transmitted by the aircraft during communications with ATS units did not include the runway in use, showed that the formulation of the messages conveyed was inadequate, in disagreement with MCA 100-16, in force at the time of the incident.
- ATS Organ Phraseology - contributed.
The lack of questioning by the ATS units controllers, for the pilots' failure to check the runway in use, denoted inadequacy in the formulation of the messages conveyed, in disagreement with what was recommended in MCA 100-16.
- Perception - contributed.
The communication failures between the aircraft and the ATS denoted that there were failures in the situational awareness of both the crew and the controller.
- Low pilot experience - undetermined.
It is possible that the little experience of the SIC, who was acting as a PF and was beginning his training in the company, may have compromised his performance in terms of monitoring the communications and instructions passed on by the ATS organ.
It is worth mentioning that it was the first experience of the SIC performing an RNAV type procedure as a FP.
Accident investigation:
|
| |
Investigating agency: | CENIPA |
Report number: | |
Status: | Investigation completed |
Duration: | 4 years |
Download report: | Final report |
|
Sources:
CENIPA
History of this aircraft
Other occurrences involving this aircraft
5 March 2024 |
PT-MXH |
LATAM Chile |
0 |
Rio de Janeiro/Galeão International Airport, RJ (GIG) |
|
min |
Bird strike |
Revision history:
Date/time | Contributor | Updates |
02-Oct-2022 17:29 |
harro |
Added |
02-Oct-2022 17:30 |
harro |
Updated [Date] |
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