Spanair Flight 5022
Encyclopedia
Spanair Flight JK 5022, from Barajas Airport in Madrid to Gran Canaria Airport in Gran Canaria
, Spain, crashed just after take off from runway 36L of Barajas Airport at 14:24 CEST
(12:24 UTC
) on 20 August 2008. The aircraft was a McDonnell Douglas MD-82, registration EC-HFP. It was the first fatal accident for Spanair
(part of the SAS Group
) in the 20-year history of the company, and the 14th fatal accident and 24th hull loss
involving MD-80 series aircraft. It was the world's deadliest aviation accident in 2008 and Spain's deadliest in 25 years. 154 people died; six died en route to the hospital, one died overnight and one died in the hospital three days later. Only 18 people survived.
The aircraft, christened Sunbreeze (registration EC-HFP; manufacturer's serial number 53148; Douglas line number 2142) had been delivered to Korean Air
on 18 November 1993 and was acquired by Spanair in July 1999.
The flight was a Star Alliance
codeshare operated on behalf of Lufthansa
as LH 2554. When it took off it was carrying 166 passengers and six crew members.
The accident occurred as the aircraft attempted to take off, at 14:24 local time, because the pilots had omitted to deploy the flaps and slats ready for take-off. Without the use of these "high-lift" devices, the wings did not generate enough lift to keep the aircraft in the air.The basic shape of an aircraft wing is designed for optimum speed and fuel-efficiency during cruise flight (at around 500mph 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-take off checks before entering the runway. In 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. (CIAIAC final report, section 1.6.2.1). 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. The MD-82 has a warning system (TOWS - Take-Off Warning System) that should have alerted the pilots, as they commenced their take-off run, that the plane was incorrectly configured for take-off.TOWS is designed to sound a warning if the flaps and slats are not extended - or for a number of other possible omissions in the take-off configuration - and the throttles are opened while the aircraft is on the ground. The alert is in the form of an audible warning horn accompanied by a voice message that indicates the nature of the configuration error. (CIAIAC final report, section 1.6.2.2) However, TOWS did not sound a warning, and the pilots continued with the fateful take-off attempt. The aircraft left the ground momentarily, rolled to the right, and crashed in the vicinity of the runway, breaking into at least two parts which were engulfed by the subsequent fire.
Spanair reported that the pilot had previously attempted and aborted a departure due to a sensor reporting excessive temperature in an air intake, and that the temperature sensor was de-activated on the ground (reportedly an established procedure since that sensor is redundant), delaying departure by over an hour. Another takeoff was attempted, during which the fatal accident occurred.
135 of the deceased and 16 of the survivors were Spanish nationals, 19 of the deceased and 2 survivors were of other nationalities. The deceased included German
, French, Mauritania
n, Turkish
, Bulgaria
n, Gambian, Italian, Indonesia
n and Brazil
ian citizens.
Ervigio Corral, the head of the emergency services rescue team, said that the crash flung some of the survivors into a creek, lessening the severity of their burns. A 30 year old woman with British and Spanish dual citizenship survived with no burns as she was flung from row 6, still attached to her seat, and landed in a nearby stream. She suffered a punctured lung and broken left arm. Because of this ejection, she did not receive burns that the majority of the other passengers suffered.
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.
A preliminary report on the accident was released by CIAIAC on 6 October. Flight data recorders 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. 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 just repeats the flaps and slats correct 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 Take-off Warning System (TOWS). The report also made a number of safety recommendations intended to prevent incidents like this from happening again.
CIAIAC published a further progress note in August 2010, and its final report in July 2011.
sensor,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. located on the front of the aircraft near the cockpit) that initially caused the pilot to turn the plane back for maintenance before its catastrophic takeoff attempt. The maintenance logbook shows that overheating of the air temperature sensor occurred repeatedly the day before the crash. 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. 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 dysfunction of the temperature gauge itself and that since icing was not a risk on that flight, that the de-icing system had been deactivated by the mechanic with captain's approval.
