Spanair Flight 5022

Spanair Flight 5022
EC-HFP, the aircraft involved in the accident, in Star Alliance livery in July 2008.
Accident
Date 20 August 2008
Summary Crashed on take-off due to improper flaps and slats selection, Pilot error
Site Madrid–Barajas Airport, Madrid, Spain
40°31′48″N 003°34′13″W / 40.53000°N 3.57028°W / 40.53000; -3.57028Coordinates: 40°31′48″N 003°34′13″W / 40.53000°N 3.57028°W / 40.53000; -3.57028
Aircraft type McDonnell Douglas MD-82
Aircraft name "Sunbreeze"
Operator Spanair
Registration EC-HFP
Flight origin Barcelona–El Prat Airport
Stopover Madrid–Barajas Airport
Destination Gran Canaria Airport
Passengers 166
Crew 6
Fatalities 154
Injuries 18
Survivors 18

Spanair Flight 5022 (JK5022) was a scheduled domestic passenger flight from Barcelona–El Prat Airport to Gran Canaria Airport, Spain, via Madrid–Barajas Airport that crashed just after take-off from runway 36L at Madrid Airport at 14:24 CEST (12:24 UTC) on 20 August 2008. The aircraft was a McDonnell Douglas MD-82, registration EC-HFP. Of the 172 passengers and crew on board, 154 died and 18 survived.[1][2]

It was the only fatal accident for Spanair (part of the SAS Group) in the 25-year history of the company, and the 14th fatal accident and 24th hull loss involving McDonnell Douglas MD-80 series aircraft. It was Spain's deadliest accident since the 1983 crash of Avianca Flight 011.[3]

The accident further worsened Spanair's already negative image at the time[4] and exacerbated its financial difficulties. Spanair subsequently ceased operations on 27 January 2012.[5][6]

Flight and aircraft

Map showing crash location

The aircraft, named Sunbreeze (registration EC-HFP; constructor's number 53148), had been manufactured in late 1993 and was acquired by Spanair in July 1999.[7][8]

There were 166 passengers and six crew members on board, including the 39-year-old captain and the 31-year-old first officer.[9]

This was the flight's second attempted take-off: fifty-nine minutes earlier, the pilots had abandoned a departure because of excessive temperatures in the RAT probe.[10][Note 1] The aircraft was taken to a parking area where maintenance workers de-activated the RAT probe's heater.[11] (The aircraft was permitted to fly with an inoperable RAT probe heater because icing was not expected during the flight).[12] Another takeoff was then attempted, during which the accident occurred.[13]

The accident occurred during the second attempt, at 14:24 local time,[14][15] due to the pilot's failure to deploy the flaps and slats as required for takeoff.[16][17] Without the use of these "high-lift" devices, the wings could not generate enough lift to keep the aircraft airborne.[Note 2] The MD-80 has a warning system (the take-off warning system or TOWS) that should have alerted the pilots that the aircraft was not correctly configured for take-off. However, the warning did not sound, and the pilots continued with the attempt. The aircraft left the ground momentarily, rolled to the right,[19] and impacted the ground next to the runway. The wings separated from the aircraft and the fuselage broke into two main parts; the wings and the rear two-thirds of the fuselage were engulfed by fire.[20]

Victims

Of the 172 people on board, 146, including all crew members, perished in the crash or immediately after in the fire; of the twenty-six passengers rescued alive from the crash site, six died before arriving at hospital, and two more died in hospital, bringing the total number of fatalities to 154.[9][13][21][22][23][1][24]

Most of the deceased and 16 of the survivors were Spanish nationals; nineteen of the deceased and two survivors were of other nationalities.[9]

The crash flung some of the survivors clear of the wreckage and into a stream, lessening the severity of their burns.[25] A 30-year-old woman with British and Spanish dual citizenship survived with a punctured lung and broken left arm but no burns, as she was flung from row 6, still attached to her seat, into the stream.[26]

