Avianca Brasil A320 at Rio de Janeiro on Mar 3rd 2019, runway excursion on landing, "grazing aircraft"
Last Update: February 26, 2021 / 20:29:08 GMT/Zulu time
Incident Facts
Date of incident
Mar 3, 2019
Classification
Accident
Airline
Avianca Brasil
Flight number
O6-6227
Departure
Salvador, Brazil
Destination
Rio de Janeiro Galeao, Brazil
Aircraft Registration
PR-OCW
Aircraft Type
Airbus A320
ICAO Type Designator
A320
The Aviation Herald received multiple pointers to the occurrence, each of which provided a different scenario, from landing ahead of the runway threshold, grass cutting action near the runway contaminating the runway, the aircraft touching down with the left main gear in the grass, the aircraft touching down completely aside of the runway with all gear on soft ground, the aircraft veering off the runway after touchdown and returning onto the runway.
The airline reported the right hand main gear temporarily departed the runway surface during the landing roll.
On Mar 7th 2019 Brazil's CENIPA reported the aircraft performed an RNAV approach to runway 15. Following touch down on the runway the aircraft veered right off the runway and returned onto the runway. The aircraft received minor damage, the occupants remained uninjured. The occurrence was rated a serious incident and is being investigated.
On Feb 26th 2021 CENIPA released their final report concluding the probable causes of the accident were:
- 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.
CENIPA analysed:
The company was undergoing a judicial reorganization and, according to employee reports, the working environment was being affected by a feeling of uncertainty and apprehension about whether or not to remain in the company, reinforced by the lack of clearer information about the financial situation faced and its possible consequences.
Faced with a framework of spending containment, the ground coordination, such as transportation and accommodation, came under the responsibility of the crewmembers, since there was no sector in the company effectively dedicated to this subject.
Commonly, the crewmembers faced the situation of not having reservations at the hotels indicated by the company or they spent more than an hour waiting for the transfer to the hotel or airport. As a result of these facts, the company was also facing a crisis with its internal employees.
Other problems, such as reduced staff and late payment of wages, were causing constant crew availability problems.
In this context, in order to comply with the schedule, the company's CCO contingently activated all six crewmembers of this flight, including the need for the copilot and flight chief to have to perform the Guarulhos / Salvador section as extra crewmembers, which caused the delay in the presentation in SBSV.
Therefore, the copilot and the flight chief presented themselves, directly on the PROCW aircraft, with an hour and five minutes of delay in relation to the time established in the company's MGO (crew members should report for national flights. one hour before the scheduled departure time).
The takeoff took place at 18h45min (UTC).
Despite the delay, all operational procedures for the flight were performed correctly and the cruise flight went smoothly.
Although the weather conditions were much degraded in the region of Rio de Janeiro upon arrival, at no time were they below the minimums recommended by the company's MGO, as well as in all relevant legislation on the subject.
At 20h23min45s (UTC), the crew was informed by the APP RJ that SBGL had 3,000m of visibility, heavy rain and thunder, and the crewmembers estimated that, according to the company's rules, it was possible to continue the approach.
According to the commander, for a moment, he even considered the implications of going for an alternative in view of the situation that the company was going through. However, he affirmed that this fact was not determined for the decision to proceed to the landing in SBGL. For him, despite the worsening weather conditions, it was possible to continue the landing procedure.
According to reports and analysis of the descent data, the aircraft performed a stabilized approach up to approximately 490ft, when there was a significant change in the wind, which started blowing at 139° of direction with 9kt of intensity.
The commander even identified and announced, crossing approximately 100ft in height that the aircraft was off the runway axis. The copilot confirmed this information, showing that he was aware of the operational situation.
The FCTM established that the corrections, lateral and directional control of the aircraft during the final, in crosswind conditions, should be through the “crabbed approach winglevel” technique.
Thus, it was found that the commander's initial actions corresponded to that recommended in the FCTM. However, the aircraft was no longer flying towards the central strip of the runway and the corrections were not sufficient to redirect the aircraft to the center of the axis.
