What happened
On November 18, 2021, at approximately 02:35 UTC, a 737-8EH, registration PR-GXH, operated by Gol Linhas Aélaras S.A., was performing a scheduled commercial flight from São Paulo (SBGR) to Maringá (SBMG). The flight was carrying 105 passengers and six crew members.
During the approach to runway 28, the aircraft encountered deteriorating weather conditions, including moderate rain, wind gusts up to 25 knots, and nearby thunderstorms. While the aircraft met the requirements for a stabilized approach, the pilot flying (PF) struggled to maintain the correct descent path and centerline. Upon touchdown, the aircraft was approximately eight meters from the right edge of the runway. During the landing roll, the aircraft drifted further to the right, crossing the runway edge markings and striking three runway lights. The aircraft sustained minor damage to its tires, wheels, and lower fuselage panels, while the damaged lights were destroyed. All 111 occupants were unharmed.
The investigation
CENIPA examined the flight data, cockpit voice recorder, and meteorological reports. The investigation focused on the pilot's decision to disengage the autopilot at 1,100 feet above field elevation (AFE) despite the challenging environment. Investigators also reviewed the crew's performance, the impact of visibility-reducing heavy rain, and the lack of visual approach aids at the aerodrome. The investigation noted that the pilots experienced glare from runway lights and reflections off the heavy rain, which further obscured their vision during the final stages of the approach.
Findings
- Improper manual flight techniques: The pilot flying applied excessive and corrective commands, leading to oscillations in pitch and heading that resulted in an off-center touchdown.
- Inadequate decision-making: The decision to disengage the autopilot and continue the landing manually under high-workload conditions (night, heavy rain, and wind gusts) was a significant contributing factor.
- Adverse weather: Heavy precipitation and wind gusts reduced visibility and made maintaining the approach path difficult.
- Reduced situational awareness: The lack of visual glide slope indicators (such as PAPI or VASI) at the airport increased the complexity of the night approach.
- Crew coordination: The pilot monitoring (PM) observed the lateral drift but did not intervene with assertive verbal inputs to prompt a missed approach.
Safety action
CENIPA issued recommendations to the National Civil Aviation Agency (ANAC) to evaluate the installation of visual approach aids (ALS, VASIS, or PAPI) at Maringá Airport to improve pilot situational awareness during night operations. Additionally, it recommended that flight training programs review manual handling skills and simulator scenarios involving similar high-workload, adverse weather environments.