Date & Time:
Feb 2, 1995 at 0008 LT
Type of aircraft:
Boeing 737-200
Operator:
Registration:
PP-SMV
Flight Phase:
Landing (descent or approach)
Flight Type:
Scheduled Revenue Flight
Survivors:
Yes
Schedule:
São Paulo – Buenos Aires
MSN:
20968
YOM:
1974
Country:
Brazil
Region:
South America
Crew on board:
7
Crew fatalities:
0
Pax on board:
121
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
0
Captain / Total hours on type:
6500
Copilot / Total hours on type:
2500
Circumstances:
Following a night takeoff from São Paulo-Guarulhos Airport, en route to Buenos Aires, the captain informed ATC about technical problems and was cleared to return for an emergency landing. The aircraft landed at a speed of 185 knots with flaps down to 15° on wet runway 09L. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest 200 metres further. All 128 occupants were evacuated safely, among them two passengers were slightly injured. The aircraft was written off.
Probable cause:
It was determined that the n°3 leading edge flap actuator attachment fitting on the wing front spar had fractured due to corrosion. The actuator came away and caused the failure of some hydraulic lines and damage to the thrust control cables. Some 1981 Boeing Service Bulletins had not been complied with. One of these included the replacement of the aluminium leading edge flap actuator attachment fitting with a steel one; this had not been done. The following contributing factors were reported:
- Excessive workload on approach and landing due to the emergency situation,
- Poor approach planning,
- Lack of visibility due to the night,
- Poor crew coordination,
- Poor crew resources management,
- The crew forgot to lower the flaps electrically on approach, causing the speed to be 32 knots in excess,
- Poor aircraft maintenance and supervision,
- Failures in the supervision of the Company's operating sector.
- Excessive workload on approach and landing due to the emergency situation,
- Poor approach planning,
- Lack of visibility due to the night,
- Poor crew coordination,
- Poor crew resources management,
- The crew forgot to lower the flaps electrically on approach, causing the speed to be 32 knots in excess,
- Poor aircraft maintenance and supervision,
- Failures in the supervision of the Company's operating sector.
Final Report:
PP-SMV.pdf96.01 KB
