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Balearic Islands, Spain) on 1 September 2015 CCIAIIAACIAC COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Report IN-031/2015 Incident involving an Airbus A-321-211, registration G-TCDX, operated by Thomas Cook Airlines, while on approach to the Menorca Airport (Balearic Islands, Spain) on 1 September 2015 Report IN-031/2015 Incident involving an Airbus A-321-211, registration G-TCDX, operated by Thomas Cook Airlines, while on approach to the Menorca Airport (Balearic Islands, Spain) on 1 September 2015 SUBSECRETARÍA GOBIERNO MINISTERIO DE ESPAÑA DE FOMENTO COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Edita: Centro de Publicaciones Secretaría General Técnica Ministerio de Fomento © NIPO: 161-17-153-6 Depósito Legal: M-24884-2017 Diseño, maquetación e impresión: Centro de Publicaciones 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) 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. Report IN-031/2015 Table of contents Abbreviations ............................................................................................................................... ix Synopsis ........................................................................................................................................ xi 1. Factual information ............................................................................................................... 1 1.1. History of the flight........................................................................................................ 1 1.2. Injuries to persons. ......................................................................................................... 2 1.3. Damage to aircraft. ........................................................................................................ 2 1.4. Other damage. ............................................................................................................... 2 1.5. Personnel information. ................................................................................................... 2 1.6. Aircraft information. ....................................................................................................... 2 1.7. Meteorological information. ........................................................................................... 3 1.8. Aids to navigation. ......................................................................................................... 3 1.9. Communications. ........................................................................................................... 4 1.10. Aerodrome information. ................................................................................................. 4 1.11. Flight recorders. ............................................................................................................. 4 1.12. Wreckage and impact information. ................................................................................ 5 1.13. Medical and pathological information. ........................................................................... 5 1.14. Fire ................................................................................................................................ 5 1.15. Survival aspects. ............................................................................................................. 5 1.16. Tests and research. ......................................................................................................... 5 1.16.1. Reports from the aircraft crew. ........................................................................ 5 1.16.1.1. Report from the Captain ............................................................... 5 1.16.1.2. Reports from the First Officer ........................................................ 7 1.16.2. Reports from the ATC stations. ........................................................................ 8 1.16.3. Radar track. ..................................................................................................... 9 1.17. Organizational and management information. ............................................................... 9 1.18. Additional information. .................................................................................................. 10 1.18.1. Information available to plan the flight. .......................................................... 10 1.18.2. Operational flight plan. .................................................................................... 11 1.18.3. Operator’s Operations Manual, Part A. ............................................................ 13 1.19. Useful or effective investigation techniques. .................................................................. 13 2. Analysis ................................................................................................................................ 15 3. Conclusions ............................................................................................................................ 17 3.1. Findings ......................................................................................................................... 17 3.2. Causes ........................................................................................................................... 18 4. Safety recommendations ...................................................................................................... 19 5. Appendix ................................................................................................................................ 21 vii Report IN-031/2015 Abbreviations 00:00 Hours and minutes (time period) 00.00:00 Hours, minutes and seconds (elapsed time) 00º Geometric degrees / Magnetic course 00º00’00” Degrees, minutes and seconds (geographic coordinates) 00 ºC Degrees centigrade AAIB Air Accident Investigation Board (United Kingdom) ACC Area control center ADX Andraitx (IAF for the ILS approach to runway 06L at LEPA) AEMET Spain’s National Weather Agency AMC Acceptable Means of Compliance APP Approach control station ATC Air traffic control ATIS Automated terminal information system ATPL(A) Air transport pilot license (airplane) CAA Civil Aviation Authority (United Kingdom) dd/mm/aaaa Day, month and year (date) DEP . Departures ECAM Electronic centralized aircraft monitor EGSH Norwich Airport in the United Kingdom EGSS Stansted Airport in the United Kingdom FCL Flight crew licensing FDM Flight data monitoring FL Flight level FMGC Flight management guidance computer ft Feet GM Guidance Material GND Ground control hPa Hectopascals IAF Initial approach fix ILS Instrument landing system JAR Joint aviation regulations Kg Kilograms Km Kilometers LEBL / BCN Barcelona Airport (ICAO / IATA codes) LEIB / IBZ Ibiza Airport (ICAO / IATA codes) LEMH / MAH Menorca Airport (ICAO / IATA codes) LEPA / PMI Palma de Mallorca Airport (ICAO / IATA codes) LT Local time m. Meters MDA/H Minimum decision altitude/Height METAR Aerodrome routine weather report MHz Megahertz NM Nautical mile NDB Non-directional beacon NOTAM Notice distributed by telecommunications means containing information on the establishment, condition or modification of any aeronautical facility, service, procedure or hazard, knowledge of which is essential to personnel charged with flight operations OM Operations Manual PCMCIA Memory card for personal computers PF Pilot flying QAR Quick access recorder QNH Altimeter subscale setting to obtain elevation when on the ground when landing and taking off SPECI Special aerodrome weather report STAR Standard terminal arrival route TAF Terminal aerodrome forecast ix Report IN-031/2015 TOC Top of climb TOD Top of descent TWR Aerodrome control tower UTC Coordinated universal time VHF Very High Frequency VOR VHF omni-directional range x Report IN-031/2015 Synopsis Owner and Operator: Thomas Cook Airlines Aircraft: Airbus A-321-211, registration G-TCDX Date and time of incident: 1 September 2015 at 15:14 UTC1 Site of incident: On approach to the Menorca Airport (Balearic
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