Colombia

The accident was the consequence of a lateral runway excursion as a result of a loss of control on the ground caused by the loss of air pressure in the left main gear tire, as a result of the penetration of a FOD (metallic object) into the tire during the landing run. Poor risk management by the San Felipe Aerodrome operator (SKFP) and a lack of a runway FOD control program (SKFP) by the operator of the aerodrome was considered as contributing factors.

A loss of control during the takeoff roll as a result of inappropriate techniques on the part of the pilot-in-command who suffered a loss of situational awareness by not detecting the deviation in a timely manner.
The following contributing factors were identified:
- Inadequate crew decisions to apply appropriate corrective actions,
- Inadequate crew training program,
- Poor operational supervision on part of the operator.

The following findings were identified:
- Inappropriate decision by the aircraft operator to rush the aircraft's initial route to an aerodrome unknown to the company, not appropriate to the type of aircraft and not authorised in its Operating Specifications, without at least a proper risk assessment.
- Inadequate crew decision to accept and decide to proceed to an unknown aerodrome, without due knowledge of its characteristics, without prior experience or training in aerodrome operation and without at least a risk assessment.
- A side runway excursion, from 24 metres from the threshold of runway 25, as a result of a probable unstabilised approach resulting in an off-axis landing.
Contributing factors:
- Inefficient planning and supervision of operations by the aircraft operator, by scheduling the operation to an unknown airfield.
- Failure of the company to comply with the contents of the Dispatch Manual and General Operations Manual, in relation to the procedures that must be complied with before operating new routes, new airports or special airports, in aspects such as route analysis, runway analysis, risk management and crew requirements.
- Ignorance of the Tarapacá runway by the crew.

Inadequate fuel management and incomplete execution of procedures by the Pilot, by not activating in time the fuel supply from the external tanks (OUTBD) to the internal tanks (INBD) for the feeding of both the engines, causing the fuel in the internal tanks to run out and causing both engines to stop due to fuel starvation.
Contributing Factors:
- Poor flight planning on part of the pilot by not considering the amount of minimum fuel needed and not complying with the minimum fuel amount required for domestic flights.
- Loss of situational awareness by the pilot by not following the standard operation procedures.

The following findings were identified:
- Inadequate flight planning by the operator of the aircraft, and by the crew, by failure to properly perform dispatch procedures, takeoff performance calculations and verification of limitations imposed by operational conditions of the aerodrome according to the configuration of the aircraft.
- Wrong crew decision making by not considering a key aspect affecting aircraft performance, such as the prevailing tailwind at takeoff.
- Erroneous selection of takeoff speeds V1/VR and V2, by the crew, corresponding to an aircraft without modification in its flap system, which led to rotate the aircraft with five more knots of speed, increasing the takeoff run.
- Erroneous rotation technique applied by the Pilot, delayed maneuver that extended the long takeoff run even more.
- Loss of components (landing gear, trailing inboard flap right) and damage to functional systems (loss of engine power n°3 and hydraulic system) necessary to control the aircraft in flight.
- Loss of control in flight generated by asymmetries of lift, power and emptying of the main hydraulic systems that exceeded the capacity of the crew and made it impossible to maintain adequate directional control and stability of the aircraft.
Contributing Factors:
- Non-compliance with the Aeronautical Regulations by the operating company of the aircraft, operating to an aerodrome unsuitable for the operation of B727-200 equipment, which, in addition, was not authorized for that type of aircraft in the company's Operating Specifications, approved by the Aeronautical Authority.
- Lack of standardization and supervision of the operating company of the aircraft, allowing the operation of the B727-200 equipment, to which a modification had been applied to the flap system, with the reference tables of speeds corresponding to the aircraft without modification.
- Execution of take-off with a weight that exceeded the maximum value established in the aircraft performance charts for the conditions prevailing at the Germán Olano airport.
- Omission of the crew by not activating the Standby hydraulic system, which might have allowed emergency hydraulic pressure, to regain control of the aircraft.
- Lack of supervision by the Aeronautical Authority, which allowed for several years the operation of equipment B727-200 of the company operating the aircraft at the Germán Olano aerodrome in Puerto Carreño, when the characteristics of the aerodrome did not allow it and without the operator being authorized to operate equipment B727-200 in that aerodrome.

It was determined that the accident was the consequence of an inappropriate planning and execution of the flight, since the amount of fuel required to fly from the airport of destination to an alternate airport was not considered, nor was the amount of reserve fuel, nor the contingency fuel, nor the minimum landing fuel, quantities of fuel required by aeronautical regulations for the execution of the type of international flight that the aircraft CP-2339 was performing. The following factors were considered as contributing:
- Loss of situational awareness,
– Premature configuration of the aircraft for landing,
– Latent deficiencies,
– Lack of operational supervision and control of part of Operator,
– Organizational and operational deviation on the part of the Operator (non compliant to standard procedures).

The following findings were identified:
- Execution of a take-off with a weight approximately 17% higher than the maximum gross operating weight (MTOW) established for the C208B aircraft.
- Limited climb rate with signs of lift loss due to the low performance given by the overweight during the initial climb phase.
- Forced landing in mountainous terrain due to loss of lift caused by overweight during the initial climb.
- Absence in the identification of the risks associated to an overweight operation of the aircraft.
- Lack of supervision by the Aircraft Operator in relation to the dispatch of aircraft operating from the outside at the main base of operation.