On 11 May 2010, details from the cockpit voice recorder were leaked to the public and released by Spanish media. The recording showed that both pilots were concerned about a repair job performed earlier the day of the crash, in which mechanics used an ice pack to cool an overheating temperature sensor and removed a fuse. The BBC
reported that the judge investigating the crash was to question three mechanics on suspicion of manslaughter. These were the two mechanics who checked the plane before take-off and the head of maintenance for Spanair at Barajas.
in 1991, since it was found to be in the deployed position in the wreckage. Indeed one of the photographs released on the day of the accident appears to show a deployed reverser. If the reverser deployed during takeoff, and not as a result of impact, it has been suggested that the plane would have yawed suddenly to the right. Since the MD-82 has tail-mounted engines, however, positioned quite close to each other, and close to the plane's longitudinal axis, the activation of a reverser may not have produced uncontrollable yaw, even though the situation may still have been critical. Thrust reversers are normally employed just after touch down to reduce braking distances. Evidence which has more recently come to light suggests that the aircraft took to the sky with a known pre-existing problem with one of its thrust reversers, which was the subject of a temporary "work around" to keep the aircraft operational. On 7 September, El Mundo reported that the thrust reverser deployment was commanded after the crash, to bring the aircraft to a stop; the left reverser deployed normally, while the right one (with the pre-existing condition) did not. If this last suggestion is accepted, then the deployment of one or both thrust reversers, deliberate or otherwise, would not appear to be the direct cause of the crash.
showed that the pilot had said "Flaps
OK, Slats
OK" to the co-pilot. The article confirmed that the flaps
had not been extended and that the alarm for that condition had not sounded. The final report concluded that the failure to deploy flaps was the cause of the accident. The pilots stated they checked the flaps while reviewing the pre-flight checklist, but did not actually test them. The warning signal that the flaps were not set failed to sound for unknown reasons.
The maintenance logbook of the airplane has comments, 2 days before the crash, for an "autoslats failure" visual alarm occurring on slats extension; however autoslats are not used on takeoff, and it can not be inferred that the slats system had a defect.
and slats
alarm had not sounded, since this alarm is disabled in flight mode.
and may have prevented the detection of technical problems with the aircraft. A judge has ordered Spanair to provide all of the computer's logs from the days before and after the crash.
It determined that the cause of the accident was:
The CIAIAC determined the following contributory factors:
, Delta Air Lines Flight 1141
, and Mandala Airlines Flight 091
.
In the case of Northwest Airlines Flight 255, also an MD-82, the crew had similarly been disrupted from routine operation before the fatal takeoff, and the alarm similarly had not sounded. In that accident, the reason for the lack of TOWS alarm was a tripped (or pulled) circuit breaker. However, examination of the alarm and its circuit breaker in Spanair 5022 had not revealed any fault.
El País
Guardia Civil
NASA
Civil Aviation Accident and Incident Investigation Commission
Gran Canaria
Gran Canaria is the second most populous island of the Canary Islands, with a population of 838,397 which constitutes approximately 40% of the population of the archipelago...
, Spain, crashed just after take off from runway 36L of Barajas Airport at 14:24 CEST
Central European Summer Time
Central European Summer Time is one of the names of the Daylight saving time offset using the UTC offset of UTC+02:00, 2 hours ahead of Coordinated Universal Time. It is used as a summer daylight saving time in most European countries. During the winter, Central European Time is used...
(12:24 UTC
Coordinated Universal Time
Coordinated Universal Time is the primary time standard by which the world regulates clocks and time. It is one of several closely related successors to Greenwich Mean Time. Computer servers, online services and other entities that rely on having a universally accepted time use UTC for that purpose...
) on 20 August 2008. The aircraft was a McDonnell Douglas MD-82, registration EC-HFP. It was the first fatal accident for Spanair
Spanair
Spanair is a Spanish airline, with its head office in the Spanair Building in L'Hospitalet de Llobregat, near Barcelona. It was, until 2009, a subsidiary of Scandinavian Airlines, which now holds slightly under 20% of the company. Spanair provides a scheduled passenger network within Spain and...
