Fly Jamaica B752 at Georgetown on Nov 9th 2018, hydraulic failure causes runway excursion on landing
Last Update: June 3, 2024 / 17:44:22 GMT/Zulu time
Incident Facts
Date of incident
Nov 9, 2018
Classification
Accident
Airline
Fly Jamaica Airways
Flight number
OJ-256
Departure
Georgetown, Guyana
Destination
Toronto, Canada
Aircraft Registration
N524AT
Aircraft Type
Boeing 757-200
ICAO Type Designator
B752
Airport ICAO Code
SYCJ
Guyana's Minister of Public Infrastructure reported the aircraft carried 118 passengers, two infants and 8 crew. The crew declared emergency and returned to Georgetown. 6 people received minor injuries and were taken to the local hospital. On Nov 19th 2018 the Minister told Guyana's parliament that the crew actually did not declare emergency, but advised of their hydraulic problem and that they would return to Georgetown. Emergency services were deployed nonetheless.
On Nov 18th 2018 it became known that a Canadian woman (86), a passenger who orignally was not listed injured, needed to be admitted to hospital a few days after the accident and died in hospital care on Nov 18th 2018. On Nov 20th 2018 the family reported the lady needed to be taken to hospital two days after the accident with a skull fracture resulting in her brain swelling, which could not be controlled anymore.
According to information The Aviation Herald received the woman was not able to move away from the escape slide quickly enough and was unfortunately hit by another passenger coming down the slide.
The airline reported the aircraft returned to Georgetown with a technical problem and suffered an accident on landing.
On Nov 18th 2018 a ground observer reported that the aircraft overran the end of the runway, collided with a concrete barrier causing the right main gear to collapse and the aircraft veer off the runway. The aircraft subsequently slid sidewards for about 275 meters coming to a stop abeam the upcoming new threshold as part of the ongoing runway extension.
On Nov 18th 2018 The Aviation Herald was able to verify that the runway had already been lengthened by approximately 390-400 meters, the runway markings were already completed, the extension is still marked closed with crosses. However, none of the official documents in the AIP or NOTAMs released by Guyana's Civil Aviation Authority makes any reference to the runway extension although crucial to make pilots aware of the possible confusion of thresholds.
On Dec 9th 2018 the recovery of the aircraft was completed and the aircraft was moved to the air force apron near the runway 06 threshold south of the runway. The Aviation Herald learned at the same time the gear doors of the aircraft remained open due to the manual gear extension that had been performed prior to landing. Leading and trailing edge flaps had been extended to 20 degrees in alternate mode, too.
On Jan 17th 2019 the Canadian TSB reported the aircraft experienced a hydraulic failure while climbing through FL200 and returned to Georgetown. On landing on runway 06 the aircraft overran the end of the runway and came to a stop past the runway end and to the right of the runway. The passengers and crew evacuated via slides. 10 persons received injuries during the evacuation, one of the injured persons died in Toronto 8 days later a result of the injuries. The aircraft received substantial damage. The Canadian TSB is assisting Guyana's Aircraft Accident Investigation Unit (GCAA) with Human Factors and Cabin Safety expertise.
Guyana's CAA released their final report concluding the probable causes of the accident were:
Loss of hydraulic fluid, failure of the pressure switch and subsequent total failure of the hydraulic system (firstly the left and subsequently the right) which affected the deployment of some spoilers, thrust reversers and efficacy of the main brakes caused the aircraft to continue the landing roll at a high-speed resulting in an overrun and excursion and severe damage to the aircraft.
CONTRIBUTING FACTORS
- Flight Crew lost main brakes after 'pumping the brakes' several times which bled off main brake pressure, and their failure to use accumulator brake that was available at the time to stop the aircraft after losing the main brakes.
- Setting the flaps to 20 degrees instead of landing flap configuration. This resulted in a higher landing speed and roll and with the combination of loss of main brake pressure due to "pumping" the brakes rather than applying and holding the brakes made it difficult to stop the aircraft on the runway.
- Maintenance deficiencies and inadequate maintenance actions regarding the hydraulic system. Leaking hydraulic system. FDR readings indicated a trend of hydraulic system difficulties, more so, during the previous 6 flights before the accident. These maintenance lapses may have led to further deterioration and loss of the hydraulic systems.
- Poor FJA maintenance quality assurance and quality control may have led to the maintenance deficiencies which may have contributed to the ineffective resolution of the hydraulic system leakages and other hydraulic system maintenance issues indicated by the FDR.
