ASN Wikibase Occurrence # 218725
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| Date: | Wednesday 28 November 2018 |
| Time: | 15:43 LT |
| Type: |  Boeing 737-2Y5 Adv. |
| Owner/operator: | Avior Airlines |
| Registration: | YV2937 |
| MSN: | 23847/1414 |
| Year of manufacture: | 1987 |
| Fatalities: | Fatalities: 0 / Occupants: 44 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG) -
 Brazil
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Caracas-Simón Bolívar International Airport (CCS/SVMI) |
| Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG) | |
| Investigating agency: | CENIPA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Avior Airlines flight 9V1272 , a Boeing 737-200 suffered a runway excursion after landing on Manaus' runway 29. There were no injuries. The aircraft stopped 100 m past the end of runway 29 with the landing gear on soft ground (dirt).
During the descent towards Manaus, there was failure of hydraulic system A. The flight crew misjudged the effects and did not inform the Tower controller. At the time of arrival, a thunderstorm was passing the area.
During the entire approach runway 29 was the active runway. However, when calling the Tower for landing, the flight was informed that the wind was 180 degrees at 16kt, a favorable condition for landing on runway 11.
During the landing, therefore, there was a cross wind, which at that time produced a tail component of approximately 5kt.
The copilot questioned the weather conditions and he was informed by the controller that the airport was operating under VMC, with light rain on the approach.
Contributing factors.
- Control skills – undetermined.
The inadequate application of flight controls may have contributed to the excess speed at which the aircraft approached for landing on SBEG, which required greater distance for the aircraft to stop.
- Communication – a contributor.
There were flaws in the communication process established between the crewmembers of the YV2937 and the TWR-EG, characterized by the lack of accurate information on the intensity of the existing rain, as well as on the change of runway threshold for landing operations.
These failures contributed to the landing on runway 29, with tailwind, favoring the runway excursion.
Thus, the control agencies were also unaware of the aircraft's failure condition, since there was no declaration of urgency or emergency, contributing to their failure to activate the ground support means as required by the Aerodrome Emergency Plan.
- Adverse meteorological conditions – a contributor.
The distance required to stop the aircraft was increased due to the weather conditions present, as well as making it difficult to visualize the runway exit, by the TWR-EG, which culminated in the delay of the ground support means.
- Crew Resource Management – undetermined.
It is possible that an inadequate cockpit coordination has caused the crewmembers to not realize that they were approaching the runway with tailwind, as well as that they did not observe, as recommended in the QRH, that the aircraft could not be taxied after landing, which could be corroborated by the fact that the crew did not request any ground support from the control agencies.
- Use of phraseology by the crew – undetermined.
The fact that the crew did not expressly declare that the landing would be carried out in a contingency situation may have made it possible that the other agencies involved in the operation could not provide the necessary support for the landing of the aircraft
- Use of phraseology by ATS – a contributor.
There was a failure in the transmission of meteorological information by the ATCO to the YV2937, not being informed that the threshold in use had already been changed to 11, which allowed the landing to be carried out on runway 29, with tailwind.
- Piloting judgment – a contributor.
There was an inappropriate judgment of the consequences inherent to the Loss of System A failure, mainly considering that the approach took place in adverse weather conditions and with tailwind, and without requiring any type of ground support.
- Aircraft maintenance – undetermined.
The sequence of failures observed at the time of the loss of the Hydraulic System A, followed by secondary failures, such as the incomplete lowering of the flaps by the emergency system and the failure to activate the #1 reverser, may have been caused by poor maintenance of these systems, however such a hypothesis could not be confirmed.
- Perception – undetermined.
A possible decrease in the level of situational awareness on the part of the crew may have created difficulties in adequately perceiving the adverse effects generated by the combination of the failures in the aircraft systems and the existing weather conditions.
Possibly, there was a misinterpretation about the severity of rain present at the Aerodrome, by the TWR-EG, which led to the transmission of inaccurate information to the crewmembers of the YV2937.
- Decision-making process – a contributor.
The inaccurate assessment of meteorological information and the impact of the hydraulic system failures culminated in the decision to proceed to landing at threshold 29, despite adverse circumstances, which favored the runway excursion.
Weather at the time of the incident (1943Z):
SBEG 282000Z 10014KT 1000 +TSRA BKN008 FEW020CB SCT025 25/2 3 Q1008
SBEG 281920Z 23003KT 9999 TS VCSH SCT012 SCT018 FEW023CB 30/24 Q1008
SBEG 281900Z 29003KT 9999 VCSH SCT012 SCT020 FEW025TCU 31/2 3 Q1008
Accident investigation:
 |
|
Sources:
https://g1.globo.com/am/amazonas/noticia/2018/11/28/aviao-derrapa-em-pista-durante-pouso-e-aeroporto-de-manaus-fica-interditado.ghtml
CENIPA
Media:
Avião derrapa no aeroporto de Manaus durante a forte chuva que atingiu a capital https://t.co/fzOhVKLAz4 pic.twitter.com/zRE0MrQdpp
— Amazonas Notícias (@am_noticias) November 29, 2018
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 29-Nov-2018 06:59 | Goklerdeyiz.net | Added |
| 29-Nov-2018 07:03 | harro | Updated [Time, Aircraft type, Registration, Cn, Other fatalities, Location, Destination airport, Source, Embed code, Narrative] |
| 29-Nov-2018 07:05 | harro | Updated [Embed code, Narrative] |
| 29-Nov-2018 07:07 | harro | Updated [Cn] |
| 23-Jul-2021 19:06 | harro | Updated [Total occupants, Source, Narrative, Category, Accident report] |
| 23-Jul-2021 19:07 | harro | Updated [Accident report] |
| 23-Jul-2021 19:19 | harro | Updated [Narrative] |
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