What happened
On May 25, 2022, a Cessna 650, registration PR-DIO, was performing a private flight from Belém to São Paulo. During the approach to Congonhas Airport (SBSP), São Paulo Approach Control authorized the aircraft to perform an RNP S approach for runway 35R. The São Paulo Tower subsequently authorized the aircraft to land on runway 35R. However, the crew landed the aircraft on runway 35L, which is parallel to the authorized runway. At the time of the landing, runway 35L was clear and no other aircraft were waiting at the holding point. There were no injuries to the two crew members or the six passengers, and the aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the breakdown in communication and coordination between the flight crew and air traffic controllers. The investigation examined the flight history, pilot qualifications, and the sequence of radio communications. Investigators analyzed the lack of proper readbacks (cotejamento) by the crew regarding critical instructions, such as descent levels and runway assignments. The investigation also reviewed the performance of the air traffic controllers, specifically noting the lack of assertive intervention when the crew failed to repeat essential information correctly.
Findings
- The flight crew failed to perform mandatory readbacks of critical instructions, including the assigned descent level, vectoring limits, and the specific runway in use.
- The crew did not verify the expected approach procedure during the descent, leading to a loss of situational awareness.
- The air traffic controllers failed to correct the crew's erroneous or incomplete readbacks, allowing the discrepancy in runway assignment to go unaddressed.
- The crew's perception was compromised by an incorrect expectation regarding the authorized procedures.
- The airport infrastructure, specifically the parallel runway layout and the necessity of crossing runways to access parking areas, may have influenced the crew's error.