Given the situation, the copilot did not consider interfering in the command of the aircraft because, according to his report, he considered that it was not a situation of incapacitation of the pilot in command and relied on the commander's information that he was correcting the position.
The uncertainty regarding the effectiveness of the correction of the approach axis with the center of the runway, coupled with the sudden worsening of the visibility conditions, caused by the increase in the intensity of the rain, as well as by the change in the wind direction for the left abeam and the increase of its intensity, led the commander to act with greater amplitude in the commands, in order to try to correct the drift tendency to the right that was more and more accentuated.
Added to this action is the fact that the aircraft flew over the threshold at 80ft of altitude, resulting in the crossing of the 1,000ft mark of the runway, still flying, at 46ft of altitude, 138kt speed and 480ft / min descent rate. At that moment, the wind marked the direction of 120º with an intensity of 12kt.
At 30ft height, the copilot made a new callout regarding the aircraft's alignment; however, there was no further response from the commander.
From that moment on, the weather conditions deteriorated even more, with the increase in the intensity of the rain on the Aerodrome, to the point of impairing the pilots' peripheral vision, compromising the exact notion of depth of the aircraft in relation to the runway.
From the data studied, it could be said that, during the final approach phase, from 20h31min07s (UTC), already flying below 100ft height, it was observed that the crew had an exact notion that the aircraft was outside the central axis of the runway.
However, there was no perception that this situation would lead to an approach to a destabilized condition.
According to the FCTM, the go-around procedure should be made if the stabilized approach parameters were not maintained until landing. That document established that a go-around procedure close to the ground could be considered at any time. However, it warned that the maneuver should not be performed after the pilot in command selected the use of the reversers.
The copilot reported several times that the aircraft was off the runway axis. The commander checked the correction a few times; however, there was no effective action on the flight controls to correct this situation. At no time was there a callout to start the missed approach procedure.
For being close to the ground, already flying over the runway, the commander did not consider the possibility of discontinuing the landing and proceeding to the alternative as a viable action. He reported being committed to landing and that, to avoid a heavier landing, he was modulating the flare with the thrust of the engines.
Given the facts described above, two points must be considered. The first refers to the non-application of the procedure suggested in the FCTM for the situation of aircraft destabilized for landing.
Although the crewmembers were with their training updated and considered it adequate, it is possible to assume that the non-application of the procedures recommended in the operator's and aircraft manufacturer's manuals resulted from the lack of understanding of the destabilization condition, since they identified the lateral deviation of the aircraft and remained focused until the landing.
Another point to consider is related to the internal environment that existed in the organization, due to the financial crisis faced. The climate, as mentioned, was one of apprehension and uncertainty as to what could happen to the company and its employees.
Thus, the company's scenario coexisted with the adverse scenario of the occurrence and the implications of opting for a go-around procedure. It is a fact that, if they chose to proceed to the planned alternative, this decision would result in an increase in expenses by the company to cover mandatory assistance to passengers.
In addition, it is assumed that the company could also encounter difficulties in allocating these passengers because it was a period of a lot of touristic activity at the alternative location, which would represent another addition of problems to a scenario that was already a crisis.
Although the commander did not recognize this situation as a decisive factor to proceed towards approach and landing, these factors may have had an influence on the decision-making process, even if not voluntarily, leading him to try until the last moment to correct the aircraft, although not responding and with very degraded weather conditions.
This scenario, in which the pilots did not identify a condition of destabilized approach, coupled with the organizational factors described above, resulted in the non-execution of a go-around procedure in flight. When crossing 20ft height, the commander reduced the throttles to idle, keeping the pitch up, varying between 4th and 5th and leveled wings, with the intention of landing the aircraft.
The landing took place under unfavorable weather conditions, caused by heavy rain over the airfield, sudden variation in the direction and intensity of the surface wind. At the exact moment of the touch, the wind calculated by the aircraft's navigation system indicated a 057º direction with an intensity of 19kt.
