Crash-aerien 13 DEC 2003 d'un Boeing 737-2A9 OB-1544-P - Lima-J Chavez International Airport (LIM)
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Statuts:Accident investigation report completed and information captured
Date:samedi 13 dcembre 2003
Heure:22:48
Type/Sous-type:Silhouette image of generic B732 model; specific model in this crash may look slightly different
Boeing 737-2A9
Compagnie:Aero Continente
Immatriculation: OB-1544-P
Numéro de série: 20956/386
Année de Fabrication: 1974-11-18 (29 years 1 months)
Heures de vol:62716
Cycles:62162
Moteurs: 2 Pratt & Whitney JT8D-9A
Equipage:victimes: 0 / à bord: 6
Passagers:victimes: 0 / à bord: 94
Total:victimes: 0 / à bord: 100
Dégats de l'appareil: Perte Totale
Conséquences: Written off (damaged beyond repair)
Lieu de l'accident:Lima-J Chavez International Airport (LIM) (   Pérou)
Phase de vol: A l'atterrissage (LDG)
Nature:Transport de Passagers Intern.
Aéroport de départ:Caracas-Simón Bolívar International Airport (CCS/SVMI), Vénézuela
Aéroport de destination:Lima-Jorge Chávez International Airport (LIM/SPIM), Pérou
Numéro de vol: 341
Détails:
Aero Continente Flight 341 was cleared for an approach to Lima's runway 15. During the approach the crew noted a flap asymmetry warning. The approach was continued, but the crew forgot to lower the landing gear. The airplane belly landed at a speed of 190 kts and slid for 2347 meters before coming to rest.

Probable Cause:

CONCLUSIONS
The Aviation Accident Investigation Commission of the Ministry of Transportation and Communications determines the probable cause(s) of the accident as follows:
Operational human factor by omission.
Failure to verify and check the Non Normal Checklist of the Quick Reference Handbook (QRH) when technical problems occurred at the time of approach and landing, causing the omission of the extension of the landing gear and subsequent contact of the aircraft with the runway, with the landing gear retracted.

NOTES
AIRCRAFT: During the approach there was an indication of flap asymmetry.
TECHNICAL CREW: Due to the tightness of the itinerary programmed by the company, the total flight hours and the working day of the flight were within the limits of the maximum allowed by the RAP, which could have influenced (due to fatigue) in the deficient performance of the crew.
FLIGHT RECORDERS - The lack of recording of some parameters of the flight recorders (FDR and CVR) prevented the resolution of some important and useful details for the investigation.

CONTRIBUTING CAUSES
1. Flap asymmetry indication, due to an indication failure in the Flap Position Indicator caused by a high electrical resistance originating from the winding inside the right side Flap Position Transmitter synchro transmitter.
2. The omission of the use in the approach phase, of the procedures described in the QRH for this type of abnormal situations.
3. The lack of decision to perform a Go Around, taking into account that the period of time to carry out the QRH procedures for this abnormal situation was not going to be enough.
4. Overconfidence (complacency) during the approach phase in abnormal conditions (flap asymmetry indication).
5. Lack of Crew Resource Management during the approach and landing phases, especially under abnormal conditions.
6. Lack of leadership during the abnormal situation presented.
7. Lack of communication with the Control Tower about the abnormal conditions in which the approach and landing were to be carried out.
8. Itinerary very tight to the limits of flight day and time.

Accident investigation:

cover
Investigating agency: CIAA Peru
Status: Investigation completed
Duration: 171 days (6 months)
Accident number: CIAA-ACCID-003-2003
Download report: Final report


Photos

photo of Boeing-737-2A9-HR-SHI
accident date: 13-12-2003
type: Boeing 737-2A9
registration: HR-SHI
 

Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Caracas-Simón Bolívar International Airport et Lima-Jorge Chávez International Airport est de 2738 km (1712 miles).

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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