What happened
On April 5, 2022, at approximately 22:10 UTC, an ERJ 190-200 LR, registration PR-AXH, was operating a scheduled commercial flight from Congonhas Airport (SBSP) to Santos Dumont Airport (SBRJ) in Rio de Janeiro. The aircraft was carrying 53 passengers and 5 and 5 crew members.
During the approach to SBRJ, air traffic controllers authorized the aircraft to land on runway 20L. However, the landing was actually executed on runway 20R. The aircraft sustained no damage, and all occupants were unharmed.
The investigation
CENIPA's investigation focused on why the aircraft landed on a runway other than the one authorized. Investigators examined the airfield lighting control and monitoring system (ACAMS-ALCMS) and found that the lighting for runway 20L had been extinguished for approximately 7 minutes and 17 seconds, spanning the period of the aircraft's approach and landing.
While the lighting for runway 20R remained operational, the investigation scrutinized the performance of the air traffic controllers and the operational environment at the tower. The investigation also reviewed the technical interface of the lighting control system and the distribution of duties among the controllers on duty.
Findings
- The unintentional deactivation of runway 20L lighting was the primary factor leading to the landing on the alternative runway.
- The air traffic controller in the assistant position failed to properly support the tower controller, which hindered situational awareness.
- The ACAMS-ALCMS system failed to issue an alert regarding the deactivation of the runway lights, and the system's color interface was not intuitive for identifying the status of the lights.
- There was a lack of adequate supervision, as the person in charge of ATS (Air Traffic Services) was performing administrative duties, and no specific supervisor or coordinator position was active at the time.
- The organization of work and the distribution of tasks among the remaining operational positions may have contributed to the failure to identify the lighting outage.
Safety action
CENIPA issued several recommendations to ANAC and DECEA, including the need to disseminate lessons learned to operators and to investigate the installation of camera systems in the tower to monitor workload and task distribution. Additionally, recommendations were made to improve the ACAMS-ALCMS interface by using more intuitive colors (such as green for 'on' and red for 'off') and implementing audible or visual alarms for the deactivation of critical airfield lighting.