ASN Wikibase Occurrence # 213181
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| Date: | Thursday 12 July 2018 |
| Time: | 10:50 UTC |
| Type: |  Cessna 150M |
| Owner/operator: | Aeroclube de Itápolis |
| Registration: | PR-JEA |
| MSN: | 15077030 |
| Year of manufacture: | 1975 |
| Fatalities: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Itápolis Airport, Itápolis-São Paulo (SDIO) -
 Brazil
|
| Phase: | Landing |
| Nature: | Training |
| Departure airport: | Itápolis-Aeroclube de Itápolis Airport, SP (SDIO) |
| Itápolis-Aeroclube de Itápolis Airport, SP (SDIO) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Two Aircraft collided during the landing procedure at the same time at the Airport of Itápolis ,. A Cessna 152 aircraft (PR-EJK) and a Cessna 150M aircraft (PR-JEA). There were no injuries.
Contributing factors.
- Application of commands - contributed.
The pilot of the PR-JEA aircraft, due to an oversight at the beginning of the descent in the base leg, made a lower than normal approach and without flaps.
Both situations added up and contributed to an approach with a more belligerent attitude, which made it difficult for this pilot to see the aircraft ahead.
- Organizational culture - undetermined.
The RELPREV filled in both organizations (despite the low quantity in face of the volume of operation) dealt, for the most part, with the issue of conflicts in the traffic circuit, the same situation of this occurrence. Despite this, little importance was given to the treatment and analysis of this information, and no mitigating action was adopted to reduce the possibility of air traffic conflicts in the SDIO circuit.
Therefore, it is possible to assume that, in the institutions, there was a little ingrained culture regarding the treatment of flight safety issues, which may have contributed to the occurrence on screen.
- Crew Phraseology - undefined.
The lack of standard phraseology in the SDIO traffic circuit, as well as the possible omission of some messages, led to poor communication between the aircraft, culminating in a decrease in the situational awareness of the crews regarding the position of other aircraft in the circuit, which may have contributed to the occurrence.
- Flight discipline - contributed.
The pilot-student instructor abandoned his position on the ground, leaving the instructor unsupervised, thus eliminating an important protection barrier against a possible student error that could compromise flight safety, which ended up happening and consuming the occurrence.
- Pilot judgment - contributed.
Although it was not possible to determine which of the two aircraft performed the wind leg out of the predicted trajectory, it is a fact that there was a trajectory "cut" (shortening of the distance) in the framing curve of the base leg. In addition, one of the aircraft performed a low ramp without flaps.
Both situations added up and contributed to an approach with a more bent attitude which made it difficult for this pilot to visualize the aircraft ahead.
- Perception - contributed.
The expectation of the PR-JEA pilot that the aircraft that entered a direct approach was the PR-EJK aircraft and the imprecision regarding the position of the other aircraft, allied to the communication failure, showed the existence of factors that interfered with the situational awareness of that pilot, in such a way that its operation was affected.
- Little pilot experience - contributed.
The PR-JEA pilot-student had little flight experience, which contributed to inefficient in-flight traffic management and resulted in the aircraft in front of him not being seen and colliding with it.
- Management oversight - undetermined.
There was inadequate management of operational safety by senior management of both organizations, which may have contributed to the occurrence, as they were unable to accurately identify and properly mitigate the latent factors in the SDIO traffic circuit, even with the completion of prevention reports on the subject at the time of the occurrence.
Accident investigation:
 |
|
Sources:
https://g1.globo.com/sp/bauru-marilia/noticia/aeronaves-batem-durante-pouso-em-aeroclube-de-itapolis.ghtml
https://www.clubefm.com.br/noticias/alunos-se-envolvem-em-acidente-com-dois-avioes-no-aeroclube-de-itapolis
http://jornalcidadesonline.com.br/site/2018/07/12/acidente-entre-dois-avioes-em-itapolis/
Media:
Aeródromo de Itápolis Hoje(12/07/2018) de Manhã , em breve mais informações .https://t.co/SVCVbYcqVv pic.twitter.com/H5ugqosxud
— AFAC Casa Branca (@AfacCasa) July 12, 2018
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 12-Jul-2018 16:26 | Diogo Saavedra | Added |
| 12-Jul-2018 16:32 | harro | Updated [Aircraft type, Registration, Cn, Operator, Total occupants, Location, Nature, Departure airport, Destination airport, Damage, Narrative] |
| 12-Jul-2018 16:33 | harro | Updated [Embed code] |
| 13-Jul-2018 06:35 | cleberjc | Updated [Operator, Total occupants, Location, Departure airport, Destination airport, Embed code, Narrative] |
| 13-Jul-2018 06:35 | cleberjc | Updated [Total occupants, Location, Departure airport, Destination airport, Source, Embed code] |
| 14-Jul-2018 17:50 | cleberjc | Updated [Operator, Narrative] |
| 05-Aug-2020 17:34 | harro | Updated [Time, Departure airport, Destination airport, Narrative, Accident report, ] |
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