ASN Wikibase Occurrence # 348510
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Date: | Friday 14 October 2022 |
Time: | 10:35 |
Type: | Cessna 402C |
Owner/operator: | Aerea |
Registration: | HK-3065 |
MSN: | 402C-0484 |
Year of manufacture: | 1975 |
Total airframe hrs: | 5441 hours |
Engine model: | Continental TSIO-520-VB |
Fatalities: | Fatalities: 0 / Occupants: 5 |
Aircraft damage: | Minor |
Category: | Serious incident |
Location: | Bahía Solano - Quibdó -
Colombia
|
Phase: | En route |
Nature: | Passenger - Non-Scheduled/charter/Air Taxi |
Departure airport: | Bahía Solano |
Destination airport: | Quibdó-El Caraño Aerodrome |
Investigating agency: | Aerocivil |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:The Cessna 402C took off from Bahía Solano aerodrome bound for El Caraño Aerodrome in Quibdó, Chocó. After 25 minutes of flight at an altitude of 5500 feet, the propeller of the left engine suddenly detached. Based on the engine parameter indications, the crew deduced that a sudden stop had occurred. While applying the corresponding procedures, they noticed that the propeller had detached. The crew declared an emergency, El Caraño aerodrome in Quibdó activated the Emergency Action Plan, and the aircraft landed in a controlled manner without further incident. The occupants were uninjured.
The investigation identified the Probable Causes of the Serious Incident as follows:
Total detachment of the left engine propeller in flight due to high vibrations that fractured the securing bolts and tore other bolts from the propeller hub, resulting from incorrect adjustment of these components during the propeller installation in the last routine inspection.
Inadequate maintenance procedures and improper inspection by Quality Control during the propeller installation and adjustment.
It also identified the following Contributing Factors:
Lack, in the operator, of a specific procedure indicating parameters or specific conditions required for conducting inspections and maintenance activities, such as qualification or suitability of technical personnel.
Deficient written inspection procedures in the operator's General Maintenance Manual, guiding maintenance personnel toward appropriate decision-making during inspection processes, as processes such as visual inspections with required inspection and supervision (RII) are not evident.
Incorrect maintenance Quality Control processes during the installation of the propeller and engine, as Quality Control performed this control not as an Inspector but as a Maintenance Technician.
Lack in the company's General Maintenance Manual of an effective procedure ensuring the operation and functionality of the aircraft systems in a technical and controlled manner for special cases, such as the removal and installation of internal engine components, despite the existence of a procedure for the delivery of aircraft and their engines after scheduled and unscheduled maintenance work.
Accident investigation:
|
| |
Investigating agency: | Aerocivil |
Report number: | COL-22-69-DIACC |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
Aerocivil
Revision history:
Date/time | Contributor | Updates |
30-Nov-2023 20:46 |
harro |
Added |
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