(part of the SAS Group
SAS Group
Scandinavian Airlines System Aktiebolag , trading as SAS Group and SAS AB, is a holding company based in Solna, Sweden. It is the parent company of the airlines Scandinavian Airlines, Blue1 and Widerøe, and the aviation services companies SAS Business Opportunities, SAS Cargo Group, SAS Ground...
) in the 20-year history of the company, and the 14th fatal accident and 24th hull loss
Aviation accidents and incidents
An aviation accident is defined in the Convention on International Civil Aviation Annex 13 as an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, in which a...
involving MD-80 series aircraft. It was the world's deadliest aviation accident in 2008 and Spain's deadliest in 25 years. 154 people died; six died en route to the hospital, one died overnight and one died in the hospital three days later. Only 18 people survived.
Crash
Korean Air
Korean Air Lines Co., Ltd. , operating as Korean Air, is both the flag carrier and the largest airline of South Korea, with global headquarters located in Seoul, South Korea. Korean Air's international passenger division and related subsidiary cargo division together serve 130 cities in 45...
on 18 November 1993 and was acquired by Spanair in July 1999.
The flight was a Star Alliance
Star Alliance
Star Alliance is the world's first and largest airline alliance, headquartered in Frankfurt am Main, Germany . The alliance was founded in 1997 by five of the world's leading airlines: Air Canada, Lufthansa, Scandinavian Airlines, Thai Airways International and United Airlines...
codeshare operated on behalf of Lufthansa
Lufthansa
Deutsche Lufthansa AG is the flag carrier of Germany and the largest airline in Europe in terms of overall passengers carried. The name of the company is derived from Luft , and Hansa .The airline is the world's fourth-largest airline in terms of overall passengers carried, operating...
as LH 2554. When it took off it was carrying 166 passengers and six crew members.
The accident occurred as the aircraft attempted to take off, at 14:24 local time, because the pilots had omitted to deploy the flaps and slats ready for take-off. Without the use of these "high-lift" devices, the wings did not generate enough lift to keep the aircraft in the air.The basic shape of an aircraft wing is designed for optimum speed and fuel-efficiency during cruise flight (at around 500mph 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-take off checks before entering the runway. In 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. (CIAIAC final report, section 1.6.2.1). 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
Flap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...
and slats
Leading edge slats
Slats are aerodynamic surfaces on the leading edge of the wings of fixed-wing aircraft which, when deployed, allow the wing to operate at a higher angle of attack. A higher coefficient of lift is produced as a result of angle of attack and speed, so by deploying slats an aircraft can fly at slower...
for more information. The MD-82 has a warning system (TOWS - Take-Off Warning System) that should have alerted the pilots, as they commenced their take-off run, that the plane was incorrectly configured for take-off.TOWS is designed to sound a warning if the flaps and slats are not extended - or for a number of other possible omissions in the take-off configuration - and the throttles are opened while the aircraft is on the ground. The alert is in the form of an audible warning horn accompanied by a voice message that indicates the nature of the configuration error. (CIAIAC final report, section 1.6.2.2) However, TOWS did not sound a warning, and the pilots continued with the fateful take-off attempt. The aircraft left the ground momentarily, rolled to the right, and crashed in the vicinity of the runway, breaking into at least two parts which were engulfed by the subsequent fire.
Spanair reported that the pilot had previously attempted and aborted a departure due to a sensor reporting excessive temperature in an air intake, and that the temperature sensor was de-activated on the ground (reportedly an established procedure since that sensor is redundant), delaying departure by over an hour. Another takeoff was attempted, during which the fatal accident occurred.
Casualties
Of the 172 people on board, 146, including all crew members, perished in the crash or immediately after in the fire; of the 26 passengers rescued alive from the crash site, six died before arriving at the hospital, and two more in hospital, bringing the total number of fatalities to 154.135 of the deceased and 16 of the survivors were Spanish nationals, 19 of the deceased and 2 survivors were of other nationalities. The deceased included German
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
, French, Mauritania
Mauritania
Mauritania is a country in the Maghreb and West Africa. It is bordered by the Atlantic Ocean in the west, by Western Sahara in the north, by Algeria in the northeast, by Mali in the east and southeast, and by Senegal in the southwest...
n, Turkish
Turkey
Turkey , known officially as the Republic of Turkey , is a Eurasian country located in Western Asia and in East Thrace in Southeastern Europe...
