ASN logo
ASN Wikibase Occurrence # 218725
Last updated: 16 September 2021
This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information. If you feel this information is incomplete or incorrect, you can submit corrected information.

Date:28-NOV-2018
Time:15:43 LT
Type:Silhouette image of generic B732 model; specific model in this crash may look slightly different
Boeing 737-2Y5 Adv.
Owner/operator:Avior Airlines
Registration: YV2937
MSN: 23847/1414
Fatalities:Fatalities: 0 / Occupants: 44
Other fatalities:0
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)
Destination airport:Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG)
Investigating agency: CENIPA
Narrative:
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

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

Accident investigation:
cover
  
Investigating agency: CENIPA
Status: Investigation completed
Duration: 2 years and 7 months
Download report: Final report
Location

Media:


Images:

Photo of YV2937 courtesy AirHistory.net


Willemstad / Curaçao - Hato (TNCC / CUR)
16 January 2015; (c) LRS747

Revision history:

Date/timeContributorUpdates
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]

Corrections or additions? ... Edit this accident description