Incident Overview

Date: Saturday 28 January 2017
Aircraft Type: Boeing 737-476 (SF)
Owner/operator: AerCaribe Cargo
Registration Number: HK-5197
Location: Leticia-Alfredo V squez Cobo Airport (LET) – ÿ Colombia
Phase of Flight: Landing
Status: Substantial, repaired
Casualties: Fatalities: 0 / Occupants: 4
Component Affected: Aircraft Brake System, Landing Gear, Hydraulic Lines, HarnessesAircraft Brake System, Landing Gear, Hydraulic Lines, Harnesses
Investigating Agency: AerocivilAerocivil
Category: Accident
An Aer Caribe Boeing 737-400 cargo plane suffered a significant incident at Leticia Airport, Colombia, following a runway excursion after landing. The aircraft experienced a sudden explosion resulting from a brake system failure, exacerbated by a combination of factors including poor maintenance practices, a hydraulic line break, and tire failure. The crew initiated manual braking, which resulted in the aircraft rolling and crossing the threshold, prompting an evacuation. The investigation points to a root cause stemming from inadequate maintenance procedures and a failure to address repeated tire issues, compounded by a critical landing maneuver and inadequate risk management.An Aer Caribe Boeing 737-400 cargo plane suffered a significant incident at Leticia Airport, Colombia, following a runway excursion after landing. The aircraft experienced a sudden explosion resulting from a brake system failure, exacerbated by a combination of factors including poor maintenance practices, a hydraulic line break, and tire failure. The crew initiated manual braking, which resulted in the aircraft rolling and crossing the threshold, prompting an evacuation. The investigation points to a root cause stemming from inadequate maintenance procedures and a failure to address repeated tire issues, compounded by a critical landing maneuver and inadequate risk management.

Description

An Aer Caribe Boeing 737-400 cargo plane suffered a runway excursion after landing at Leticia Airport, Colombia. The aircraft took off from the Bogot  Airport at 15:50 hours local time. The flight was normal and the aircraft was cleared for the VOR approach to runway 21. The controller notified the crew of a 350ø wind at 4 knots and a wet runway. At 16:57, the aircraft touched down abeam taxiway Alpha. Immediately afterwards, when the deceleration began, with the application of the reverses, an explosion occurred. The crew observed that the auto-braking system was not operating, so they decided to deactivate it and execute manual braking. Both captain and first officer failed to get a response when applying the brakes so the captain decided to activate the reversers again with 400 metres of runway remaining. The aircraft continued to roll and crossed the threshold stopping in the safety zone, twenty meters from the runway threshold. Approximately one minute after the plane stopped, the crew opened the cargo door and evacuated by their own means; the four occupants were unharmed. Probable cause(s) The investigation determined that the accident was caused by the following causal factors: Poor maintenance procedures of the aircraft operator, by not applying complete and adequate corrective actions to determine the root cause of repeated tire failure. Brake system failure as a result of a break in the hydraulic lines and harness housed in the right landing gear compartment caused by pieces of rubber from tire No. 4 bursting during the landing run. Bursting of tire No. 4 due to the over bending action it suffered as a result of being inflated and over inflated repeatedly, due to different reports of low tire pressure. Runway departure during the deceleration during the landing manoeuvre in Leticia. Contributing Factors Inadequate risk management of the Operator, since the repeated reports of discrepancies were not known or dealt with by its Operational Safety Management area. Poor conditions in the safety zone, in the extension of the Leticia aerodrome’s header 03, whose unevenness and flooding contributed to the damage to the aircraft.

Source of Information

http://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/Listado%20de%20Accidentes%20ao%202017/ACCIDENTE%20HK5197%20AERCARIBE.pdfhttp://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/Listado%20de%20Accidentes%20ao%202017/ACCIDENTE%20HK5197%20AERCARIBE.pdf

Primary Cause

Repeated tire failure, specifically tire No. 4, leading to a hydraulic line break and harness failure during the landing run, causing the aircraft to roll and cross the threshold.Repeated tire failure, specifically tire No. 4, leading to a hydraulic line break and harness failure during the landing run, causing the aircraft to roll and cross the threshold.

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