- FJA management's lackadaisical attitude and bypassing recommendations from the Director of Maintenance and Quality Assurance Manager may have led to bad culture, unsafe practices and may have furthered improper maintenance.
- Management's interference may have had an adverse effect on maintenance and safety practices generally.
- The soft mud and loose sand in the overrun area contributed to damage to the aircraft during the excursion.
The GCAA analysed:
Using a combination of information gathered from the CVR, FDR and interviews, it was determined that the left hydraulic system failed, this influenced the decision made by the Flight Crew to return to SYCJ. Subsequently the right electrical hydraulic pump overheated, and this was turned off, the pump eventually cooled, but there was no requirement for this pump to be turned back on. With a failed left hydraulic system, the aircraft would not have alternate brakes, no left reverse thrust and no nose wheel steering. The numbers computed by the Flight Crew were within the operational limits of the aircraft and confirmed that the aircraft could land safely at SYCJ. The computations considered that only brakes would be used to stop the aircraft. Any other stopping mechanisms such as reverse thrust, or deployment of spoilers were considered to be extra assets.
The landing was briefed to be done with 20° flaps, no doubt taking into consideration the possibility of an overshoot or a balked landing. With the 20° flaps, the Captain correctly briefed for a fast landing and maximum manual braking. However, on touchdown the right hydraulic pressure dropped to zero psi, indicating failure of the right hydraulic system. At this point the emphasis should have been only on stopping the aircraft, the pilot attempted to use right reverse thrust to do this, but it was not available due to the failure of both hydraulic systems.
At this point of the flight, it was apparent that the Captain gave up all hope, he said that he felt like a 'passenger on the aircraft'. He did not see the brake source light. If the switch located just below the brake source light was activated immediate braking would have been available, even with a total hydraulic failure, and may have stopped the aircraft on the runway and prevent the excursion. However, it was noted that this possibility was not briefed during the entire process, which suggested that this method of stopping the aircraft was never considered since this switch was not required to be operated in this phase of flight (according to the checklist).
The CVR data indicated that during the flight there was excellent coordination between the Flight Crew. However, the totally unexpected failure of the right hydraulic system at a crucial time, just at touchdown as indicated by the FDR, would have taken the Flight Crew by surprise. The suddenness of this occurrence may have affected the Flight Crew's ability to react.
It is believed that the Flight Crew's mind set for maximum manual braking, may have contributed to loss of situational awareness after the aircraft touched down.
Related NOTAM:
A0091/18 NOTAMN
Q) SYGC/QFALC/IV/NBO/A/000/999/0629N05815W005
A) SYCJ B) 1811090800 C) 1811091300
E) AD CLSD DUE DISABLED ACFT ON RWY
F) GND G) UNL
A0093/18 NOTAMN
Q) SYGC/QFAAL///A/000/999/0629N05815W005
A) SYCJ B) 1811091230 C) 1811121230
E) AD OPR. ACFT NOT ALLOWED TO LAND RWY 24 DUE DISABLED ACFT APRX 385M
NE OF THR RWY 24, AT A HGT OF 30FT ABV THR.
F) GND G) UNL
Metars:
SYCJ 090800Z VRB02KT CAVOK 23/22 Q1009 NOSIG=
SYCJ 090700Z VRB02KT CAVOK 23/22 Q1010 NOSIG=
SYCJ 090600Z VRB02KT CAVOK 23/22 Q1010 NOSIG=
SYCJ 090500Z VRB02KT CAVOK 23/23 Q1010 NOSIG=
SYCJ 090400Z VRB02KT CAVOK 24/23 Q1010 NOSIG=
SYCJ 090300Z VRB02KT CAVOK 24/23 Q1010 NOSIG=
SYCJ 090200Z 05004KT CAVOK 24/24 Q1010 NOSIG=
SYCJ 090100Z 08004KT CAVOK 25/24 Q1010 NOSIG=
Aircraft Registration Data
Incident Facts
Date of incident
Nov 9, 2018
Classification
Accident
Airline
Fly Jamaica Airways
Flight number
OJ-256
Departure
Georgetown, Guyana
Destination
Toronto, Canada
Aircraft Registration
N524AT
Aircraft Type
Boeing 757-200
ICAO Type Designator
B752
Airport ICAO Code
SYCJ
This article is published under license from Avherald.com. © of text by Avherald.com.
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