Date & Time:
Mar 28, 2017 at 1628 LT
Type of aircraft:
Boeing 737-300
Operator:
Registration:
OB-2036-P
Flight Phase:
Landing (descent or approach)
Flight Type:
Scheduled Revenue Flight
Survivors:
Yes
Schedule:
Lima - Jauja
MSN:
25071/2039
YOM:
1991
Flight number:
P9112
Country:
Peru
Region:
South America
Crew on board:
7
Crew fatalities:
0
Pax on board:
142
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
0
Aircraft flight hours:
62817
Aircraft flight cycles:
44025
Circumstances:
The aircraft departed Lima-Jorge Chavez Airport on a 20-minute flight to Jauja, carrying 142 passengers and 7 seven crew members. The approach to Jauja-Francisco Carlé was uneventful and completed in good weather conditions. Two seconds after the nose gear touched down on runway 31, the crew activated the reverse systems when he felt strong vibrations and oscillations. The aircraft started to bounce and became uncontrollable. The right main gear collapsed then the aircraft veered off runway to the right, lost its right engine and came to rest in a grassy area, bursting into flames. All 149 occupants evacuated safely and the aircraft was totally destroyed by fire.
Probable cause:
Failure of the mechanical components of the shimmy damper system in each of the main landing gears which, being out of tolerance range, did not allow the correct damping of the vibrations and lateral oscillations of the wheels after touchdown, generating sequential shimmy events in both gears and causing their collapse.
Contributing factors:
- Incorrect and probable absence of measurements on mechanical components of the 'cimmetic chain for shimmy damper operation', as indicated by the operator's PM AMM Task, which would have allowed for the timely detection and replacement of out-of-tolerance components, ensuring their integrity and correct operation.
- The Service Letter 737-SL-32-057-E 'broken torsion link', does not provide for mandatory actions, it only recommends maintenance practices to prevent fractures in mechanical components of the 'cimmetic chain for shimmy damper operation'.
- Service Letter 737-SL-32-057-E 'fractures in lower torsion link', makes a proper interpretation difficult; that could induce errors to choose the corresponding AMM Task and determine its scope.
Contributing factors:
- Incorrect and probable absence of measurements on mechanical components of the 'cimmetic chain for shimmy damper operation', as indicated by the operator's PM AMM Task, which would have allowed for the timely detection and replacement of out-of-tolerance components, ensuring their integrity and correct operation.
- The Service Letter 737-SL-32-057-E 'broken torsion link', does not provide for mandatory actions, it only recommends maintenance practices to prevent fractures in mechanical components of the 'cimmetic chain for shimmy damper operation'.
- Service Letter 737-SL-32-057-E 'fractures in lower torsion link', makes a proper interpretation difficult; that could induce errors to choose the corresponding AMM Task and determine its scope.
Final Report:
OB-2036-P.pdf8.14 MB
