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MD83, Barcelona Spain, 2006

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Summary
On 9 January 2006, a Mc Donnell Douglas MD83 being operated by Spanair on a scheduled passenger flight from Bilbao to Barcelona made an unstablised day VMC approach to a dry runway 07R at destination and landed long with apparently locked brakes before coming to a stop 140 metres from the end of the 2660 metre long runway. Following ATC reports of a fire in the area of the left main landing gear, an evacuation was ordered using the right side doors during which five of the 96 occupants received minor injuries. The RFFS arrived at the scene during the evacuation and extinguished the fire. Significant damage occurred to both main landing gear assembles and to both wings and the tail assembly but there was no damage to the primary structure.
Event Details
When January 2006
Actual or Potential
Event Type
Fire Smoke and Fumes, Human Factors, Runway Excursion
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft MCDONNELL DOUGLAS MD-83
Operator Spanair
Domicile Spain
Type of Flight Public Transport (Passenger)
Origin Bilbao Airport
Actual Destination Barcelona/El Prat Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Landing
LDG
Location - Airport
Airport vicinity Barcelona/El Prat Airport
General
Tag(s) Approach not stabilised,
Non Precision Approach,
Inadequate Aircraft Operator Procedures
FIRE
Tag(s) Landing Gear Overheat
HF
Tag(s) Ineffective Monitoring,
Manual Handling,
Procedural non compliance,
Inappropriate crew response (automatics)
RE
Tag(s) Excessive Airspeed,
Late Touchdown
EPR
Tag(s) Emergency Evacuation
Outcome
Damage or injury No
Aircraft damage Major
Injuries Few occupants
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation
Investigation Type
Type Independent


Description

On 9 January 2006, a Mc Donnell Douglas MD83 being operated by Spanair on a scheduled passenger flight from Bilbao to Barcelona made an unstablised day Visual Meteorological Conditions (VMC) approach to a dry runway 07R at destination and landed long with apparently locked brakes before coming to a stop 140 metres from the end of the 2660 metre long runway. Following ATC reports of a fire in the area of the left main landing gear, an evacuation was ordered using the right side doors during which five of the 96 occupants received minor injuries. The Rescue and Fire Fighting Services arrived at the scene during the evacuation and extinguished the fire. Significant damage occurred to both main landing gear assembles and to both wings and the tail assembly but there was no damage to the primary structure.

Investigation

An Investigation was carried out by the Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC) with successful replay of both the Cockpit Voice Recorder (CVR) and the DFDR. It was established that the aircraft commander had been PF for the approach. Both pilots had several years aircraft type experience; in the First Officer’s case, this aircraft type had provided the majority of his total recorded experience.

Damage to the aircraft occurred to both main gear assemblies and to their tyres, rims and brake units which on the left leg had also been affected by the fire. Friction and impact damage also caused hydraulic lines in the left main gear assembly to rupture. The fire also caused damage to the left-side wing flap, some skin panels and the landing gear bay doors and the lower part of the tail cone was damaged and cracked after ejection as part of the normal deployment the rear slide.

A reconstruction of the flight found that it had been uneventful until shortly before the start of the initial approach, with the aircraft on a heading of 150° and at a relatively high altitude in relation to distance to go. ATC reminded the crew of the noise abatement restriction not to descend below 5,000 ft before crossing the coastline - the position of this is shown on the diagram included later in this summary and taken from the Official Report.

CVR evidence indicated that the aircraft commander decided that, despite the altitude, he would cut the track miles by planning to intercept the ILS LLZ at the FAF, located at just under 9nm from the landing runway threshold. The First Officer noted that if they had to maintain 5000 feet until the coastline, they would be high, since at that point, they should be at 3000 feet. The AP was disconnected as the runway centreline was acquired at the FAF at 3700 feet aal and at a speed of 250 KIAS. This speed was well inside the AFM maximum speed for extension of the landing gear, but this had not been done until 1.5 minutes later and the air brakes had not been used either.

Since the aircraft remained above the ILS GS for most of the final approach, the descent was very steep, averaging around 2500 fpm, and although the aircraft eventually established on the GS, the airspeed remained very high and engine thrust was set to flight idle during the entire approach. Between approximately 900 feet aal and just below 200 feet aal, there were repeated GPWS/TAWS ‘SINK RATE’ and ‘TOO LOW TERRAIN’ alerts as well as several ‘PULL UP’ Hard Warnings none of which elicited any pilot response. Flap selection to the landing position 40° was made just before the runway threshold was crossed at an altitude of 30 feet, and a speed of 190 KCAS, the latter being 66 knots above the applicable Vref of 124 KIAS. Landing configuration was finally achieved “a few seconds before touchdown and while flying over the runway”. At an estimated 800 metres past the landing threshold, the nose gear made contact with the runway but the first main gear contact, the left side only, did not occur until an estimated 1600 metres from the threshold. Complete main gear touchdown then occurred 120 metres further on, a position over halfway along the full runway length of 2660 metres. However, the aircraft came to a full stop 1520 metres from the beginning of the runway, taking a stopping distance similar to the 800 metre LDR which would have applied if following a correctly flown approach. Because of the prolonged prior nosewheel runway contact, the four main wheels locked on touchdown and began to skid before quickly blowing out with the resultant sparks, frictional heat, melted rubber and hydraulic fluid leaks resulting in the fire seen in the left main gear assembly when the aircraft stopped. The reversers were deployed during the landing skid with the corresponding EPR recorded as reaching up to 1.9.

Track followed to runway 07R showing the coastline (reproduced from the Official Report)

It was noted by the Investigation that the Operator’s SOPs for the flying of an approach, including those relating to the configuration of the aircraft and the requirement for a stabilised approach, had been comprehensively disregarded. There was also no evidence that the PM had made any of the standard calls or that either pilot responded in any way to any of the many GPWS activations

Three Safety Recommendations were made as a result of the Investigation:

  • That Spanair establish a monitoring program specifically intended to check the real extent of compliance by its crews with the MD-80 operating procedures, with specific focus on evaluating the approach and landing phases. (REC 10/11)
  • That Spanair provide additional training to its crews to reinforce the concepts of:
− Stabilised approach
− Standard operating procedures (SOPs)
− Crew resource management. (REC 11/11)
  • That Spain’s Aviation Safety Agency (AESA) reinforce its supervision program for Spanair in the following:
− Aspects concerning the real extent of compliance by its crews with the MD-80 operating procedures, with specific focus on evaluating the approach and landing phases.
− The training provided by the company in concepts such as stabilised approach, standard operating procedures (SOPs) and Crew Resource Management. (REC 12/11)

The Final Report of the Investigation REPORT IN-001/2006 was approved on 9 June 2011

Further Reading