Passaredo AT72 at Rondonopolis on Jan 9th 2016, landed short of runway, took out airport fence
Last Update: November 16, 2023 / 11:41:33 GMT/Zulu time
Incident Facts
Date of incident
Jan 9, 2016
Classification
Accident
Airline
Passaredo Linhas Aereas
Flight number
P3-2330
Departure
Brasilia, Brazil
Destination
Rondonopolis, Brazil
Aircraft Registration
PR-PDD
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
The Secretary of Transport and Traffic of Rondonopolis stated, the incident didn't have any gravity, the plane landed safely and normally some time later.
The airline stated that due to weather the aircraft needed to go around following a first touch down at 00:23L (03:23Z). The aircraft positioned for another approach and landed safely on the second approach. The passengers disembarked normally.
On Jan 20th 2016 the French BEA reported based on notification by Brazil's CENIPA, that the aircraft touched down short of the runway and went around, joined a traffic pattern and landed normally in a second approach. The aircraft collided with a fence during the maneouver, however. The CENIPA have not yet rated the occurrence, an investigation is underway.
Rondonopolis features a runway 02/20 of 1850 meters/6070 feet length.
Brazil's CENIPA released their final report dated Nov 16th 2021 concluding the probable causes of the accident were:
- Control skills – a contributor.
When subjected to the effects of visual illusions during the final approach for landing, the pilots had the false perception of being high on the ramp, acting on the flight controls in order to correct their position in relation to the false perception. The inadequate performance of the controls led the aircraft to be excessively close to the ground, still about 400m from the Aerodrome. This condition had the consequence of touching the ground before the head of the threshold.
- Adverse meteorological conditions – a contributor.
The presence of fog at the Aerodrome, as well as reduced horizontal visibility, contributed to the pilots being subjected to visual illusions during the final approach for landing.
- Crew Resource Management – a contributor.
Despite the physical characteristics of the Aerodrome and the associated meteorological phenomena, the pilots were able, by monitoring basic flight instruments, to determine the height and distance of the aircraft in relation to the runway to which they were making the approach.
The fact that the pilots reacted to the condition of proximity to the ground, only after the aircraft's automatic call-outs system announced that they were 50ft heigh, showed that the flight management between them was not adequate, compromising the quality of their flight conduction and its monitoring, particularly concerning a primary parameter of the visual flight such as the height of the aircraft. If the CRM and the workload distribution were adequate, pilots would recognize the proximity to the terrain earlier, and it would have been possible to start a Go Around procedure without the aircraft touching the ground.
Thus, it was concluded that, in the accident flight, the coordination of cabin resources was not performed properly, contributing to this occurrence.
- Use of phraseology by ATS – a contributor.
The informality with which the OAS carried out communications with the aircraft prevented the crewmembers from having access to relevant factual information from the SPECI at 0130 (UTC) and the METAR at 0200 (UTC). In addition, the significant difference between the values contained in the formal meteorological messages (SPECI and METAR) and the informal description transmitted via radio, showed inadequacy in the formulation of messages by the OAS of the Rondonópolis Radio.
The fact that the crew was not clearly informed about the visibility conditions contained in the METAR from 0200 (UTC) affected their level of situational awareness and compromised the decision-making capacity, since visibility values below the minimum established in the ICA 100-12 could lead pilots to decide not to perform the visual landing procedure in SBRD.
- Illusions – a contributor.
The operation at an Aerodrome in which pilots had little or no recent experience, with a narrower runway than they had previously landed, in a sector with homogeneous terrain characteristics, in a dark night, without moon, without sources of light between the aircraft and the runway threshold and without accurate meteorological information constituted a favorable scenario for the emergence of visual illusions, especially the Black Hole effect.
This visual illusion led pilots to the false perception of being in a higher position than they actually were, causing them to fly at a very low altitude, culminating in a flight path below the ideal 3° ramp, which resulted in touching the ground 400m before the runway.
- Airport infrastructure – a contributor.
The physical characteristics of the Aerodrome, especially the absence of luminous visual aids for approaches (ALS, VASIS, PAPI), contributed to the crew not realizing that the aircraft was traveling a flight path below the ideal 3°ramp. Although the operation without aid of the ALS, VASIS and / or PAPI types is in accordance with the regulations in force for visual night operation, the presence of such aid increases the situational awareness of pilots and is reflected in a significant contribution to flight safety during nighttime visual approaches.
- Piloting judgment – a contributor.
