Aeromexico Connect E190 at Durango on Jul 31st 2018, veered off and overran runway after failed takeoff and burst into flames

Last Update: February 25, 2019 / 21:19:23 GMT/Zulu time

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Incident Facts

Date of incident
Jul 31, 2018


Aircraft Registration

Aircraft Type
Embraer ERJ-190

ICAO Type Designator

On Feb 23rd 2019 Mexico's Secretaria de Communicationes y Transportes (SCT) released their final report in Spanish 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 Spanish only 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 report concludes the probable cause of the accident was:

The aircraft impacted the runway as result of loss of control in the final stages of the takeoff due to windshear at low height causing a loss of speed and lift.

Contributing factors with respect to the crew were:

- Decreased situational awareness by the crew of AM-2431 because the commander conducted unauthorized instructional tasks without qualication to provide flight instruction and assign co-pilot and pilot flying functions to a pilot not certified and authorized.

- Non-detection of airspeed indicator fluctuations on the primary flight display during the takeoff run.

- Lack of adherence to sterile cockpit procedures as well as to operating procedures.

Contributing factors with respect to ATC were:

- Lack of adherence to "windshear at low altitude" procedures.

- Lack of adherence to procedures requiring to provide information about significant variations in speed and direction of winds as well as visibility and significant other weather conditions.

- Lack of supervisory staff at Durango Tower.

The SCT reported that the aircraft had been delayed some. The crew performed their preflight briefings preparing to depart from runway 03. After engine start the aircraft was taxiing out of departure and received current weather information from tower indicating winds from 070 degrees at 12 knots, altimeter 30.23. While the aircraft is nearing the hold short line surveillance cameras of the airport show rain setting in, however, still permitting flight under visual meteorologic conditions. The crew reads the after start up checklist, subsequently receives clearance for takeoff, tower reporting the winds at 090 degrees at 20 knots. The aircraft lines up, the crew reading the before takeoff checklist, the surveillance cameras show the intensity of rain intensified, strong gusts arrive impeding the visibility from the terminal towards the runway. After lining up on the runway the crew commences takeoff (TOGA being used, no reduced thrust being used), the engines reach takeoff thrust, the call "80 Knots" occurs, at that point the airspeed indicators of captain and first officer disagreed by about 8.5 knots, a second later the first officer confirms "checked" (difference between the IAS had reduced to 1.75 knots by then), at 144 KIAS the captain calls "V1" and at 147 KIAS Rotate. The first officer rotates the aircraft to become airbirne, the captain announces "positive rate of climb", airspeed indication was 148 KIAS at the captain and 150 KIAS at the first officer's instruments (the report annotates 150 KIAS was the highest speed recorded) at about 10.2 degrees nose up, the first officer commands "gear up" when the aircraft was about 2 feet above the runway. The airspeed dropped to 146/148 KIAS, the captain commands "my controls" at 11 feet of height and 139 KIAS/144 KIAS, the aircraft continues to climb until reaching 30 feet AGL at 130/134 KIAS and began to lose height continuing to lose speed, a "Don't sink!" GPWS warning occurred, the aircraft descends through 20 feet AGL at 125 KIAS, the surveillance camera ceased at that point due to discontinuity in power supply. The GPWS warning was the last recording to the CVR. The aircraft impacts ground 2150 meters down the runway to the left of the center line of runway, at approximately abeam taxiway B the aircraft collides with 9 runway edge lights, the right hand engine contacts ground followed by the detachment of both engines. The aircraft continued parallel to the runway and came to a stop 400 meters past the end of the runway. When the surveillance camera stopped it showed visibility had dropped to zero just after the camera had caught a tree to be disrooted. Ground observers pointed out other trees were knocked down as well, one of the trees knocked down communication lines.

Tower tried to call the aircraft but was left without response, talked to the approach sector to see whether they were in contact with the aircraft, approach wasn't in contact, and dispatched vehicles to inspect the runway. The runway inspection found the detached engines and noticed smoke rising from beyond the runway end, while driving towards the smoke the spotted the aircraft with passengers evacuating the airframe and walking away. The vehicle declared Mayday and began to fight the fires. Emergency services arrive and join the efforts to fight the fires and guide the occupants to safety. The visibility improves about 3 minutes after the failed takeoff.

The captain, one flight attendant and 12 passengers received serious, the first officer, the observing pilot, another flight attendant and 22 passengers received minor injuries, 63 passengers and one flight attendant trainee remained uninjured.

The captain (ATPL, 3,700 hours total, 1,064 hours on type) occupied the left hand seat. A first officer (ATPL, 1,973 hours total, 460 hours on type) was assigned to the flight, a third crewman (CPL, 3,296 hours total, 0 hours on type) however occupied the right hand (first officer's seat), the assigned first officer occupied the observer's seat. The crewman was pilot flying initially.

The SCT analysed that as the aircraft neared the hold short line for departure tower cleared the aircraft for takeoff reporting the wind from 090 degrees at 20 knots. The surveillance camera subsequently showed rain setting in and viibility reducing, strong gusts arrive. However, no transmission can be heard in which tower would have informed the crew about the changing weather conditions. The crew sets maximum takeoff power, the aircraft accelerates down the runway, at 54 KIAS there is a first fluctuation of airspeeds, at 85.75 KIAS the captain called "80 knots", the first officer's ASI showed 94.25 knots (8.5 knots difference). The aircraft rotates and become airborne, a "Don't Sink" GPWS call taking priority over a Windshear Alert occurs, a windshear alert is not being issued. Following the "Don't sink" the captain assumes control of the aircraft, according to the CVR the aircraft impacted the runway 8 seconds later.

The SCT analysed the first officer relinquished his seat to the crewman, the captain subsequently provided instructions to the crewman, who also became pilot flying for the takeoff, although the captain was not qualified or authorized to provide instructions. Neither was the communication of the crew with tower effective as result nor did tower provide the crew with updated weather information. The controller was in the best position to observe the deteriorating weather conditions and inform the crew, the lack of such information violated established operating procedures.

When the aircraft lined up runway 03 rain set in, the crew however did not change their FMS settings from dry runway to wet runway or consider recomputing takeoff performance.

Runway 03 became wet as result of a microburst condition. However, there was no equipment to detect windshear at Durango. Due to the gusts a number of trees were uprooted, one of the trees took down power and communication lines causing a power supply failure at the aerodrome for 8 seconds until the backup power generator jumped in, the batteries (UPS) located at the tower were discharged and could not keep the computer systems powered up. The computers subsequently needed 6 minutes to reboot.
Incident Facts

Date of incident
Jul 31, 2018


Aircraft Registration

Aircraft Type
Embraer ERJ-190

ICAO Type Designator

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