What happened
On April 10, 2018, at approximately 00:30 UTC, a runway incursion occurred at Presidente Juscelino Kubitschek International Airport (SBBR) in Brasília. A Boeing 737-8EH, registration PR-GTN, operated by Gol Linhas Aéreas, was performing a scheduled takeoff for a flight to São Luís. During its takeoff roll, the flight crew identified that a Brazilian Air Force (FAB) C-95M (registration FAB 2345) was still occupying the runway after having just landed.
The crew of the 73 and 8EH proceeded with the takeoff, passing over the stationary military aircraft. There were no injuries to the 154 passengers and 6 crewmembers on the Boeing, nor to the 5 passengers and 3 crewmembers on the Embraer. No damage was sustained by either aircraft.
The investigation
CENIPA's investigation focused on the communication and visibility factors at the tower. The investigation established that the Tower controller authorized the 737-8EH to align and maintain on the runway while the C-95M was still on the active runway.
Investigators found that the Tower controller instructed the C-95M crew to contact Ground Control without first requiring them to report when the aircraft had cleared the runway. This instruction led the military crew to switch frequencies while still on the runway. Furthermore, the investigation noted that the controller's ability to visually monitor the runway was compromised by several factors, including airport infrastructure and lighting.
Findings
- ATC Phraseology and Procedures: The controller did not use the instruction for the aircraft to report when it had cleared the runway. The instruction to switch to Ground Control without conditioning it on runway clearance induced the military crew to change frequencies while still occupying the runway.
- Airport Infrastructure: The presence of several blind spots at the aerodrome prevented the controller from seeing the C-95M. Additionally, the lack of a Surface Movement Radar (SMR) contributed to the inability to detect the aircraft's position.
- Visual Obstructions: Lighting from the apron spotlights interfered with the controllers' line of sight, and certain areas of the taxiway were obscured by vegetation.
- Human Perception: The controller's perception was affected by an expectation that the aircraft would follow guidance, and the visual similarity between the letters "C" and "G" in taxiway designations may have contributed to pilot misperception.
- Crew Performance: The C-95M crew did not comply with the initial instruction to clear the runway via Taxiway "G", instead using Taxiway "F", which kept them on the runway longer than anticipated.