, Bulgaria
Bulgaria
Bulgaria , officially the Republic of Bulgaria , is a parliamentary democracy within a unitary constitutional republic in Southeast Europe. The country borders Romania to the north, Serbia and Macedonia to the west, Greece and Turkey to the south, as well as the Black Sea to the east...
n, Gambian, Italian, Indonesia
Indonesia
Indonesia , officially the Republic of Indonesia , is a country in Southeast Asia and Oceania. Indonesia is an archipelago comprising approximately 13,000 islands. It has 33 provinces with over 238 million people, and is the world's fourth most populous country. Indonesia is a republic, with an...
n and Brazil
Brazil
Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people...
ian citizens.
Ervigio Corral, the head of the emergency services rescue team, said that the crash flung some of the survivors into a creek, lessening the severity of their burns. A 30 year old woman with British and Spanish dual citizenship survived with no burns as she was flung from row 6, still attached to her seat, and landed in a nearby stream. She suffered a punctured lung and broken left arm. Because of this ejection, she did not receive burns that the majority of the other passengers suffered.
Summary
Civil Aviation Accident and Incident Investigation Commission
The Civil Aviation Accident and Incident Investigation Commission is the Spanish national agency responsible for air accident investigation. It is a division of the Ministry of Public Works and Transport...
(CIAIAC). Representatives from the US National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
, the aircraft manufacturer Boeing
Boeing
The Boeing Company is an American multinational aerospace and defense corporation, founded in 1916 by William E. Boeing in Seattle, Washington. Boeing has expanded over the years, merging with McDonnell Douglas in 1997. Boeing Corporate headquarters has been in Chicago, Illinois since 2001...
(as successor to McDonnell Douglas
McDonnell Douglas
McDonnell Douglas was a major American aerospace manufacturer and defense contractor, producing a number of famous commercial and military aircraft. It formed from a merger of McDonnell Aircraft and Douglas Aircraft in 1967. McDonnell Douglas was based at Lambert-St. Louis International Airport...
, the original aircraft manufacturer), and the engine manufacturer Pratt and Whitney supported the investigation.
A preliminary report on the accident was released by CIAIAC on 6 October. Flight data recorders showed that the aircraft had taken off with flaps
Flap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...
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. 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 just repeats the flaps and slats correct 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 Take-off Warning System (TOWS). The report also made a number of safety recommendations intended to prevent incidents like this from happening again.
CIAIAC published a further progress note in August 2010, and its final report in July 2011.
Fire or explosion
Some early eye-witness accounts had suggested that the aircraft had 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. 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", surmising that a chain of events combining together was more likely than a single cause.Temperature sensor
There has been considerable interest in the faulty air temperature probe (the total air temperatureTotal air temperature
Total air temperature is a term used generally in aviation. In other applications it is called stagnation temperature. Total air temperature is measured by a specially designed temperature probe mounted on the surface of the aircraft. The probe is designed to bring the air to rest relative to the...
sensor,The aircraft's computer
Air data computer
An air data computer is an essential avionics component found in modern glass cockpits. This computer, rather than individual instruments, can determine the calibrated airspeed, Mach number, altitude, and altitude trend from input data from sensors such as an aircraft's pitot-static system,...
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
True airspeed of an aircraft is the speed of the aircraft relative to the airmass in which it is flying. True airspeed is important information for accurate navigation of an aircraft.-Performance:...
. 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
Indicated airspeed
Indicated airspeed is the airspeed read directly from the airspeed indicator on an aircraft, driven by the pitot-static system. IAS is directly related to calibrated airspeed , which is the IAS corrected for instrument and installation errors....
, a measure of the relative wind
Relative wind
In aeronautics, the relative wind is the direction of movement of the atmosphere relative to an aircraft or an airfoil. It is opposite to the direction of movement of the aircraft or airfoil relative to the atmosphere...
