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Ciaiac@Fomento.Es C/ Fruela, 6 Fax: +34 91 463 55 35 28011 Madrid (España) Foreword CCIAIIAACIAC COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL Informe técnico A–043/2013 Accident involving a BOEING 767-332 ER aircraft, registration N-182DN, operated by DELTA AIR LINES, at the Madrid-Barajas Airport (Madrid, Spain) on 5 December 2013 Report A–043/2013 Accident involving a BOEING 767-332 ER aircraft, registration N-182DN, operated by DELTA AIR LINES, at the Madrid-Barajas Airport (Madrid, Spain) on 5 December 2013 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: 161-16-335-5 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 A-043/2013 Table of contents Abbreviations ............................................................................................................................... vii Synopsis ........................................................................................................................................ ix 1. Factual information ............................................................................................................... 1 1.1. History of the flight ....................................................................................................... 1 1.2. Injuries to persons .......................................................................................................... 5 1.3. Damage to aircraft ......................................................................................................... 5 1.4. Other damage ................................................................................................................ 5 1.5. Personnel information .................................................................................................... 6 1.5.1. Crew ................................................................................................................ 6 1.5.2. Controllers ....................................................................................................... 6 1.6. Aircraft information ........................................................................................................ 7 1.6.1. General information ......................................................................................... 7 1.6.2. Wing structure ................................................................................................. 8 1.6.3. Hydraulic system .............................................................................................. 9 1.6.4. Brake system .................................................................................................. 12 1.6.5. Landing gear .................................................................................................... 12 1.6.6. Engine reversers ............................................................................................... 14 1.6.7. Fuel system ...................................................................................................... 15 1.6.8. Information in the Quick Reference Handbook (QRH) ..................................... 15 1.6.9. Retread certification process ............................................................................ 16 1.7. Meteorological information ............................................................................................ 17 1.8. Aids to navigation .......................................................................................................... 17 1.9. Communications ............................................................................................................ 17 1.10. Aerodrome information .................................................................................................. 22 1.10.1. General information ........................................................................................... 22 1.10.2. Runway 36L ....................................................................................................... 22 1.10.3. Runway 32 L...................................................................................................... 23 1.10.4. Emergency procedures at the airport ................................................................. 25 1.10.5. ATS procedures .................................................................................................. 25 1.10.6. Operating Instruction 10-36-GEOPS-01 on handling FOD1 ................................ 26 1.11. Flight recorders .............................................................................................................. 26 1.11.1. Digital Flight Data Recorder ............................................................................... 26 1.11.2. Cockpit Voice Recorder ...................................................................................... 29 1.12. Wreckage and impact information ................................................................................. 34 1.12.1. Damaged aircraft systems and components ....................................................... 34 1.12.2. Other damage to the airport ............................................................................. 38 1.12.3. Debris found on the runways ............................................................................ 38 1.13. Medical and pathological information ............................................................................ 40 1.14. Fire ................................................................................................................................. 40 1.15. Survival aspects .............................................................................................................. 40 1 Foreign Object Debris v Report A-043/2013 1.16. Tests and research .......................................................................................................... 40 1.16.1. Analysis of piece found on runway 36L............................................................. 40 1.16.2. Visual inspection of tear on the tire by the manufacturer ................................. 41 1.16.3. Study of the tear on the tire ............................................................................. 41 1.17. Organizational and management information ................................................................ 43 1.17.1. Manufacture of landing gear tires ..................................................................... 43 1.17.2. Tire retreading ................................................................................................... 48 1.17.3. Information provided by the control service ....................................................... 51 1.17.4. Information provided by the airport ................................................................... 56 1.18. Additional information. .................................................................................................. 57 1.18.1. Manufacturer of the landing gear tires .............................................................. 57 1.18.2. Retreading tires .................................................................................................. 58 1.19. Useful or effective investigation techniques ................................................................... 60 2. Analysis ................................................................................................................................ 61 2.1. General aspects of the emergency and its progression .................................................. 61 2.2. Aspects involving the design of the aircraft ................................................................... 64 3. Conclusions ............................................................................................................................ 67 3.1. Findings ........................................................................................................................
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