Report IN-017/2017 ______
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Report IN-017/2017 ______________________________ Serious incident involving a Boeing B787-900, registration N825AA, and a Cessna 172-M, registration EC-IEO, in the Madrid TMA on 8 August 2017 Please note that this report is not presented in its final layout and therefore it could include minor errors or need type corrections, but not related to its content. The final layout with its NIPO included (Identification Number for Official Publications) will substitute the present report when available. SUBSECRETARÍA COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Notice This report is a technical document that reflects the point of view of the Civil Aviation Accident and Incident Investigation Commission (CIAIAC) regarding the circumstances of the accident object of the investigation, and its probable causes and consequences. In accordance with the provisions in Article 5.4.1 of Annex 13 of the International Civil Aviation Convention; and with articles 5.5 of Regulation (UE) nº 996/2010, of the European Parliament and the Council, of 20 October 2010; Article 15 of Law 21/2003 on Air Safety and articles 1., 4. and 21.2 of Regulation 389/1998, this investigation is exclusively of a technical nature, and its objective is the prevention of future civil aviation accidents and incidents by issuing, if necessary, safety recommendations to prevent from their reoccurrence. The investigation is not pointed to establish blame or liability whatsoever, and it’s not prejudging the possible decision taken by the judicial authorities. Therefore, and according to above norms and regulations, the investigation was carried out using procedures not necessarily subject to the guarantees and rights usually used for the evidences in a judicial process. Consequently, any use of this report for purposes other than that of preventing future accidents may lead to erroneous conclusions or interpretations. This report was originally issued in Spanish. This English translation is provided for information purposes only. ii CONTENTS Notice...............................................................................................................................ii CONTENTS .................................................................................................................... iii ABBREVIATIONS ........................................................................................................... v Synopsis ....................................................................................................................... viii 1. FACTUAL INFORMATION ................................................................................... 10 1.1. History of the flight .......................................................................................... 10 1.2. Injuries to persons .......................................................................................... 12 1.2.1. Aircraft N825AA ...................................................................................... 12 1.2.2. Aircraft EC-IEO ....................................................................................... 12 1.3. Damage to aircraft .......................................................................................... 13 1.4. Other damage ................................................................................................ 13 1.5. Personnel information .................................................................................... 13 1.5.1. Aircraft N825AA ...................................................................................... 13 Captain ............................................................................................. 13 Copilot .............................................................................................. 13 Relief pilot ........................................................................................ 14 1.5.2. Aircraft EC-IEO ....................................................................................... 14 Instructor .......................................................................................... 14 Student ............................................................................................. 14 1.5.3. ATCOs .................................................................................................... 15 Executive controller .......................................................................... 15 Planning controller ........................................................................... 15 1.6. Aircraft information ......................................................................................... 16 1.6.1. Aircraft N825AA ...................................................................................... 16 1.6.2. Aircraft EC-IEO ....................................................................................... 16 1.7. Meteorological information ............................................................................. 17 1.8. Aids to navigation ........................................................................................... 18 1.9. Communications ............................................................................................. 21 1.10. Aerodrome information ............................................................................... 23 1.11. Flight recorders ........................................................................................... 23 1.12. Wreckage and impact information .............................................................. 24 1.13. Medical and pathological information ......................................................... 25 1.14. Fire .............................................................................................................. 25 1.15. Survival aspects .......................................................................................... 25 1.16. Tests and research ..................................................................................... 25 1.16.1. Statements from crews and controllers ............................................... 25 Aircraft N825AA ............................................................................... 25 Aircraft EC-IEO ................................................................................ 26 Control service ................................................................................. 27 1.17. Organizational and management information ............................................. 29 1.17.1. Control center ...................................................................................... 29 1.18. Additional information ................................................................................. 31 1.18.1. Flight plan of aircraft ACR31 ............................................................... 31 1.18.2. Operation of the conflict alert ............................................................... 32 1.19. Useful or effective investigation techniques ................................................ 33 2. ANALYSIS ............................................................................................................ 34 iii 2.1. Analysis of flight plan of aircraft ACR31 ......................................................... 34 2.2. Analysis of takeoffs from LECU toward the north ........................................... 35 2.3. Considerations involving the control station ................................................... 35 2.4. Actions taken by the flight crews .................................................................... 39 3. CONCLUSIONS.................................................................................................... 40 3.1. Findings .......................................................................................................... 40 3.2. Causes/Contributing factors ........................................................................... 41 4. SAFETY RECOMMENDATIONS .......................................................................... 42 iv ABBREVIATIONS ‘ “ Sexagesimal degrees, minutes and seconds C Degrees Celsius 3D Three dimensions AC Conflict alert ACAS Airborne collision avoidance system ACP Area control procedural rating ACS Area control surveillance rating ADF Automatic direction-finding equipment ADI Aerodrome Control Instrument rating ADV Aerodrome Control Visual rating AESA Spanish National Aviation Safety Agency AIP Aeronautical information publication AIR Air Control endorsement AMC Acceptable means of compliance APP Approach Control Procedural Rating APS Approach Control Surveillance rating ARO Air traffic services reporting office ATC Air traffic control ATCO Air Traffic Controller ATPL Airline Transport Pilot License ATS Air traffic service ATZ Aerodrome traffic zone Visibility, cloud and present weather better than prescribed values or CAVOK conditions CB Cumulonimbus CDR Conditional route CFL Cleared Flight Level COM Communications equipment CPL Commercial pilot license CRI Class rating instructor DEN East takeoffs in north configuration DME Distance measuring equipment DSH Horizontal safety distance DSV Vertical safety distance DVOR Doppler VHF omnidirectional radio range DWN West takeoffs in north configuration EASA European Aviation Safety Agency ELT Emergency locator transmitter ENR En route v FI Flight instructor FIR Flight information region FL Flight level ft Feet ft/min Feet/minute GMC Ground Movement Control endorsement GMS Ground Movement Surveillance endorsement GND Ground