ASN Wikibase Occurrence # 228696
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| Date: | Wednesday 19 July 2017 |
| Time: | 11:22 UTC |
| Type: |  Airbus A319-115 |
| Owner/operator: | Avianca Brasil |
| Registration: | PR-AVC |
| MSN: | 4287 |
| Year of manufacture: | 2010 |
| Engine model: | CFMI CFM56-5B7/P |
| Fatalities: | Fatalities: 0 / Occupants: 124 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Rio de Janeiro/Galeão International Airport, RJ (GIG/SBGL) -
 Brazil
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | São Paulo-Congonhas Airport, SP (CGH/SBSP) |
| Rio de Janeiro/Galeão International Airport, RJ (GIG/SBGL) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
The aircraft took off from the São Paulo-Congonhas Airport (SBSP) on a scheduled flight to Rio de Janeiro-Antônio Carlos Jobim Airport (SBGL), Brazil.
During an instrument approach (RNAV Y) to SBGL runway 28, the crew performed the missed approach procedure below the Minimum Descent Altitude (MDA) and, almost simultaneously with the beginning of the go-around procedure there were two EGPWS warnings related to proximity to the terrain (Too Low, Terrain).
Due to the inertia, the aircraft reached 291ft of barometric altitude. The radio altitude was 162ft.
After the go-around procedure, a new instrument approach was made to runway 15 of the same Airport (ILS T), and the landing occurred successfully.
Contributing factors.
- Control skills – a contributor.
The use of the Vertical Speed guiding mode associated with the application of an excessive descent rate contributed to the destabilization of the approach.
- Attention – a contributor.
During the landing procedure, pilots did not observe relevant aspects that would indicate the destabilized approach. In addition, the copilot did not pay attention to the fact that the commander had increased the rate of descent instead of reducing it after reporting that the aircraft was too low. This inattention on the part of the crew contributed to the occurrence, as it made possible the descent of the aircraft beyond the expected parameters.
- Attitude – a contributor.
Failure to comply with the procedures established in the Aerodrome approach chart contributed to the occurrence of the serious incident, as it added greater risk and greater complexity to that air operation.
- Crew Resource Management – a contributor.
Although it was not possible to analyze the data of the voice recorder of the aircraft, it was evident a deficiency in the coordination of the cabin by not observing several operating procedures, such as: stabilized approach parameters, procedures for EGPWS warning of Too Low, Terrain, compliance with DOP 28/17, among others cited in the report.
- Team dynamics – a contributor.
The interaction of the pilots during the approach and landing moments was compromised, in view of the absence of a detailed briefing on the technique used in the approach to the landing and the work overload to which they underwent by choosing a procedure divergent from the predicted, thus favoring the continuation of the flight below the established minimum limits.
- Piloting judgment – a contributor.
The evaluation of performing a dive and drive approach, based on the final approach of the SBGL RNAV Y RWY 28 procedure, proved to be inadequate, as it did not bring operational advantage to that crew, yet it did not comply with parameters and restrictions of safety.
- Perception – a contributor.
The lack of precision regarding the perception of the parameters of the aircraft during the final approach resulted in the surpassing of restrictions imposed on the chart profile, indicating a lowering of the level of situational awareness presented by the crew.
- Decision-making process – a contributor.
The decision to proceed with the landing approach, as well as the technique chosen to carry out this procedure, showed a precipitous and imprecise assessment of the risks involved in that type of operation.
- Organizational processes – undetermined.
The excess of existing communication channels in the airline, the lack of prioritization of messages of greater operational relevance, as well as the possible difficulties in communication between the different sectors may have led to the emergence of a scenario unfavorable to the proper assimilation of operational procedures and standardization of the crew.
- Support systems – undetermined.
The discrete form, such as the procedure for air operations, in case of a ceiling below the minimums presented in the approach charts, was dealt with in DOP 28/17, may have contributed to a low assimilation of the crew on the guidelines defined by the airline.
Accident investigation:
 |
|
Sources:
IG-105/CENIPA/2017
Images:
graph: CENIPA
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 02-Sep-2019 19:01 | harro | Added |
| 02-Sep-2019 19:02 | harro | Updated [Location, Destination airport] |
Corrections or additions? ... Edit this accident description
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