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. located on the front of the aircraft near the cockpit) that initially caused the pilot to turn the plane back for maintenance before its catastrophic takeoff attempt. The maintenance logbook shows that overheating of the air temperature sensor occurred repeatedly the day before the crash. The mechanic simply deactivated the probe because the aircraft's Minimum Equipment List
Minimum equipment list
In aviation, a Master Minimum Equipment List, or MMEL, is a categorized list of systems, instruments and equipment on an aircraft which are not required to be operative for flight. Specific procedures or conditions may be associated with operation with the relevant item inoperative...
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. 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 dysfunction of the temperature gauge itself and that since icing was not a risk on that flight, that the de-icing system had been deactivated by the mechanic with captain's approval.
On 11 May 2010, details from the cockpit voice recorder were leaked to the public and released by Spanish media. The recording showed that both pilots were concerned about a repair job performed earlier the day of the crash, in which mechanics used an ice pack to cool an overheating temperature sensor and removed a fuse. The BBC
BBC
The British Broadcasting Corporation is a British public service broadcaster. Its headquarters is at Broadcasting House in the City of Westminster, London. It is the largest broadcaster in the world, with about 23,000 staff...
reported that the judge investigating the crash was to question three mechanics on suspicion of manslaughter. These were the two mechanics who checked the plane before take-off and the head of maintenance for Spanair at Barajas.
Thrust reverser
Rumours suggested that investigators were focusing on the possibility that the thrust reverser of the No. 2 (right side) engine activated during the climb , similar to Lauda Air Flight 004Lauda Air Flight 004
Lauda Air Flight 004 was an international passenger flight that crashed due to a thrust reverser deployment of the number 1 engine in flight.-History of the flight:...
in 1991, since it was found to be in the deployed position in the wreckage. Indeed one of the photographs released on the day of the accident appears to show a deployed reverser. If the reverser deployed during takeoff, and not as a result of impact, it has been suggested that the plane would have yawed suddenly to the right. Since the MD-82 has tail-mounted engines, however, positioned quite close to each other, and close to the plane's longitudinal axis, the activation of a reverser may not have produced uncontrollable yaw, even though the situation may still have been critical. Thrust reversers are normally employed just after touch down to reduce braking distances. Evidence which has more recently come to light suggests that the aircraft took to the sky with a known pre-existing problem with one of its thrust reversers, which was the subject of a temporary "work around" to keep the aircraft operational. On 7 September, El Mundo reported that the thrust reverser deployment was commanded after the crash, to bring the aircraft to a stop; the left reverser deployed normally, while the right one (with the pre-existing condition) did not. If this last suggestion is accepted, then the deployment of one or both thrust reversers, deliberate or otherwise, would not appear to be the direct cause of the crash.
Flaps and slats
El Mundo, citing a source in the investigation team, reported that the cockpit voice recorderCockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
showed that the pilot had said "Flaps
Flap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...
OK, Slats
Leading edge slats
Slats are aerodynamic surfaces on the leading edge of the wings of fixed-wing aircraft which, when deployed, allow the wing to operate at a higher angle of attack. A higher coefficient of lift is produced as a result of angle of attack and speed, so by deploying slats an aircraft can fly at slower...
OK" to the co-pilot. The article confirmed that the flaps
Flap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...
had not been extended and that the alarm for that condition had not sounded. The final report concluded that the failure to deploy flaps was the cause of the accident. The pilots stated they checked the flaps while reviewing the pre-flight checklist, but did not actually test them. The warning signal that the flaps were not set failed to sound for unknown reasons.
The maintenance logbook of the airplane has comments, 2 days before the crash, for an "autoslats failure" visual alarm occurring on slats extension; however autoslats are not used on takeoff, and it can not be inferred that the slats system had a defect.
Flight mode
In an article published on 7 September, El Mundo stated that during the flight preparation and takeoff attempts, the aircraft had some of its systems in flight mode rather than ground mode. If true, this might explain why de-icing of the Total Air Temperature probe activated on the ground, causing overheat, since in flight the heater would activate only when there was no air flow in the probe, a sign of icing. This might also explain why the flapsFlap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...
and slats
Leading edge slats
Slats are aerodynamic surfaces on the leading edge of the wings of fixed-wing aircraft which, when deployed, allow the wing to operate at a higher angle of attack. A higher coefficient of lift is produced as a result of angle of attack and speed, so by deploying slats an aircraft can fly at slower...
alarm had not sounded, since this alarm is disabled in flight mode.