The contact of the aircraft with the ground occurred about 916m far from the threshold 15, with the right main landing gear outside the lateral limits of the runway, speed of 121kt, descent rate of 400ft / min, magnetic heading of 140º and flight path of 149º. After the touch, the aircraft traveled 668m outside the runway. The commander regained control of the aircraft and returned it to the inner limits of runway 15.
Analyzing the runway conditions, the investigation team concluded that it offered all the necessary conditions for the aircraft to make the landing, therefore, its contribution to this occurrence was discarded.
The aircraft cleared the runway via taxiway “E” and parked at position 20 of apron 1. The crewmembers did not report the event involving landing off the runway to the ATC, nor the landing roll on the right side of runway 15.
According to the crew, there was no standardized procedure by the company for this type of reporting. The AQD only prevised that this type of occurrence would be reported immediately to the company.
As a result, the control agencies were not immediately aware of the fact and, therefore, it was not possible to inform the teams of the RIOgaleão Operations Center, the supervision of aprons and runways or, even, the Emergency and Safety Center.
The supervision of aprons and runways, when receiving flight O66227 in position 20 of apron 1, was communicated by the mechanic of the airline about the presence of grass stuck in the lower fuselage and in the landing gear of the aircraft. Thus, the supervision requested the inspection of runways 10/28 and 15/33. The inspection located grass and pieces of asphalt on the right side of runway 15, between taxi lanes C and D, with the tire tracks of the aircraft.
After the confirmation of the event by the supervision, the concessionaire cleaned runway 15/33 according to the procedures prevised and, normal operation was restored at 2100 (UTC) on 04MAR2019.
Possibly related NOTAMs:
K1620/18 NOTAMN
Q) SBCW/QICAS/I/NBO/A/000/999/2250S04314W005
A) SBGL
B) 1812091952 C) 1903082359
E) IGL ILS RWY 15 U/S
K0186/19 NOTAMN
Q) SBCW/QITCG/I/NBO/A/000/999/2249S04315W005
A) SBGL
B) 1902221918 C) 1903242100
E) ILS CAT II RWY 10 DOWNGRADED TO CAT I
K0184/19 NOTAMN
Q) SBCW/QLPXX/IV/BO/A/000/999/2249S04315W005
A) SBGL
B) 1902211825 C) 1905202359
E) PAPI RWY 15 CHANGED MEHT TO 65FT
METARs:
SBGL 032200Z 22001KT 6000 -TSRA FEW012 SCT015 FEW025CB OVC100 23/23 Q1015=
SBGL 032100Z 32006KT 0800 R15///// R33///// R10/1700 R28/P2000 +TSRA FEW004 SCT008 BKN015 FEW025CB 23/22 Q1015=
SBGL 032043Z 02008G22KT 0500 R15///// R33///// R10/1000 R28/170 0 +TSRA FEW004 BKN009 BKN020 FEW030CB 23/22 Q1016=
SBGL 032018Z 08004KT 3000 +TSRA FEW012 BKN025 FEW030CB OVC090 27/25 Q1014=
SBGL 032000Z 15006KT 9999 4000NE -TSRA FEW012 BKN025 FEW027TCU FEW030CB OVC080 27/24 Q1013=
SBGL 031900Z 12008KT 9999 FEW010 SCT025 FEW030TCU BKN100 28/25 Q1012=
SBGL 031800Z 13010KT 9999 FEW010 SCT025 BKN100 29/25 Q1012=
Incident Facts
Date of incident
Mar 3, 2019
Classification
Accident
Airline
Avianca Brasil
Flight number
O6-6227
Departure
Salvador, Brazil
Destination
Rio de Janeiro Galeao, Brazil
Aircraft Registration
PR-OCW
Aircraft Type
Airbus A320
ICAO Type Designator
A320
This article is published under license from Avherald.com. © of text by Avherald.com.
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