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MD-82) Aircraft, Registration EC-HFP, Operated by Spanair, at Madrid-Barajas Airport, on 20 August 2008

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MD-82) Aircraft, Registration EC-HFP, Operated by Spanair, at Madrid-Barajas Airport, on 20 August 2008 CIAIACCIAIAC COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Report A-032/2008 Accident involving a McDonnell Douglas DC-9-82 (MD-82) aircraft, registration EC-HFP, operated by Spanair, at Madrid-Barajas Airport, on 20 August 2008 Report A-032/2008 Accident involving a McDonnell Douglas DC-9-82 (MD-82) aircraft, registration EC-HFP, operated by Spanair, at Madrid-Barajas Airport, on 20 August 2008 SECRETARÍA DE ESTADO DE TRANSPORTES COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Edita: Centro de Publicaciones Secretaría General Técnica Ministerio de Fomento © NIPO: 161-11-160-4 Depósito legal: M. 23.129-2003 Diseño y maquetación: Phoenix comunicación gráfica, S. L. COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Tel.: +34 91 597 89 63 E-mail: [email protected] C/ Fruela, 6 Fax: +34 91 463 55 35 http://www.ciaiac.es 28011 Madrid (España) Foreword 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) n° 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. Report A-032/2008 Table of contents List of figures ................................................................................................................................xi Abbreviations ................................................................................................................................ xii Synopsis ......................................................................................................................................... xvii 1. Factual information ............................................................................................................... 1 1.1. History of the flight ........................................................................................................ 1 1.2. Injuries to persons .......................................................................................................... 6 1.3. Damage to aircraft .........................................................................................................7 1.4. Other damage ................................................................................................................ 7 1.5. Personnel information .................................................................................................... 7 1.5.1. Cockpit crew ..................................................................................................... 7 1.5.1.1. Captain ............................................................................................. 7 1.5.1.1.1. General information ...................................................... 7 1.5.1.1.2. Flight, duty and rest hours ............................................ 8 1.5.1.1.3. Last recurrent training completed .................................. 9 1.5.1.1.4. Additional information ................................................... 9 1.5.1.1.5. Seventy-two hours before the flight .............................. 9 1.5.1.2. First officer ....................................................................................... 10 1.5.1.2.1. General information...................................................... 10 1.5.1.2.2. Flight, duty and rest hours ............................................ 11 1.5.1.2.3. Last recurrent training completed .................................. 12 1.5.1.2.4. Additional information ................................................... 12 1.5.1.2.5. Seventy-two hours before the flight .............................. 12 1.5.2. Flight attendants ............................................................................................... 13 1.5.3. Maintenance technicians ................................................................................... 13 1.5.3.1. AMT 1 (Aviation Maintenance Technician - Madrid) ........................ 13 1.5.3.2. AMT 2 (Aviation Maintenance Technician - Barcelona) .................... 14 1.5.3.3. AMT 3 (Aviation Maintenance Technician - Madrid) ........................ 14 1.5.3.4. AMT 4 (Aviation Maintenance Technician - Madrid) ........................ 15 1.5.3.5. AMT 5 (Aviation Maintenance Technician - Madrid) ........................ 15 1.5.3.6. AMT 6 (Aviation Maintenance Technician - Madrid) ........................ 16 1.6. Aircraft information ........................................................................................................ 16 1.6.1. General ............................................................................................................. 16 1.6.2. Systems description ........................................................................................... 17 1.6.2.1. High-lift devices ................................................................................ 17 1.6.2.1.1. Operation/actuation (see Figure 1) ................................. 17 1.6.2.1.2. Flaps/slats cockpit controls ............................................. 20 1.6.2.1.3. Flaps and slats position sensors and indicating systems . 22 1.6.2.2. TOWS, takeoff warning system ........................................................ 23 1.6.2.3. Ground sensing system. The R2-5 relay ............................................ 24 1.6.2.4. Ram Air Temperature probe heater circuit ....................................... 28 1.6.2.5. Stall protection system ..................................................................... 29 1.6.2.6. Autothrottle ...................................................................................... 30 v Report A-032/2008 1.6.2.7. Automatic Reserve Thrust system ..................................................... 31 1.6.2.8 Approach idle control system ........................................................... 31 1.6.2.9. Flight data recording system ............................................................. 32 1.6.3. Maintenance information .................................................................................. 33 1.6.3.1. Maintenance program ...................................................................... 33 1.6.3.2. Faulty operation of the RAT probe heater ........................................ 34 1.6.3.2.1. Excessive RAT probe temperature indications on the ground in aircraft EC-HFP .............................................. 34 1.6.3.2.2. Instructions in manufacturer’s manuals ......................... 36 1.6.3.2.3. Operator’s Minimum Equipment List (MEL) ................... 37 1.6.3.2.4. Statements from flight crew and maintenance personnel regarding high RAT indications ...................................... 38 1.6.3.3. Maintenance records ........................................................................ 41 1.6.3.3.1. Maintenance record requirements ................................. 41 1.6.3.3.2. Spanair procedures for making ATLB entries ................. 42 1.6.3.3.3. ATLB maintenance records for EC-HFP .......................... 42 1.6.4. Weight and balance .......................................................................................... 43 1.7. Meteorological information ............................................................................................ 44 1.7.1. METAR information ........................................................................................... 44 1.7.2. ATIS information ............................................................................................... 44 1.7.3. Wind data ......................................................................................................... 45 1.7.4. Control clearance information ........................................................................... 46 1.8. Aids to navigation .......................................................................................................... 46 1.9. Communications ............................................................................................................ 46 1.10. Aerodrome information .................................................................................................. 47 1.10.1. General information and location .................................................................... 47 1.10.2. Access to crash site ........................................................................................
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