Despite the Aerodrome's physical characteristics, the pilots had their judgment to determine the aircraft's position in relation to the 3° ramp. During visual approach operations, it is the pilots' responsibility to provide separation of the aircraft from obstacles and other aircraft in flight. That way, pilots should have been able to realize that they were below the ideal 3° ramp before the aircraft got too close to the ground.
The pilots' inadequate assessment of the aircraft's position in relation to the 3° ramp and the runway contributed to the aircraft touching the ground 400m before the runway.
- Management planning – undetermined.
The qualification, experience and crew pairing criteria defined in the MGO did not require previous experience for operating in SBRD. This way, it was scheduled a commander who had never operated in the locality with a copilot who, despite having landed on that Aerodrome seven times before the accident, had never operated on the aircraft's controls.
Although it does not contradict any regulations in force, the pairing of pilots for an Aerodrome with operational restrictions/recommendations, such as those contained in the Airport Briefing of SBRD, may have represented an inadequate management of available human resources.
- Insufficient pilot’s experience – a contributor.
The pilots' little experience in that location contributed to them not paying attention to the physical characteristics and, also, to the presence of fog, a meteorological phenomenon typical of that region in January.
- ATS publication– undetermined.
The publications dealing with the dissemination of meteorological information (ICA 105-1) and air traffic phraseology (MCA 100-16), in force at the time of the accident, did not have guidelines regarding the phraseology to be used by the OAS when passing on meteorological information to aircraft, as well as the obligation to pass on the information contained in the METAR of the hour.
The absence of specific phraseology procedures and guidelines may have contributed to the informality of communications observed in this accident.
- Support systems – undetermined.
The SBRD's Airport Briefing noted that the Aerodrome was subject to Black Hole at both thresholds. However, there was no description of piloting techniques in the operator's manuals associated with preventing the effects of this visual illusion on flight. Thus, it was concluded that the publications, made available by the operator, were incomplete with regard to the risks associated with the visual illusion of Black Hole and may have contributed to the accident, since the pilots did not have theoretical references that would allow them to know the effect, nor to prevent the risks of this illusion to flight.
CENIPA provided this abstract of the accident:
During approach for visual landing, at night, at the Maestro Marinho Franco Aerodrome (SBRD), Rondonópolis - MT, the crewmembers performed the final approach keeping an approach ramp lower than the ideal and, when they realized the situation, they started a goaround procedure in the air, 20ft high.
During the go-around procedure, the aircraft continued to descend and touched the ground in a soybean plantation, about 400m before the runway threshold. The plane traveled a distance of approximately 72m on the ground before taking off again. In that distance, the aircraft collided with two concrete fence posts.
After leaving the ground, the pilots repositioned the aircraft for landing in the direction of runway 20, opposite to that used initially (runway 02).
The second landing attempt was made without major complications.
The aircraft had substantial damage.
All the occupants left unharmed.
CENIPA analysed:
It was a passenger transport flight. All crewmembers were qualified. However, it was the first time that the commander would land on SBRD, since he was hired by the operator. The copilot, in turn, had landed another seven times on that location, however, all as a Pilot Monitoring.
The company's MGO defined previous experience parameters only for Aerodromes classified as special. However, SBRD was not considered special, neither by the ANAC nor by the operator. As a result, the operator's manuals did not specify requirements for recent experience for pilots operating in SBRD. Thus, the fact that the commander and the copilot did not have recent experience in the locality, despite being relevant to this accident, did not contradict any provision of the referred manuals.
The flight from SBBR to SBRD was the third leg of the day for that crew and would be carried out entirely at night.
The Maestro Marinho Franco Aerodrome had some peculiar characteristics that were described in the Airport Briefing produced by the operator (Figures 20 and 21).
According to the RBAC 154,305 (j) (1) (i) (B), items (1) and (2), which regulated the installation of visual approach ramp systems, the Aerodrome should have the aids described, however, the ANAC's understanding, explicited in Decision n°134, made it clear that the items cited applied only to airports that did not exist in 12MAY2009 or, for existing ones, in specific cases defined by the Agency.
Thus, it was concluded that the items mentioned above of RBAC 154, Amendment 01, of 12JUN2012, were not applicable to SBRD and that, therefore, the absence of visual approach ramp systems did not contradict the regulations in force at the time of the accident.
However, the Aerodrome's geographic location, associated with the absence of luminous aids and significant artificial light, made the entire terrain around the runway very homogeneous. Thus, there was little or no visual reference that could assist pilots in determining the aircraft's position in relation to the approaching landing ramp.
