The Investigators’ Report
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On 24 June 2020, the GPIAA final report concluded the probable cause of the Air Astana ERJ190LR flight KC1388 accident was “the incorrect installation of the aircraft's flight control cables system during heavy maintenance activities, resulted in the aircraft's aileron system reversal operation and consequent loss of control during flight”.
Contributing factors included: “gaps in the maintenance service provider quality assurance system and failure to implement an effective internal and external maintenance activities oversight”, and “the aircraft design and the corresponding maintenance instructions regarding the ailerons control system configuration”.
The report stated: “The crew, by adopting a teamwork strategy, discussing options with the third cockpit occupant and with the technicians on board, complemented each other in the necessary actions to face the encountered difficulties and collaborated for an outcome with minimal consequences for all on board”.
The report begins with this important caveat: “The only aim of this report is to collect lessons which may help to prevent future accidents. Its use for other purposes may lead to incorrect conclusions”.
To read the full GPIAA report (in Portuguese and English), click on this link: www.gpiaa.gov.pt/upload/membro.id/ficheiros/i007172.pdf
