What happened
On July 19, 2017, an A319-115, registration PR-AVC, operated by Oceanair Airlines, was performing a scheduled passenger flight from São Paulo to Rio de Janeiro. The aircraft was on an RNAV Y approach to runway 28 at Antônio Carlos Jobim Aerodrome (SBGL). During the final approach, the crew initiated a go-around procedure while below the Minimum Descent Altitude (MDA).
Immediately following the start of the missed approach, the Enhanced Ground Proximity Warning System (EGPWS) issued two "Too Low, Terrain" alerts. The aircraft's descent inertia caused it to reach an altitude of approximately 291 feet, with the radio altimeter recording a height of 162 feet above the terrain at its lowest point. Following the go-around, the crew transitioned to an ILS approach for runway 15, completing the landing safely. There were no injuries to the 118 passengers or 6 crewmembers, and the aircraft sustained no damage.
The investigation
CENIPA's investigation focused on the flight profile and crew performance during the approach. Investigators found that the crew utilized a Vertical Speed (V/S) guiding mode, a technique not explicitly foreseen in the airline's Flight Crew Operating Manual (FCOM) for this specific RNAV procedure. This choice led to an excessive descent rate that destabilized the approach.
Furthermore, the investigation noted that a specific altitude restriction at fix GL083 was not clearly indicated on the approach charts provided by DECEA, contributing to the crew's inability to maintain the required profile. The investigation also examined the crew's failure to follow established EGPWS warning procedures and the lack of effective coordination during the critical moments of the missed approach.