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MD82, Spanair, Madrid Barajas Spain, 2008 (HF LOC)
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| Category: | Weather | 
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| Content source: | SKYbrary | 
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| Content control: | EUROCONTROL | 
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Description
On 20 August 2008, an MD82 aircraft operated by Spanair took off from Madrid Barajas Airport with flaps and slats retracted; the incorrect configuration resulted in loss of control, collision with the ground, and the destruction of the aircraft.
The investigation into this accident by the Spanish authorities is on-going.
Interim Report
This is an extract from the History of Flight from the Interim Report published by CIAIAC on 17 August 2009:
“...Upon reaching the runway, the crew reported a problem and informed ATC that they had to return to the stand.
The problem, high temperature indication on the RAT, was resolved and the aircraft was again cleared for engine start.
...the crew started to perform the prestart and before start checklists. After starting the engines, the after start checklist was performed, with the flaps/slats item omitted since at that moment the captain told the copliot to request clearance from ATC to taxi to runway 36L...At 14:23 the airplane was situated at the head of runway 36L, at which time it was cleared for takeoff once more.
...Once airborne, the aircraft reached an altitude of 40ft above the ground before descending and impacting the ground.
The stick shaker and aural warnings were recorded on the CVR, beginning just after rotation. During the takeoff run and until the end of the CVR recording, no sounds were heard relating to the system warning of an inadequate takeoff configuration (TOWS). During the entire period from engine start-up at parking stand R11 to the end of the DFDR recording, the deflection values recorded for the flaps were 0 degrees"
The report states that:
"...the CIAIAC is of the opinion that three safety barriers provided to avoid the take-off in an inappropriate configuration were defeated: the airplane configuration checklist, the checklist to confirm and verify the airplane's actual configuration, and the TOWS, which did not warn of the improper takeoff configuration. As a consequence, improvements should be taken in the area of design and operations so that future accidents as this one can be prevented."
EASA Airworthiness Directive
On 29 October 2008, EASA issued an airworthines directive (EASA AD No. 2008-0197) applicable to airplane models DC-9-10, DC-9-20, DC-9-30, DC-9-40, DC-9-50, DC-9-81 (MD-81), DC-9-82 (MD82), DC-9-83 (MD83), DC-9-87 (MD-87), MD-88, MD-90-30, and 717-200.
The directive required that the AFM section on procedures be revised within 15 days from the effective date (12 November 2008) to add the requirement to check the TOWS before engine start-up and prior to each flight.
FAA Safety Alert
On 5 November 2008, the FAA issued SAFO 08021, "Importance of Standard Operating Procedures (SOP) as evidenced by take off Configuration Hazard in Boeing DC-9 Series, MD-80 series, MD-90, and B-717 airplanes"
The SAFO made reference to the 1987 McDonnell Douglas telex which recommended that operator check the TOWS before each flight and indicated that the risk of improperly configuring the flaps and slats could be mitigated in two different ways: warning systems and standard operating procedures.
The SAFO recommended that Operations, Maintenance, Safety and training Managers review their procedures to ensure that the maintenance and operating procedures are effective in ensuring the proper operations of the TOWS. It also urged proper training for maintenance personnel to ensure the approved procedures for the airplane type in question were followed.
The instructions contained in the SAFO are not mandatory.
Related Articles
- MD82, Northwest Airlines, Detroit MI USA, 1987 (HF LOC): An almost identical accident - On 16 August 1987, an MD82 operated by Northwest Airlines took off from Detroit Metropolitan Wayne County Airport, USA, with flaps retracted, resulting in loss of control and impact with the ground. Contributing to the accident was the absence of electrical power to the airplane takeoff warning system (TOWS) which thus did not warn the flightcrew that the airplane was not configured properly for takeoff.
Further Reading
- NTSB Safety Recommendation A09-67 through to 71 published 20 Aug 09 in response to the CIAIAC report.