What happened
On November 28, 2018, an Avior Airlines B737-2Y5, registration YV2937, was performing a flight from Maiquetia Aerodrome, Venezuela, to Eduardo Gomes Aerodrome (SBEG) in Manaus, Brazil. The aircraft was carrying 39 passengers and 5 crewmembers.
During the landing phase on runway 29, the aircraft experienced a failure in hydraulic System A. This failure resulted in the flaps only extending to position 10 and prevented the operation of the number 1 engine reverser. Due to the combination of the mechanical failures, heavy rain, and a tailwind component of approximately 5 knots, the aircraft could not stop within the available landing distance. The aircraft overran the runway, crossing the limits and coming to a stop on unpaved, soft terrain approximately 100 meters past the threshold of runway 11. There were no fatalities and no injuries to the occupants, though the aircraft sustained minor damage.
The investigation
CENIPA's investigation focused on the sequence of mechanical failures and the breakdown in operational communications. Investigators examined the aircraft's maintenance records, which noted a prior discrepancy regarding hydraulic pressure drops when selecting flap 5. The investigation also reviewed meteorological data, which showed heavy rain and thunderstorms in the area, and analyzed the communication between the flight crew and the Manaus tower.
Findings
- Inaccurate meteorological information: The air traffic controller failed to inform the crew that the runway threshold had been changed to runway 11, which would have provided a more favorable landing condition.
- Hydraulic system failure: The loss of hydraulic System A led to secondary issues, including limited flap extension and the loss of the number 1 reverser.
- Communication flaws: There was a lack of accurate information regarding rain intensity and runway changes between the crew and the tower. Additionally, the crew did not declare an emergency or urgency, which prevented the activation of ground support services.
- Decision-making and judgment: The crew's decision to proceed with the landing on runway 29, despite the tailwind and the known hydraulic failure in adverse weather, contributed to the excursion.
- Adverse weather: Heavy rain and thunderstorms increased the required stopping distance and hindered the tower's ability to monitor the runway exit.