Estado: | Accident investigation report completed and information captured |
Fecha: | domingo 3 marzo 2019 |
Hora: | 20:31 UTC |
Tipo: |  Airbus A320-214 (WL) |
Operador: | Avianca Brasil |
Registración: | PR-OCW |
Numéro de série: | 6813 |
Año de Construcción: | 2015-10-13 (3 years 5 months) |
Horas Totales de la Célula: | 13495 |
Motores: | 2 CFMI CFM56-5B4/3 |
Tripulación: | Fatalidades: 0 / Ocupantes: 6 |
Pasajeros: | Fatalidades: 0 / Ocupantes: 162 |
Total: | Fatalidades: 0 / Ocupantes: 168 |
Daños en la Aeronave: | Considerable |
Consecuencias: | Repaired |
Ubicación: | Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ ( Brasil)
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Fase: | Aterrizaje (LDG) |
Naturaleza: | Vuelo Doméstico Programado |
Aeropuerto de Salida: | Salvador-Deputado Luís Eduardo Magalhães International Airport, BA (SSA/SBSV), Brasil |
Aeropuerto de Llegada: | Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ (GIG/SBGL), Brasil |
Descripción:Avianca Brasil flight O66227, an Airbus A320-200, touched down partially outside the runway while landing in heavy rainfall on runway 15 at Rio de Janeiro/Galeão Airport, Brazil.
The landing of the aircraft occurred under unfavorable weather conditions caused by heavy rain over the airfield and sudden variation in the direction and intensity of the surface wind. At the exact moment of the touch down, the wind was from a direction of 057° at 19kts.
The contact of the aircraft with the ground occurred about 916m beyond the threshold of runway 15 with the right main landing gear completely outside the lateral limits of the runway, at a speed of 121kts. After landing, the aircraft traveled 668m outside the runway. The pilot regained control of the aircraft and returned it to runway 15.
Probable Cause:
Contributing factors.
- Control skills a contributor.
The corrections applied to the flight commands, in order to control the tendency of the aircraft to laterally deviate to the right in relation to the center of SBGL runway 15, were not sufficient to stop this movement, nor to redirect the aircraft to the central axis of flight. Consequently, the aircraft touched the ground with the right main landing gear outside the runway's lateral limits.
- Organizational climate undetermined.
When considering the organizational climate present in the company at the time of the occurrence, it is possible that this scenario has influenced the assessments and, consequently, the crew's decision to proceed with the landing, despite the adverse conditions encountered.
- Adverse meteorological conditions a contributor.
The significant change in the direction and intensity of the wind in the final approach, which started to blow from the left abeam, and the increase in the intensity of the rain on the Aerodrome, which impaired the pilots' peripheral vision and compromised the exact notion of depth of the aircraft in relation to the runway, contributed to the drifting movement of the aircraft to the right side of the SBGL runway 15.
- Crew Resource Management a contributor.
When the aircraft was flying below 100ft height, the copilot conducted several callouts stating that the aircraft was off the runway axis. The commander collated the first ones, however, after a certain moment; he no longer properly responded to the copilot's callouts and proceeded to land, despite the repeated alerts received.
The copilot, even realizing that the commander's corrections were not enough to control the aircraft and return it to the central axis of the runway, did not ask the commander, more assertively, to execute a go-around procedure in flight.
This showed that the crewmembers had enough information to discontinue the landing, but they chose not to use this feature, which contributed to the occurrence.
- Piloting judgment a contributor.
There was an incomplete assessment of the aircraft's flight conditions. Once the tendency of lateral deviation to the right of the central axis of the runway was detected, the pilots thought it possible to correct this tendency in time to make the landing safely, which contributed to the outcome of the occurrence.
- Perception a contributor.
The maintenance of the focus on the lateral deviation of the aircraft interfered in the identification of other variables present, such as the condition of destabilization and low visibility, which could affect the landing in a safe way. Thus, this selective perception, reinforced by the expectation of completing the landing at the destination, contributed to the outcome of this occurrence.
- Management planning undetermined.
All crewmembers on flight O66227 were called for the mission in accordance with the on notice roster. The calling of the copilot and the flight chief did not adhere to the established in the company's MGO; consequently, both were late to present themselves for the aircraft commander. Flight O66227 took off 30 minutes after the scheduled time.
It is possible to consider that the delayed takeoff from Salvador to Rio de Janeiro had a negative influence on the assessments and the decision of the crewmembers to proceed with the execution of the landing.
- Decision-making process a contributor.
There was a compromised analysis of the information available to the crew, so that the aircraft's destabilization condition was not considered, as well as the meteorological degradation in the final approach, culminating in the decision to try to correct the aircraft until the last moment, even if unanswered, and proceed with the landing on SBGL.
Accident investigation:
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Investigating agency: | CENIPA  |
Status: | Investigation completed |
Duration: | 2 years | Accident number: | A-036/CENIPA/2019 | Download report: | Final report
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METAR Weather report:
20:00 UTC / local time:
SBGL 032000Z 15006KT 9999 4000NE -TSRA FEW012 BKN025 FEW027TCU FEW030CB OVC080 27/24 Q101320:18 UTC / local time:
SBGL 032018Z 08004KT 3000 +TSRA FEW012 BKN025 FEW030CB OVC090 27/25 Q101420:43 UTC / local time:
SBGL 032043Z 02008G22KT 0500 R15///// R33///// R10/1000 R28/170 0 +TSRA FEW004 BKN009 BKN020 FEW030CB 23/22 Q1016
Subsiguiente / acciones de seguridad
CENIPA issued 3 Safety Recommendations
Issued: 16-MAY-2019 | To: Avianca Brasil | IG-036/CENIPA/2019 - 01 |
Work together with Oceanair Airlines S.A (Avianca), so that the operator ensures and provides the presentation of the crewmembers for the beginning of the trip in adequate time on the ground, aiming at the appropriate service to the plane, to the crewmembers and passengers, in accordance with the company\'s MGO, approved by the Civil Aviation Authority. |
Issued: 16-MAY-2019 | To: Avianca Brasil | IG-036/CENIPA/2019 - 02 |
Work together with Oceanair Airlines S.A (Avianca), so that the operator ensures the disclosure of relevant information about the situation of judicial recovery experienced, through the company\'s internal communication channels, seeking to stabilize the organizational climate and consequently, maintaining acceptable levels of operational safety. |
Issued: 12-FEB-2021 | To: ANAC | IG-036/CENIPA/2019 - 03 |
Develop and implement specific monitoring and control processes and protocols in regular and non-regular public air transport companies, which are in the process of judicial reorganization, in order to prevent their crewmembers, maintainers and other employees from carrying out their daily work activities with their respective salaries and bonuses in arrears, in order to ensure that air operations take place as established in their MGO, as well as that these companies operate with the appropriate number of crewmembers to the size of their air network. |
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Salvador-Deputado Luís Eduardo Magalhães International Airport, BA to Rio de Janeiro/Galeão-Antonio Carlos Jobim International Airport, RJ as the crow flies is 1212 km (757 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.