What happened
On November 27, 2008, a GOL Linhas Aéreas Boeing 737-700, registration PR-GIF, was performing a scheduled flight from Congonhas (SBSP) to Florianópolis (SBFL). During the landing phase on runway 14, the aircraft's left engine nacelle struck the runway, resulting in a heavy landing.
Prior to the incident, the flight crew had been operating the aircraft with the co-pilot as the pilot flying (PF) and the commander as the pilot monitoring (PM). While the approach was stabilized and the weather conditions were favorable, the commander observed a lateral deviation. At approximately 300 feet above the ground, the commander abruptly issued a "my controls" call and took over the flight controls.
The investigation
The CENIPA investigation examined the flight data from the Digital Flight Data Recorder (DFDR) and the aircraft's physical condition. Investigators ruled out mechanical failures, noting that there were no discrepancies in the flight controls and no fuel imbalance that could have caused the lateral drift. The investigation also noted that the Cockpit Voice Recorder (CVR) failed to record due to technical issues.
Analysis of the flight controls revealed that during the takeover, the commander applied significant rudder input to correct the perceived deviation. However, the investigation found that the pilot's feet may have been obstructed by the co-pilot's feet on the pedals, as the co-pilot was significantly taller than the commander. This led to a large wing tilt caused by rudder input without corresponding aileron correction, ultimately causing the engine nacelle to strike the pavement.
Findings
- Abrupt command takeover: The commander decided to assume control of the aircraft during short final rather than providing verbal guidance to the co-pilot to correct the lateral deviation.
- Inadequate Crew Resource Management (CRM): There was a lack of effective cockpit coordination and a failure in the management of human resources within the cabin.
- Improper control application: The use of high-amplitude rudder input without aileron coordination caused excessive wing tilt.
- Pilot judgment: The commander made an inadequate assessment of the approach stability and chose to continue the landing rather than performing a go-around, despite perceiving a control issue.