Investigation

Summary

The accident was investigated by the Civil Aviation Accident and Incident Investigation Commission (CIAIAC). Representatives from the US National Transportation Safety Board, the aircraft manufacturer Boeing (as successor to McDonnell Douglas, the original aircraft manufacturer), and the engine manufacturer Pratt and Whitney supported the investigation.[15]

A preliminary report on the accident was released by CIAIAC on 6 October 2008.[27] Information extracted from the Flight data recorder showed that the aircraft had taken off with flaps at 0°, and that the alarm for that abnormal takeoff configuration had not sounded. The report hinted at no other cause of the accident. Both the engines and thrust reversers were excluded as causes of the accident.

On 17 August 2009, CIAIAC released an interim report on the incident.[28] The interim report confirmed the preliminary report's conclusion that the crash was caused by an attempt to take off with the flaps and slats retracted, which constituted an improper configuration, and noted that safeguards that should have prevented the crash failed to do so. The cockpit recordings revealed that the pilots omitted the "set and check the flap/slat lever and lights" item in the After Start checklist. In the Takeoff Imminent verification checklist the copilot had simply repeated the correct flap and slat position values without actually checking them, as shown by the physical evidence. All three safety barriers provided to avoid the takeoff in an inappropriate configuration were defeated: the configuration checklist, the confirm and verify checklist, and the Take-off Warning System (TOWS). The report also made a number of safety recommendations intended to prevent accidents like this from happening again.[29]

CIAIAC published a further progress note in August 2010,[30] and its final report in July 2011.

Theories

Fire or explosion

Some early eye-witness accounts suggested that the aircraft suffered an engine fire or explosion before crashing, but the Spanish airport authority AENA released a video showing that the engines neither exploded nor caught fire during take-off.[31][32] Manuel Bautista, Director General of Spain's civil aviation authority, went as far as to state: "The engine is not the cause of the accident",[31] surmising that a chain of events combining together was more likely than a single cause.[33]

Temperature sensor

There has been considerable interest in the faulty air temperature probe (the total air temperature sensor,[Note 3] located on the front of the aircraft near the cockpit) that initially caused the pilot to turn the aircraft back for maintenance before the second takeoff attempt.[34] The mechanic simply deactivated the probe because the aircraft's Minimum Equipment List allowed it to be left inoperative. On 22 August investigators interviewed the mechanic, who defended his action by saying that it had nothing to do with the crash. Spanair has supported the mechanic's view that deactivation of the probe is an accepted procedure.[35] On 1 September a report, quoting Spanair, stated that the problem detected on the first takeoff attempt was overheating caused by a temperature gauge's de-icing system, rather than a malfunction of the temperature gauge itself, and that since icing was not a risk on that flight, the de-icing system had been deactivated by the mechanic with the captain's approval.[36]

On 11 May 2010, leaked details from the cockpit voice recorder (CVR) were released by Spanish media. The recording showed that both pilots were concerned about a repair job performed earlier on the day of the crash, in which mechanics used an ice pack to cool an overheating temperature sensor and removed a fuse.[37] The BBC reported that the judge investigating the crash was to question three mechanics on suspicion of manslaughter. These were the head of maintenance for Spanair at Barajas and the two mechanics who checked the aircraft before take-off.[38]

Thrust reverser

Pictures of the wreckage showed one of the thrust reversers in the deployed position,[Note 4] and an early theory constructed in the media was that the thrust reverser of the No. 2 (right side) engine activated during the climb causing the aircraft to yaw suddenly to the right.[40][41] This theory fell apart for three reasons: firstly, aircraft engineer Alberto Garcia pointed out that the MD-82 has tail-mounted engines positioned close to each other and to the aircraft's longitudinal axis, so that any yaw from asymmetric thrust would be small.[41] Secondly, examination of the aircraft's maintenance logs showed that the thrust reverser on the right-side engine had been deactivated pending repair. It had been wired shut, and tape placed over the cockpit control to alert the crew. The MD-82 is permitted to fly with just one operable thrust reverser.[42][43] Thirdly, the engine which had been pictured was the left engine, not the right one.[42] The investigation concluded that the position of its thrust reverser was a result of the accident, not a cause of it.[42]

