Incident Overview

Date: Wednesday 25 August 2010
Aircraft Type: Embraer EMB-145LU (ERJ-145LU)
Owner/operator: Passaredo Linhas A‚reas
Registration Number: PR-PSJ
Location: Vit¢ria da Conquista Airport, BA (VDC) – ÿ Brazil
Phase of Flight: Landing
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 38
Component Affected: Aircraft Flight Controls & Pilot’s ActionsAircraft Flight Controls & Pilot’s Actions
Investigating Agency: CENIPACENIPA
Category: Accident
An Embraer ERJ145 sustained significant damage during a runway excursion accident at Vit¢ria da Conquista Airport, resulting in a substantial landing gear and underside impact with a small mound on the final segment of a VFR approach to runway 15. The aircraft subsequently skidded 300 meters and exited the runway via its left side, impacting the ground at approximately 35 meters. The incident was attributed to a confluence of contributing factors, including attention lapses, a reliance on a suboptimal approach angle, pilot error related to glide path correction, and visual illusions related to the runway’s characteristics.An Embraer ERJ145 sustained significant damage during a runway excursion accident at Vit¢ria da Conquista Airport, resulting in a substantial landing gear and underside impact with a small mound on the final segment of a VFR approach to runway 15. The aircraft subsequently skidded 300 meters and exited the runway via its left side, impacting the ground at approximately 35 meters. The incident was attributed to a confluence of contributing factors, including attention lapses, a reliance on a suboptimal approach angle, pilot error related to glide path correction, and visual illusions related to the runway’s characteristics.

Description

An Embraer ERJ145 sustained substantial damage in a runway excursion accident at Vit¢ria da Conquista Airport, BA (VDC). On the final segment of a VFR approach to runway 15, the main landing gear and the underside of the aircraft hit a small mound located short of the runway threshold. The aircraft skidded for 300 meters and ended up exiting the runway via its left side. It came to rest at approximately 35 meters from the runway. The aircraft sustained substantial damage. Contributing factors. – Attention – a contributor. During the approach, the flight crew’s attention was focused on the characteristics of the geographical relief and presence of birds, reducing their awareness as to the maintenance of the approach slope. – Work-group culture – a contributor. The group culture of maintaining a low angle of approach led the crew to choose the runway aspect instead of the VASIS as a reference for the approach, making them susceptible to various types of spatial illusion. – Handling of aircraft flight controls – undetermined. Taking into account copilot’s report that he was not succeeding in correcting the aircraft glide path relative to the runway, one may suppose that he was not applying the appropriate amplitude for such correction. – Visual illusions – a contributor. The physical characteristics of the runway 15 (the active one) contributed to a wrong perception of the ideal glide path. The pronounced acclivity of the runway, its width (narrower than the runways on which the crew was accustomed to operate), and the low terrain near the threshold, caused in the pilots a perception that they were above the ideal approach slope, leading them to seek correction, which resulted in an angle of approach below the ideal one. – Management planning – undetermined. For the flight in question, the company chose two pilots who had never operated in SBQV. A crewmember with previous experience in the locality would have a higher level of awareness in relation to the specific characteristics of the aerodrome. – Support systems – a contributor. No company publications were found that could provide the pilots with guidance on the specifics of SBQV, capable of helping with the management of the risks associated with the operation in that aerodrome.

Primary Cause

Suboptimal Approach Angle and Pilot ErrorSuboptimal Approach Angle and Pilot Error

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