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Last updated: 27 October 2020
Statuts:Enquête Officielle
Date:dimanche 11 novembre 2018
Heure:13:35
Type/Sous-type:Silhouette image of generic E190 model; specific model in this crash may look slightly different
Embraer ERJ-190LR (ERJ-190-100 LR)
Compagnie:Air Astana
Immatriculation: P4-KCJ
Numéro de série: 19000653
Année de Fabrication: 2013
Heures de vol:13152
Moteurs: 2 General Electric CF34-10E5
Equipage:victimes: 0 / à bord: 3
Passagers:victimes: 0 / à bord: 3
Total:victimes: 0 / à bord: 6
Dégats de l'appareil: Substantiels
Conséquences: Written off (damaged beyond repair)
Lieu de l'accident:NE of Lisbon (   Portugal)
Phase de vol: En vol (ENR)
Nature:Convoyage
Aéroport de départ:Alverca Air Base (AVR/LPAR), Portugal
Aéroport de destination:Minsk-2 International Airport (MSQ/UMMS), Biélorussie
Numéro de vol:KC1388
Détails:
Air Astana flight 1388 diverted to Beja Airport, Portugal after suffering control issues after departure from Lisbon's Alverca Air Base, Portugal.
The aircraft had arrived at Lisbon on October 2, 2018, to undergo maintenance at the OGMA facilities, located at the Alverca Air Base. The heavy maintenance consisted of a basic C2-Check, including complex modifications through the accomplishment of several service bulletins (SB), requiring modular avionics unit removal and installation, some additional work requested by the operator and the discrepancies correction.
On October 9, a service bulletin (SB190-57-0038R2) was initiated, which changed the type of routing of the ailerons' control cables, with the replacement of pulleys and respective structural supports by a non-contact support, aiming to reduce the control cable friction on that area. Another service bulletin, SB190-27-0037R1 was accomplished, which consisted of replacing the installed stainless-steel control cables by carbon steel cables. Other maintenance works were also carried out on the aileron control cable system, such as lubrication, adjustments and tests.
On October 26 and following the operational tests after aircraft power-up, a message appeared in the engine indication and crew alerting system (EICAS) that the aircraft could not be dispatched for flight due to problems related with the flight control system (FLT CTR NO DISPATCH).
The maintenance work lasted until October 31st, during this time several tests were performed on the aircraft, including engines run-up and the aircraft final inspection, which included the flight control tests. However, the maintenance personnel did not identify the inversion of the aileron control cables during this late operational check, even though the maintenance instructions required them to confirm the correct surface deflections with control wheel inputs.
Again, the FLT CTR NO DISPATCH error message appeared on the EICAS. The area manager allocated a small team to the aircraft in order to carry out the investigation of the anomaly.
The maintenance organization began to suffer from internal and external pressures for aircraft delivery and return to service, especially since the original scheduled delivery date had been postponed by a week from October 24. The operator tried to assist and after a period of troubleshooting, which ran until November 11th, involving all AMO operational areas, operator and Embraer, the aircraft was released for return to service by the. The aircraft was prepared and positioned for the operator’s delivery crew that was waiting for the maintenance work completion and documentation delivery.
After some new discrepancies had been resolved, the aircraft was ready to depart. Flight KC1388 was the first post-maintenance flight. The aircraft was to be ferried back to the operator base at Almaty, Kazakhstan, with a refueling stop-over at Minsk, Belarus. On board were a captain, two copilots, and three technicians. The aircraft took off at 13:31 hours with the captain as Pilot Flying.
Immediately after take-off, with adverse meteorological conditions, the crew felt that the aircraft was not responding adequately to the commands, developing oscillatory wing movements.
The crew, using all the aircraft control resources for its three axis, immediately tried to counter the movements, however without understanding the cause for the flight instability and without being able to engage the autopilot.
Realising that they were without effective control of the aircraft, only being able – with considerable effort – to minimize the oscillatory movements, with high structural loads involved during some recovery manoeuvres and using crossed commands.
The crew immediately declared emergency while trying to diagnose the cause for the abnormal roll of the aircraft, continuing to struggle to gain its control, having no malfunction indication from the aircraft systems, just the continuous alerts for abnormal flight attitudes and autopilot system (AP FAIL) fault information.
The flight requested to return to Alverca. About 13:37 the flight requested to climb to FL100, again stating they had "flight control problems".
The situation did not improve, and the performed trajectories caused the aircraft and the persons on board to sustain intense G-forces, and causing the aircraft complete loss of control for some moments at multiple instances.
Considering the situation criticality, the crew requested several times for headings in order to be able to reach the sea for ditching, not being able, however, to keep the intended headings.
The crew then started a team work basis, discussing options with the third crewmember (co-pilot in the jump-seat) and trying to communicate with the technicians on board, to explore hypothesis and define an action plan. Despite no warnings for system failures, the crew decided to activate the flight controls direct mode elevators, rudder and spoilers), where the flight control module (FCM) is removed from the flight surfaces command chain, which are then controlled in a direct relationship with the pilots’ inputs on the yoke.
The situation improved considerably, however, without restoring normal operation and keeping the difficulties to control the aircraft roll-axis.
The crew realised that the ailerons were behaving erratically and therefore any command for the aircraft roll was kept to its minimum. Having gained some control of the situation, the crew flew East, searching for better weather conditions and started to follow the flight plan defined by the air traffic control for an emergency landing in a suitable airport, with good weather and physical conditions to deal with the sustaining aircraft control difficulties.
At this moment, when the pilots were able to keep altitude and heading, and had sufficient visual references, the aircraft was joined by a pair of F-16 fighters from the Portuguese Air Force that were scrambled from the Monte Real Air Base. They assisted in guiding to Beja Air Base, which had been selected in the meantime as the best emergency landing option.
After two non-stabilised approaches, the aircraft managed to land safely on runway 19L at the third approach. The intended runway was 19R, but due to drift, they finally managed to land on the left runway.
All on board were physically and emotionally shaken, one of the passengers sustaining a leg injury.
The aircraft sustained damage to the fuselage skin panels, showing waviness in some areas. All wing fixed leading edges were found wrinkled. The experienced overloads during the accident flight may have caused other non-visible damage to the aircraft structure. An assessments on the aircraft primary structure showed exceedance of the limit loads, and according to the structural evaluation that was conducted, some degree of detrimental permanent deformation was found on the aircraft.