Flaps and slats

El Mundo reported that the CVR showed that the pilot had said "Flaps OK, Slats OK" to the co-pilot.[44] The article confirmed that the flaps had not been extended and that the alarm for that condition had not sounded.[45] The final report concluded that the failure to deploy flaps was the cause of the accident.

The maintenance logbook of the aircraft has comments, two days before the crash, for an "autoslats failure" visual alarm occurring on slats extension; however autoslats are not used on takeoff, and it cannot be inferred that the slats system had a defect.[46]

Flight mode

In an article published on 7 September, El Mundo suggested that during the flight preparation and takeoff attempts, the aircraft had some of its systems in flight mode rather than ground mode.[47] Investigators noted that one particular ground-sensing relay (relay R2-5) was responsible for de-energizing the Total Air Temperature probe heater when on the ground, and for inhibiting TOWS when in the air. They theorized that a fault in this relay could explain both the overheating of the probe and why the flaps and slats alarm had not sounded. When the R2-5 relay was recovered from the wreckage it was subjected to detailed examination. Two stuck contacts within the relay were identified, which would explain the overheating both on the day of the accident and the intermittent incidents recorded over the previous few days. That fault, however, would not have affected the operation of the TOWS system, and no fault was found that would have affected TOWS.[47][48][49]

James W. Hudspeth, an investigator of a previous near accident (an MD-83, starting from Lanzarote) that was superficially similar, pointed out that the fuse of the so-called "left ground control relay" at position K-33 of the control panel might have been the actual culprit in the erroneous flight mode: Hudspeth found out during a 2-week investigation at Lanzarote that it is customary in normal maintenance routine to temporarily remove this circuit-breaker to engage flight mode, but the circuit-breaker is afterwards sometimes not replaced correctly. Because of the frequent handling of this circuit-breaker, it is also not easy to visually check that it is set properly (as is customary for the pilots to do when they enter the cockpit). The CIAIAC team on the case of JK 5022 discounted this possibility because if the circuit-breaker had been left open it would also have affected the operation of the stall warning system, and the CVR recording showed that the stall warning system was functioning normally.[50][51][52]

Malware

Spanish daily El Pais reported that, as revealed in an internal report issued by Spanair, malware which had infected the airline's central computer system used to monitor technical problems with its aircraft may have resulted in a failure to raise an alarm over multiple problems with the aircraft. A judge ordered the airline to provide all the computer system's logs from the days before and after the crash.[53][54][55]

Final report

The CIAIAC published its final report into the accident on 26 July 2011.[16]

It determined that the cause of the accident was:

  • The crew lost control of the aircraft as a result of a stall immediately after takeoff, which was caused by an incorrect configuration for take-off (i.e. not deploying the flaps and slats, following a series of errors and omissions), coupled with the absence of any warning of the incorrect configuration.
  • The crew did not recognize the indications of stall, and did not correct the situation after takeoff, and – by momentarily retarding the engine power and increasing the pitch angle – brought the aircraft closer to a stall condition.
  • The crew did not detect the configuration error because they did not properly use the checklists to select and check the position of the flaps and slats during flight preparation, specifically:
    • they failed to select the flaps/slats lever during the corresponding step in the "After Start" checklist;
    • they did not cross-check the position of the lever and the state of the flaps/slats indicator lights during the "After Start" checklist;
    • they omitted the flaps/slats check on the 'Take Off Briefing' (taxi) checklist;
    • no visual inspection of the flaps and slats was carried out in execution of the "Final Items" step of the "Take Off Imminent" checklist.