In addition, the Aerodrome did not have, at the time of the accident, an air traffic control organ, nor an instrument approach procedure. There was, in the locality, an EPTA that provided AFIS service and made messages of the METAR and SPECI types. In this way, the landing and take-off operations were exclusively visual and the decisions about the traffic circuit and the direction of approach were completely the responsibility of the crewmembers, as long as they complied with the air traffic rules in force and associated with the type of operation.
The meteorological minimums established in the ICA 100-12, in force at the time, for visual operation were 5,000m of horizontal visibility and 1,500ft of ceiling. At the time of preparation for the flight leg between SBBR and SBRD, the last meteorological information from SBRD, which was available for consultation by the crew, was the EPTA closing SPECI, made at 2030 (UTC) on 08JAN2016.
In that SPECI, it was said that the horizontal visibility was above 10,000m and with few clouds at 2,000ft in height. Values above the minimum established for visual operation.
The aircraft took off from SBBR, at 0033 (UTC), on 09JAN2016, with a lag of just over four hours in relation to the last official meteorological information available.
At about 0156 (UTC), the crew made contact with the Rondonópolis Radio, in order to obtain information about the meteorological conditions at the Aerodrome. During this communication, the OAS informally described the current weather conditions. He reported that the SPECI at 0130 (UTC) contained information on very intense fog in the South sector, but that the horizontal visibility was 20km and that the fog was already less dense. Finally, he said that it was not possible to visualize the base of the cloud layer over the Aerodrome.
Despite making comments on the 0130 SPECI (UTC), the OAS did not read the message in its entirety. It is worth mentioning that the SPECI provided information on horizontal visibility equal to 1,000m, presence of fog and vertical visibility equal to 100ft, as highlighted below.
SPECI SBRD 090130Z /////KT 1000 FG VV010 ///// Q1010=
These conditions were below the meteorological minimums for visual operation established by the ICA100-12 and, therefore, constituted information of relevant importance for pilots. However, the crew never took notice of the visibility and ceiling values described in the SPECI message of 0130 (UTC), since the OAS did not read it during communications with the aircraft.
In an interview, the OAS reported that, at the time of this communication with the aircraft, he was able to view the lights of the city of Rondonópolis. Aware that the city was about 20 km from the Aerodrome, he passed on the horizontal visibility information equal to 20 km to the aircraft, despite the fact that the SPECI contained 1,000m.
During the communications, the OAS reported that it was still making the METAR from 0200 (UTC). The fact that the METAR for the next hour was still being made was understandable, since it was about four minutes before 0200 (UTC) and the OAS would have until 0205 (UTC) to send the METAR in force at the time, according to the ICA 105-1.
Whenever a METAR message was sent outside the window defined by the ICA 105-1, the DECEA database recorded the time at which the message had been transmitted for the purpose of punctuality statistics. Only the delayed messages were recorded in the system. The data relating to the time of sending messages received within the time window defined by the ICA were not recorded.
There was no record in the DECEA database of a delay in sending the METAR from 0200 (UTC) to the SBRD Aerodrome, on 9JAN2016. Although the system did not record the time that the OAS sent METAR to DECEA, it is possible to state that the message was sent within the window established by the ICA 105-1, that is, at 0205 (UTC) at the latest. If the 0200 (UTC) METAR had not been sent on time, the system would have treated the message as delayed and would record its sending time.
Although the OAS verbalized to the PR-PDD, at 0156 (UTC), that the visibility at the Aerodrome was 20km, the METAR at 0200 (UTC), made minutes after the communications with the aircraft, brought a horizontal visibility value equal to 4,000m, as highlighted:
METAR SBRD 090200Z 10007KT 4000 BR SCT007 SCT100 23/23 Q1011=
It is worth mentioning that this value was below the minimum horizontal visibility value for approach operations under visual flight rules defined by the ICA 100-12 (5,000m). Therefore, according to the METAR of 0200 (UTC), the meteorological conditions in SBRD continued to be incompatible with the visual operation.
At 0210 (UTC), already descending to the traffic altitude, the PR-PDD definitively established contact with the Rondonópolis Radio. During communications with the aircraft, the OAS did not read the METAR at 0200 (UTC), which it had prepared minutes before. Again, the EPTA operator carried out an informal description of the meteorological conditions recorded at the time, informing about the presence of fog banks which, according to him, the wind was being able to dissipate. In that communication, the OAS did not comment on the horizontal visibility at the Aerodrome.
