AD2856 - Incident: Azul E195 at Rio de Janeiro on Apr 5th 2022

An Azul Linhas Aereas Embraer ERJ-195, registration PR-AXH performing flight AD-2856 from Sao Paulo Congonhas,SP to Rio de Janeiro Santos Dumont,RJ (Brazil) with 53 passengers and 5 crew, was cleared to land on Santos Dumont's runway 20L however aligned with and touched down on the shorter runway 20R at 19:09L (22:09Z). The aircraft rolled out without further incident.

The airline confirmed the incident stating the landing was safe, an investigation has been opened.

Brazil's CENIPA have opened an investigation into the occurrence, too.

On Apr 8th 2022 CENIPA reported the aircraft performed a landing approach to runway 20L but landing was made on runway 20R. The occurrence was rated a serious incident and is being investigated.

On Dec 10th 2025 Brazil's CENIPA released their final report in Portuguese only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Portuguese only or no release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe). The final report concludes the probable causes of the serious incident were:

Attention – contributed.

The deliberate and exclusive focus of attention on information from the radar repeater resulted in selective inattention and contributed to the ATCO not noticing important stimuli for the operation, such as the fact that the RWY 20L light signal was off and that the aircraft was not aligned with the authorised runway for landing.

Attitude – contributed.

Failure to comply with items in ICA 100-37 demonstrated attitudes of non-compliance on the part of controllers and pilots with regard to guidelines designed to ensure safer and more appropriate practices in the air environment, contributing to the occurrence in question.

Knowledge of ATS standards – contributed.

The failure of ATCO TWR to apply various standards contributed to the occurrence, since, during the provision of air traffic services, by failing to comply with the procedures for landing and take-off authorisation established in both ICA 100-37/2020 and ICA 81-4, the ATCO failed to exercise effective control of aircraft in sight and to scan the runway.

The failure of ATCO TWR to apply the rules related to the cross-check procedure also contributed to the serious incident, since the pilot of AZU2856 incompletely cross-checked the authorisation received, and ATCO TWR did not listen to the entire message issued nor correct the erroneous message, failing to comply with the items mentioned in the incident analysis.

The operational failure of ATCO ASSTWR contributed to the incident, considering that it was expected, for the position it occupied, to assist ATCO TWR, in accordance with ICA 63-33 and MOP of TWR-RJ, during the provision of air traffic services.

Organizational culture – undetermined.

The non-observance of several items of ICA 100-37 pointed to a possible fragile organizational culture regarding operational safety, since such an attitude did not reflect a positive practice for mitigating the risks inherent to the activity, as the probable impacts of non-compliance with safety procedures were not considered.

Work organization – undetermined.

The organization of work in the Air Traffic Control environment, regarding the division of labor and distribution of tasks, may have contributed to the non-identification of the runway lights going out, thus reducing the barriers to landing in safer conditions.

Perception – contributed.

By failing to become aware of external stimuli through runway scanning and aircraft tracking on final approach, the ATCO's situational awareness was impaired, which impacted his understanding of the conditions affecting the operation and contributed to the incident.

Replacement in the position (ATS) – undetermined.
The distribution of operational assignments may have contributed to the occurrence, since specific functions that were deactivated may not have been adequately transferred to the remaining operational positions. The performance of administrative functions by the ATS Officer may have reduced their situational awareness during the performance of the service.

Supervision (ATS) – contributed.

It was found that there was no supervisor or coordinator at the time of the occurrence, due to the fact that they were not activated positions. However, item 4.2.1.1.3 of the MOP defined that the ATS Officer would assume the actions inherent to the Supervisor.

The fact that the runway lights remained off during the takeoff operations of TAM3933, the landing of AZU2856 and the approach of TAM3180 without any of the ATCOs present noticing this circumstance, characterized inadequate ATS supervision.

Other/ACAMS-ALCMS System – contributed.

The fact that the ACAMS-ALCMS system did not issue an alert regarding the turning off of the beacon contributed to the reduction of the ATCO's situational awareness and, consequently, to the occurrence. In addition, the color interface used by the system was not intuitive, since the traditional colors, green for ON and red for OFF, would cause a more appropriate perception of alert.

Related Flight: AD2856, Twitter: #AD2856, Azul Brazilian Airlines News