Azul E190 at Porto Seguro on Sep 22nd 2014, blew tyres on landing and overran runway

Last Update: November 16, 2017 / 21:27:52 GMT/Zulu time

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Incident Facts

Date of incident
Sep 22, 2014

Classification
Incident

Airline
Azul Linhas Aereas

Flight number
AD-4210

Departure
Belo Horizonte, Brazil

Destination
Porto Seguro, Brazil

Aircraft Registration
PR-AXK

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

Airport
Porto Seguro Airport, Porto Seguro

Airport ICAO Code
SBPS

An Azul Linhas Aereas Embraer ERJ-190, registration PR-AXK performing flight AD-4210 from Belo Horizonte,MG to Porto Seguro,BA (Brazil) with 105 passengers and 5 crew, landed on Porto Seguro's runway 10 at about 13:23L (16:23Z) but burst a number of tyres during roll out and came to a stop disabled just past the runway end.

Brazil's Air Force, in charge of air traffic control, reported the aircraft caught a gust during landing, the crew corrected but needed to apply hard brakes causing the tyres to blow and the aircraft to overrun the end of the runway. Brazil's CENIPA have opened an investigation.

Ground observers reported the aircraft came to a stop within 10 meters of the runway end.

The return flight needed to be cancelled.

Porto Seguro features a runway 10/28 of 2000 meters length.

On Nov 16th 2017 Brazil's CENIPA released their final report in Portugese concluding the probable causes of the serious incident were:

Inadequate use of reverse thrust and brakes caused an increase in landing distance required to complete the landing safely.

It is possible that inadequacies in the aircraft handling caused a prolonged flare further increasing the landing distance required.

It is possible that the non-transmission of essential information about water standing on the runway by ATC contributed to misconfiguration of the aircraft for landing.

The improper assessment of the weather conditions by the crew led to the crew preparing the aircraft for landing on a dry runway although with the information available a wet runway was more likely.

A similiar misjudgement contributed to the delayed application of reverse thrust and brakes further increasing the landing distance required.

It is possible that the crew's concern about possible windshear influenced their ability to evaluate the actual conditions of the runway.

The inadequate assessment of weather conditions by the crew compromised the planning of the the landing performance. Under the present conditions the crew followed a mistaken decision making process, which compromised the management of landing on a wet runway.

The CENIPA analysed that during the approach to Porto Seguro ATC informed the crew that the aerodrome was operating in instrument meteorogical conditions, there was rain in the vicinity. ATC was in possession of the information, that the runway was wet, however, this information was not relayed to the crew, nor did the crew request the runway status at any time. Despite this mistake in the communication the aircraft could have safely landed requiring 1,847 meters landing distance on the wet runway with 2000 meters landing distance being available. However, although the approach was stable and the aircraft crossed the threshold at 50 feet and Vref+6 the aircraft touched down 1586 feet past the runway threshold with the "excessive flare" possibly being the result in inadequate control inputs causing an increase in landing distance required.

This control inadequacy could possibly have been caused by the crew anticipating crosswind gusts or even windshear. The fact that the crew reacted to a non-existing condition shows inappropriate assessment of the weather conditions by the crew. In any of these circumstances retardation of the touchdown, even unintetionally, contradicts company guidelines.

In addition, the flight data recorder reveals that reverse thrust as well as braking were applied with delay, without an obvious reason. After the touchdown priority should be to reduce speed, the investigation thus found the mishandling of the controls contributed to the increase in landing distance.

The tyre damage was caused by runway friction when the wheels locked up as result of emergency brakes.

The investigation also analysed that the automatic terminal information service did not include the information about the runway being wet.

Metars:
SBPS 221800Z 19011KT 140V230 8000 BKN015 SCT020 OVC040 23/18 Q1 017
SBPS 221700Z 19007G17KT 4000 BR BKN010 SCT020 OVC030 22/20 Q1017
SBPS 221600Z 18007KT 090V240 4000 -RA BR BKN009 SCT020 BKN050 22/21 Q1017
SBPS 221500Z 18009KT 100V220 6000 -RA BKN010 SCT020 BKN050 23/21 Q1018 RESHRA
SBPS 221420Z VRB10KT 4000 -SHRA BKN007 SCT015 BKN050 23/22 Q1018
SBPS 221400Z 18010G22KT 130V240 8000 VCSH SCT010 SCT020 BKN050 24/22 Q1018
SBPS 221300Z VRB04KT 9999 VCSH SCT015 BKN050 26/21 Q1018