It was concluded, therefore, that the crew was not aware of the meteorological conditions described in the METAR at 0200 (UTC), having only the description verbalized by the OAS as a source of information. This information passed by the OAS to the aircraft suggested that the weather conditions in SBRD were favorable for visual flight. For the PRPDD pilots, there was therefore no restriction on visual operation that night.
Regarding the informality of the messages transmitted by the EPTA operator during communications with the aircraft, it is emphasized that the ICA 105-1 and MCA 100-16, in force at the time of the accident, did not have detailed information regarding the phraseology to be used nor did it oblige the OAS to pass on the information contained in the METAR of the hour to aircraft requesting meteorological information from the Aerodrome.
Even more recent publications such as MCA 100-16 and ICA 100-37 did not contain detailed information regarding the obligation for the OAS to pass on the information contained in METAR to aircraft, nor were they clear about the origin of the information to be transmitted.
At 0213 (UTC), the pilots informed the Radio that they were seeing the Aerodrome and that they were observing the presence of very heavy fog in the North sector of the city of Rondonópolis. The OAS, once again, did not read the METAR of the hour, having made informal comments on the weather, adding that threshold 20 seemed to be in better weather conditions than threshold 02. However, at the end of the transmission, it stressed that the pilots would have better conditions for observing meteorology in flight than it would have on the ground.
The pilots informed that they would proceed to threshold 02, despite the OAS
reservation regarding the apparently better conditions at threshold 20. They then performed a standard visual traffic circuit, with turns to the left.
During the traffic circuit, the pilots carried out the configuration of the aircraft for landing at points other than those recommended by the SOP.
The flaps were lowered to 15º on the Aerodrome's crossing axis (perpendicular to the runway), while the SOP established that this procedure should be performed on the wind leg, across the runway's threshold.
The landing gears were lowered close to the threshold’s abeam, before the end of the wind leg. The SOP instructed to perform this procedure at the beginning of the turn for the base leg.
The flaps were lowered to 30º still in the wind leg, while the SOP established that this procedure was carried out only during the base leg.
Finally, the autopilot was disconnected on the base leg, while the SOP established that this procedure should be performed during the final approach, with a guaranteed landing.
Upon entering the final approach ramp, the aircraft was in the following conditions:
- altitude: 2,100ft (633ft in relation to the runway);
- distance from the runway: 1.9 NM;
- indicated speed: 124kt;
- ground speed: 118kt;
- descent rate: 1,080ft / min;
- landing gear: down; and
- flaps: 30°.
According to the FSF and FAA studies, maintaining a ramp trajectory with an angle of 3°, at an approximate speed of 120kt, an aircraft should be 600ft high, when at a distance of 2 NM from the runway. The PR-PDD was 633ft high, 1.9 NM away from the runway, so it was in a condition very close to the ideal.
However, it is clear that the descent rate of 1,080ft/min was high, compared to the ideal rate of descent of 600ft/min, for the speed being maintained by the aircraft.
The MGO specified that the aircraft should be in a condition compatible with that of stabilized approach when reaching a height of 500ft above the Aerodrome. When it reached that point of approach, the aircraft was in the following conditions:
- altitude: 1,967ft (500ft in relation to the runway);
- distance from the runway: 1.6 NM;
- indicated speed: 123kt;
- TLA engine #1: 41.84°;
- Tq engine #1: 14.5%
- TLA engine #2: 41.14°;
- Engine #2: 9%;
- descent rate: 960ft/min;
- landing gear: down; and
- flaps: 30°.
Following the parameters defined for an approach stabilized by the MGO, it is clear that the aircraft was in the flight path, at the appropriate speed and configuration for landing.
However, the power adjustment was reduced (engine #1 41.84°; engine #2 41.14°), with values close to the flight idle range (37° TLA) and with a rate of descent above the ideal.
During the final approach, the aircraft started to fall below the ideal 3° ramp without the pilots realizing it. The average rate of descent, during the final approach, was 844ft/min. This value was above the 600ft/min recommended by the FSF for a 3° ramp when maintaining 120kt of indicated speed.
In addition to the lack of accurate meteorological information, some factors contributed to the pilots not realizing that the aircraft was approaching the ground, in a position still distant from the runway threshold.
The first one was the dark night, due to the absence of the moon. On the night of the occurrence, the moon had set at 1833 (UTC-2), on 08JAN2015, and its rise took place only at 0617 (UTC-2), on 9JAN2015. Therefore, at the time of approaching and landing the aircraft, the night had no moon, and can therefore be considered a dark night. According to the FSF studies, dark nights can lead pilots to experience an illusion of being too high in relation to the runway.
