Date:	Thursday 3 December 2020
Time:	14:42 UTC
Type:	Embraer ERJ-195AR
Owner/operator:	Azul Linhas Aéreas Brasileiras
Registration:	PR-AUJ
MSN:	19000688
Year of manufacture:	2015
Fatalities:	Fatalities: 0 / Occupants: 73
Other fatalities:	0
Aircraft damage:	None
Category:	Serious incident
Location:	São Paulo-Congonhas Airport, SP (CGH/SBSP) -   Brazil
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Rio de Janeiro-Santos Dumont Airport, RJ (SDU/SBRJ)
Destination airport:	São Paulo-Congonhas Airport, SP (CGH/SBSP)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Azul flight 4003, an Embraer ERJ-195AR (PR-AUJ) and Gol flight 1700, a Boeing 737-800 (PR-GUD), were involved in a serious runway incursion incident at São Paulo-Congonhas Airport, SP (CGH).

At 14:38:44 UTC, PR-GUD was instructed by the Congonhas Tower controller to line up and hold position on runway 35L, behind Gol flight 1068, a Boeing 737-800 that was on short final.
At that moment, PR-AUJ was 6.9 NM from runway 35L, 2 minutes and 16 seconds from landing, with a speed of 186 kt. At 14:39:25 UTC, PR-AUJ called the Tower controller and reported that it was 1 NM from SURBU. Then, at 14:39:29 UTC, the Tower controller reported the altimeter setting and asked PR-AUJ to wait for clearance to land.
Meanwhile PR-GUD had taxied onto the runway and was waiting for takeoff clearance.
At 14:42:23 UTC, when he was 0.7 NM away from runway 35L, PR-AUJ asked the Tower controller if there was an aircraft on the runway. At this point, PR-AUJ was at an altitude of 2,900 ft, 24 seconds from landing, at a speed of 122 kts.
At 14:42:26 UTC, even after PR-AUJ's questioning, the Tower controller authorised the aircraft to land on runway 35L. At that point, PR-AUJ was 0.3 NM short of the threshold of 35L, 12 seconds away from landing, crossing 213 ft, with a speed of 122 kt.
At 14:42:33 UTC, the flight crew of PR-GUD observed an aircraft very close to them via the Traffic Collision Avoidance System (TCAS) and hearing the Tower controller clear him to land on runway 35L, immediately informed the controller that he was lined up at the threshold of that runway awaiting clearance to take off. At 14:42:34 UTC, the Tower controller instructed PR-AUJ to go around.

PR-AUJ passed over the threshold of runway 35L (overflying PR-GUD) at 113 ft. Considering that the vertical stabiliser of PR-GUD (Boeing 737-800) was 41.2 ft high, it was determined that the smallest separation between the two flights was 71.8 ft or 21.7 m

Contributing Factors
- Attention - contributed
The Air Traffic Controller (ATCO) did not fully observe the unfolding situation and authorized the landing of PR-AUJ on runway 35L, which was still occupied by another aircraft. This lapse in attention allowed the situation of aircraft approaching below the required minimums to escalate.

- Attitude - contributed
The ATCO did not perform a visual sweep of the runway, as required by ICA 63-21 - “Runway Incursion Prevention Program for ATS.” Had this procedure been followed, the ATCO would have noted that PR-GUD was still on the threshold of 35L and would not have authorized the landing of PR-AUJ.

During the incident, the SPVS (Supervisor) was not attentive to the tasks being carried out by the on-duty controllers, as they were engaged in filling out the incident logbook.

- Perception - contributed
When asked about the reasons for not intervening, the SPVS reported that at the time of the runway incursion, they were occupied with filling out the incident logbook. This activity reduced the SPVS's situational awareness, hindering their ability to visualize the emerging runway incursion (RI) scenario.

- Supervision (ATS) - contributed
There was inadequate monitoring of the ATCO’s actions at the TWRSP position by the SPVS, which would have enabled an assertive correction to prevent the runway incursion.

SBSP 031400Z 32015KT CAVOK 29/15 Q1014
SBSP 031500Z 31007KT CAVOK 29/15 Q1014

CENIPA

Other occurrences involving this aircraft


8 July 2021	PR-AUJ	Azul Linhas Aéreas Brasileiras	0	Foz do Iguaçu/Cataratas Airport, PR (IGU/SBFI)		min
Bird strike

Date/time	Contributor	Updates
31-Oct-2024 20:09	ASN	Updated [Other fatalities, ]
31-Oct-2024 20:10	ASN	Updated [Other fatalities, Accident report, ]
31-Oct-2024 20:14	ASN	Updated [Other fatalities, Narrative, Category, ]
01-Nov-2024 15:42	ASN	Updated [Other fatalities, Narrative, ]