Air Astana KC1388 Flight - Scary hours over Lisbon

It is obligatory to regularly give 'Human Factors Training' to the personnel working in Part-145 organizations where Aircraft Maintenance service is provided. In this training, human-induced factors that negatively affect the maintenance process are discussed and important incidents in aircraft or aircraft accidents due to maintenance errors are used as examples. The aim is to prevent similar mistakes from being made and to make aircraft maintenance personnel aware of the important consequences of their work.

Modifications to aircraft must be carried out in accordance with the Service Bulletins published by the manufacturers. Faulty actions during modification applications may cause the aircraft to lose very important functions or to crash, depending on the importance of the system to which it is applied.

Prior to the incident, which is the subject of our article, modifications were made to the aircraft by the EASA authorized Part-145 organization, which is not part of Astana Airlines and has an agreement for aircraft maintenance. Due to the fact that the Service Bulletin used does not contain information and warnings to prevent misapplication (ignoring Murphy's rule), the aileron control cables of both wings were inserted in reverse during the application. After the modification, the warning message “FLT CTRL NO DISPATCH” was received from the EICAS system of the aircraft. The work carried out with the technical support of the aircraft manufacturer took 11 days, but the reason for the error message could not be found. Thereupon, the Maintenance Center concluded that the error message received was not related to a real fault and issued a Maintenance Release Certificate to the aircraft.

BRIEF SUMMARY OF THE EVENT:

Horrors on an Embraer ERJ 190-100 LR type passenger plane that took off from the Portuguese capital Lisbon on Sunday, 11 November 2018, just 12 days after the Lion Air Airlines B737 MAX plane crashed into the sea in Indonesia and 189 people died in this accident. There were exciting moments.

Embraer 190-100 LR, flight KC1388 of Air Astana Airlines, took off from Alverca do Ribatejo Air Base in Lisbon, Portugal in a rainy and stormy weather at 13:31 UTC. The plane would refuel from Minsk, Belarus, and continue to Alma Ata, Kazakhstan, where the airline's home base is located. There was a captain, two co-pilots and three technicians on board. The aircraft, operated by Air Astana Airlines and holding the Aruba P4-KCJ registration mark, has undergone maintenance at the OGMA Maintenance Center facilities located at Alverca Air Base; During this maintenance, which lasted for 40 days, modification processes were also applied to the aircraft.

After takeoff, the flight crew had difficulty controlling the plane, the autopilot was not engaged and the flight controls were not making the desired movements.

The team declared a state of emergency. During this time, the aircraft was making out-of-control movements and was under severe structural loads due to rescue maneuvers. An experienced aviator, who examined the aircraft's FDR data, said that the people inside the aircraft during the incident felt as if they were inside a Roller Coaster.

In this incident, the flight crew, with their composure and experience, disabled the automatic systems of the aircraft and switched to manual flight and prevented a possible disaster.

The crew first wanted to return to Alverca Air Base, but when they saw that the aircraft could not be properly controlled, they gave up. Then they wanted to go seaward for a possible launch scenario. They saw that this was not possible with the current state of the aircraft.

They could hardly prevent dangerous situations caused by the unintentional movements of the aircraft. The continuous alarm warnings due to the abnormal flight of the aircraft, while the absence of any malfunction information about the aircraft systems, made the situation more complicated.

The captain of the plane started a teamwork to solve the problem by consulting other pilots and technicians. As a result of this work, they made the decision to control the aircraft completely manually and also disabled the Flight Control Computer. In manual flight, they noticed that the movement in the Roll axis did not comply with the commands given due to the problem with the ailerons. Therefore, they decided to fly using only the elevator, rudder and spoilers.

With the implementation of this decision, they could now control the aircraft more easily. Meanwhile, Portuguese F-16 aircraft, which took off with an emergency call, accompanied the aircraft to Beja Air Base. The plane, which did not use its ailerons, was able to put a wheel on the Beja Air Base runway on its third attempt by using the elevator, rudder and spoiler.

Some of the runway lights were damaged as the runway could not be centered during the descent. As a result of the incident, one of the technicians was injured in his leg, and everyone on the plane died.

Portugal Aviation and Train Accident Prevention and The Investigation Board (GPIAAF) released its preliminary report on this accident on 31 May 2019.

In the GPIAAF report, he stated that after the incident flight, significant structural damage was detected on both half wings, fuselage and flight control surfaces of the aircraft and stated that he classified the incident as an Accident according to the ICAO Annex 13 recommendations.

At the OGMA Maintenance Center, the aircraft was modified with the Embraer's Service Bulletin numbered 190-57-0038. Flight Controllers on Embraer 190 aircraft are moved by devices called PCU (Power Control Unit). These devices get their power from the hydraulic system and are mechanically controlled by cables coming from the cockpit.

The graph shows the area near RIB 21 where the control cable to the aileron is plugged in reverse after the mod. The cable path support part used before the mod had features that would prevent the cable from being passed incorrectly, while the new cable path support part installed with the mod did not have these features.

After the application of the mod, the warning message “FLT CTRL NO DISPATCH” was received on the EICAS (Engine Indicating and Crew Alerting System) display of the aircraft during the tests performed during maintenance. When the origin of this message could not be understood by the personnel at the Maintenance Center, assistance was sought from the aircraft manufacturer, Embraer. The work carried out with the technical support of the aircraft manufacturer company took 11 days, but the reason for the error message, namely that the aileron cables were inserted backwards, could not be determined. Thereupon, the Maintenance Center concluded that the error message received was not related to a real fault and issued a Maintenance Release Certificate to the aircraft.

During the Operational Aircraft Tests conducted by the Flight Crew before the aircraft took off to leave the maintenance base, it was not noticed that the ailerons were malfunctioning due to the fact that the control cables were inserted in reverse.

ACTIONS TO BE TAKEN BY AIRCRAFT MANUFACTURER EMBRAER AND AIRCRAFT MAINTENANCE CENTER OGMA

In its preliminary report, the Portuguese Aviation and Train Accident Prevention and Investigation Board (GPIAAF) requested the aircraft manufacturer, Embraer, to take a series of measures:

By September 30, 2019, Embraer will review all maintenance documents (including SB 190-57-0003) published for the flight control system of Embraer 170/190 aircraft and correct any statements that may lead to incorrect maintenance operations.

Embraer will prepare an informative document on possible maintenance errors in the flight control system and how to prevent them, and will distribute this document to all companies that use Embraer aircraft in their operations or provide maintenance services to these aircraft.

Embraer will prepare a document containing the tests and methods that will enable the recognition of the faulty operation after the application, if a faulty operation has been made during the maintenance applications of the aircraft's main flight controls, and will distribute this document to all companies that use Embraer aircraft in their operations or provide maintenance services to these aircraft.

The Board also determined in its preliminary report that the OGMA company, which applied the faulty mode to the aircraft, also made procedural deviations and requested the company to develop an action plan to eliminate the factors causing these procedural deviations.