On May 31, 2019, GPIAAF Portugal published in investigation update, reporting that a detailed examination of the aircraft flight controls showed an incorrect ailerons control cable system installation.
A modification carried out in accordance with an Embraer Service Bulletin (SB 190-57-0038) changed a cable routing support near rib 21 of the aircraft. This change made it harder to understand the maintenance instructions and spot reversed aileron cables.

Probable Cause:

Probable causes
The investigation determined as most probable cause for the accident the improper aileron cable installation on both ailerons during maintenance activities and subsequent inadequate independent inspection to the aircraft flight control systems, which resulted in a reversal operation of the aircraft aileron system and led to loss of control in-flight.

Contributing factors
For the accident, the following factors contributed:
- Insufficient functioning of the AMO quality assurance and failure to implement an effective production oversight, including but not limited to the independent inspection procedures to detect maintenance escapes;
- The AMO lack of proper risk management, based on an effective SMS program with maintenance escapes reporting system;
- The lack of maintenance teams properly managed and organized by skills and specialties, with the necessary training and experience;
- Weaknesses in the aircraft design, referring to the ailerons control system configuration, allowing the inverted cables installation in both PCU quadrants;
- The aircraft manufacturer’s inaccurate depiction, complex and limitations on presentation of the aileron cables routing maintenance publications;
- The aircraft manufacturer’s lack of proper maintenance instructions to detect the aircraft misconfiguration during the flight controls return to service procedure;
- The lack of proper guidance or best practices from the OEM to the operator and AMO regarding aircraft acceptance and return to service, after a heavy or complex maintenance event;
- The poor supervision of the maintenance organisation by the operator;
- Deficient maintenance organisation oversight by the supervising authorities, namely on the internal maintenance supervision procedures and occurrence reporting;
- The lack of proper guidance from the operator to the crew regarding aircraft acceptance after a heavy maintenance event;
- The crew failure to detect the ailerons misconfiguration during the operational check procedures following limited SOP’s on the highly routine pre-flight checks.

Accident investigation:
cover
Investigating agency: GPIAAF Portugal
Status: Investigation completed
Duration: 1 year and 8 months
Accident number: 08/ACCID/2018
Download report: Final report

Sources:
» Radio Traffic the last 18 minuters of the flight
» Unofficial ATC transcript
» GPIAAF investgation update 31 May 2018

METAR Weather report:
13:00 UTC / 13:00 local time:
LPAR 111500Z 04005KT 3500 -RADZ SCT005 SCT010 BKN015 13/12 Q1010

14:00 UTC / 14:00 local time:
LPBJ 111400Z 19017KT 9999 SCT030 BKN048 19/14 Q1011

14:00 UTC / 14:00 local time:
LPAR 111400Z 35005KT 2000 -RA SCT005 SCT010 BKN015 13/13 Q1010

15:00 UTC / 15:00 local time:
LPBJ 111500Z 20019KT 9999 SCT030 BKN048 19/14 Q1010

15:00 UTC / 15:00 local time:
LPAR 111300Z 04005KT 3000 RA FEW005 SCT010 BKN015 14/13 Q1010

15:20 UTC / 15:20 local time:
LPBJ 111520Z 20017KT 9999 SCT030 BKN048 19/13 Q1010


Opérations de secours

GPIAAF issued 4 Safety Recommendations

Show all...

Photos

photo of Embraer-ERJ-190LR-P4-KCJ
abnormal aircraft attitude FDR example
photo of Embraer-ERJ-190LR-P4-KCJ
cable reversion zone, between wing ribs 19 and 23
photo of Embraer-ERJ-190LR-P4-KCJ
photo of Embraer-ERJ-190LR-P4-KCJ
abnormal aircraft attitude FDR example
photo of Embraer-ERJ-190LR-P4-KCJ
FDR readout
photo of Embraer-ERJ-190LR-P4-KCJ
approach profiles to Beja
 

Video, social media

Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Alverca Air Base et Minsk-2 International Airport est de 3221 km (2013 miles).

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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