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A343, Rio de Janeiro Galeão Brazil, 2011

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Summary
On 8 December 2011, an Airbus A340-300 did not become airborne until it had passed the end of the takeoff runway at Rio de Janeiro Galeão, which was reduced in length due to maintenance. The crew were unaware of this fact nor the consequent approach lighting, ILS antennae and aircraft damage, and completed their intercontinental flight. The Investigation found that the crew had failed to use the full available runway length despite relevant ATIS and NOTAM information and that even using rated thrust from where they began their takeoff, they would not have become airborne before the end of the runway.
Event Details
When December 2011
Actual or Potential
Event Type
Controlled Flight Into Terrain (CFIT), Human Factors, Runway Excursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft AIRBUS A-340-300
Operator TAP Portugal
Domicile Portugal
Type of Flight Public Transport (Passenger)
Origin Rio de Janeiro/Galeão International Airport
Intended Destination Lisbon Portela Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Take Off
TOF
Location - Airport
Airport Rio de Janeiro/Galeão International Airport
General
Tag(s) Airport Layout,
Inadequate Airport Procedures,
CVR overwritten,
Delayed Accident/Incident Reporting,
Deficient Pilot Knowledge
CFIT
Tag(s) Into obstruction
HF
Tag(s) Inappropriate ATC Communication,
Procedural non compliance,
Ineffective Monitoring - SIC as PF
GND
Tag(s)
RE
Tag(s) Overrun on Take Off,
Runway Length Temporarily Reduced
Outcome
Damage or injury Yes
Aircraft damage Minor
Non-aircraft damage Yes
Causal Factor Group(s)
Group(s) Aircraft Operation,
Air Traffic Management,
Airport Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management,
Airport Management
Investigation Type
Type Independent

Description

On 8 December 2011, an Airbus A340-300 (CS-TOD) being operated by TAP Portugal on a scheduled international passenger flight (TP074) from Rio de Janeiro Galeão to Lisbon overran departure runway 10, which was reduced in length due to notified work-in-progress, during its night, normal visibility takeoff and then collided with runway 28 approach lights and ILS localiser antennae. Damage to the aircraft landing gear was not discovered until the flight had been completed and only when this was advised to the departure airport, did an inspection find the infrastructure damage caused.

Investigation

An Investigation was carried out by CENIPA, the Brazilian Aeronautical Accidents Investigation and Prevention Centre. Relevant data from the CVR and FDR had been overwritten due to the completion of the flight and the delay in notification of the event to CENIPA respectively. However, data of assistance to the Investigation were available from the QAR.

It was noted that the Captain had a total of 14,000 flying hours which included 700 hours on type and the First Officer, who was PF for the departure, had a total of 6,000 flying hours which included 900 hours on type. However, as per TAP Standard Operating Procedures (SOPs), taxiing until lined up for takeoff was always to be carried out by the Captain who would only hand over the control to a PF First Officer once lined up on the departure runway.

It was established that at the time of the takeoff, the first 1270 metres of 4000 metre-long runway 10 up to the taxiway AA intersection - see the illustration below - were out of service for the period of 31 October to 12 January due to ‘Work in Progress’. A corresponding NOTAM was in force and the ATIS included information on the reduced runway length. In order to make full use of the remaining 2730 metres, a departing aircraft would need to enter via taxiway AA or backtrack to reach that point. However, the ATC clearance issued by GND was found to have been to route via taxiways ‘M’, ‘T’ and ‘BB’. The Captain subsequently stated that, having seen an ‘X’ marking as the aircraft passed through the AA / BB taxiway intersection, he had “considered that it was closed” and continued ahead in accordance with the clearance received. As the aircraft was approaching the runway on taxiway ‘BB’, a takeoff clearance was given by TWR and immediately upon reaching the runway centreline, the First Officer took the controls and a rolling takeoff was commenced. Both pilots stated that they had “noticed a slight vibration at the end of the runway for about 3 to 4 seconds” but, with the aircraft already rotated they had attributed the vibration to an uneven pavement.

An extract from the current aerodrome chart showing the taxiways referred to. [Reproduced from the Brazil AIS due to the poor quality of the chart in the Official Report]

After takeoff, there had been a right main gear overheat indication, so the crew had delayed retraction to allow the gear to cool down. Unaware of their excursion and not notified differently by ATC, the flight was completed to the intended destination without further event. A routine post flight maintenance inspection found parts of the runway lighting system stuck between the right main gear and wheel no. 8 as well as damage to the right main landing gear and to main gear wheels no. 3, 7 and 8. It was also found that some parts of the right main landing gear were missing. The Galeão airport operator was advised and an inspection was made.

