ASN Wikibase Occurrence # 322710
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| Date: | Saturday 13 December 2003 |
| Time: | 22:48 |
| Type: |  Boeing 737-2A9 |
| Owner/operator: | Aero Continente |
| Registration: | OB-1544-P |
| MSN: | 20956/386 |
| Year of manufacture: | 1974 |
| Total airframe hrs: | 62716 hours |
| Cycles: | 62162 flights |
| Engine model: | Pratt & Whitney JT8D-9A |
| Fatalities: | Fatalities: 0 / Occupants: 100 |
| Aircraft damage: | Destroyed, written off |
| Category: | Accident |
| Location: | Lima-J Chavez International Airport (LIM) -
 Peru
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Caracas-Simón Bolívar International Airport (CCS/SVMI) |
| Lima-Jorge Chávez International Airport (LIM/SPIM) | |
| Investigating agency: | CIAA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Aero Continente Flight 341 was cleared for an approach to Lima's runway 15. During the approach the crew noted a flap asymmetry warning. The approach was continued, but the crew forgot to lower the landing gear. The airplane belly landed at a speed of 190 kts and slid for 2347 meters before coming to rest.
CONCLUSIONS
The Aviation Accident Investigation Commission of the Ministry of Transportation and Communications determines the probable cause(s) of the accident as follows:
Operational human factor by omission.
Failure to verify and check the Non Normal Checklist of the Quick Reference Handbook (QRH) when technical problems occurred at the time of approach and landing, causing the omission of the extension of the landing gear and subsequent contact of the aircraft with the runway, with the landing gear retracted.
NOTES
AIRCRAFT: During the approach there was an indication of flap asymmetry.
TECHNICAL CREW: Due to the tightness of the itinerary programmed by the company, the total flight hours and the working day of the flight were within the limits of the maximum allowed by the RAP, which could have influenced (due to fatigue) in the deficient performance of the crew.
FLIGHT RECORDERS - The lack of recording of some parameters of the flight recorders (FDR and CVR) prevented the resolution of some important and useful details for the investigation.
CONTRIBUTING CAUSES
1. Flap asymmetry indication, due to an indication failure in the Flap Position Indicator caused by a high electrical resistance originating from the winding inside the right side Flap Position Transmitter synchro transmitter.
2. The omission of the use in the approach phase, of the procedures described in the QRH for this type of abnormal situations.
3. The lack of decision to perform a Go Around, taking into account that the period of time to carry out the QRH procedures for this abnormal situation was not going to be enough.
4. Overconfidence (complacency) during the approach phase in abnormal conditions (flap asymmetry indication).
5. Lack of Crew Resource Management during the approach and landing phases, especially under abnormal conditions.
6. Lack of leadership during the abnormal situation presented.
7. Lack of communication with the Control Tower about the abnormal conditions in which the approach and landing were to be carried out.
8. Itinerary very tight to the limits of flight day and time.
Accident investigation:
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Sources:
Location
Images:
photo (c) via Werner Fischdick; Miami International Airport, FL (MIA); November 1991
Revision history:
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