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ASN Wikibase Occurrence # 253768
Last updated: 3 October 2021
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Date:18-APR-2019
Time:21:09 UTC
Type:Silhouette image of generic CL60 model; specific model in this crash may look slightly different
Canadair CL-600-1A11 Challenger 600
Owner/operator:private
Registration: N100QR
MSN: 1043
Fatalities:Fatalities: 0 / Occupants: 10
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Cabo Frio, RJ (SBCB) -   Brazil
Phase: Approach
Nature:Unknown
Departure airport:San Fernando Airport, BA (FDO/SADF)
Destination airport:Cabo Frio Airport, RJ (CFB/SBCB)
Investigating agency: CENIPA
Narrative:
The Sikorsky S-76C, registered PR-CHE, took off from Jacarepaguá, Brazil, around 20:45 UTC, in order to perform a repositioning flight, with two pilots on board. Destination was Cabo Frio.
A Canadair Challenger 600 jet, registered N100QR, was also flying towards Cabo Frio, carrying two pilots and eight passengers.
After starting from an instrument approach procedure, the crew of N100QR changed to a visual approach and, on final approach, overtook PR-CHE, passing under the helicopter, which was also on final approach, with approximately 100 feet of vertical separation.
After the crossing, both aircraft landed without further problems.

Contributing factors.
- Attitude - contributed.
The actions of the N100QR pilots, from the moment they commanded the take-off, indicated a complacent attitude towards the compliance with the air traffic regulations applicable to that flight, fact that favored the air traffic conflict between the aircraft involved in the occurrence and led to inappropriate postures such as overconfidence, improvisation and inobservance of procedures that contributed to this incident.
- Communication - contributed.
The deficiencies observed in the communication process, especially from the moment the N100QR commander decided to abandon the IFR procedure and perform the landing under visual flight rules, contributed to the conflict that occurred in this incident.
From this point on, there were difficulties to organize and express ideas and facts in a coherent way, confusion or absence of information pertinent to the procedure performed, limitation of the receiver's ability to understand the information and misinterpretation of both parties (controller and N100QR crew).
- Flight Discipline - contributed.
The deviations from the applicable standards by the N100QR crew, by not accomplishing the missed approach profile foreseen in the chart, without prior notification or authorization, changed the air traffic control expectations for the flight evolution, influencing the controller's decisions.
- Traffic Planning (ATS) - undetermined.
The non-compliance with the requirements established in paragraph 6.2.4.2 of the Operational Model of the APP-ES implied in the issuance of authorizations without having previously established the separation and proper ordering of approaching aircraft, compromising the quality of traffic planning, which may have contributed to the conflict object of this report.

Sources:

CENIPA

Accident investigation:
cover
  
Investigating agency: CENIPA
Status: Investigation completed
Duration:
Download report: Final report
Other occurrences involving this aircraft

27 Sep 2020 N100QR private 0 Sur del Lago region, Zulia dst


Images:

Photo of N100QR courtesy AirHistory.net


Asunción - Silvio Pettirossi (SGAS / ASU)
10 December 2019; (c) Arie Meijvogel

Revision history:

Date/timeContributorUpdates
21-Apr-2021 18:46 harro Updated [Aircraft type, Registration, Cn, Operator, Total occupants, Nature, Departure airport]
21-Apr-2021 18:49 harro Updated [Narrative]

Corrections or additions? ... Edit this accident description