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ASN Wikibase Occurrence # 213181
Last updated: 3 March 2021
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Time:10:50 UTC
Type:Silhouette image of generic C150 model; specific model in this crash may look slightly different
Cessna 150M
Owner/operator:Aeroclube de Itápolis
Registration: PR-JEA
C/n / msn: 15077030
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:Itápolis Airport, Itápolis-São Paulo (SDIO) -   Brazil
Phase: Landing
Departure airport:Itápolis-Aeroclube de Itápolis Airport, SP (SDIO)
Destination airport:Itápolis-Aeroclube de Itápolis Airport, SP (SDIO)
Investigating agency: CENIPA
Two Aircraft collided during the landing procedure at the same time at the Airport of Itápolis ,. A Cessna 152 aircraft (PR-EJK) and a Cessna 150M aircraft (PR-JEA). There were no injuries.

Contributing factors.
- Application of commands - contributed.
The pilot of the PR-JEA aircraft, due to an oversight at the beginning of the descent in the base leg, made a lower than normal approach and without flaps.
Both situations added up and contributed to an approach with a more belligerent attitude, which made it difficult for this pilot to see the aircraft ahead.
- Organizational culture - undetermined.
The RELPREV filled in both organizations (despite the low quantity in face of the volume of operation) dealt, for the most part, with the issue of conflicts in the traffic circuit, the same situation of this occurrence. Despite this, little importance was given to the treatment and analysis of this information, and no mitigating action was adopted to reduce the possibility of air traffic conflicts in the SDIO circuit.
Therefore, it is possible to assume that, in the institutions, there was a little ingrained culture regarding the treatment of flight safety issues, which may have contributed to the occurrence on screen.
- Crew Phraseology - undefined.
The lack of standard phraseology in the SDIO traffic circuit, as well as the possible omission of some messages, led to poor communication between the aircraft, culminating in a decrease in the situational awareness of the crews regarding the position of other aircraft in the circuit, which may have contributed to the occurrence.
- Flight discipline - contributed.
The pilot-student instructor abandoned his position on the ground, leaving the instructor unsupervised, thus eliminating an important protection barrier against a possible student error that could compromise flight safety, which ended up happening and consuming the occurrence.
- Pilot judgment - contributed.
Although it was not possible to determine which of the two aircraft performed the wind leg out of the predicted trajectory, it is a fact that there was a trajectory "cut" (shortening of the distance) in the framing curve of the base leg. In addition, one of the aircraft performed a low ramp without flaps.
Both situations added up and contributed to an approach with a more bent attitude which made it difficult for this pilot to visualize the aircraft ahead.
- Perception - contributed.
The expectation of the PR-JEA pilot that the aircraft that entered a direct approach was the PR-EJK aircraft and the imprecision regarding the position of the other aircraft, allied to the communication failure, showed the existence of factors that interfered with the situational awareness of that pilot, in such a way that its operation was affected.
- Little pilot experience - contributed.
The PR-JEA pilot-student had little flight experience, which contributed to inefficient in-flight traffic management and resulted in the aircraft in front of him not being seen and colliding with it.
- Management oversight - undetermined.
There was inadequate management of operational safety by senior management of both organizations, which may have contributed to the occurrence, as they were unable to accurately identify and properly mitigate the latent factors in the SDIO traffic circuit, even with the completion of prevention reports on the subject at the time of the occurrence.


Accident investigation:
Investigating agency: CENIPA
Status: Investigation completed
Download report: Final report


Revision history:

12-Jul-2018 16:26 Diogo Saavedra Added
12-Jul-2018 16:32 harro Updated [Aircraft type, Registration, Cn, Operator, Total occupants, Location, Nature, Departure airport, Destination airport, Damage, Narrative]
12-Jul-2018 16:33 harro Updated [Embed code]
13-Jul-2018 06:35 cleberjc Updated [Operator, Total occupants, Location, Departure airport, Destination airport, Embed code, Narrative]
13-Jul-2018 06:35 cleberjc Updated [Total occupants, Location, Departure airport, Destination airport, Source, Embed code]
14-Jul-2018 17:50 cleberjc Updated [Operator, Narrative]
05-Aug-2020 17:34 harro Updated [Time, Departure airport, Destination airport, Narrative, Accident report, ]

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