What happened
On April 18, 2019, at approximately 21:09 UTC, a serious incident involving a loss of separation occurred during the final approach to Cabo Frio Airport (SBCB), Brazil. The two aircraft involved were a Sikorsky S-76C, registration PR-CHE, and a Canadair CL-600-1A11, registration N100QR.
The S-76C was performing a ferry flight from Rio de Janeiro under Visual Flight Rules (VFR). Meanwhile, the N100QR was arriving from Argentina on an RNAV (GNSS) instrument approach. During the approach, the crew of the N100QR executed a missed approach (go-around) but failed to follow the prescribed missed approach procedure. Instead, the crew performed a left turn and entered the visual traffic pattern without notifying air traffic control (ATC) of their change in flight rules or requesting a visual approach.
As the N100QR proceeded on short final, it overtook the PR-CHE, passing underneath the helicopter with a vertical separation of approximately 100 feet. Both aircraft landed safely without damage, and all occupants—including four crew members on the PR-CHE and ten occupants on the N100QR—remained uninjured.
The investigation
CENIPA's investigation focused on the breakdown in communication and flight discipline. The investigation established that the crew of the N100QR deviated from established norms by not notifying APP-ES (São Pedro da Aldeia Approach) regarding the cancellation of their IFR flight plan or their transition to VFR.
Furthermore, the investigation examined the role of air traffic controllers. It was noted that the controller transferred communications for the second aircraft in the sequence to the local tower (EPTA-CB) before the first aircraft, which did not meet the operational requirements for traffic sequencing. The investigation also highlighted potential language barriers, noting that while the N100QR crew was proficient in English, the controller's proficiency in English for complex operations in that region was likely inadequate, leading to errors in interpretation and communication.