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CENIPA published the final report of the serious incident of the Boeing 737 MAX from GOAL at Rio de Janeiro With a maintenance truck.
After six months of an incident that could have been catastrophic for Brazilian aviation, The entity in charge in Brazil of the Cenipa investigations, made public the final report of the accident.
The document of more than 100 pages is available for broader reading on the official website of the entity or by clicking here.
Final Incident Incident Report Boeing 737 Max in Rio
The 12 February 2025, a Boeing airplane 737-8 MAX, with PS-GPP registration, from the Gol Linhas Aéreas Inteligentes airline, experienced a serious incident during operations at Galeão International Airport, In janeiro river. The aircraft, that was preparing to take off on the runway 10, collided with a lights maintenance vehicle that was on the same runway. The impact, occurred during the take -off race, caused minor damage to the aircraft and destruction of the vehicle. Fortunately, there were no fatalities, although the occupants of the vehicle suffered minor injuries. The crew and 103 Passengers came out unharmed.
Accident details:
- Date and time: 12 February 2025, 01:08 UTC.
- Location: Galeão International Airport – Antonio Carlos Jobim, Rio de Janeiro, RJ.
- operators: Gol Linhas Aéreas Inteligentes S.A..
- aircraft: Boeing 737-8 MAX.
- Registration: PS-GPP.
- Damage to Aircraft: The plane suffered significant damage to multiple systems., including hydraulic system, of air conditioning, made out of fuel, of inert gas and landing train. The fuselage was also damaged., including a deformation and a hole.
- Victims: The vehicle's occupants suffered minor injuries.. The crew and passengers were unharmed..
Summary of the flight
The flight was a regular air transport of passengers from Gol Linhas Aéreas Inteligentes bound for Pinto Martins Airport in Fortaleza., CE. The aircraft transported 6 crew and 103 passengers. Takeoff began at approximately 01:08 UTC. During the takeoff roll, The aircraft collided with a lighting maintenance vehicle that was stopped in the center of the runway 10.
Research findings
The main cause of the incident was a lack of situational awareness and poor coordination in the control tower. Controllers and supervisor failed to notice or take appropriate action to avoid collision.
The final investigation report revealed a number of significant findings that go beyond the incident itself. Flight crew and air traffic controllers confirmed to have valid certifications and ratings. The weather conditions were favorable and no technical anomalies were found in the navigation aids or communication equipment..
Nevertheless, critical flaws in operating procedures and culture were identified that directly contributed to the accident. The investigation found that the control tower supervisor was distracted by his mobile phone and did not supervise the actions of the controllers. What's more, there was an informal group culture that tolerated unsafe behavior, such as the use of personal telephones and non-operational conversations during service.
It was concluded that the recurrence of operational failures, Despite previous similar events, demonstrated the ineffectiveness of corrective measures. This indicated weaknesses in the organizational culture to positively reinforce a safety culture..
Contributing factors
The investigation identified the following contributing factors, which are summarized in the report as oversight deficiencies, Group culture, team dynamics, Memory, the perception, The decision -making process and organizational processes:
- Supervision (ATS): The supervisor did not pay attention to the activities of the shift controllers, since he was using his cell phone, which diverted him from his duty of continuous supervision. What's more, adopted a passive stance during and after the emergency. He was found to have misinterpreted his responsibilities, believing that their supervisory role ended after a specific time, which exempted him from the responsibility of aborting the takeoff or supporting the other controllers.
- Group culture: A climate of excessive informality, with tolerance for mobile phone use and non-operational conversations, normalized behaviors incompatible with operational safety. This weakened defensive barriers and encouraged repetition of errors..
- Organizational culture: The recurrence of operational failures, even after 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, such as the use of cell phones and the lack of use of headphones, pointed to deficiencies in institutional mechanisms to reinforce a security culture.
- Team dynamics: Failures were observed in the interaction between members of the control tower team, characterized by the absence of supervisor support, confusion among drivers after the collision and inefficiency in task management.
- Memory: The omission of the visual runway scan and lock screen check in the TATIC system evidenced memory lapses related to the execution of routine procedures. These lapses were exacerbated by distractions.
- Perception: The inability to perceive the vehicle on the track indicated a deterioration in the drivers' situational awareness., which facilitated the continuation of an incorrect operational procedure.
- Decision -making process: The decision to maintain takeoff authorization, even after the driver remembered the presence of the vehicle, showed a failure in the decision-making process, which was incompatible with the principles of flight safety.
- Organizational processes: Despite mitigation measures previously taken for similar incidents, the persistence of the same operational behaviors demonstrated their ineffectiveness. The report indicated that organizations often treat symptoms rather than the structural causes of problems, which perpetuates failures and undermines the continuous improvement cycle.
Regarding the recommendations, one was issued to disseminate the lessons learned from this investigation to class III and IV aerodrome operators, in order to share the risks identified in internal events and promote operational safety. Immediately after the incident, measures were taken such as the removal of the air traffic controllers involved from their operational duties and the provision of psychological support.
Recommendations and research findings
A formal recommendation was issued to the General Directorate of the Airspace Control Department (Decea). The objective is for this recommendation to be disseminated to all class III and IV aerodrome operators.. The intention is to share the lessons learned from this research, as well as risks identified during internal events, To strengthen operational security and prevent similar situations from repeating.
- Removal of personnel: Immediately after the incident, The air traffic controllers and supervisor involved were removed from operational duties and temporarily prohibited from performing air traffic control-related duties..
- Psychological support: The staff involved received psychological support to mitigate the emotional impact of the event..
- Security monitoring: A follow-up was carried out on the operational information meetings of the Galeão control tower team.
- Training and awareness: The topic of “incursion on the runway” was presented to operational personnel. Best practices for radio communication were reinforced, the use of hearing aids and attention to operational responsibilities. The report emphasizes the need to combat informal behaviors, such as the use of personal telephones, that affect security.
- Process evaluation: The report noted that, despite mitigation measures taken in the past, The persistence of the same operational behaviors demonstrated the ineffectiveness of said actions. This revealed the need to review and strengthen organizational strategies to improve safety culture and governance of critical processes.. Analysis of organizational processes suggests that organizations tend to address the symptoms of problems rather than their structural causes., which perpetuates failures and undermines continuous improvement.
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