Date & Time:
Oct 21, 2009 at 1531 LT
Sharjah - Khartoum
Copilot / Total hours on type:
Aircraft flight hours:
Aircraft flight cycles:
The Aircraft was operating a flight from Sharjah International Airport, UAE to Khartoum International Airport, Sudan, with a total of six persons on board: three flight crew members (captain, co-pilot, and flight engineer), a ground engineer, and two load masters. All of the crew members sustained fatal injuries due to the high impact forces. Sometime after of liftoff, the core cowls of No. 4 engine separated and collapsed onto the departure runway, consequently No. 4 Engine Pressure Ratio (“EPR”) manifold flex line ruptured leading to erroneous reading on the EPR indicator. The crew interpreted the EPR reading as a failure of No. 4 engine; accordingly they declared engine loss and requested the tower to return to the Airport. The Aircraft went into a right turn, banked and continuously rolled to the right at a high rate, sunk, and impacted the ground with an approximately 90° right wing down attitude.
The Investigation identified the following Causes:
(a) the departure of the No. 4 engine core cowls;
(b) the consequent disconnection of No. 4 engine EPR Pt7 flex line;
(c) the probable inappropriate crew response to the perceived No. 4 engine power loss;
(d) the Aircraft entering into a stall after the published maximum bank angle was exceeded; and
(e) the Aircraft Loss of Control (“LOC”) that was not recoverable.
Contributing Factors to the Accident were:
(a) the Aircraft was not properly maintained in accordance with the Structure Repair
Manual where the cowls had gone through multiple skin repairs that were not up to
(b) the Operator’s maintenance system failure to correctly address the issues relating to the No. 4 engine cowls failure to latch issues;
(c) the failure of the inspection and maintenance systems of the maintenance organization, which performed the last C-Check, to address, and appropriately report, the damage of the No. 4 engine cowls latches prior to issuing a Certificate of Release to Service;
(d) the Operator’s failure to provide a reporting system by which line maintenance personnel report maintenance deficiencies and receive timely and appropriate guidance and correction actions;
(e) the Operator’s quality system failure to adequately inspect and then allow repairs that were of poor quality or were incorrectly performed to continue to remain on the Aircraft; and
(f) the SCAA safety oversight system deficiency to adequately identify the Operator’s chronic maintenance, operations and quality management deficiencies.