Vliegtuigongeval op 21 FEB 2011 met ATR 72-212 PR-TTI - Altamira Airport, PA (ATM)
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Status:Accident investigation report completed and information captured
Datum:maandag 21 februari 2011
Tijd:18:45
Type:Silhouette image of generic AT72 model; specific model in this crash may look slightly different
ATR 72-212
Luchtvaartmaatschappij:TRIP Linhas Aéreas
Registratie: PR-TTI
Constructienummer: 454
Bouwjaar: 1995-05-11 (15 years 10 months)
Aantal vlieguren:32886
Motoren: 2 Pratt & Whitney Canada PW124B
Bemanning:slachtoffers: 0 / inzittenden: 4
Passagiers:slachtoffers: 0 / inzittenden: 47
Totaal:slachtoffers: 0 / inzittenden: 51
Schade: Groot
Gevolgen: Written off (damaged beyond repair)
Plaats:Altamira Airport, PA (ATM) (   Brazilië)
Fase: Landing (LDG)
Soort vlucht:Binnenlandse lijnvlucht
Vliegveld van vertrek:Belém/Val-de-Cans International Airport, PA (BEL/SBBE), Brazilië
Vliegveld van aankomst:Altamira Airport, PA (ATM/SBHT), Brazilië
Beschrijving:
An ATR-72-212, registered PR-TTI, was damaged in a runway excursion accident at Altamira Airport, PA (ATM), Brazil.
The airplane operated on a domestic flight from Belém/Val-de-Cães International Airport. The approach for landing was visual and stabilized. The touchdown on runway 25 was smooth, with gradual deceleration, in which only ground idle power was utilized.
After the 70kt callout, a strong noise was heard, and the left main gear collapsed, with the aircraft veering off to the left. The aircraft exited the runway and came to a stop in a grass area.

Probable Cause:

Contributing factors
1 Human Factor
1.1 Medical aspect
Nil.
1.2 Psychological aspect
Nil.
1.2.2 Psychosocial information
Nil.
1.2.3 Organizational information
a) Capacitation - a contributor
The lack of capacitation and training of the subcontractors’ professionals for handling aircraft material hindered the execution of an efficient maintenance work as prescribed by the manufacturer's manual, culminating in inadequate machining during the maintenance process.
b) Organizational Processes - a contributor
The lack of an effective process of supervision, both on the part of TRIP Linhas Aéreas and on the part of the other contractors and subcontractors allowed the existing maintenance services’ latent failures not to be checked and corrected, in a way capable of subsidizing, in an adequate and safe manner, the execution of the landing gear maintenance service
The process of supervision of the TRIP Linhas Aéreas and the AV Indústria Aeronáutica Ltda. companies by the Civil Aviation Authority, prescribed by specific legislation in force, was not enough to mitigate the latent conditions present in the accident in question.
2 Operational Factor
2.1 Concerning the operation of the aircraft
a) Aircraft maintenance - a contributor
According to the technical opinion issued by the DCTA, the AFT PIVOT PIN (D61000 and SN 25) presented fracture surfaces with ± 45º inclination, as well as a flat area with multiple initiations, indicative of a fracture mechanism related to fatigue.
In examinations of the external surface of the pin, in a region close to the fatigue fracture, cracks were observed that had initiated from scratches created by an inadequate maintenance machining process.
In the region where the overload-related fracture occurred, it was also possible to identify that the machining process had modified the profile of the part in the section transition region, by producing a depression. Thus, it can be said that the AFT PIVOT PIN (D61000 and SN 25) of the PR-TTI left main gear broke on account of fatigue, whose onset was facilitated by an inadequate machining process that had been performed in the section transition region of the pin.
3 Material Factor
Not a contributor.

Accident investigation:

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Investigating agency: CENIPA Brazil
Status: Investigation completed
Duration: 2 years and 9 months
Accident number: A - 012/CENIPA/2013
Download report: Final report

Bronnen:
» Pista de Aeroporto de Altamira segue parcialmente interditada (G1)
» REGISTRO FOTOGRÁFICO DO ACIDENTE COM AVIÃO DA TRIP EM ALTAMIRA (SBHT)


Veiligheidsmaatregelen

CENIPA issued 6 Safety Recommendations

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Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Belém/Val-de-Cans International Airport, PA en Altamira Airport, PA bedraagt 466 km (292 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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