The CIAIAC determined the following contributory factors:

  • The absence of any warning of the incorrect take-off configuration because the TOWS did not work. It was not possible to determine conclusively why the TOWS system did not work.
  • Inadequate crew resource management (CRM), which did not prevent the deviation from procedures and omissions in flight preparation.

"Deadly Delay", a 2016 episode of Mayday, covered the investigation into the crash.[56]

Similar accidents

See also

Notes

  1. ↑ The RAT probe measures the outside air temperature
  2. ↑ The basic shape of all aircraft wings is designed for optimum speed and fuel-efficiency during cruise flight (at around 500mph/430 knots IAS [indicated airspeed] in the MD-82). At lower speeds, such as those associated with take-offs and landings (typically 160mph), the lift generated by the wings is much less than at cruise speed – or would be were it not for the use of high-lift devices such as flaps and slats. For low-speed flight, the pilot alters the shape of the wing by deploying the flaps and slats. For take-off, this is done during the pre-takeoff checks, before entering the runway; on the MD-82, flaps and slats are controlled by a single lever on the cockpit's central console. The flaps are located at the trailing edge of the wings and, when deployed, extend backward and downward from the wing. The slats extend forward from the leading edge of the wing.[18] The effect of both flaps and slats is to increase the surface area and "camber" of the wing, thereby increasing the amount of lift produced. See flaps and slats for more information.
  3. ↑ The aircraft's computer uses total air temperature to help calculate the ambient air temperature, which in turn is needed to calculate the aircraft's true airspeed. True airspeed is needed for high altitude navigation, but is not so important for maintaining stable flight. Ground Speed is calculated directly from GPS position change (or Inertial navigation position change on earlier models). When TAS (true airspeed) is compared with Groundspeed, however, the actual wind direction and speed at that altitude can be calculated and presented to the pilot. Indicated airspeed, a measure of the relative wind over the aircraft's surfaces, is a more important measure for ensuring stable, safe flight. The aircraft's stall speed closely relates to indicated airspeed, for example.
  4. ↑ Thrust reversers are normally employed just after touch down to reduce braking distances.[39]

