Accident Boeing 737-8HO (WL) 9Y-SXM,
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ASN Wikibase Occurrence # 319975
 
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Date:Tuesday 29 November 2016
Time:07:36
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8HO (WL)
Owner/operator:Caribbean Airlines
Registration: 9Y-SXM
MSN: 37935/3716
Year of manufacture:2011
Engine model:CFMI CFM56-7B26E
Fatalities:Fatalities: 0 / Occupants: 187
Aircraft damage: Substantial, repaired
Category:Accident
Location:Georgetown-Cheddi Jagan International Airport (GEO) -   Guyana
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:New York-John F. Kennedy International Airport, NY (JFK/KJFK)
Destination airport:Georgetown-Cheddi Jagan International Airport (GEO/SYCJ)
Investigating agency: GAAIU
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Caribbean Airlines Flight 527, a Boeing 737-800 aircraft (9Y-SXM), departed from New York-JFK Airport, NY, USA on a scheduled flight to Georgetown-Cheddi Jagan International Airport, Guyana.
The aircraft landed on runway 06 at 11:33 hrs and was cleared by ATC to taxi via taxiways Charlie and Alpha to the International Apron. The First Officer’s read back was correct. However, one minute and 30 seconds later, as the aircraft was taxiing on Charlie, the Captain asked the First Officer "Where we goin’? Bravo?", to which the First Officer responded affirmatively.
The aircraft then turned right onto taxiway Bravo, then turned left on to the apron and taxied behind a Fly Jamaica Boeing 767 (N767WA) parked in Parking Position 3. There was a wing walker on the ramp ahead, at the tail end of Parking Position 1 near to taxiway Alpha. Another wing walker was standing by the tail of the B767 in Parking Position 3, and a marshaller was at the head of Parking Position 2.
At 11:36, as the B737 taxied behind the B767, the right winglet of the B737, hit the trailing edge of the B767’s right elevator, cut off the tail cone and sliced through the left elevator. The B737 then came to a halt and the captain shut down the engines.

Findings: Causal.
1. The NTHS ramp personnel were not aware of the Airside Directive forbidding the taxiing of large aircraft behind parked B767s on the International Apron.
2. The CAL flight crew was not aware of the Airside Directive forbidding the taxiing of large aircraft behind parked B767s on the International Apron.
3. The Airside Directive forbidding the taxiing of large aircraft behind parked B767s on the International Apron was inadequately distributed.
4. After preparation of its AIRSIDE DIRECTIVE, the CJIA did not follow through with its responsibility to ensure that relevant information was transmitted to the GCAA and Jeppesen for inclusion in the AIP and the Jeppesen Charts respectively.
5. The Jeppesen and AIP airport charts for CJIA did not forbid the taxiing of large aircraft behind parked B767s on the International Apron.
6. The B737 First Officer erred when he misdirected the Captain to turn on taxiway Bravo, rather than taxiway Alpha.
7. Wing walker C intentionally moved the safety cone placed to mark the position of the B767’s tail.
8. Wing walker C did not adequately monitor the track of the B737’s right winglet to ensure clearance from the B767’s tail.
9. Wing walker B did not adequately monitor the track of the B737’s right winglet to ensure clearance from the B767’s tail.
10. Wing walker B attempted to marshal the B737 aircraft off to the left of the yellow taxi line to avoid the B737’s right winglet hitting the tail of the B767.
11. Wing walker B did not give a "Stop" signal to the B737 in time.
12. Wing walker C did not give a "Stop" signal to the B737 in time.
13. The right hand Number 3 Windshield Panel of the B737 was not heated, and was obscured by moisture, preventing the First Officer from adequately monitoring the clearance of the right winglet from the tail of the B767.
14. The right winglet of the B737 struck the elevators and tail cone of the B767.
15. Wing walker C had not been adequately trained.
16. The practical marshaller training by NTHS was not approved or monitored by CAL, CJIA or GCAA.
17. Wing walkers/marshallers on the CJIA ramp were following an unapproved procedure of directing aircraft off the yellow line to avoid other aircraft.
18. CAL and CJIA management were not aware of this unapproved procedure.
19. NTHS was aware of, and condoned, this unapproved procedure.
20. B737 pilots were routinely taxiing off the yellow line.
21. No hazard reports regarding this unapproved procedure were made to NTHS, CJIA or GCAA.
22. The dimensions of the layout of the CJIA International Apron did not meet the ICAO Recommended Standards for the aircraft it handled.
23. The SMSs of CJIA and CAL were inadequate.
24. NTHS had an SMS program, but it was not approved, nor was it required to be approved.
25. NTHS was not certified, approved or monitored by any other organization or authority, nor was this required.
26. Neither GCAA nor CJIA provided oversight of CJIA ramp operations.
27. The GCAA approved the Aerodrome Manual which was deficient. This was especially so in the SMS
28. GCAA inspection of records, during aerodrome inspections, was deficient as there was no demand for presentation of agreements/records between the CJIA and its clients operating at the airport.
29. GCAA did not adequately assess the inherently unsafe situation existing in the dimension and layout of the international apron.

Accident investigation:
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Investigating agency: GAAIU
Report number: GAAIU 3/1/12
Status: Investigation completed
Duration: 2 years and 5 months
Download report: Final report

Sources:


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