ASN Wikibase Occurrence # 317466
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| Date: | Sunday 27 October 2013 |
| Time: | 18:20 UTC |
| Type: |  Boeing 737-8EH (WL) |
| Owner/operator: | Gol Transportes Aéreos |
| Registration: | PR-GGY |
| MSN: | 37599/3191 |
| Year of manufacture: | 2010 |
| Fatalities: | Fatalities: 0 / Occupants: 97 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Rio de Janeiro-Galeão International Airport, RJ (GIG) -
 Brazil
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | São Paulo-Congonhas Airport, SP (CGH/SBSP) |
| Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Due to the intensity of the wind at Santos Dumont Airport, the flight diverted to Galeão Aerodrome and used part of the runway that was closed, according to NOTAM D2914/2013.
The aircraft had no damage. The crew and passengers were not injured.
Contributing factors
- Attitude - contributed
The commander's declared experience in this type of flight influenced his confidence in his ability to accomplish the mission without the assistance of the co-pilot and also disregarding the risks involved and the procedures foreseen. In contrast, the co-pilot demonstrated passivity and complacency in flight when the commander stopped sharing the duties on board.
- Communication - contributed
There was inadequate communication between the commander and the co-pilot during the flight and especially after the need to land at an alternate airport, which led to a lack of division of tasks and transmission of information foreseen and necessary for the landing in question.
- Cabin coordination - contributed
The management of the available cabin resources, such as the elevation of situational awareness, crew dynamics, communication between pilots and the construction of the decision-making process, was not properly utilized by the crew, contributing to the consummation of the serious incident.
- Organizational culture - contributed
Due to the policy of granting full autonomy to instructors, there was no standardization of instruction, thus allowing the adoption of methodology, posture and own criteria of instruction, which in this specific case did not favor flight safety.
- Team dynamics - contributed
There was no integration of the crew members during the flight, in which they did not share information, did not act in a collaborative and friendly manner, in order to compromise the safety of the operation, culminating in this occurrence.
- Emotional state - contributed
The tense and stressful atmosphere in the cabin, among the crew members, resulting from the incompatibilities that arose in the development of the instruction, interfered with the work dynamics and the management of the flight, since they interrupted, therefore, the flow of communication.
- Education, Training and Capacity Building - contributed
The long period of absence between the copilot's last flight of instruction and his resumption caused the discontinuity of the learning process, thus impacting on the slowdown in response to existing demands, which generated discomfort and a hostile climate among the crew.
- Perception - contributed
The crew members showed low situational awareness when they did not realize the risk of operating with only one crew member assuming the tasks in flight, which was also reflected when they did not identify the severity of the landing on a partially interdicted runway, proceeding to the last stage of the flight, even after this occurrence.
- Flight planning - contributed
During the planning of the landing at SBGL, there was no careful study of the available information by the crew members, in accordance with the Aeronautical Command Instruction - ICA 100-12, in its item 3.4 Responsibilities regarding compliance with the rules of the air, sub-item 3.4.2 Flight planning and 3.4.2.1 and 3.4.2.2.
- Decision-making process - contributed
There was no proper assessment of the SBGL Flight Status and ATIS information, which culminated in the decision to approach for landing on a runway, the final leg of which was closed.
- Organizational processes - contributed.
The company did not follow up and monitor the instructions carried out, contributing to the adoption of non-standard procedures during the instruction.
- Support systems - contributed.
The documents provided by the company presented not very clear information (colors, markings, etc.) and contributed to the failures in the commander's decision-making process.
The Airspace Control agency of that location also did not alert the crew members about the approach of the aircraft on a partially interdicted runway, which contributed to the occurrence.
There was no signaling of the partial interdiction of the last section of runway 28, so there was no demarcation of the new limits for operation.
Accident investigation:
 |
|
Sources:
IG-195/CENIPA/2013
History of this aircraft
Other occurrences involving this aircraft
| 8 March 2014 | PR-GGY | Gol Transportes Aéreos | 0 | between São Paulo and Rio de Janeiro | |
min |
| Cowling loss | ||||||
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 14-Jul-2023 19:46 | harro | Updated |
Corrections or additions? ... Edit this accident description
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