References

  1. 1 2 "Spanish plane that crashed had overheated valve". Associated Press. 21 August 2008. Archived from the original on 2 September 2008.
  2. ↑ "Madrid crash claims another life". BBC. 23 August 2008. Archived from the original on 28 August 2008. Retrieved 25 August 2008.
  3. ↑ Santafe, Elisa (22 August 2008). "Families struggle to face up to losses in Spain air disaster". Brisbane Times. Archived from the original on 24 August 2008. Retrieved 22 August 2008.
  4. ↑ Flottau, Jens (30 January 2012). "Spanair Shuts Down; Future Uncertain". Aviation Week. Aviation Daily. Archived from the original on 31 December 2014. Retrieved 30 December 2014.
  5. ↑ "Spanair collapses, stranding 20,000 people". BBC News. 30 January 2012. Retrieved 20 August 2018.
  6. ↑ "Spanish airline Spanair ceases operations after running out of funds". Washington Post. Associated Press. 27 January 2012. Retrieved 27 January 2012.
  7. ↑ "Accident Description, McDonnell Douglas DC-9-82 (MD-82) EC-HFP". Aviation Safety Network. Flight Safety Foundation. Retrieved 27 February 2018.
  8. ↑ "Archived copy". Archived from the original on 17 September 2016. Retrieved 2 July 2016.
  9. 1 2 3 CIAIAC final report, section 1.2 (page 6, PDF page 26 of 284)
  10. ↑ CIAIAC final report, section 1.1 (page 1, PDF page 21 of 284)
  11. ↑ Keeley, Graham (20 August 2008). "Madrid crash: 'The plane came to a sharp stop. I heard a horrible noise'". The Guardian. UK. Archived from the original on 2 September 2013. Retrieved 23 May 2010.
  12. ↑ CIAIAC final report, section 1.6.3.2.3 (pages 37-38, PDF pages 57-58 of 284)
  13. 1 2 "Many dead in Madrid plane crash". BBC News. 20 August 2008. Archived from the original on 17 February 2009. Retrieved 4 January 2010.
  14. ↑ Simon Hradecky (16 September 2008). "Crash: Spanair MD-82 at Madrid on 20 August 2008, went off runway during takeoff".
  15. 1 2 CIAIAC final report, Synopsis, (page xvii, PDF page 19 of 284)
  16. 1 2 "Final Report A-032/2008" (PDF). CIAIAC. 29 July 2011. Archived (PDF) from the original on 2 April 2015. Retrieved 27 March 2015.
  17. ↑ "¿A qué hora ocurrió exactamente el accidente?". El Mundo. Archived from the original on 23 August 2008. Retrieved 22 August 2008.
  18. ↑ CIAIAC final report, section 1.6.2.1, pages 17–23 (PDF pages 37–43 of 284)
  19. ↑ "What caused the Madrid crash?". BBC. 21 August 2008. Archived from the original on 21 September 2008. Retrieved 4 January 2010.
  20. ↑ Final report, section 1.12
  21. ↑ Brothers, Caroline; Maynard, Micheline (20 August 2008). "More Than 150 Die in Madrid Plane Crash". The New York Times. Archived from the original on 19 May 2014. Retrieved 23 May 2010.
  22. ↑ "147 killed in plane crash at Madrid airport". Associated Press. 20 August 2008. Archived from the original on 23 August 2008.
  23. ↑ "Death toll climbs in Spanair plane crash". UPI. 20 August 2008. Archived from the original on 23 January 2009.
  24. ↑ Worden, Tom; Couzens, Gerard (21 August 2008). "'Scene from Hell': More than 150 tourists burned alive as plane was ripped apart in runway fireball". Daily Mail. UK.
  25. ↑ "153 killed in Madrid airport plane crash". Reuters. 20 August 2008. Archived from the original on 28 August 2008. Retrieved 22 August 2008.
  26. ↑ "British woman's incredible escape from doomed Madrid plane". Mirror Group Newspapers. 24 August 2008. Archived from the original on 1 March 2009.
  27. ↑ "20-08-2008. EC-HFP. McDonnell Douglas MD-82. Aeropuerto de Barajas (Madrid). Preliminary report" (PDF). CIAIAC. 14 October 2008. Archived from the original (PDF) on 13 June 2010. (Spanish version Archived 11 July 2009 at the Wayback Machine.)
  28. ↑ "20-08-2008. EC-HFP. McDonnell Douglas MD-82. Aeropuerto de Barajas (Madrid). Interim report" (PDF). CIAIAC. 17 August 2009. Archived from the original (PDF) on 29 December 2009. (Spanish version Archived 15 February 2010 at the Wayback Machine.; press release Archived 23 September 2009 at the Wayback Machine.)
  29. ↑ "El informe de la tragedia de Spanair revela dos errores de los pilotos y un fallo técnico (Spanish)". El País. 17 August 2009.
  30. ↑ "Progress Note A-032/2008" (PDF). CIAIAC. Archived (PDF) from the original on 27 August 2010. (Spanish version) Archived 23 September 2010 at the Wayback Machine.
