CICIAIAIACAC COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL 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 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 SUBSECRETARÍA GOBIERNO MINISTERIO DE ESPAÑA DE FOMENTO COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL © Ministerio de Fomento Secretaría General Técnica Centro de Publicaciones NIPO Línea: 161-18-244-2 NIPO Papel: 161-18-247-9 Deposito Legal: M-36530-2018 Maquetación: ASAP Global Solution S.L. 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) 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. Report IN-017/2017 Contents ABBREVIATIONS .............................................................................................................................. vi Synopsis .......................................................................................................................................... x 1. FACTUAL INFORMATION .......................................................................................................... 1 1.1 History of the flight ........................................................................................................ 1 1.2 Injuries to persons .......................................................................................................... 3 1.2.1 Aircraft N825AA (AAL37) .. ............................................................................... 3 1.2.2 Aircraft EC-IEO .. ............................................................................................... 4 1.3 Damage to aircraft ......................................................................................................... 4 1.4 Other damage................................................................................................................ 4 1.5 Personnel information .................................................................................................... 4 1.5.1 Aircraft N825AA .. ............................................................................................ 4 1.5.1.1 Captain ............................................................................................ 4 1.5.1.2 Copilot ............................................................................................. 5 1.5.1.3 Relief pilot ........................................................................................ 6 1.5.2 Aircraft EC-IEO (ACR31) .. ................................................................................. 7 1.5.2.1 Instructor ......................................................................................... 7 1.5.2.2 Student ............................................................................................ 7 1.5.3 Air Traffic Controlers (ATCOs) .. ......................................................................... 8 1.5.3.1 Executive controller .......................................................................... 8 1.5.3.2 Planning controller ........................................................................... 9 1.6 Aircraft information ....................................................................................................... 9 1.6.1 Aircraft N825AA.. ............................................................................................. 9 1.6.2 Aircraft EC-IEO ................................................................................................. 10 1.7. Meteorological information ............................................................................................ 12 1.8. Aids to navigation .......................................................................................................... 13 1.8.1 Lower ATS routes – R753.. ................................................................................ 13 1.8.2 Current airspace configuration for departures toward N from LECU/LEVS... ....... 14 1.9 Communications ............................................................................................................ 15 1.10 Aerodrome information ................................................................................................. 17 1.11 Flight recorders .............................................................................................................. 17 1.11.1 Radar information.. ........................................................................................... 18 1.12 Wreckage and impact information ................................................................................. 19 1.13. Medical and pathological information ............................................................................ 19 1.14 Fire ................................................................................................................................ 19 1.15 Survival aspects .............................................................................................................. 19 1.16 Test and research ........................................................................................................... 19 1.16.1 Statements from crews and controllers ............................................................. 19 iv Report IN-017/2017 1.16.1.1 Aircraft N825AA .............................................................................. 19 1.16.1.1.1 Captain ........................................................................... 19 1.16.1.1.2 Copilot ............................................................................ 20 1.16.1.1.3 Relief pilot ....................................................................... 20 1.16.1.2 Aircraft EC-IEO ................................................................................. 21 1.16.1.3 Control service ................................................................................. 21 1.16.1.3.1 Executive controller ......................................................... 21 1.16.1.3.2 Planning controller .......................................................... 23 1.17 Organizational and management information ................................................................ 24 1.17.1 Control center .. ............................................................................................... 24 1.17.2 Team resource management (TRM) .. ................................................................ 25 1.18 Additional information ................................................................................................... 26 1.18.1 Flight plan of aircraft ACR31 .. .......................................................................... 26 1.18.2 Operation of the conflict alert .. ........................................................................ 27 1.19 Useful or effective investigation techniques .................................................................... 29 2. ANALYSIS ................................................................................................................................. 30 2.1 Analysis of flight plan of aircraft ACR31 ......................................................................... 30 2.2 Analysis of takeoffs from LECU toward the north .......................................................... 31 2.3 Considerations involving the control station .................................................................. 31 2.3.1 Airspace considerations .. .................................................................................. 31 2.3.2 Actions taken by sector WDN controllers .. ........................................................ 32 2.3.3 Considerations involving the conflict alert ........................................................ 34 2.3.4 Considerations involving TRM training. .. .........................................................