What happened
On October 28, 2017, a Cessna 210L, registration PT-ICY, was performing a police transport mission from Brasília to Alto Paraíso de Goiás. The flight carried two crew members and three passengers. During the landing at the Alto Paraíso de Goiás Aerodrome (SDXF), the aircraft experienced a long landing. After touching down near the midpoint of the runway, the aircraft failed to stop within the available distance, overran the end of the runway, crossed an embankment, and collided with a perimeter fence.
The impact caused substantial damage to the aircraft's landing gear, left wing, and propeller. All five occupants of the aircraft were unharmed.
The investigation
CENIPA investigators established that the crew performed an unstabilized approach. The pilot maintained an approach profile significantly higher than the standard glide slope and approached at 90 knots with 20 degrees of flaps, which was 10 to 20 knots above the recommended checklist speed. The investigation also noted that the crew chose runway 09 arbitrarily because they could not identify the windsock at the time of arrival.
Furthermore, the investigation identified a lack of assertiveness from the second crew member, who observed the long landing but did not call for a go-around. The investigators also noted that the runway surface, while recently resurfaced, was shedding small pebbles, which may have hindered braking efficiency and contributed to a tire burst.
Findings
- The pilot executed an unstabilized approach above the prescribed glide slope.
- The landing touchdown occurred too far forward, near the middle of the runway.
- The crew demonstrated a decision-making failure by continuing the landing despite parameters indicating a go-around was necessary.
- A culture of informality within the unit led to the adoption of non-standard operational procedures, such as flying higher approaches to facilitate emergency landings.
- Contributing factors included errors in pilot judgment, flight planning, decision-making processes, and management oversight.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to work with the operator (Distrito Federal Military Fire Brigade) to:
- Improve Crew Resource Management (CRM) training, specifically regarding interpersonal interactions for operational safety.
- Emphasize go-around techniques and the necessity of executing them during unstabilized approaches.
- Ensure the application of corrective actions to maintain acceptable operational safety performance as required by the Safety Management System (SMS).