What happened
On the night of January 26, 2003, a VASP Boeing 737-200, registration PP-SPJ, was performing a night approach to runway 06 at Rio Branco Airport, Acre, Brazil. The flight had originated in Manaus, and the crew had previously experienced difficult weather conditions at the destination on the preceding day.
During the approach, the crew was executing a VOR/DME procedure. While the aircraft was descending, it struck a tree at an altitude of approximately 57 feet, about 3..'360 meters from the runway threshold. Following this impact, the aircraft struck the ground 100 meters from the threshold, causing the landing gear to collapse. The aircraft then slid approximately 600 meters through the grass, parallel to the runway, before coming to a stop. Despite the heavy damage to the airframe, all 6 crew members and 89 passengers evacuated the aircraft without injury.
The investigation
CENIPA's investigation focused on the flight crew's adherence to Standard Operating Procedures (SOP) and the operational environment. Investigators found that the crew had failed to perform several critical tasks, including the descent briefing and the analysis of the approach charts. The descent was conducted with significant deviations from established parameters: the crew shortened the outbound leg by 54 seconds, descended to 900 feet during the turn (instead of the required 1,900 feet), and maintained a descent rate of 1,222 feet per minute, far exceeding the prescribed 600 feet per minute.
Furthermore, the investigation examined the crew's experience levels. The commander had only been in the command position for five months and was unfamiliar with this specific route. The co-pilot was relatively inexperienced on the Boeing 737-200, having recently transitioned from a light piston aircraft. The investigation also noted potential psychological pressure from ground dispatch personnel, who had urged the crew to land to accommodate arriving passengers.
Findings
- Inadequate cockpit management due to the failure to follow SOPs during the descent, which reduced the crew's situational awareness.
- Improper flight planning and execution, characterized by a lack of proper descent briefings and the failure to define critical parameters such as call-outs and cross-checks.
- Deviations from established approach parameters, including excessive descent rates and speeds, which led to an error in altitude assessment.
- Inadequate crew experience for the specific operational requirements of the Amazon region, combined with a lack of recent CRM training.
- Organizational failures regarding crew supervision and human resources, specifically the assignment of a newly promoted commander and an inexperienced co-pilot to a complex route.
- External pressure from company dispatch staff to complete the landing, which may have influenced the crew's decision-making.