What happened
On September 24, 2009, an ATR-42-320, registration PP-PTJ, operated by TRIP Linhas Aéreas S/A, was performing a scheduled flight from Ribeirão Preto (SBRP) to Rio de Janeiro (SBRJ). During the final approach to Santos Dumont Airport, Rio de Janeiro Tower (TWR-RJ) instructed the crew to reduce their approach speed to the minimum possible to allow an inspection vehicle to check runway 20R for standing water following recent rainfall.
As the crew observed the inspection vehicle on runway 20R, they automatically continued their approach toward runway 20L. Although a NOTAM was in effect indicating that runway 20L was closed for maintenance, the crew did not identify the runway closure markings—consisting of plastic, stones, and tarps—until the moment of touchdown. The aircraft landed on the unavailable runway, but the crew and all 9 passengers escaped without injury, and the aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the crew's failure to adhere to standard communication protocols and the effectiveness of the airport's visual signaling. The investigation established that while the crew was aware of the runway closure via NOTAM and ATIS prior to the flight, they failed to effectively manage cockpit resources or verify instructions during the critical approach phase.
Investigators noted that the crew did not perform the mandatory read-back of ATC instructions as required by ICA 100-12. Had the pilot in command properly read back the specific runway assignment, the discrepancy between the instruction and the intended landing runway could have been identified. Furthermore, the investigation examined the visibility of the runway closure markers, which were obscured by recent rain and the crew's focus on the inspection vehicle on the parallel runway.
Findings
- Inadequate cockpit coordination: The crew failed to cross-check ATC instructions and did not effectively utilize available information, such as the NOTAM and ATIS, during the descent briefing.
- Failure to verify ATC communications: The crew did not comply with the requirement to fully read back essential ATC instructions, which would have clarified the specific runway in use.
- Ineffective runway signaling: The use of tarps and stones to mark the closed runway was likely insufficient for the weather conditions, as the crew did not visually identify the markings until landing.
- Distraction and habit: The presence of the inspection vehicle on the adjacent runway and the crew's habitual use of runway 20L likely contributed to the oversight.