This inspection found damage to several runway 28 approach lights and to three antennae serving the runway 28 ILS. Tyre marks were found for up to 200 metres beyond the end of the runway 10 stopway with the final obstacle hit by the aircraft during takeoff being ILS localiser antennae which were 300 metres past the end of the stopway. Since this stopway was 60 metres in length, the distance between the end of runway 10 and the last obstacle hit by the aircraft was 360 metres and on the extended runway centreline.

Both pilots subsequently confirmed that they had been aware of the reduced available length of runway 10 and the Investigation was able to confirm that the crew had correctly inserted the reduced TODA into the FMGC and that the flex thrust setting used was valid for a takeoff commenced at the start of this available distance - although not for a takeoff commenced from the BB intersection. It was clear that the crew was unaware that their taxi clearance would leave them with approximately 600 metres less runway than they believed would be available. Prevailing ATC procedures were found to envisage two ways for aircraft to reach the beginning of the available runway, one via taxiways N, BB and AA and the other an alternative for “wide body aircraft” which might be unable to make the 135° turn from taxiway BB onto taxiway AA to remain on taxiway N until its intersection with taxiway AA where the left turn onto it was less severe.

The Investigation concluded that although responsibility for accepting and following a taxi clearance lay with the flight crew, the clearance given by ATC had been not only inadequate but also not in accordance with either of the documented options and specifically not the one envisaged for wide body aircraft such as the A340. The positional awareness of the pilots involved was assessed to have been poor although in their defence, it was concluded that the briefing material provided to them by TAP on the prevailing arrangements at Galeão had been inadequate.

The actual take off distance from the BB intersection was 2095 metres which was not only insufficient for a reduced thrust take off but also not even enough for a rated thrust take off so the overrun which occurred was inevitable.

Three Contributing Factors in respect of the event were documented as:

  • Airport Infrastructure - the arrangements in place because of the reduced runway length were inadequate.
  • Flight Planning - the crew accepted the clearance given without any reference to the aerodrome chart and passively assumed that they had entered the runway at its full available length.
  • Management Planning - pre flight briefing material provided to the crew by TAP was inadequate.

Two further possible Contributing Factors were classified as “undetermined”:

  • Managerial Oversight - the use of the term “wide body aircraft” against the alternative taxi route to the beginning of the available runway length instead of listing specific aircraft types.
  • Use of phraseology by ATS – the lack of clear guidance in respect of the location of the beginning of the available runway length and the best way to get to it may have induced the pilots to begin their takeoff from the wrong position.

Safety Action taken as a result of the event whilst the Investigation was in progress were noted as having included but not necessarily been limited to:

  • The Galeão Airspace Control Department (DTCEA-GL) issued revised instructions for taxi clearances issued to wide body aircraft departing from the restricted length of runway 10 limiting them to either taxiways M, U or AA or M, T, N and AA.
  • TAP issued revised pre-flight briefing information which more adequately described the situation at Galeão whilst runway 10 was only available at a reduced length.

A total of six Safety Recommendations were made as a result of the Investigation as follows:

  • that the Brazil National Civil Aviation Agency (ANAC) require that, in the case of work in progress at airports, Airport Operators strive to write requests for NOTAMs in a clear, simple, concise and ambiguity-free way so that NOTAMS can be understood without the need to consult other documents, in accordance with the prescriptions of the ICA 53-1/2012. [IG-556/CENIPA/2018 - 01]
  • that the Brazil National Civil Aviation Agency (ANAC) require that during the planning of works at aerodromes, Airport Operators provide the crews with written explanatory material containing information on the works, with widespread publicity to the operators that make use of the airport. [IG-556/CENIPA/2018 - 02]
  • that the Brazil National Civil Aviation Agency (ANAC) require that, during the planning of works at aerodromes, Airport Operators simulate aeronautical occurrences in all the phases of the works, with the objective of eliminating the hazards and mitigating the risks involved and monitor compliance accordingly. [IG-556/CENIPA/2018 - 03]
  • that the Brazil National Civil Aviation Agency (ANAC) require that airline companies operating in Brazil and regulated by RBAC 129 (which is applicable to foreign aircraft operations) inform the Brazilian Aeronautical Investigation Authority (CENIPA) of any aeronautical occurrence involving their aircraft within Brazilian territory, taking into account the requirements of the relevant legislation in force. [IG-556/CENIPA/2018 - 04]
  • that the Brazil Airspace Control Department (DECEA) require that ATC units establish and maintain, during the time operational agreements (relating to airport work in progress) are in force, an appropriate and standardised radiotelephony communication process taking into consideration the wingspan, length and weight of aircraft. [IG-556/CENIPA/2018 – 05]
  • that the Brazil Airspace Control Department (DECEA) require that ATC units refrain from using generic terms during the time in which operational agreements due to work in progress at the aerodrome are in force, and establish specific aircraft taxi routes taking into account the type of aircraft to which a clearance is being given. [IG-556/CENIPA/2018 - 06]

The Final Report was published on 4 September 2018.

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