Passaredo E145 at Vitoria da Conquista on Aug 25th 2010, landed short of runway
Last Update: August 6, 2023 / 13:40:20 GMT/Zulu time
Incident Facts
Date of incident
Aug 25, 2010
Classification
Accident
Airline
Passaredo Linhas Aereas
Flight number
P3-2231
Departure
Sao Paulo Guarulhos, Brazil
Destination
Vitoria da Conquista, Brazil
Aircraft Registration
PR-PSJ
Aircraft Type
Embraer ERJ-145
ICAO Type Designator
E145
Airport ICAO Code
SBQV
The airline said, that the crew was unable to extend the landing gear forcing a belly landing.
The airport said, that the airplane performed a normal approach but then touched down with the tail (tail strike) before the runway and went entirely out of control. Both engines were hit hard and received serious damage, one engine burst into flames which were doused by airport fire services.
Witnesses on the ground said, that the airplane appeared to conduct a normal approach with landing gear down before it landed short of the runway and went out of control.
TV pictures showed the gear struts distributed over the runway.
The NTSB reported on Sep 9th that PR-PSJ received substantial damage while landing short of the runway following a visual approach.
The airport features a runway 15/33 of 1775 meters (5800 feet) length.
Some time in the past (at the earliest in 2016) CENIPA released their final report concluding the probable causes of the accident were:
- Attention - a contributor.
During the approach, the flight crew „s attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope.
- Work-group culture - a contributor.
The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion.
- Handling of aircraft flight controls - undetermined.
Taking into account copilot‟s report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction.
- Visual illusions - a contributor.
The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one.
- Management planning - undetermined.
For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome.
- Support systems - a contributor.
No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.
CENIPA analysed:
The first aspect of the occurrence to be analyzed was the fact that the crew had qualification for the flight in question, their training was up-to-date, and the captain was rather experienced in the aircraft model (with more than 3,000 flight hours).
Comparatively, the copilot‟s experience was shorter, but his more than 800 hours of flight in the model were an indication that he had the ability of evaluating the aircraft performance in the various phases of flight.
Thus, the fact that an experienced crew was not able to prevent the aircraft from colliding with an obstacle in the undershoot sector led the investigating committee to questioning whether a technical discrepancy of the aircraft might have contributed to the outcome of the event.
Initially, the analysis focused on contingent aircraft problems capable of hindering an effective recovery from a low approach.
Upon examining the data recorded by the FDR, the investigating committee verified that the engines had responded accordingly to the crew‟s inputs until the moment of the impact.
The committee also verified that there was no technical discrepancy in the navigation systems, flight controls, or equipment utilized for the approach. Thus, the focus of the analysis was directed to the operational issue.
During the whole final approach, only once did the copilot mention that the approach was being made with red VASIS lights, an indication that the aircraft was below the standard glide path (which was 3º for the runway in question).
In addition to the fact that the aircraft was below the ideal glide path, it was observed that the aircraft speed was 8 kt above the VAP, the flaps were extended to the position required for landing (45º) at 250ft AGL at a distance of 2 nautical miles to the runway threshold, in disagreement with the manufacturer‟s recommendations for a stabilized approach, which could have increased the probability of a safe landing.
It took long for the copilot to communicate his difficulty correcting the approach slope, and when he did it, he was not sufficiently assertive to draw the captain‟s attention to the situation.
Some of the aspects observed in the context of the occurrence may have contributed to a failure of the perceptive process:
- the attention of the crew being turned away from the glide path parameters in order to focus on obstacles close to the approach course of the runway 15;
- the characteristics of the runway and surrounding terrain, which may have induced an optical illusion in the crew when they aligned with the runway; and
- the culture of the company pilots, who had the custom of approaching the runway below the standard glide path, believing that, by doing so, they would decrease the distance required for landing, since their aircraft was not equipped with thrust-reversers.
Thus, the aircraft was flown along a lower approach slope (red VASIS lights) taking the runway aspect (as perceived by the pilots from the cockpit) as the only reference for landing.
Taking into account that the pilots had never operated in that aerodrome, and that the company had never issued any warnings with regard to the runway characteristics, there was a poor crew‟s situational awareness in relation to the special care to be taken for the operation in SBQV.
Since a more effective action was never taken in flight for correcting the lower approach slope, the idea of a visual illusion on the part of the captain is reinforced.
A significant number of visual illusions may occur during the approach, and the means available for preventing their occurrence are training, application of CRM, and use of approach aids (navigation aids and visual approach slope indicators - VASIS and PAPI).
The occurrence in question may have been the result of a poor flight planning, since, from what could be observed in the interviews, there was not concern in the pre-flight briefing, besides the fact that the very company did not publish warnings related to the specific characteristics of SBQV.
It is worth pointing out that there was inadequate management on the part of the company, since it failed to identify the risks inherent to the operation in that location and, consequently, did not publish any alerts to assist the pilots.
At the time of the occurrence, the company flight-safety sector consisted of just one person, who also had to meet the demands of the flight schedule, something not desirable for a company of that size, since a deficient number of qualified personnel in the area of flight safety will necessarily result in poor management of the potential risks present in the operation of the airline.
Metars:
SBQV 251900Z 10012KT 9999 FEW018 23/16 Q1021
SBQV 251800Z 08015KT 9999 SCT015 22/17 Q1021
SBQV 251700Z 09011KT 9999 FEW010 BKN015 23/18 Q1022
SBQV 251600Z 09009KT 9999 -RA SCT010 BKN015 21/19 Q1022
SBQV 251500Z 10010KT 9999 BKN015 22/18 Q1023
Incident Facts
Date of incident
Aug 25, 2010
Classification
Accident
Airline
Passaredo Linhas Aereas
Flight number
P3-2231
Departure
Sao Paulo Guarulhos, Brazil
Destination
Vitoria da Conquista, Brazil
Aircraft Registration
PR-PSJ
Aircraft Type
Embraer ERJ-145
ICAO Type Designator
E145
Airport ICAO Code
SBQV
This article is published under license from Avherald.com. © of text by Avherald.com.
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