Investigation Summary
During the descent toward Puerto Ordaz, the aircraft experienced a malfunction in its Centralized Crew Alerting System (CCAS), which erroneously activated the stall warning system (stick shaker and pusher). Simultaneously, the aircraft's elevators became decoupled, a condition that required significant physical effort from the Captain to maintain pitch control. The crew became overwhelmed by the conflicting information and the physical demands of the aircraft. Instead of identifying the stall warning as erroneous, the crew's situational awareness degraded, leading to poor coordination and ineffective decision-making. The Captain's cognitive and emotional state deteriorated under the stress, resulting in a lack of leadership and judgment. Shortly before impact, the aircraft struck a 116kV power line, which contributed to the final loss of control. The aircraft eventually crashed into a waste dump area belonging to the SIDOR steel works. The impact site was located approximately 8 to 9 kilometers short of the runway 07 threshold, which corresponds to a general location approximately 11 to 13 kilometers southwest of the airport center.
Final Conclusions
The JIAAC (Venezuela) concluded in its final report dated 31 December 2015 that the probable cause was the malfunction of the Centralized Crew Alerting System (CCAS/CAC) with erroneous activation of the stall warning system. Contributing factors included deficiencies in Crew Resource Management (CRM), loss of situational awareness, inadequate coordination during the decision-making process for abnormal situations, lack of knowledge regarding the stall warning system, and inadequate handling of flight controls while the elevators were decoupled.
Video Analysis
Conviasa Flight 2350 - Crash Animation — A 3D visualization of the final moments of Conviasa Flight 2350, which crashed near Ciudad Guayana, Venezuela, following a loss of control during approach.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Systems & Failure Modes
Centralized Crew Alerting System (CCAS)
The system responsible for monitoring aircraft parameters and alerting the crew to malfunctions; its failure provided the pilots with false stall indications.
Elevators
The primary pitch control surfaces; these became decoupled during the flight, requiring the pilot to exert extreme physical force to maintain control.
Stall Warning System
Includes stick shakers and pushers designed to prevent an aerodynamic stall; it activated erroneously due to a CCAS malfunction.
Interesting Facts
- 01The aircraft had completed 27,085 flight hours and 29,603 cycles at the time of the accident.
- 02The crash occurred in an industrial area used for storing steel mill materials belonging to the SIDOR works.
- 03The Venezuelan government grounded the entire Conviasa fleet for a technical review following the accident.
- 04The final official death toll was 17, after several survivors succumbed to their injuries in the days following the crash.
- 05The aircraft struck a 116kV power line shortly before impacting the ground.
Safety Actions & Advisories
Fleet Grounding
Source ↗The Venezuelan government grounded all Conviasa flights on 17 September 2010 to perform a comprehensive technical review of the airline's fleet and flight operations.
Operational Suspension
Trinidad and Tobago's Civil Aviation Authority suspended Conviasa's services into the country immediately following the crash due to safety concerns.