Narrative:During landing at Belo Horizonte International Airport, Brazil, at the moment of touch down, a loud noise was heard by the cabin crew. The aircraft taxied to the apron, where passengers disembarked normally.
When conducting the post-flight inspection, the maintenance team identified a leakage of hydraulic fluid and a break in the aft trunnion pin of the right main landing gear.
Probable Cause:
Contributing factors.
- Aircraft maintenance - undetermined.
It is possible that, during the process of grinding the chrome layer of the aft trunnion pin SN E4798, excessive wear occurred, which generated heat, burning and weakening of the base metal of the part.
- Design - undetermined.
It is possible that the mandatory inspections provided by the Standard Overhaul Pratices Manual, Grinding of Chrome Plated Parts 10-20-04, item 4, Quality Control, after grinding the chrome layer, did not have the necessary effectiveness to detect a burn in the base metal occurred during an overhaul caused by an excessive grinding on this layer of the Aft Trunnion Pin.
- Support systems - undetermined.
It is possible that the material provided to maintainers to perform the visual inspection tasks did not contains clear procedures and criteria regarding the need to repair the pin.
Accident investigation:
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Investigating agency: | CENIPA Brazil  |
Status: | Investigation completed |
Duration: | 3 years and 4 months | Accident number: | A-119/CENIPA/2018 | Download report: | Final report
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Classification:
Runway mishap
Follow-up / safety actions
CENIPA issued 1 Safety Recommendation
Issued: 16-NOV-2021 | To: ANAC | A-119/CENIPA/2018 - 01 |
Work with the Boeing Company, manufacturer of the aircraft, in order to verify the effectiveness of the mandatory quality control inspections to be applied to the aft trunnion pin and similar parts, after the chrome plated grinding process, mainly with regard to the provisions of the Standard Overhaul Practices Manual, Grinding of Chrome Plated Parts 20- 10-04, item 4, Quality Control. |
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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 São Paulo-Congonhas Airport, SP to Belo Horizonte-Tancredo Neves International Airport, MG as the crow flies is 522 km (326 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.