Status: | Accident investigation report completed and information captured |
Datum: | woensdag 16 februari 2022 |
Tijd: | 15:13 |
Type: |  Swearingen SA226-AT Merlin IV |
Luchtvaartmaatschappij: | Colcharter |
Registratie: | HK-5225 |
Constructienummer: | AT-027 |
Bouwjaar: | 1974 |
Motoren: | 2 Garrett TPE331-10UA-511G |
Bemanning: | slachtoffers: 0 / inzittenden: 2 |
Passagiers: | slachtoffers: 0 / inzittenden: 3 |
Totaal: | slachtoffers: 0 / inzittenden: 5 |
Schade: | Groot |
Plaats: | San Andres Island-Gustavo Rojas Pinilla Airport (ADZ) ( Colombia)
|
Fase: | Taxi (TXI) |
Soort vlucht: | Ambulance |
Vliegveld van vertrek: | San Andres Island-Gustavo Rojas Pinilla Airport (ADZ/SKSP), Colombia |
Vliegveld van aankomst: | Medellín-Enrique Olaya Herrera Airport (EOH/SKMD), Colombia |
Beschrijving:The Swearingen SA226-AT Merlin IV, HK-5225, belonging to the company Colcharter, was scheduled to perform two flights as an air ambulance, first from Barranquilla to San Andres (ADZ) and then with a patient to Medellin (EOH). The first leg was uneventful.
The controller cleared the flight to back track on runway 06/24 to the threshold of runway 06 for takeoff.
After having taxied about 200 m, the right engine apparently experienced a substantial periodic acceleration to a taxi speed of 36 knots, where a maximum speed of 10 knots is allowed by the manufacturer. After the right engine accelerated, there was a trajectory change to the left side of the runway centerline. The crew attempted to keep the aircraft within the runway, however, the crew's efforts did not have a positive result, allowing the aircraft to drift out of the runway into the safety zone. When the aircraft was over the safety zone, the crew attempted to use the braking system, however, the brakes were not effective due to the poor traction of the aircraft's wheels with the grass surface in the safety zone.
The aircraft continued to taxi to the left of the runway, until coming to a complete stop when the nose of the aircraft collided with a concrete wall bordering the airport.
The aircraft suffered substantial damage in the nose area, however, the stress concentration due to the impact was more evident in the left front fuselage area, structurally compromising a large part of the skin.
Probable Cause:
Probable Cause
Runway excursion, as a result of loss of directional control of the aircraft, when exceeding the maximum taxi speed allowed by the aircraft manufacturer.
Contributing Factors
Possible misuse of the nose wheel steering control system, nose wheel steering, by the crew when using it above the allowed speed, hindering directional control.
Lack of standardization of the company's operating procedures, as it lacks its own taxiing policies and procedures.
Probable self-imposed pressure from the crew, due to their desire to comply with the scheduled operation.
Overconfidence, complacency, loss of situational awareness, and inadequate application of CRM by the crew, during a normal operation of the aircraft, which was apparently free of hazards.
Accident investigation:
|
Investigating agency: | Aerocivil  |
Status: | Investigation completed |
Duration: | 1 year and 2 months | Accident number: | COL-22-10-DIACC | Download report: | Final report
|
|
Bronnen:
» Aerocivil
Veiligheidsmaatregelen
Aerocivil issued 3 Safety Recommendations
Issued: 12-APR-2023 | To: Colcharter | REC. 01-202202-1 |
Create a Standard Operating Procedures (SOPs) Manual for each type of aircraft in the company\'s fleet, based on the manufacturer\'s manuals, operational conditions, and own experience. This will emphasize and reinforce compliance with established procedures. |
Issued: 12-APR-2023 | To: Colcharter | REC. 02-202202-1 |
Review and train the crews in landing, taxiing, and ground control techniques and procedures for the aircraft at both high and low speeds. Emphasize Crew Resource Management (CRM) in ground operations, where the apparent risks are lower. |
Issued: 12-APR-2023 | To: Aerocivil | REC. 03-201916-1 |
Disseminate this investigation report to operators of Special Aerial Work, Air Ambulances, and operators of the Merlin SA226 AT equipment. They should apply the recommendations as relevant and consider the report to improve their Operational Safety Management Systems. |
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Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft
niet de exacte vliegroute weer.
De afstand tussen San Andres Island-Gustavo Rojas Pinilla Airport en Medellín-Enrique Olaya Herrera Airport bedraagt 970 km (606 miles).
Accident location: Exact; as reported in the official accident report.
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.
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