Conviasa AT42 near Puerto Ordaz on Sep 13th 2010, loss of control
Last Update: April 5, 2020 / 14:22:52 GMT/Zulu time
Incident Facts
Date of incident
Sep 13, 2010
Classification
Crash
Airline
Conviasa
Flight number
V0-2350
Departure
Porlamar, Venezuela
Destination
Puerto Ordaz, Venezuela
Aircraft Registration
YV1010
Aircraft Type
ATR ATR-42
ICAO Type Designator
AT42
The airline reported 43 passengers and 4 crew on board of the aircraft.
Venezuela's Minister of Transport and Communciation said shortly after the accident, YV1010 had taken off from the airport of Puerto Ordaz (suggesting it was flight V0-2351, later corrected) with 43 passengers and 4 crew and requested to return about 6nm from the airport. The airplane impacted a waste dump near an entrance gate of the Venzuelean steel works Sidor about 9km west of the airport. At the time of the statement he confirmed 2 fatalities and a number of survivors, the actual numbers were unclear.
In the evening of Sep 13th (Venezuelean time) the Minister updated his statement that 47 passengers and 4 crew were on board of the flight from Porlamar to Puerto Ordaz (V0-2350), 15 people perished and 36 survived.
On Sep 15th the Minister said, that two more passengers succumbed to their injuries. A number of people could be released from hospital care.
The local governor of the state of Bolivar said in the afternoon (Venezuelean time), that the crew reported control problems while on approach arriving from Porlamar and then loss of control shortly before impact. There have been no casualties on the ground. 47 passengers and 4 crew were on board, in total 14 people have perished, 33 people survived and were taken to local hospitals.
Ground witnesses reported, that the airplane attempted to return to the airport but got entangled with a high voltage line before impacting ground. Although the airplane fell into a crowded area, there have been no casualties and injuries on the ground.
Aviation sources in Venezuela said, the airplane was arriving from Porlamar on flight V0-2350 and about 30nm from the airport when the crew reported control issues.
The ATR-42-300s of Conviasa feature 46 passenger seats.
On Apr 4th 2020, after the Venezuelan website for accident investigation came back online after a few years, The Aviation Herald got hold of the final report in Spanish dated Dec 31st 2015 (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 JIAAC concluded the probable cause of the accident was:
the malfunction of the centralized crew alert system (CCAS/CAC) with erroneous activation of the stall warning system.
Contributig factors were:
- deficiencies in the cockpit resource management
- loss of situational awareness
- inadequate coordination during decision making processes in the face of abnormal situation in flight
- ignoring the failure of the stall warning system
- inadequate handling of flight controls
The JIAAC reported the crew had already flown two sectors on the accident aircraft that day. The aircraft departed for the accident flight with 47 passengers and 4 crew on board. After departure from Porlamar the aircraft climbed to FL150, deviated around weather enroute and was 64.1nm before Puerto Ordaz when the crew alerted Maiquetia Control of a control problem and requested to descend to FL110. Maiquetia control alerted Puerto Ordaz tower via telephone about the incoming emergency aircraft. Descending through FL135 the crew reported on Purto Ordaz's tower frequency requesting priority and stating they had a failure in the controls. Tower advised runway 07 was active and cleared the flight to fly directly to Puerto Ordaz. 20nm from Puerto Ordaz the crew reported they were descending through FL060 heading directly towards runway 07.
15nm from Puerto Ordaz the crew called "Mayday! Mayday! Mayday!" at about 3000 feet, tower radioed acknowledgement of the Mayday call but did not receive any response. The crew of another aircraft, asked for help by tower, was not able to establish contact, too.
An aircraft waiting for takeoff on the ground at Puerto Ordaz informed tower smoke was rising in the approach path of runway 07. Tower requested the airborne aircraft, that had attempted to establish contact, to overfly the scene, the crew confirmed an aircraft had crashed at that location and was on fire. Tower immediately activated the airport's emergency response prepared for aircraft accidents.
The JIAAC reported 3 crew and 14 passengers perished in the accident, one flight attendant and 9 passengers received serious injuries, 24 passengers survived with minor injuries.
The aircraft broke through the perimeter fence of SIDOR steel works company, damaged a 116kV power line, five empty metal containers for transporting cargo, a number of contained containing iron materials and wooden boxes containing equipment, the wooden boxes also suffered fire damage.
The captain (62, ATPL, total hours and hours on type unknown due to no records found prior to 2006) was assisted by a first officer (38, CPL, 1038 hours total, 483 hours on type).
The aircraft had been built in 1994 and was registered in Venezuela for Conviasa in November 2006.
The final report also quotes the weather data for Ciudad Bolivar (as AVH did in 2010 due to lack of METARs available fo Puerto Ordaz).
The JIAAC analysed in the final minutes the crew received an aural "cricket sound" (stall) warning as well as the as the stick shaker activation. The first officer called "wait! wait!" and pushed the control column forward, the captain pulled the control column back in order to prevent the aircraft descending, that was flying at a normal speed and in normal attitude. The warnings should not have activated as the aircraft was not close at all to any boundary of the flight envelope. The first officer calls "Stick Shaker! Stick Shaker! Go, stop the stick shaker, go!", the captain replies "it is faulty". The first officer subsequently noticed the amber fault light on the stick shaker had activated and replied "okay, go on, pull".
The JIAAC analyse the fault light of the stick shaker indicated a malfunction of the CAC computer. The procedures would requireto press the fault light which would deactivate the stick shaker and stick pusher. The captain instructs the first officer to press that light, however, the warnings continue. If the button was indeed pressed by the first officer, this means the fault condition was still present and was intermittent.
The CAC monitors both AoA vanes and compares them. If a difference of more than 4 degrees exist between them, an according fault condition is generated. If that fault condition does not exist the values of both AoA vanes are averaged, if that value exceeds the critical angle of attack, the stick shaker is being activated.
24 seconds after the stick shaker activated the pitch controls were decoupled and the according warning, the left and right pitch controls were disconnected, sounded, each pilot was now controlling the elevator of his side (captain the left elevator, first officer the right elevator). The investigation assumes, the controls were disconnected because both pilots provided different inputs on the pitch.
This would require the two pilots to coordinate so that the elevators are moved in sync. However, the situation was complicated by the fact that the pilots were "fighting" each other providing counteracting control forces. The captain applied significant efforts and force to maintain level flight.
Post impact inspection revealed the stick pusher on the left side was in a nose down position. Several simulations at the aircraft maufacturer revealed that due to the force applied onto the elevator it was impossible to maintain level flight with the stick pusher activating.
No Metars and no local weather data are available, available Metars for Ciudad Bolivar [SVCB] 50nm westsouthwest of Puerto Ordaz [SVPR]:
SVCB 131600Z 00000KT 9999 BKN025 27/24 Q1011
SVCB 131400Z 30007KT 9999 BKN015 27/23 Q1013
SVCB 131300Z 18010KT 9999 BKN015 27/24 Q1012
SVCB 131200Z 00000KT 9999 BKN015 26/25 Q1010
SVCB 131100Z 00000KT 9999 BKN015 26/25 Q1010
Incident Facts
Date of incident
Sep 13, 2010
Classification
Crash
Airline
Conviasa
Flight number
V0-2350
Departure
Porlamar, Venezuela
Destination
Puerto Ordaz, Venezuela
Aircraft Registration
YV1010
Aircraft Type
ATR ATR-42
ICAO Type Designator
AT42
This article is published under license from Avherald.com. © of text by Avherald.com.
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