What happened
On October 27, 2013, a 737-8EH, registration PR-GGY, operating for VRG Linhas Aé and part of the GOL Group, was performing a flight from Congonhas (SBSP) to Santos Dumont (SBRJ) as part of a training/adaptation session for the co-pilot. Due to high winds and gusts reaching 38 knots at Santos Dumont, the crew decided to divert to Galeão Airport (SBGL) in Rio de Janeiro.
During the approach to SBGL, the aircraft landed on a portion of the runway that was actually closed for maintenance work. The landing was characterized as a long landing, and the aircraft entered the section of the runway that was under construction. While the crew and all 91 passengers escaped without injury, the aircraft entered an area that was restricted per NOTAM D2914/201 and was subject to ongoing works for shoulder widening.
The investigation
CENIPA's investigation revealed a breakdown in cockpit coordination and situational awareness. The investigation established that during the flight, a high level of tension existed between the pilots. The commander, acting as an instructor, had become dissatisfied with the co-pilot's performance during the initial leg of the flight, leading him to unilaterally decide to assume all piloting duties and suspend the training session. This effectively eliminated the division of tasks and the collaborative nature of the crew.
Furthermore, the investigation found that the crew failed to properly evaluate the flight status information and ATIS, which indicated the runway closure. The investigation also noted that the Air Traffic Control (ATC) service did not alert the crew to the specific risks of the approaching closed section, and the physical signage at the runway did not clearly demarcate the new operational limits. Additionally, the company's internal flight status documents were found to be visually unclear, which hindered the crew's decision-making process.
Findings
- Improper decision-making regarding the landing on a partially closed runway due to inadequate evaluation of available aeronautical information.
- Failure in Crew Resource Management (CRM), characterized by a breakdown in communication and coordination between the commander and the co-pilot.
- Degraded situational awareness resulting from the commander's decision to operate the aircraft without the active assistance of the co-pilot.
- Negative cockpit climate caused by interpersonal tension and an instructional approach that led to a lack of teamwork.
- Inadequate organizational support, including non-standardized instructional methodologies and unclear flight status documentation.
- Inadequate runway signaling and a lack of timely warnings from Air Traffic Services regarding the specific hazards of the closed runway segment.