What happened
On April 9, 2014, a Fokker F28MK0100, registration PR-OAL, operated by Ocean Air Linhas Aéreas, was conducting a scheduled flight from Porto Alegre to Guarulhos International Airport (SBGR). The aircraft was carrying 86 passengers and 5 crew members.
During the approach, the crew was authorized to land on runway 27L. However, due to the unavailability of the ILS equipment for that runway, the crew transitioned to a VOR procedure. During the final stages of the approach, the aircraft landed on runway 27R. There were no injuries to the passengers or crew, and the aircraft sustained no damage.
The investigation
CENIPA's investigation focused on why the crew failed to identify the correct runway despite having authorization for 27L. The investigation examined the aeronautical charts, NOTAMs, and ATIS information available at the time.
Investigators found that while a NOTAM had indicated the ILS for 27L was inoperable, this specific information was not included in the ATIS message used by the crew. Furthermore, the crew's flight planning was impacted by a lack of familiarity with the specific longitudinal offset between the 27L and 27R runway thresholds, which exceeds 1,000 meters. The investigation also noted that the aircraft's ADC (Aerodrome Chart) at the time did not fully represent taxiway 'A', and the VOR approach chart lacked a specific remark regarding the runway displacement.
Findings
- The crew's attention was diverted by the unexpected unavailability of the ILS and the need to manage the transition to a VOR approach, leading them to overlook the specific runway layout.
- A perceptual distortion occurred where the crew, expecting to see runway 27L, identified the visible runway 27R as the intended target.
- The decision to proceed with a visual approach after passing the Final Approach Fix (FAF) prevented the crew from executing the 5-degree left turn prescribed in the VOR procedure, which might have helped distinguish the correct runway.
- There was a lack of situational awareness regarding the longitudinal offset between the two runways.
- The crew demonstrated a degree of complacency by not adequately reviewing the NOTAM content regarding equipment inoperability.