Vliegtuigongeval op 13 DEC 2003 met Boeing 737-2A9 OB-1544-P - Lima-J Chavez International Airport (LIM)
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Status:Accident investigation report completed and information captured
Datum:zaterdag 13 december 2003
Tijd:22:48
Type:Silhouette image of generic B732 model; specific model in this crash may look slightly different
Boeing 737-2A9
Luchtvaartmaatschappij:Aero Continente
Registratie: OB-1544-P
Constructienummer: 20956/386
Bouwjaar: 1974-11-18 (29 years 1 months)
Aantal vlieguren:62716
Aantal vluchten:62162
Motoren: 2 Pratt & Whitney JT8D-9A
Bemanning:slachtoffers: 0 / inzittenden: 6
Passagiers:slachtoffers: 0 / inzittenden: 94
Totaal:slachtoffers: 0 / inzittenden: 100
Schade: Afgeschreven
Gevolgen: Written off (damaged beyond repair)
Plaats:Lima-J Chavez International Airport (LIM) (   Peru)
Fase: Landing (LDG)
Soort vlucht:Internationale lijnvlucht
Vliegveld van vertrek:Caracas-Simón Bolívar International Airport (CCS/SVMI), Venezuela
Vliegveld van aankomst:Lima-Jorge Chávez International Airport (LIM/SPIM), Peru
Vluchtnummer: 341
Beschrijving:
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


Foto's

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

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Caracas-Simón Bolívar International Airport en Lima-Jorge Chávez International Airport bedraagt 2738 km (1712 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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Boeing 737-200

  • 1114 built
  • 97e ongeval
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 Peru
  • 73e zwaarste ongeval (toen het plaatsvond)
  • 81e zwaarste ongeval (op dit moment)
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