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ASN Wikibase Occurrence # 188628
Last updated: 21 November 2018
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Date:12-JUL-2016
Time:07:22 LT
Type:Silhouette image of generic B190 model; specific model in this crash may look slightly different
Beechcraft 1900D
Owner/operator:Air Georgian opf Air Canada Express
Registration: C-GORF
C/n / msn: UE-330
Fatalities:Fatalities: 0 / Occupants: 17
Other fatalities:0
Aircraft damage: Minor
Location:Calgary International Airport, AB (YYC/CYYC) -   Canada
Phase: Landing
Nature:Domestic Scheduled Passenger
Departure airport:Lethbridge Airport, AB (YQL/CYQL)
Destination airport:Calgary International Airport, AB (YYC/CYYC)
Narrative:
Air Canada flight AC7212 departed Lethbridge Airport, Canada at 05:33 hours for a 47-minute flight to Calgary Airport.
The Beech 1900D was approaching the runway at 06:02 when the nose landing gear failed fully lock down. The flight entered a holding pattern but the crew was unable to get the nose landing gear fully down and locked.
The crew did a fly-by, and the tower observed that the nose gear was not fully extended, tilted aft.
The nose gear did collapse on landing at 07:22 and aircraft came to a stop on the runway abeam Taxiway D4.

Findings as to causes and contributing factors:
The lack of lubrication caused the pivot/stop bolt in the nose landing gear yoke to seize and break, which eventually prevented the nose landing gear from fully extending.
The nose landing gear pivot/stop bolt was not properly lubricated because maintenance personnel were not adequately trained on lubrication and the use of equipment.
Air Georgian's safety management system (SMS) was ineffective at identifying and correcting improper and unsafe maintenance practices relating to nose landing gear lubrication tasks.
Air Georgian's quality control program contributed to ineffective lubrication activities going undetected for an extended period of time prior to the occurrence.
Transport Canada's surveillance of Air Georgian focused primarily on its SMS rather than regulatory compliance. As a result, ineffective lubrication processes went undetected in the process inspection and 2 program validation inspections prior to the occurrence.

Sources:

https://www.flightradar24.com/data/flights/ac7212/#a502b9c
https://calgary.ctvnews.ca/plane-makes-emergency-landing-at-calgary-airport-1.2983411
http://nationalpost.com/news/contractor-that-operates-thousands-of-air-canada-flights-had-faulty-maintenance-safety-systems-federal-investigation-finds
http://aerossurance.com/safety-management/b1900d-maintenance-standards-practices/
http://bst-tsb.gc.ca/eng/rapports-reports/aviation/2016/a16w0092/a16w0092.asp


Revision history:

Date/timeContributorUpdates
12-Jul-2016 15:18 harro Added
14-Jul-2016 05:37 harro Updated [Time, Embed code, Narrative]
05-Jun-2018 15:21 Aerossurance Updated [Operator, Source, Damage, Narrative]
24-Jun-2018 14:57 Aerossurance Updated [Time, Total occupants, Source]

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