Public Cenipaó the final report of the serious incident of the Boeing 737 MAX from GOAL at Rio de Janeiro With a maintenance truck.
AfteréS six months of an incident that could be catastrócost for aviationón brazilña, The entity in charge in Brazil of the Cenipa investigations, hizo púthe war final report of the accident.
The M documentás de 100 páginas is available for reading más wide on the official website of the entity or Clicking hereí.
Final Incident Incident Report Boeing 737 Max in Rio
The 12 February 2025, I saw oneón Boeing 737-8 MAX, with marriageíps-gpp cula, from the airíNEA GOL LINES AéSmart areas, experimentó A serious incident during operations at Gale International AirportãO, an RíJanuary's. The aircraft, which is availableíTo take off the track 10, collisionó with a vehicleílight maintenance ass on the same track. The impact, occurred during the take -off race, causó andñminor in the avión and the destructionóvehicle numberíass. Fortunately, There was no vídearest mortals, although the occupants of the vehicleíass suffered minor injuries. The crewón and the 103 Passengers came out unharmed.
Accident details:
- Date and time: 12 February 2025, 01:08 UTC.
- Locationón: Gale International AirportãO – AntôNio Carlos Jobim, RíJanuary's, RJ.
- operators: Gol Lines AéReas Intelligentes S.A..
- aircraft: Boeing 737-8 MAX.
- foodíbutt: PS-GPP.
- Andñto the aircraft: the grandfatherón sufferó andñthe significant in múLtas systems, including the hydro systemáthe street, of air conditioning, made out of fuel, of inert gas and landing train. The fuselage tooén sufferó andños, including a deformationón and a hole.
- Víhonor: The occupants of the vehicleíass suffered minor injuries. The crewón and the passengers came out unharmed.
Summary of the flight
The flight was a transport toéRegular Passenger Passengers Linhas AéIntelligent areas bound for Pinto Martins Airport of Fortaleza, CE. The aircraft transported 6 crew and 103 passengers. The takeoff is initialó approximately at 01:08 UTC. During the takeoff roll, The collision aircraftó with a vehicleílight maintenance ass that was stopped at the center of the track 10.
Research findingsón
The main cause of the incident was the lack of situational awareness and coordinationóN poor in the control tower. The controllers and the supervisor did not perceive or take the appropriate measures to avoid the colisión.
The final report of the investigationón reveló a series of significant findings that go más allá of the incident in Sí. Se confirmó that the crewóN flight and TR controllersáI'm theéinmate had certifications and qualifications Váread. Meteorological conditionsógica were favorable and no anomal were foundías téCnics in navigation aidóNo in the communication teamsón.
Nevertheless, CR faults were identifiedíethics in the procedures and operational culture that contributed directly to the accident. The investigationón foundó that the supervisor of the control tower was distractedído with your teléphono móvile and not supervisó The actions of the controllers. Además, existíto an informal group culture that tolerated insecure behaviors, as the use of Telépersonal phones and non -operational conversations during service.
It is concludedó that the recurrence of operational failures, Despite previous similar events, demonstratedó The inefficiency of corrective measures. This indicatesó weaknesses in organizational culture to positively reinforce a culture of security.
Contributing factors
The investigationóI don't identifyó The following contributing factors, that are summarized in the report as deficiencies in the supervisión, Group culture, to fromáTeam Mica, Memory, I perceive itón, The decision -making process and organizational processes:
- Supervisionón (ATS): The supervisor no PERó attentionón to the activities of the shift controllers, since he was using his telécell phone, What diverted itó Of his duty of Supervisión continues. Además, adoptó A passive posture during and afterés of the emergency. It wasó that you haveíto one interpretón erróNEA of your responsibilities, believing that its functionón de supervisión ended afterés of a specific scheduleífico, WHAT I EXIMó of the responsibility of aborting to take off or support the other controllers.
- Group culture: A climate of excessive informality, With tolerance to the use of Teléphones móViles and non -operational conversations, NORMALIZó behaviors incompatible with operational safety. This weakesó Defensive barriers and fomentó The repetitionón of errors.
- Organizational culture: The recurrence of operational failures, even afteréS of similar events, and the low effectiveness of the corrective actions adopted revealed weaknesses in the organizational culture. The tolerance of behaviors that do not comply with the rules, as the use of Telécell phones and the lack of headphones use, readyó A deficiencies in institutional mechanisms to strengthen a security culture.
- fromáTeam Mica: Failures were observed in the interactionón Among the members of the control tower team, characterized by the absence of supervisor support, confusedón among the controllers afterés of the colisión and inefficiency in managementón of tasks.
- Memory: I left itón of the visual sweep of the track and the verificationón of the lock screen in the tatic system evidenced memory -related memory failuresón of routine procedures. These lapses were exacerbated by distractions.
- Perceiveón: The inability to perceive the vehicleíass on the track indicatesó A deterioration in the situational consciousness of the controllers, What facilitatesó the continuationón of an incorrect operational procedure.
- Decision -making process: I decided itón of maintaining authorizationótakeoff number, even afterés that the Record driveró The presence of the vehicleíass, recordsó A failure in the decision -making process, which was incompatible with the principles of flight safety.
- Organizational processes: Despite mitigation measuresón previously taken for similar incidents, the persistence of the same operational behaviors demonstratesó Its inefficiency. THE INDICE REPORTó that organizations often treat the Síntomas instead of the structural causes of problems, What perpetúto the failures and undermines the continuous improvement cycle.
Regarding the recommendations, se emitió one to disseminate the lessons learned from this researchón to Aer operatorsóClass III and IV dromos, in order to share the risks identified in internal events and promote operational safety. Immediately afterés of the accident, Measures such as Remoci were takenón of TR controllersáI'm theéinmate involved in their operational functions and the provisionóPS PSYCHOL Nógic.
Recommendations and research discoveriesón
SE Emitió a recommendationón formal to the directionóGeneral of the space control department Aéreo (Decea). The objective is that this recommendationón is disseminated to all Aer operatorsóClass III and IV dromos. The to intendón is to share the lessons learned from this researchón, así as the risks identified during internal events, To strengthen operational security and prevent similar situations from repeating.
- Remocióstaff number: Immediately afterés of the accident, tr driversáI'm theéinmate and the supervisor involved were removed from their operational functions and prohibited themó temporarily perform tasks related to TR controlánsito aéreo.
- PSYCHOL SUPPORTógic: The personnel involved receivedó PSYCHOL SUPPORTóGico to mitigate the emotional impact of the event.
- Monitoringóno of security: It takesó carried out a monitoring of information meetingsóN Operational of the Gale Control Tower TeamãO.
- Trainingón and awarenessón: The theme of «incursón on the track» It was presented to the operational staff. The best PR were reinforcedáCTICS FOR COMMUNICATIONón by radio, The use of Audíphones and attentionón to operational responsibilities. The report emphasizes the need to combat informal behaviors, as the use of TeléPersonal phones, that affect security.
- Evaluationón of processes: The report isñaló what, Despite mitigation measuresón adopted in the past, the persistence of the same operational behaviors demonstratesó The inefficiency of these actions. This revealsó The need to review and strengthen organizational strategies to improve the culture of security and governance of CR processesíticos. El anáLisis of organizational processes suggests that organizations tend to address the Síproblems of problems instead of its structural causes, What perpetúto failures and undermines continuous improvement.
