Status: | Accident investigation report completed and information captured |
Date: | Wednesday 20 August 2008 |
Time: | 14:24 |
Type: | McDonnell Douglas DC-9-82 (MD-82) |
Operator: | Spanair |
Registration: | EC-HFP |
MSN: | 53148/2072 |
First flight: | 1993-11-01 (14 years 10 months) |
Engines: | 2 Pratt & Whitney JT8D-219 |
Crew: | Fatalities: 6 / Occupants: 6 |
Passengers: | Fatalities: 148 / Occupants: 166 |
Total: | Fatalities: 154 / Occupants: 172 |
Aircraft damage: | Destroyed |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | Madrid-Barajas Airport (MAD) ( Spain)
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Crash site elevation: | 610 m (2001 feet) amsl |
Phase: | Takeoff (TOF) |
Nature: | Domestic Scheduled Passenger |
Departure airport: | Madrid-Barajas Airport (MAD/LEMD), Spain |
Destination airport: | Las Palmas-Airport de Gran Canaria (LPA/GCLP), Spain |
Flightnumber: | JK5022 |
Narrative:An MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain. Of the aircrafts occupants, 154 were killed, including all six crew members. Eighteen passengers were seriously injured.
The MD-82 aircraft operated Spanair flight JK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA). The estimated departure time was 13:00.
The aircraft was authorized by control for engine start-up at 13:06:15. It then taxied to runway 36L from parking stand T21, which it occupied on the apron of terminal T2 at Barajas. The flaps were extended 11°. Once at the runway threshold, the aircraft was cleared for takeoff at 13:24:57. The crew informed the control tower at 13:26:27 that they had a problem and that they had to exit the runway. At 13:33:12, they communicated that they were returning to the stand.
The crew had detected an overheating Ram Air Temperature (RAT) probe. The aircraft returned to the apron, parking on remote stand R11 of the terminal T2 parking area. The crew stopped the engines and requested assistance from maintenance technicians to solve the problem. The mechanic confirmed the malfunction described in the ATLB, checked the RAT probe heating section of the Minimum Equipment List (MEL) and opened the electrical circuit breaker that connected the heating element. Once complete, it was proposed and accepted that the aircraft be dispatched.
The aircraft was topped off with 1080 liters of kerosene and at 14:08:01 it was cleared for engine start-up and to taxi to runway 36L for takeoff.
The crew continued with the tasks to prepare the airplane for the flight. The conversations on the cockpit voice recorder revealed certain expressions corresponding to the before engine start checklists, the normal start list, the after start checklist and the taxi checklist. During the taxi run, the aircraft was in contact with the south sector ground control first and then with the central sector. On the final taxi segment the crew concluded its checks with the takeoff imminent checklist.
At 14:23:14, with the aircraft situated at the head of runway 36L, it was cleared for takeoff. Along with the clearance, the control tower informed the aircraft that the wind was from 210° at 5 knots.
At 14:23:19, the crew released the brakes for takeoff. Engine power had been increased a few seconds earlier and at 14:23:28 its value was 1.4 EPR. Power continued to increase to a maximum value of 1.95 EPR during the aircrafts ground run. The CVR recording shows the crew calling out "V1" at 14:24:06, at which time the DFDR recorded a value of 147 knots for calibrated airspeed (CAS), and "rotate" at 14:24:08, at a recorded CAS of 154 knots. The DFDR recorded the signal change from ground mode to air mode from the nose gear strut ground sensor. The stall warning stick shaker was activated at 14:24:14 and on three occasions the stall horn and synthetic voice sounded in the cockpit: "[horn] stall, [horn] stall, [horn] stall". Impact with the ground took place at 14:24:23.
During the entire takeoff run until the end of the CVR recording, no noises were recorded involving the takeoff warning system (TOWS) advising of an inadequate takeoff configuration. During the entire period from engine start-up while at parking stand R11 to the end of the DFDR recording, the values for the two flap position sensors situated on the wings were 0°.
The length of the takeoff run was approximately 1950 m. Once airborne, the aircraft rose to an altitude of 40 feet above the ground before it descended and impacted the ground. During its trajectory in the air, the aircraft took on a slight left roll attitude, followed by a fast 20° roll to the right, another slight roll to the left and another abrupt roll to the right of 32°. The maximum pitch angle recorded during this process was 18°.
