What happened
On November 30, 2017, an A320-232, registration PR-MBG, operated by TAM Airlines, was landing at Brasília Aerodrome (SBBR) following a flight from Santarém (SBSN). The aircraft was carrying 149 passengers and 6 crewmembers. During the landing roll, the aircraft crossed the left side of the runway, resulting in a runway excursion. The aircraft struck several beacon lights and damaged electrical junction boxes. While the aircraft sustained minor damage to its left main landing gear tires, all occupants remained unharmed.
The investigation
CENIPA's investigation established that the flight was operating under Instrument Meteorological Conditions (IMC) with heavy rain, thunderstorms, and significant wind shear. The aircraft was operating with the Auto Thrust (A/THR) system in the OFF position due to a Minimum Equipment List (MEL) deferral. The investigation examined the flight crew's performance, the meteorological conditions, and the airline's scheduling practices. Investigators noted that the crew had previously initiated a missed approach due to destabilized approach conditions and high winds before attempting a second landing.
Findings
Several contributing factors were identified that led to the excursion:
- Inadequate pilot control: The crew reduced the thrust levers to IDLE and initiated the flare at approximately 80 feet, which, combined with insufficient rudder and aileron control, led to the off-axis landing.
- Adverse weather: Heavy rain, thunderstorms, and a strong wind component of up to 20 knots created a challenging operational environment.
- Fatigue and scheduling: The airline's flight scheduling and roster planning placed the crew in a state of susceptibility to fatigue, which likely degraded their physical and mental performance and decision-making capabilities.
- Operational judgment: The decision to proceed with the second landing approach despite deteriorating weather conditions was identified as an inaccurate assessment of the risks.
- Technical configuration: The absence of the Auto Thrust system increased the workload and complexity of the landing maneuver during adverse conditions.