ASN Aircraft accident Boeing 737-8F2 (WL) LV-HQY Cataratas del Iguazú-M.C.E. Krause Airport, MI (IGR)
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Status:Accident investigation report completed and information captured
Date:Monday 16 July 2018
Time:00:30
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8F2 (WL)
Operator:Flybondi
Registration: LV-HQY
MSN: 34406/1852
First flight: 2006-01-14 (12 years 6 months)
Total airframe hrs:46278
Cycles:22063
Engines: 2 CFMI CFM56-7B26
Crew:Fatalities: 0 / Occupants: 6
Passengers:Fatalities: 0 / Occupants: 65
Total:Fatalities: 0 / Occupants: 71
Aircraft damage: Substantial
Aircraft fate: Repaired
Location:Cataratas del Iguazú-M.C.E. Krause Airport, MI (IGR) (   Argentina)
Phase: Takeoff (TOF)
Nature:Domestic Scheduled Passenger
Departure airport:Cataratas del Iguazú-M.C.E. Krause Airport, MI (IGR/SARI), Argentina
Destination airport:El Palomar Airport, BA (EPA/SADP), Argentina
Flightnumber:FO5111
Narrative:
A Flybondi Boeing 737-800, suffered a tail scrape accident on takeoff from Cataratas del Iguazú Airport, Argentina.
The aircraft experienced a pronounced pitch up during the takeoff roll, causing the underside of the rear fuselage to strike the runway. The takeoff was aborted and the aircraft taxied back to the stand. There were no personal injuries. The aircraft suffered serious local damage.

Probable Cause:

Conclusions regarding factors related to the accident
- During the start of take-off, the aircraft experienced an abrupt positive uncommanded pitch that caused the rear ventral area of the fuselage to contact the runway surface (tail strike).
- The distribution of passengers on board the aircraft did not correspond to that established by the operational dispatch form prepared for the flight.
- The CG position was in the range of 38% to 40% of MAC at takeoff.
- The aircraft's CG was outside the flight envelope.
- At the time of the accident, Flybondi hired the company FlySeg S.A. to perform the traffic and operational dispatch tasks at the Iguazú Falls International Airport.
- The traffic personnel informed the dispatcher about the distribution of passengers on the aircraft through a series of photos taken at the check-in monitor which were sent by cell phone.
- The Flybondi MOE did not include a specific procedure for the transmission of information between the traffic and operational dispatch areas.
- The ARMS computer system used by dispatch was separate from the Radixx system used by traffic.
- During the dispatch process, there was no visual control of the distribution of passengers, in disagreement with the Flybondi AOM.
- It was not possible to determine the reasons for the discrepancy between the operational dispatch schedule and the actual distribution of passengers on board the aircraft.
- The clearance of the dispatcher did not comply with RAAC 65.
- The appointment of the chief cabin crew did not comply with the Flybondi AOM.
- The cabin crew was unaware of the potential hazards associated with the distribution of passengers on the aircraft.
- The investigation did not obtain records of a stopover clearance inspection of the Iguazu Falls International Airport prior to the start of operations on January 26, 2018.
- From the start of operations until the day of the accident, ANAC conducted only one stopover inspection on June 29th. It only recorded that the dispatchers had not complied with the operational familiarization flight.
- Between June and July 2018, the stopover accounted for a 425% increase in the number of movements, from 32 to 136 respectively. The accident flight corresponded to operation No. 70 in July.
- Between June and July 2018, one operational dispatcher and one traffic agent were added to the scale, increasing the staff assigned to it from five to seven people (one base manager, two dispatchers and four traffic agents).
- Since the beginning of the service, FlySeg S.A. did not receive any operational safety audits or inspections from Flybondi.
- The service time performed by the dispatcher during the week prior to the accident was 60 hours, including a total of 39 hours between 14:00 on July 13 and 2:00 on July 16. Three of the shifts performed in this period involved more than 10 consecutive hours of work.
- The time of service performed by the dispatcher of flight FO5111 was not in compliance with the provisions of RAAC 121.
- The RAACs do not establish service and rest time requirements for base managers and traffic personnel because they are not included as aeronautical personnel in the current regulations.
- At the time of the accident, Flybondi was in the process of implementing phase 2 of the SMS.
- Between January and July 2018 a total of three different people were in charge of the Flybondi GSO. During this period, the company went approximately two months without appointing an operational safety manager.
- At the time of the accident, Flybondi did not have a program for voluntary safety reporting.
- The investigation obtained no records of safety publications made by SMS prior to the accident.
- At the time of the accident, Flybondi personnel had not received training on the ERP.
- Current regulations do not establish operational safety training requirements for performing the duties of a base or traffic manager.

Accident investigation:

Investigating agency: JST Argentina
Status: Investigation completed
Duration: 2 years and 3 months
Accident number: 33752127/18
Download report: Final report

Classification:
Rejected takeoff
Tailstrike
Runway mishap

Follow-up / safety actions

JST issued 10 Safety Recommendations

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Cataratas del Iguazú-M.C.E. Krause Airport, MI to El Palomar Airport, BA as the crow flies is 1060 km (662 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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