  31. 1 2 Keeley, Graham (22 August 2008). "Madrid air disaster video shows new light on cause of crash". The Guardian. UK. Archived from the original on 24 January 2016. Retrieved 22 August 2008.
  32. ↑ "Madrid plane burst into flames after runway skid". CNN. 22 August 2008. Archived from the original on 25 August 2008. Retrieved 24 August 2008.
  33. ↑ "'Chain of faults' in Madrid crash". BBC. 22 August 2008. Archived from the original on 23 August 2008. Retrieved 22 August 2008.
  34. ↑ Flottau, Jens (22 August 2008). "Spanair Continues MD-80 Services As Madrid Investigation Begins". Aviation Week. Archived from the original on 24 January 2016. Retrieved 23 August 2008.
  35. ↑ "Spanish mechanic who cleared doomed plane quizzed". Associated Press. 23 August 2008. Archived from the original on 10 February 2010.
  36. ↑ Elven, Tree; Percept, Adeline (1 September 2008). "Speculation over causes of Spanair crash". France 24. Archived from the original on 3 September 2008.
  37. ↑ Govan, Fiona (11 May 2010). "Last moments of doomed Spanair flight caught on tape". London: The Telegraph. Archived from the original on 14 May 2010. Retrieved 24 August 2010.
  38. ↑ "Spanair mechanics face crash quizz". BBC. 16 October 2008. Archived from the original on 25 January 2009. Retrieved 4 January 2010.
  39. ↑ "Triebwerk im Spanair-Jet war auf Umkehrschub geschaltet". Der Spiegel (in German). 26 August 2008. Archived from the original on 27 August 2008. Retrieved 26 August 2008.
  40. ↑ Hernández, José Antonio (25 August 2008). "La pérdida de potencia de los motores centra las pesquisas". El País. Retrieved 25 August 2008.
  41. 1 2 "Los motores están enteros y sin signos de haber sufrido incendio, según la investigación". ElMundo.es. 26 August 2008. Archived from the original on 28 August 2008. Retrieved 26 August 2008.
  42. 1 2 3 Final report, section 1.12.7 "Wreckage and impact information: Engines
  43. ↑ Govan, Fiona (28 August 2008). "Spanish crash plane had known mechanical problem". Daily Telegraph. UK. Archived from the original on 31 August 2008. Retrieved 29 August 2008.
  44. ↑ "Los alerones del avión estrellado en Madrid no estaban activados" (in Spanish). Google News. AFP. 6 September 2008. Archived from the original on 8 September 2008.
  45. ↑ Bremner, Charles (6 September 2008). "Basic pilot error blamed for Spanair crash in Madrid that killed 154". The Times. UK. Archived from the original on 6 September 2008. Retrieved 23 May 2010.
  46. ↑ H. B. (15 September 2008). "More faults revealed about fated Spanair plane". Typically Spanish. Archived from the original on 16 September 2008.
  47. 1 2 "Las claves de la investigación del accidente del JK 5022 en Barajas". El Mundo (in Spanish). 7 September 2008. Archived from the original on 11 September 2008.
  48. ↑ "Spanair MD-82 crash inquiry battles to understand absent flap warning". Flight International. 16 September 2008. Archived from the original on 19 September 2008.
  49. ↑ CIAIAC final report, section 2.4.1.1, pages 192-198 (PDF pages 212-218 of 284)
  50. ↑ Méndez, Rafael (5 October 2008). "Avisé a España que podía pasar lo del MD y no hicieron nada". El País (in Spanish). Archived from the original on 31 December 2014.
  51. ↑ CIAIAC final report, section 2.4.1.2, page 200 (PDF pages 220 of 284)
  52. ↑ CIAIAC final report, section 1.16.7, page 95 (PDF pages 115 of 284)
  53. ↑ Leyden, John (20 August 2010). "Trojan-ridden warning system implicated in Spanair crash". The Register.
  54. ↑ Hernández, José Antonio (20 August 2010). "El ordenador de Spanair que anotaba los fallos en los aviones tenía virus". El País (in Spanish). Archived from the original on 22 September 2010.
  55. ↑ "Malware implicated in fatal Spanair plane crash". TechNewsDaily. 20 August 2010.
  56. ↑ "Archived copy". Archived from the original on 28 April 2017. Retrieved 27 April 2017.
  57. ↑ "Interim Report A-032/1998" (PDF). CIAIAC. p. 34. Archived from the original (PDF) on 29 December 2009.

Media related to Spanair Flight JK 5022 at Wikimedia Commons

This article is issued from Wikipedia. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.