What happened
On January 6, 2012, an ATR 42-500, registration PR-TKB, operated by TRIP Linhas Aéreas, was descending through FL110 toward Guarulhos (SBGR) when the flight crew received a Traffic Advisory (TA) followed by a Resolution Advisory (RA) from the TCAS equipment.
To avoid a potential mid-air conflict, the crew executed the prescribed TCAS maneuvers. During these maneuvers, a female passenger who was standing near the lavatory lost her footing and fell. The passenger sustained minor injuries, specifically fractures to her right foot and ankle, and was subsequently treated at a local hospital.
The investigation
CENIPA's investigation examined the flight's descent profile, air traffic control (ATC) communications, and the crew's performance. The investigation revealed that the aircraft was following the RONUT 1 arrival procedure but had deviated from the prescribed minimum altitude. While the aircraft was cleared to descend to FL120, the pilot flying selected FL100 on the altitude selector, which was below the minimum altitude required for that specific segment of the arrival.
Investigators also scrutinized the organizational and operational environment of the operator. The investigation found significant deficiencies in Crew Resource Management (CRM) and cockpit coordination. The captain failed to monitor cabin safety or provide adequate leadership during the emergency, and the crew's communication was found to be minimal and uncoordinated. Furthermore, the investigation identified a lack of integration between the company's safety, operations, and training sectors.
Findings
- Navigation deviation: The crew unintentionally deviated from the standard arrival procedure by descending to FL110, which was below the minimum altitude prescribed for that segment of the RONUT 1 STAR.
- Inadequate cockpit coordination: Communication between the crew members was minimal, with tasks being performed in isolation rather than through coordinated effort.
- Leadership and monitoring failures: The captain failed to monitor cabin processes, did not conduct a pre-flight briefing, and did not appropriately respond to the co-pilot's failure to comply with altitude procedures or the abrupt control inputs during the TCAS maneuver.
- Organizational and training deficiencies: The company's CRM training was decentralized and lacked integration between different sectors, and the safety department was understaffed and unable to effectively manage risk-reporting processes.
- Use of non-standard phraseology: The use of non-standard terms by ATC, such as "Re-intercept the Arrival," may have contributed to reduced situational awareness for the crew.