Accident Ilyushin Il-18D-40 CU-T1539,

ASN Wikibase Occurrence # 322429

Date:	Monday 28 March 2005
Time:	16:15
Type:	Ilyushin Il-18D-40
Owner/operator:	Aerocaribbean
Registration:	CU-T1539
MSN:	2964017102
Year of manufacture:	1983
Total airframe hrs:	4997 hours
Engine model:	Ivchenko AI-20M
Fatalities:	Fatalities: 0 / Occupants: 94
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	Caracas-Simón Bolívar International Airport (CCS) - Venezuela
Phase:	Take off
Nature:	Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:	Caracas-Simón Bolívar International Airport (CCS/SVMI)
Destination airport:	Havana-José Martí International Airport (HAV/MUHA)
Investigating agency:	JIAAC Venezuela
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
Cubana flight 4311, an Ilyushin Il-18D, suffered a runway excursion after an aborted takeoff from runway 09 at Caracas-Simón Bolívar International Airport, Venezuela.
The aircraft operated on a round trip from Havana to Caracas and back. The first officer was pilot flying for the return leg.
The initial part of the takeoff was performed by the captain. After reaching a speed of 150 km/h the captain handed over the flight controls to the first officer.
After passing through 220-230 km/h, the pilot noticed that he had no control of the elevator and immediately reported the failure to the captain, who again took the controls to verify the anomaly. During this check, approximately 11 seconds passed and the airplane's speed reached 282 km/h, while covering some 693 meters. The aircraft now had covered a total runway distance of 2230 meters, leaving 815 meters of runway remaining for braking. The takeoff was aborted but the aircraft was not able to stop on the remaining runway. The landing gear separated after running over a channel located approximately 20 meters after the runway. The aircraft came to a stop on a downslope.

CAUSES:
Human Factor, Material Factor and Physical Factor and taking into account the characteristics of the Accident and the evidence gathered during the course of the investigation, considers the Human Factor as the causal factor of this accident due to the following:
- The flight crew did not perform the respective manual check of the flight controls (elevators).
- The flight crew did not perform the visual check on the panel of the locked/red and unlocked/green warning lights of the flight control surfaces (ailerons, elevators, directional rudder).
- There was no adequate Cockpit Management, or assertive behavior by the crew, in terms of decision making during the takeoff abort.
- There were no accurate calculations for takeoff speed references (V1-Vr-V2) in analogy to takeoff weights.
- The evacuation of the passengers was not efficient and correct, since it was evidenced that the exit of the passengers was carried out through the least convenient doors, due to the position of the aircraft, which had to be blocked by the cabin crew.
- There was no deployment of the slides for evacuation, which resulted in some passengers suffering dislocated limbs when they had to jump.

Accident investigation: