What happened
On January 4, 2012, an Antonov AN-2-100, registration OB-1859-P, operated by Amazon Sky S.A.C., was conducting a simulator supplement flight at Pisco Airport, Peru. The flight crew, which included a pilot, instructor/copilot, navigator, and flight engineer, was performing maneuvers to complement recent simulator training.
During a touch-and-go maneuver on runway 22, the pilot instructed the flight engineer to set the flaps to 15 degrees. However, after completing the landing configuration, the flight engineer activated the landing gear retraction switches without a specific request. This triggered the landing gear retraction cycle while the aircraft was still in a low-altitude phase of the maneuver. Consequently, the nose of the aircraft dropped, causing the number 1 engine propeller to strike the runway surface. The crew managed to maintain directional control and brought the aircraft to a stop 1,400 meters down the runway, subsequently initiating an emergency evacuation. There were no injuries to the crew or the DGAC inspector on board.
The investigation
The CIAA investigation examined the flight crew's actions, the aircraft's mechanical state, and the company's operational manuals. Investigators reviewed the cockpit voice recorder (CVR) and GPS data, though the flight data recorder (FDR) could not be accessed. The investigation also scrutinized the crew's adherence to Standard Operating Procedures (SOPs) and the completeness of the company's training and operational documentation regarding specific maneuvers.
Findings
- The primary cause was the erroneous retraction of the landing gear by the flight engineer during an unauthorized touch-and-go maneuver.
- Crew Resource Management (CRM) was deficient during the execution of the maneuver.
- The company's General Operations Manual (MGO) lacked procedures for performing touch-and-go maneuvers.
- The aircraft's flight manual did not provide detailed descriptions or operating instructions for the flap and landing gear switches or their mechanical safety locks.
- The crew failed to perform required precision approach call-outs, which would have verified the landing gear position.
- The assigned DGAC inspector was operating with an expired aircraft type refresher course.