Malware
Spanish daily El Pais reports that malware which had infected the airline's central computer system resulted in a failure to raise an alarm over multiple problems with the plane. An internal report issued by the airline revealed that their central computer system used to monitor technical problems with the aircraft was infected with malwareMalware
Malware, short for malicious software, consists of programming that is designed to disrupt or deny operation, gather information that leads to loss of privacy or exploitation, or gain unauthorized access to system resources, or that otherwise exhibits abusive behavior...
and may have prevented the detection of technical problems with the aircraft. A judge has ordered Spanair to provide all of the computer's logs from the days before and after the crash.
Final report
The CIAIAC published its final report into the accident on 26 July 2011.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, because they did not have the correct plane configuration for take-off (by 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 about a deterioration in the flight 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 under 'Take Off Briefing' (taxi) checklist;
- the visual inspection carried out in execution of the "Final Items" step of the "Take Off Imminent" checklist – no confirmation was made of the position of the flaps and slats, as shown by the cockpit instruments.
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.
Similar accidents
CIAIAC's interim report specifically mentioned three other fatal accidents caused by the failure to deploy flaps and slats prior to take-off: Northwest Airlines Flight 255Northwest Airlines Flight 255
Northwest Airlines Flight 255 was a flight that originated at MBS International Airport in Saginaw, Michigan, and was scheduled to terminate at John Wayne Airport in Orange County, California, with intermediate stops at Detroit Metropolitan Wayne County Airport in Romulus, Michigan, near Detroit,...
, Delta Air Lines Flight 1141
Delta Air Lines Flight 1141
Delta Air Lines Flight 1141 was a routine domestic passenger flight between Dallas-Fort Worth International Airport and Salt Lake City International Airport, Salt Lake City, Utah...
, and Mandala Airlines Flight 091
Mandala Airlines Flight 091
On 5 September 2005 , a Jakarta-bound Boeing 737-200 jetliner operated by Mandala Airlines crashed into a heavily-populated residential area seconds after taking off from Polonia International Airport in Medan, Indonesia. There were 143 fatalities.Dozens of houses and cars were destroyed, and at...
.
In the case of Northwest Airlines Flight 255, also an MD-82, the crew had similarly been disrupted from routine operation before the fatal takeoff, and the alarm similarly had not sounded. In that accident, the reason for the lack of TOWS alarm was a tripped (or pulled) circuit breaker. However, examination of the alarm and its circuit breaker in Spanair 5022 had not revealed any fault.
See also
- List of accidents and incidents involving commercial aircraft
External links
Spanair- Press release 1, 20 August 2008
- Press release 2, 20 August 2008
- Press release 3
El País
- Video of the accident, which had been examined by the official investigating team. The video, from an airport security camera, showed the aircraft gaining very little altitude, returning to the ground, apparently just to the right of the runway, continuing forward for some distance beyond the end of the runway and then dropping into the river-bed and catching fire.
Guardia Civil
- Infographic
- Photos of the crashed airliner from AirDisaster.com
- Pre-crash photos of the airliner at airliners.net
NASA
NASA
The National Aeronautics and Space Administration is the agency of the United States government that is responsible for the nation's civilian space program and for aeronautics and aerospace research...
Civil Aviation Accident and Incident Investigation Commission
Civil Aviation Accident and Incident Investigation Commission
The Civil Aviation Accident and Incident Investigation Commission is the Spanish national agency responsible for air accident investigation. It is a division of the Ministry of Public Works and Transport...
- 20 August 2008. EC-HFP. McDonnell Douglas MD-82. Aeropuerto de Barajas (Madrid). Index of reports.
- Progress Note A-032/2008 , August 2010
- Interim Report A-032/2008 , August 2009
- Safety Recommendation REC 0/19 , February 2009
- Preliminary Report A-32/2008 , October 2008
- Final Report A-032/2008