Incident Overview

Date: Monday 28 March 2005
Aircraft Type: Ilyushin Il-18D-40
Owner/operator: Aerocaribbean, opf Cubana de Aviaci¢n
Registration Number: CU-T1539
Location: Caracas-Sim¢n Bol¡var International Airport (CCS) – ÿ Venezuela
Phase of Flight: Take off
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 94
Component Affected: Flight Controls (Elevators & Rudder)Flight Controls (Elevators & Rudder)
Investigating Agency: JIAAC VenezuelaJIAAC Venezuela
Category: Accident
A Cubana IL-18D flight from Havana to Caracas experienced a significant runway excursion following an aborted takeoff from Runway 09 at Caracas-Sim¢n Bol¡var International Airport, Venezuela. The aircraft’s initial takeoff was controlled by the captain, but after reaching 150 km/h, the first officer took over, and the pilot subsequently experienced a loss of control, resulting in a significant runway excursion. The aircraft’s speed increased to approximately 282 km/h, covering 693 meters of runway and leaving 815 meters remaining. The aircraft’s landing gear separated after running over a channel, resulting in a controlled stop on a downslope. The evacuation process was inefficient, with passengers exiting through less convenient doors, leading to some passengers suffering dislocated limbs. The incident highlights a combination of human error, inadequate procedures, and a failure to adequately address critical safety aspects during the takeoff and landing phases.A Cubana IL-18D flight from Havana to Caracas experienced a significant runway excursion following an aborted takeoff from Runway 09 at Caracas-Sim¢n Bol¡var International Airport, Venezuela. The aircraft’s initial takeoff was controlled by the captain, but after reaching 150 km/h, the first officer took over, and the pilot subsequently experienced a loss of control, resulting in a significant runway excursion. The aircraft’s speed increased to approximately 282 km/h, covering 693 meters of runway and leaving 815 meters remaining. The aircraft’s landing gear separated after running over a channel, resulting in a controlled stop on a downslope. The evacuation process was inefficient, with passengers exiting through less convenient doors, leading to some passengers suffering dislocated limbs. The incident highlights a combination of human error, inadequate procedures, and a failure to adequately address critical safety aspects during the takeoff and landing phases.

Description

Cubana flight 4311, an Ilyushin Il-18D, suffered a runway excursion after an aborted takeoff from runway 09 at Caracas-Sim¢n Bol¡var International Airport, Venezuela. The aircraft operated on a round trip from Havana to Caracas and back. The first officer was pilot flying for the return leg. The initial part of the takeoff was performed by the captain. After reaching a speed of 150 km/h the captain handed over the flight controls to the first officer. After passing through 220-230 km/h, the pilot noticed that he had no control of the elevator and immediately reported the failure to the captain, who again took the controls to verify the anomaly. During this check, approximately 11 seconds passed and the airplane’s speed reached 282 km/h, while covering some 693 meters. The aircraft now had covered a total runway distance of 2230 meters, leaving 815 meters of runway remaining for braking. The takeoff was aborted but the aircraft was not able to stop on the remaining runway. The landing gear separated after running over a channel located approximately 20 meters after the runway. The aircraft came to a stop on a downslope. CAUSES: Human Factor, Material Factor and Physical Factor and taking into account the characteristics of the Accident and the evidence gathered during the course of the investigation, considers the Human Factor as the causal factor of this accident due to the following: – The flight crew did not perform the respective manual check of the flight controls (elevators). – The flight crew did not perform the visual check on the panel of the locked/red and unlocked/green warning lights of the flight control surfaces (ailerons, elevators, directional rudder). – There was no adequate Cockpit Management, or assertive behavior by the crew, in terms of decision making during the takeoff abort. – There were no accurate calculations for takeoff speed references (V1-Vr-V2) in analogy to takeoff weights. – The evacuation of the passengers was not efficient and correct, since it was evidenced that the exit of the passengers was carried out through the least convenient doors, due to the position of the aircraft, which had to be blocked by the cabin crew. – There was no deployment of the slides for evacuation, which resulted in some passengers suffering dislocated limbs when they had to jump.

Primary Cause

Human FactorHuman Factor

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