The second important factor was the presence of fog banks in the South sector of the Aerodrome. The crew members reported having entered one of these fogs momentarily, during the final approach, making it difficult to visualize the runway. The fog banks, in addition to influencing the horizontal visibility and the ability of the pilots to see the runway, can contribute to the appearance of a visual illusion, making the pilots have the false perception of being very high in relation to the Aerodrome, everything according to the FSF.
The runway width was the third relevant factor. The SBRD runway was 30m wide. It was therefore narrower than most of the runways on which scheduled airlines operate normally. It was even narrower than the SBBR runway, a destination prior to landing in SBRD for that crew. The FSF states, in its articles, that narrower runways can give pilots the feeling of being on an approaching ramp higher than the one they actually are.
The location and airport infrastructure characteristics of the SBRD runway are the fourth important factor. The environment in which the runway was located was quite homogeneous, surrounded by soybean plantations and without any significant source of lighting other than the runway's marking lights.
In addition, the Aerodrome had no aid of the ALS, VASIS or PAPI types. These visual aids would serve as a reference for pilots to determine the aircraft's position in relation to the ideal ramp for the runway, thus preventing them from falling below the ideal ramp without realizing it.
The fifth and last factor considered was the rate of descent above the ideal, which implied a reduction in power in order to maintain the approach speed.
Approaching for landing at an Aerodrome that they were not familiar with, on a narrower than usual runway, through a sector with homogeneous terrain characteristics, in a dark night, without a moon, without light sources between the aircraft and at the end of the runway and without accurate meteorological information, the crewmembers were placed in a context favorable to the appearance of visual illusions, especially the Black Hole effect.
The Black Hole effect is a type of visual illusion that induces pilots to the false perception of being in a higher position than they actually are, causing them to fly at dangerously low heights, especially during landing approaches.
In these conditions, it is feasible to assume that the pilots acted on the aircraft's controls, in order to correct their position in relation to the false perception of being high on the ramp, including the fact of maintaining a reduced power adjustment. The results of these actions led the aircraft to follow a flight path below the ideal ramp of 3° during the approach for landing in SBRD.
When crossing 50ft in height over the terrain, the aircraft's automatic call-out system announced “fifty”. At that moment, the copilot realized that the aircraft was very close to the ground and commanded the go-around procedure announcing: “Go Around! Go Around!”.
The commander initiated the procedure, carrying out the planned actions, among them applying power. However, the aircraft continued to descend, touching the ground about 400m before the runway. It is likely that the reduced power adjustment has influenced the response of the aircraft's engines and contributed to the aircraft continuing to descend to the point of touching the ground.
The fact that the pilots reacted to the condition of proximity to the ground, only after the aircraft's automatic call-outs system announced that they were 50ft high, showed that the flight management between them was not adequate, compromising the quality of their flight conduction and its monitoring, particularly in relation to a basic parameter of visual flight such as the height/distance of the aircraft in relation to the runway. Under suitable conditions, it would have been possible to start a run at an earlier time, which would allow the procedure to be carried out without the aircraft touching the ground.
Thus, although the pilots' performance was considered satisfactory for the items related to CRM in the last simulator training to which they were submitted, it was concluded that in the accident flight, the coordination of cabin resources was not performed properly, contributing to this occurrence.
After touching the ground, the plane still covered a distance of 72m on the ground before taking off again. In that way, he collided with two concrete posts on the Aerodrome's patrimony fence.
The pilots completed the Go Around procedure, gaining height again and repositioning the aircraft for landing in the direction of threshold 20, contrary to the approach that had just been carried out.
During the second approach, the power adjustment parameters were significantly higher than those kept on the first landing attempt.
The second landing procedure was completed successfully.
All occupants left unharmed.
Metars:
SBRD 090530Z 11005KT 0100 BCFG NSC 23/23 Q1010=
SBRD 090330Z 10005KT 0100 BCFG NSC 23/23 Q1010=
SBRD 090220Z 10005KT 1000 BCFG NSC 22/22 Q1011=
SBRD 090130Z /////KT 1000 FG VV010 ///// Q1010=
SBRD 082030Z 00000KT 9999 FEW020 BKN100 25/23 Q1007=
Incident Facts
Date of incident
Jan 9, 2016
Classification
Accident
Airline
Passaredo Linhas Aereas
Flight number
P3-2330
Departure
Brasilia, Brazil
Destination
Rondonopolis, Brazil
Aircraft Registration
PR-PDD
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
This article is published under license from Avherald.com. © of text by Avherald.com.
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