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ASN Wikibase Occurrence # 232831
Last updated: 8 February 2020
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Time:21:32 LT
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8EH (WL)
Owner/operator:GOL Linhas Aéreas
Registration: PR-GTN
C/n / msn: 34267/2311
Fatalities:Fatalities: 0 / Occupants: 160
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Brasília-Presidente Juscelino Kubitschek International Airport (SBBR) -   Brazil
Phase: Take off
Nature:Domestic Scheduled Passenger
Departure airport:Brasília-Presidente Juscelino Kubitschek International Airport, DF (BSB/SBBR)
Destination airport:São Luís-Marechal Cunha Machado Airport, MA (SLZ/SBSL)
Investigating agency: CENIPA
A GOL Boeing 737-800 (PR-GTN) and a Brazilian Air Force Embraer C-95M Bandeirante (FAB 2345) were involved in a runway incursion incident at Brasília-Presidente Juscelino Kubitschek International Airport (SBBR).
The C-95M had arrived from the Rio de Janeiro-Santa Cruz Aerodrome (SBSC) with three crewmembers and five passengers on board. It was taxiing on the runway when the GOL Boeing 737 was cleared for takeoff. The 737 passed over the C-95.

Contributing factors.
- Attention – a contributor.
The attention of the Tower controller was hampered by the context in his work routine in which, due to physical obstacles, expectations were created that the aircraft would follow the instructions sent, even if they could not visually accompany them from their position, as happened in this case.
The fact that the Tower controller did not identify that the FAB, after having read back that it would clear by the TWY "G", did not do so, demonstrated that his focus of attention was not properly oriented to the situation.
In addition, the Ground controller did not identify that the aircraft, when at the first contact in his frequency, remained on the runway in use.

- Attitude – undetermined.
Despite the good technical preparation, the FAB 2345 copilot still showed little familiarity with the SBBR operation at night. This may have contributed to the fact that she did not contest the instructions received from the commander regarding the taxi sequence after landing on runway 11L, as regards the selection of the TWY to clear the runway in use.
Likewise, the attitude of not following the standard phraseology prescribed in the MCA 100-16/2016, by the Tower controller, may have contributed to the FAB 2345 crew carrying out the frequency change for the Ground Control, before its exit from the runway in use.

- Communication – a contributor.
Even not comprehending the request of the FAB 2345 crew after landing, the Tower controller did not urge them to repeat the message and issued instructions for the aircraft to clear the runway on TWY "G" (Golf), considering the proximity that the aircraft was from that intersection.
In this case, there was a selective listening, in which the spoken content was deduced from what was expected to be heard in that type of situation.
The message received by the FAB crew to "clear on Golf" may have been mistaken for a denial of the TWY "C" (Charlie) request.
Furthermore, the non-assimilation by the Ground controller of the verbal (future) time used by the crew of the FAB aircraft, by communicating the intersection where they would clear, contributed to the fact that he did not realize the aircraft was on the runway in use.

- Physical work-conditions – a contributor.
The light interference from the North Pier apron and the TWY "H" blind spot (Hotel) constituted physical characteristics of the Tower's workplace that compromised the safe operating performance considering the nighttime operation.

- Air Traffic Coordination (ATS) – a contributor.
The inadequate exchange of information between the Tower controller and the Ground Control in relation to the Air Force aircraft after its landing has contributed to the uncertainty as to the actual positioning of that traffic.

- Employment of ATS means – undetermined.
Despite all difficulties identified for the visualization of the C-95M on the runway, the Tower controller did not use the resource prevised at ICA 100-37/2017, which provided an instruction for the aircraft itself to report when it had cleared the runway in use. It is possible that the employment of this means could prevent the incident.

- Use of phraseology by ATS – undetermined.
It is possible that the phraseology used by the Tower controller, when he instructed the crew of the FAB 2345 to call the Ground Control, without conditioning this act to the exit of the aircraft of the runway in use, has induced the pilots to make the exchange of frequency being still on the respective runway.
With this action, the military pilots were unable to interfere when the Tower improperly authorized the 737 takeoff while the runway was still occupied.

- ATS Control Ability – a contributor.
There was no ability in performing ATS procedures, such as visual scanning and phraseology usage that exhausted the possibilities of identifying an aircraft on the runway at the time of the PR-GTN takeoff.

- Airport infrastructure – a contributor.
The existence of several blind spots at the aerodrome contributed to the Tower controller inferring that the FAB 2345 was in a position different from its real location after landing.
The cameras used to mitigate the risk of blind spots did not cover all areas and were not dedicated exclusively to the use of the TWR-BR.
The lighting of some aprons obfuscated the view of the TWR-BR controllers, damaging the sighting of the aircraft, especially small ones.
All these conditions, combined with the absence of a RADAR Surface Movement System, contributed to the military aircraft not being noticed on the runway in use at the time of the PR-GTN take-off was authorized.

- Clearance limit – a contributor.
Involuntarily, the crew of the FAB 2345 did not comply with the Tower instruction to clear the runway by the TWY "G" (Golf).
The remaining on the runway in use by the military aircraft, in spite of a different instruction from the controller, contributed to the incident.

- Perception – a contributor.
The similarity between the letters "C" and "G" associated with the conditions for their visualization at the night period contributed to the pilot's misperception.
The controller's perception was reduced by his expectation that the crew would strictly follow the guidance.
In addition, the failure to view the aircraft due to the TWY "H" (Hotel) blind spot led him to conclude that the runway was clear for another operation.
The expectation of not finding the aircraft in the runway in use reduced the controller's perception of the real location of that airplane, contributing to the ending of this occurrence.

- Insufficient pilot’s experience – undetermined.
The lack of familiarity of the FAB 2345 copilot with the aerodrome may have contributed for her not questioning the commander's message, requesting to clear the runway for the TWY "C" (Charlie) when, in fact, the intersection they passed by was the TWY "G" (Golf).
It is possible that the little experience of that copilot had induced her to faithfully follow the commander's guidance.

- Support systems – undetermined.
No regulation was identified that explicitly defined the position in which the aircraft should perform the frequency change for the Ground Control after landing.
The lack of prediction in standards may have contributed to the FAB 2345 crew keeping the Ground Control frequency while occupying the runway in use.



Accident investigation:
Investigating agency: CENIPA
Status: Investigation completed
Duration: 1 year and 10 months
Download report: Final report

Revision history:

08-Feb-2020 18:56 harro Added
08-Feb-2020 18:57 harro Updated [Date, Time, Accident report, ]

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