Incident Boeing 737-7K2 (WL) PH-XRZ,
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ASN Wikibase Occurrence # 186882
 
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Date:Sunday 17 April 2016
Time:21:12
Type:Silhouette image of generic B737 model; specific model in this crash may look slightly different    
Boeing 737-7K2 (WL)
Owner/operator:Transavia Airlines
Registration: PH-XRZ
MSN: 33462/1278
Year of manufacture:2003
Fatalities:Fatalities: 0 / Occupants: 137
Aircraft damage: None
Category:Incident
Location:Barcelona Airport (BCN/LEBL) -   Spain
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport:Barcelona Airport (BCN/LEBL)
Investigating agency: CIAIAC
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Transavia Airlines flight HV5133 landed at Barcelona Airport (BCN), Spain after declaring a fuel emergency (MAYDAY).
The aircraft, Boeing 737-700, operated on a flight from Amsterdam-Schiphol Airport, Netherlands.
After making an initial approach to runway 25R at the Barcelona Airport, a go-around was conducted due to a sudden change in wind direction and intensity which was in excess of the aircraft tailwind limitation. This meteorological phenomenon forced several other aircraft making the same approach to runway 25R to also execute go-around maneuvers, as a result of which ATC decided to place runway 07L/R in use.
After the go-around, the crew of PH-XRZ declared a fuel emergency (MAYDAY), as a result of which they received landing priority. They landed without further incident on runway 07L. When they reached the parking stand, they had a total of 1080 kg onboard, versus a stated final reserve of 1001 kg.

Traffic conflict
The situation created a traffic conflict when the flight paths of aircraft on final approach crossed. The Transavia crew reported the fuel shortage as soon as they went around and requested priority. They were thus prompted by the controller to declare an emergency (MAYDAY) if required. Once the fuel emergency was declared, the crew received vectors to establish on final for runway 07L.
In the meantime, ATC arranged to remove two aircraft that were at the runway 25R localizer from the approach by ordering them to go around to the south of the airfield.
The second aircraft in the approach sequence, a Ryanair airplane, was taken out at the localizer while an EasyJet Airbus A319 (G-EZBY, flight EZY2267) airplane was kept on approach, the goal being to increase the separation between them.
On very short final, the EasyJet aircraft was instructed to go around and proceed south, but with no altitude restrictions. The crew began the go-around maneuver, but their proximity to the landing zone made the local arrivals controller for runway 25R think they were attempting to land, as a result of which he called the crew to clear the maneuver. Eventually, due to the two conflicting clearances and to the adverse weather conditions, the EasyJet crew went around and was instructed to execute the standard go-around maneuver. At the same time, they were instructed to contact the approach sector, which at that time was handling the approach of HV5133.
This instruction directed the EasyJet aircraft in the opposite direction, toward the Transavia approaching on 07L.
Once in contact with the approach sector, the EasyJet aircraft was instructed to turn immediately to heading 130, which cleared the conflict.
Both aircraft reported having the other in sight. The minimum distance between the two was 2,2 NM and 500 ft, though this separation occurred after the EasyJet aircraft turned south and diverged from the flight path of the Transavia aircraft.

Fuel emergency
Prior to departure from Amsterdam, the flight crew accepted 6100 kg fuel load specified in the flight plan. Although the weather was fine and no delays were expected, the captain thought this amount of fuel was a bit tight. He would probably have asked for a little more fuel, however, the flight crew was occupied with a medical emergency involving a passenger.
The flight plan assumed instrument departure LEKKO 1S from runway 24, but the flight was cleared to fly the instrument departure maneuver LEKKO 3V for runway 36L (locally also known as Polderbaan). This meant an extended period of taxiing (54 kg increase in fuel burn) and additional flying time to the LEKKO fix (168 kg increase).
The result of this was that the estimated fuel remaining on arrival was less than that required to proceed to the alternate airport. At the time when strong tailwinds were reported on the approach, the flight crew of HV5133 should have reported 'Minimum Fuel' to inform ATC in advance that any change (e.g. a go around) might result in a landing with less than final reserve fuel. Four minutes later a go-around was carried out.
When being prompted by ATC, a Fuel Emergency was declared, without reporting the number of minutes of usable fuel left.
Also, ATC did not request this information when the crew failed to report it.
After landing the amount of fuel was still above Minimum Fuel (the amount needed for 30 minutes of flight at 1500 feet over the airport).

Causes/contributing factors:
The incident was caused by the Transavia crew’s improper planning of the fuel consumption for the flight.
The following factors contributed to the incident:
- The change in the preferred runway configuration at the Barcelona Airport as the result of an unpredicted sudden shift in wind direction.
- Improper coordination by the different ATS stations, which resulted in a head-on approach between two aircraft under their control.

Weather about the time of the incident (21:12 LT /19:12 Z):

METAR LEBL 171800Z 23015KT 9999 FEW010 20/09 Q1013 NOSIG
METAR LEBL 171830Z 24011KT CAVOK 19/10 Q1013 NOSIG
METAR LEBL 171900Z 05011KT 9999 FEW020 18/10 Q1014 NOSIG
METAR LEBL 171930Z 05013KT 9999 FEW020 17/11 Q1015 NOSIG

Accident investigation:
cover
  
Investigating agency: CIAIAC
Report number: IN-012/2016
Status: Investigation completed
Duration: 1 year and 8 months
Download report: Final report

Sources:

http://web.archive.org/web/20160611011345/http://www.fomento.gob.es:80/MFOM/LANG_CASTELLANO/ORGANOS_COLEGIADOS/CIAIAC/INVESTIGACION/2016/012_2016.htm

History of this aircraft

Other occurrences involving this aircraft
6 May 2015 PH-XRZ Transavia Airlines 0 30nm eastsoutheast of Lille unk
Loss of pressurization

Images:


Revision history:

Date/timeContributorUpdates
30-Apr-2016 20:15 harro Added
30-Apr-2016 20:17 harro Updated [Narrative]
26-Dec-2017 20:55 harro Updated [Source]
27-Dec-2017 09:22 harro Updated [Narrative]
27-Dec-2017 09:34 harro Updated [Narrative]
27-Dec-2017 19:12 GeoffR Updated [Narrative]

Corrections or additions? ... Edit this accident description

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