Report: CIAIAC publishes final report on fatal MD-82 takeoff accident Madrid, Spain

After almost three years the Spanish investigators of the Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC) have published the final report of their investigation into the cause of the fatal accident involving a Spanair MD-82 at Madrid, Spain. 

The MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain on August 20, 2008. Of the aircraft’s occupants, 154 were killed, including all six crew members, and 18 were seriously injured. The MD-82 aircraft operated Spanair flight JKK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA).

The CIAIAC has determined that the accident occurred because *):

The crew lost control of the aircraft as a result of a stall immediately after takeoff, when the plane was not configured correctly, with the flaps / slats not being deployed, following a series of failures and omissions, with the absence of a warning of the incorrect takeoff setting.
The crew did not identify the lack of warnings nor correct the situation after takeoff –momentarily retarding engine power levers, increasing the pitch angle and failure to correct the roll– deteriorating the flight conditions.
The crew did not detect the configuration error by not properly using the checklists containing items to select and check the position of flaps / slats in the work of flight preparation, namely:

• Failure to conduct the action of selecting flaps / slats (in the “After Start Checklist”);
• No cross-checking was made of the position of the lever and the status indicator lights for flaps and slats during the “After Start” checklist;
• Omission to check the flaps and slats under “Take Off Briefing” in the taxi checklist;
• The visual inspection of the position of the flaps and slats at the point “Final Items” of the “Take Off Imminent” checks was not made, as shown by the instruments of the cockpit.

As contributory factors CIAIAC determined:

• The absence of a notice of the incorrect takeoff configuration because the TOWS did not work and therefore did not alert the crew that the takeoff configuration of the aircraft was inappropriate. It was not possible to determine conclusively the cause why the TOWS system did not work.
• Inadequate crew resource management (CRM), which did not prevent the diversion of procedures in the preparation of the flight.

*) The final report is currently available in Spanish. An English translation is being prepared by CIAIAC. In case of conflicting text, the Spanish text is valid.

More information:

• ASN Accident description
• CIAIAC Report A-032/2008

Crew distraction causes gear-up landing of CRJ200 in Spain, 2007

The Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC) published its final report regarding the gear-up landing of a  Canadair CRJ200 at Barcelona Airport, Spain in January 2007.
The airplane was on a scheduled passenger flight operated by Air Nostrum, from Valladolid Airport (VLL) to Barcelona Airport (BCN).
On the two previous flights, there had been problems with extending the flaps before landing. During the ground tests performed by the crew in Valladolid, the flaps extended and retracted normally, and so the captain decided to continue with the flights as scheduled.
During the flight, the crew went over the abnormal procedures to be followed in case of a repeat failure of the flaps system.
After taking off from Valladolid, the flaps were retracted normally and remained retracted during the cruise and descent phases until the initial approach to Barcelona, at which time they failed to extend to the 8-degree position when commanded, resulting in a “flap fail” warning on the EICAS. The copilot noted the discrepancy between the commanded 8° position on the flaps lever and the 0° indicated position. At that time they were below the clouds and under ATC radar control.
In the zero-flaps configuration, the ILS approach speed, in accordance with the relevant procedure, had to be maintained above 180 kt. ATC cleared them for the runway 25R approach and informed of a moderate intensity crosswind of 14 kt from 320°.
The aircraft descended until it touched down at an IAS of 172 kt, at which time the crew realized they had not lowered the landing gear. After a long slide on the runway, the aircraft stopped 240 m before the end of the runway.
There was no fire, though high temperatures and kerosene leaks were detected.