Status: | Accident investigation report completed and information captured |
Date: | Monday 19 October 2015 |
Time: | 06:40 |
Type: |  Learjet 35A |
Operator: | Top Air SA |
Registration: | LV-ZSZ |
MSN: | 35A-235 |
First flight: | 1979 |
Total airframe hrs: | 12190 |
Cycles: | 9517 |
Engines: | 2 Honeywell TFE731-2C-2B |
Crew: | Fatalities: 0 / Occupants: 2 |
Passengers: | Fatalities: 0 / Occupants: 0 |
Total: | Fatalities: 0 / Occupants: 2 |
Aircraft damage: | Destroyed |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | San Fernando Airport, BA ( Argentina)
|
Phase: | Takeoff (TOF) |
Nature: | Ferry/positioning |
Departure airport: | San Fernando Airport, BA (SADF), Argentina |
Destination airport: | Río Gallegos Internacional Airport, SC (RGL/SAWG), Argentina |
Narrative:A Learjet 35A, LV-ZSZ, was damaged beyond repair in a takeoff accident at San Fernando Airport, Argentina. Both crew members escaped uninjured.
In preparation for a positioning flight to Río Gallegos the crew failed to connect an inverter, a component of the electrical system that converts the direct current from 28V to an alternating current of 115V, prior to starting engine no.1. This was then rectified.
At 09:34 the aircraft taxied to the threshold of runway 05 for departure. The copilot was Pilot Flying while the experienced captain was Pilot Monitoring.
Takeoff clearance was received at 09:40 and the power levers were advanced. During the takeoff roll the copilot noticed that the no.1 engine N1 reached a value of 101% instead of 95% like the no.2 engine. At that point the aircraft had already traveled 380 m. It began to drift to the right of the runway centreline. The copilot decided to abort without voicing his intentions. he brought back the power levers to idle and began applying brakes. At this point, LV-ZSZ had traveled approximately 980 meters from the start of the take-off run.
The right engine power decreased to 30-40% N1 while the left engine continued at a value over 101% N1. The captain then took over control. Differential braking was applied to steer the aircraft back towards the runway centreline. Thrust reversers were deployed briefly but the aircraft ran off the side of the runway. The aircraft impacted with a ditch located 80 meters from the runway, causing the undercarriage to break away. After coming to rest with both engines now at 20% N1, the engine were shut down.
As a result of the impact, part of the left tip tank fuel tank had separated, causing a fire that destroyed the aircraft.
The most likely cause of the uncommanded acceleration and subsequent overspeed condition was a contamination of retained particles present within the fuel control unit (FCU). The contamination was a short-lived random condition, as evidenced by the fact that after about 30 seconds the power lever regained control of the left engine.
Probable Cause:
Conclusions of the analysis (translated from Spanish)
On a general aviation flight, during the take-off run, the LJ35 LV-ZSZ suffered a runway excursion on the right side, and a subsequent aircraft fire. The accident was due to the combination of the following factors:
- The uncommanded acceleration of the left engine at the start of the take-off run;
- The initial lack of response of the left engine to the requests of the corresponding power lever;
- The difficulties of the crew in managing an unusual condition of the aircraft in accordance with guidelines established in the AFM;
- The ambivalence in the existing regulations for the authorization of a co-pilot in an aircraft that require two pilots for certification; and
- The duality in the application of safety standards allowed by the existing normative regulations.
Although unrelated, the state of the runway 05/23 protection zone at the San Fernando Aerodrome contributed to the severity of the accident.
Accident investigation:
|
Investigating agency: | JIAAC Argentina  |
Status: | Investigation completed |
Duration: | 1 year and 2 months | Accident number: | 0298090/15 | Download report: | Final report
|
|
Classification:
Rejected takeoff
Runway excursion (veer-off)
Follow-up / safety actions
JIAAC issued 4 Safety Recommendations
Issued: 19-DEC-2016 | To: ANAC Argentina | LV-ZSZ (1) |
La claridad normativa es condición esencial sine qua non para su correcta aplicación. Por ello, se recomienda:
- Reevaluar y corregir las previsiones de las RAAC 61 en los contenidos referidos a habilitación de copilotos en aeronaves que requieren dos pilotos por certificación para su operación, de modo de asegurar de manera inequívoca niveles de conocimientos y competencias equivalentes en los miembros de una tripulación, así como para desalentar prácticas informales que distorsionen la estricta aplicación de la normativa, en letra y en espíritu. |
Issued: 19-DEC-2016 | To: ANAC Argentina | LV-ZSZ (2) |
La congruencia en la normativa existente como control de riesgo de seguridad operacional es fundamental si la normativa ha de cumplir su rol de defensa del sistema aeronáutico. Por ello, se recomienda:
- Adoptar las medidas del caso para garantizar que la dualidad de estándares de seguridad operacional auspiciados por la existencia de sistemas de normas paralelos (RAAC 91 y RAAC 135) que permiten operar una misma aeronave bajo exigencias diferentes no se conviertan en desmedro de la seguridad operacional. Esencial en estas medidas es la aplicación de rigurosos estándares de inspección y supervisión de operaciones bajo los sistemas de normas paralelos. |
Issued: 19-DEC-2016 | To: ANAC Argentina | LV-ZSZ (3) |
La más efectiva inspección de vuelo sólo es posible si se realiza bajo estándares establecidos que sirvan de patrón para los inspectores gubernamentales y de guía para los pilotos. Por ello, se recomienda:
- Definir y publicar estándares que sirvan de patrón para los inspectores gubernamentales y de guía para los pilotos para las inspecciones en vuelo de aeronaves tipo de más de 5700 kg de masa máxima de despegue. |
Issued: 19-DEC-2016 | To: San Fernando Airport | LV-ZSZ (4) |
El estado del terreno en la franja de seguridad de las pistas es determinante primario del potencial daño que pueden llegar a experimentar las aeronaves en caso de excursión de pista así como de la facilidad del acceso del SEI al lugar del accidente. Por ello, se recomienda:
Adoptar las acciones tendientes para que el estado del terreno aledaño a la pista 05/23 facilite la detención intacta de aeronaves en caso de excursiones de pista, así como el más rápido acceso para las trayectorias del SEI. |
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from San Fernando Airport, BA to Río Gallegos Internacional Airport, SC as the crow flies is 2086 km (1304 miles).
Accident location: Approximate; accuracy within a few kilometers.
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.