Serious incident Boeing 737-804 (WL) PH-CDF, Friday 8 July 2022
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Date:Friday 8 July 2022
Time:12:00
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-804 (WL)
Owner/operator:Corendon Dutch Airlines
Registration: PH-CDF
MSN: 28227/452
Year of manufacture:1999
Total airframe hrs:75776 hours
Cycles:24202 flights
Engine model:CFMI CFM56-7B
Fatalities:Fatalities: 0 / Occupants: 185
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:near Heraklion -   Greece
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Heraklion-N. Kazantzakis Airport (HER/LGIR)
Destination airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Investigating agency: Dutch Safety Board
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Corendon Dutch Airlines flight CD512, a Boeing 737-804 had taken off from Heraklion when the pilots noticed that the aircraft reacted more slowly to their control commands than usual. They therefore decided to make a precautionary landing at Athens Airport. The aircraft made a safe landing.


CONCLUSIONS
Due to a failure of the left aileron control cable, the aircraft got into a degraded state of safety, as it partially lost a primary flight control causing a continuous roll effect to the left.
The aircraft remained controllable as the flight crew managed the roll effect by applying rudder and aileron input. The aircraft flight control system design aided in keeping control over the aircraft attitude and flight path. It is to be noted however that the serious incident occurred during favourable weather conditions as the atmosphere was
smooth.
For the system configuration on the PH-CDF, the flight control check performed by the flight crew (as part of the Before taxi checklist) is not effective in detecting a deteriorating or failed flight control cable between the feel and centering unit and the ailerons. A timely detection of a defect depends on an adequate maintenance process.
The failed aileron cable was according to material specifications and it was the original cable since aircraft delivery in January 2000. Detailed examination showed that both the failed and paired cable were affected by corrosion and wear and lacked sufficient lubrication. The absence of sufficient lubrication promotes wear and corrosion.
The Dutch Safety Board could not determine why the cables were not properly lubricated. The maintenance documentation shows that the required inspections were performed and that the tasks were signed off as completed. However, it cannot be ruled out that both cables have not been treated and lubricated in accordance with applicable
maintenance procedures.
In view of the Dutch Safety Board, it is important that - in particular for cables that have aged in cycles and flight hours – a ground engineer timely detect defects. In general, for ground engineers, the detection and determination of the extent of wear during a Detailed Visual Inspection (DVI) of the cables is a difficult task because of the small size of the cable inspected ‘on condition’.
Insufficient lubrication was the case for PH-CDF, but the overall effect of wear over lifetime of the aileron cables contributed to the failure as well. It could not be determined that aging (in terms of normal wear) of the aileron cable was a more dominant factor than the effect of lack of lubrication which promoted more than normal wear and corrosion.

Accident investigation:
cover
  
Investigating agency: Dutch Safety Board
Report number: 2022086
Status: Investigation completed
Duration: 2 years 1 month
Download report: Final report

Sources:

https://www.onderzoeksraad.nl/nl/media/inline/2022/11/17/quarterly_aviation_report_q3_2022.pdf https://www.flightradar24.com/data/flights/cd512#2c8ed04f

History of this aircraft

Other occurrences involving this aircraft

21 September 2011 G-CDZH Thomson Airways 0 Paphos International Airport - LCPH non
Wrong runway/taxiway landing
11 June 2019 PH-CDF Corendon Dutch Airlines 0 Alghero Fertilia Airport min
Bird strike

Revision history:

Date/timeContributorUpdates
08-Aug-2024 11:25 ASN Updated [Total occupants, Narrative, Accident report, ]

Corrections or additions? ... Edit this accident description

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