AerCaribe B734 at Leticia on Jan 28th 2017, overran runway on landing
Last Update: August 21, 2018 / 17:41:09 GMT/Zulu time
Incident Facts
Date of incident
Jan 28, 2017
Classification
Accident
Airline
AerCaribe
Departure
Bogota, Colombia
Destination
Leticia, Colombia
Aircraft Registration
HK-5197
Aircraft Type
Boeing 737-400
ICAO Type Designator
B734
Airport ICAO Code
SKLT
Colombia's AeroCivil (Civil Aviation Authority) reported that the aircraft overran the end of the runway, the runway (2010 meters/6590 feet length) was closed until Sunday (Jan 29th). The runway might reopen at reduced length.
In Sep 2017 Aerocivil released their preliminary report in Spanish reporting that the aircraft was cleared to land on Leticia's runway 21, tower advised that the runway was wet. During deceleration, when the aircraft was about passing taxiway A, a loud bang occurred that was heard by airport personnel. The aircraft continued the roll out using the entire length of the runway, went past the runway end and paved area of the runway end safety area and stopped at position S4.2015 W69.9454 with a heading of 180 degrees. About one minute after coming to a stop the crew opened the cargo door and evacuated the aircraft. Emergency services arrived soon after.
A post flight inspection of the aircraft showed both engines ingested foreign objects and the right hand main gear fully detached. The FDR and CVR were read out with the assistance of the NTSB, the parts of the right hand main landing gear were sent for analysis. First analysis revealed the #4 tyre (outboard right main tyre) burst during the roll out.
In August 2018 the GRIAA released their final report in Spanish concluding the probable causes of the accident were:
- Deficient maintenance procedures by the aircraft operator by not applying complete and adequate corrective actions to determine the root cause of repetitive tyre failures.
- Brakes system failure as result of the rupture of the hydraulic lines and harness at the right main landing gear, the damage was caused by pieces of tyre #4 which burst during the landing roll.
- the tyre burst was caused by an overbent wheel rim as result of the tyre repeatedly being over inflated due to repeated reports of low tyre pressure.
- runway excursion during roll out in Leticia
Contributing factors were:
- Inadequate risk management by the operator as the repeated reports of discrepancies were not known or observed by the operational safety management.
- Poor conditions at the runway end safety area the unevenness and water logging of which contributed to the damage the aircraft suffered.
The GRIAA analysed that the crew acted in a safe manner in accordance with standard operating procedures, no deviations or violations of the procedures was found. The approach was stabilized with proper CRM carried out.
The GRIAA further analysed that between September and November 2016 a number of maintenance activities had taken place with regards to the right hand brakes, tyres and anti-skid systems. The tyre manufacturer established evidence that the #4 tyre had been overinflated causing the #4 wheel rim to fail. This damage could have occurred during any of the previous maintenance actions. The manufacturer also mentioned that repeated failures of the #3 and/or #4 tyres are often indicative of a non-slip or asymmetric braking condition. The investigation annotated however that these conditions were not present at the time of the occurrence.
The fracture of the #4 tyre caused damage to the hydraulic lines of the brake system and harness of the anti-skid system causing the systems as well as the manual systems to lose their effectiveness.
The GRIAA analysed with respect to the sequence of events, that the repeated tyre inflations following loss of tyre pressure, without controlling the pressure applied, caused wrinkles and opened a path of continuous exhaust of air. As this condition was not properly serviced, a latent condition of rim failure was created.
The latent situation of the defective tyre/wheel combined with the weight of the aircraft and the landing bump created an additional force on the tyre causing the tyre to burst during the landing roll. The pieces of rubber ruptured the hydraulic lines supplying the brakes and harness of the anti-skid system. As result of the loss of the hydraulic lines supplying the brakes and the loss of the anti-skid harness the automatic as well as manual brakes were disabled prompting the crew to re-apply thrust reversers as the only remaining means to stop the aircraft. The aircraft went beyond the end of the runway as result.
Related NOTAMs:
A0305/17 - DTHR 03 FST 290M, LEN AVBL 1720 MTS. H24, 29 JAN 14:45 2017 UNTIL 06 FEB 23:00 2017 ESTIMATED. CREATED: 29 JAN 14:48 2017
A0300/17 NOTAMN
Q) SKED/QMRLC/IV/NBO/A/000/999/0411S06956W010
A) SKLT B) 1701282339 C) 1701291700 EST
E) RWY 03/21 CLSD
Metars:
SKLT 290200Z 00000KT 9999 SCT010 SCT080 25/24 A2989
SKLT 290100Z 00000KT 9999 SCT010 25/24 A2987 REDZ
SKLT 290000Z 00000KT 8000 -DZ BKN010 25/25 A2984 RMK AD OPER IMC
SKLT 282300Z 00000KT 9999 -RA BKN010 BKN080 26/24 A2986 RMK AD OPER IMC
SKLT 282200Z 32003KT 9999 -DZ SCT010 BKN015 27/24 A2980 RERA
SKLT 282100Z 00000KT 9999 SCT010 BKN015 27/24 A2982
SKLT 282000Z 32004KT 9999 SCT012 BKN015 28/24 A2984
SKLT 281900Z 35004KT 9999 SCT012 BKN080 27/24 A2988
SKLT 281800Z VRB02KT 9999 BKN009 BKN080 26/24 A2990 RMK AD OPR IMC
Incident Facts
Date of incident
Jan 28, 2017
Classification
Accident
Airline
AerCaribe
Departure
Bogota, Colombia
Destination
Leticia, Colombia
Aircraft Registration
HK-5197
Aircraft Type
Boeing 737-400
ICAO Type Designator
B734
Airport ICAO Code
SKLT
This article is published under license from Avherald.com. © of text by Avherald.com.
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