PPRuNe Forums - View Single Post - Convair 340 (C-131D) ZS-BRV crash Pretoria, South Africa
Old 28th Aug 2019, 12:19
  #455 (permalink)  
Cloudee
 
Join Date: Sep 2015
Location: Australia
Posts: 555
Received 79 Likes on 38 Posts
Not a good read for both the flight and maintenance crews.

3.4. Contributory Factors:
3.4.1 Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft.
3.4.2 Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident.
3.4.3 Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident.
3.4.4 The crew not aborting take-off at 50kts prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50kts and that should have resulted in an aborted take-off.
3.4.6 Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire.
3.4.7 Lack of recency training for both the PF and PM, as well as the LAME.
3.4.8 Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation.
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