The aircrafts tailcone was the first part to impact the ground, almost simultaneously with the right wing tip and the right engine cowlings. The marks from these impacts were found on the right side of the runway strip as seen from the direction of the takeoff, at a distance of 60 m, measured perpendicular to the runway centerline, and 3207.5 m away from the threshold, measured in the direction of the runway. The aircraft then traveled across the ground an additional 448 m until it reached the side of the runway strip, tracing out an almost linear path at a 16° angle with the runway. It lost contact with the ground after reaching an embankment/drop-off beyond the strip, with the marks resuming 150 m away, on the airport perimeter road, whose elevation is 5.50 m lower than the runway strip. The aircraft continued moving along this irregular terrain until it reached the bed of the Vega stream, by which point the main structure was already in an advanced state of disintegration. It is here that it caught on fire. The distance from the initial impact site on the ground to the farthest point where the wreckage was found was 1093 m.
Probable Cause:
CAUSES:
The crew lost control of the airplane as a consequence of entering a stall immediately after takeoff due to an improper airplane configuration involving the non-deployment of the slats/flaps following a series of mistakes and omissions, along with the absence of the improper takeoff configuration warning.
The crew did not identify the stall warnings and did not correct said situation after takeoff. They momentarily retarded the engine throttles, increased the pitch angle and did not correct the bank angle, leading to a deterioration of the stall condition.
The crew did not detect the configuration error because they did not properly use the checklists, which contain items to select and verify the position of the flaps/slats, when preparing the flight. Specifically:
- They did not carry out the action to select the flaps/slats with the associated control lever (in the "After Start" checklist);
- They did not cross check the position of the lever or the status of the flap and slat indicating lights when executing the" After Start" checklist;
- They omitted the check of the flaps and slats during the "Takeoff briefing" item on the "Taxi" checklist;
- The visual check done when executing the "Final items" on the "Takeoff imminent" checklist was not a real check of the position of the flaps and slats, as displayed on the instruments in the cockpit.
The CIAIAC has identified the following contributing factors:
- The absence of an improper takeoff configuration warning resulting from the failure of the TOWS to operate, which thus did not warn the crew that the airplane's takeoff configuration was not appropriate. The reason for the failure of the TOWS to function could not be reliably established.
- Improper crew resource management (CRM), which did not prevent the deviation from procedures in the presence of unscheduled interruptions to flight preparations.
Accident investigation:
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Investigating agency: | CIAIAC Spain |
Status: | Investigation completed |
Duration: | 3 years | Accident number: | A-032/2008 | Download report: | Final report
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Classification:
Wrong takeoff configuration (flaps/trim)
Loss of control
Sources:
»
SKYbrary » Spanair
» CIAIAC
Follow-up / safety actions
NTSB issued 5 Safety Recommendations
Issued: 17-AUG-2009 | To: FAA | A-09-67 |
Require that operators of Boeing DC-9 series, MD-80 series, MD-90 series, and B-717 airplanes include items in their preflight checklists to verify that a check of the takeoff warning system is accomplished before every flight. (Closed - Unacceptable Action) |
Issued: 17-AUG-2009 | To: FAA | A-09-68 |
Modify 14 Code of Federal Regulations Part 25 to include a certification standard that will ensure either that 1) the takeoff warning system (TOWS) cannot be disabled by a single failure or 2) if the system fails or has power removed while the airplane is operating on the ground, a discrete and clear annunciation of the loss of TOWS protection is provided to flight crews. (Open Acceptable Alternate Response) |
Issued: 17-AUG-2009 | To: FAA | A-09-69 |
Assess the history of pilot errors related to takeoff configuration and identify needed mitigating design elements; require inclusion of such design elements when determining current and future aircraft certifications. (Open - Unacceptable Response) |
Issued: 17-AUG-2009 | To: FAA | A-09-70 |
Convene a meeting of industry, research, and government authorities, including international representatives, to develop guidance on industry best practices in operational areas (including checklist design, training, and procedures) that relate to flight crews properly configuring airplanes for takeoff and landing. (Open - Unacceptable Response) |
Issued: 17-AUG-2009 | To: FAA | A-09-71 |
Require operators to modify their takeoff and landing checklists to reflect the best practices identified as a result of the meeting recommended in Safety Recommendation A-09-70. (Open - Unacceptable Response) |
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Photos
accident date:
20-08-2008type: McDonnell Douglas MD-82
registration: EC-HFP
accident date:
20-08-2008type: McDonnell Douglas MD-82
registration: EC-HFP
accident date:
20-08-2008type: McDonnell Douglas MD-82
registration: EC-HFP
Aircraft history
18 Nov. 1993 |
HL7204 |
Korean Air |
delivered (leased from GPA)
|
18 June 1998 |
HL7548 |
Korean Air |
new registration (now owned by GECAS)
|
19 Oct. 1999 |
EC-HFP |
Spanair |
registered in Spain |
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Madrid-Barajas Airport to Las Palmas-Airport de Gran Canaria as the crow flies is 1754 km (1096 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.