Date & Time: Aug 20, 2008 at 1424 LT
Type of aircraft:
McDonnell Douglas MD-82
Operator:
Registration:
EC-HFP
Flight Phase:
Takeoff (climb)
Survivors:
Yes
Schedule:
Madrid - Las Palmas
MSN:
53148/2072
YOM:
1993
Flight number:
JKK5022
Country:
Spain
Region:
Europe
Crew on board:
6
Crew fatalities:
6
Pax on board:
166
Pax fatalities:
148
Other fatalities:
0
Total fatalities:
154
Captain / Total flying hours:
8476
Captain / Total hours on type:
5776
Copilot / Total flying hours:
1276
Copilot / Total hours on type:
1054
Aircraft flight hours:
31963
Aircraft flight cycles:
28133
Circumstances:
Shortly after rotation from runway 36L, stick shaker activated while the stall warning sounded. Aircraft stalled and crashed. It was completely destroyed by impact forces and post impact fire. 154 people were killed. Worst accident in Europe since December 1988.
Probable cause:
The crew lost control of the airplane as a consequence of entering a stall immediately after takeoff due to an improper airplane configuration involving the non-deployment of the slats/flaps following a series of mistakes and omissions, along with the absence of the improper takeoff configuration warning.
The crew did not identify the stall warnings and did not correct said situation after takeoff. They momentarily retarded the engine throttles, increased the pitch angle and did not correct the bank angle, leading to a deterioration of the stall condition.
The crew did not detect the configuration error because they did not properly use the checklists, which contain items to select and verify the position of the flaps/slats, when preparing the flight. Specifically:
- They did not carry out the action to select the flaps/slats with the associated control lever (in the "After Start" checklist);
- They did not cross check the position of the lever or the status of the flap and slat indicating lights when executing the" After Start" checklist;
- They omitted the check of the flaps and slats during the "Takeoff briefing" item on the "Taxi" checklist;
- The visual check done when executing the "Final items" on the "Takeoff imminent" checklist was not a real check of the position of the flaps and slats, as displayed on the instruments in the cockpit.
The CIAIAC has identified the following contributing factors:
- The absence of an improper takeoff configuration warning resulting from the failure of the TOWS to operate, which thus did not warn the crew that the airplane's takeoff configuration was not appropriate. The reason for the failure of the TOWS to function could not be reliably established.
- Improper crew resource management (CRM), which did not prevent the deviation from procedures in the presence of unscheduled interruptions to flight preparations.
Final Report:
EC-HFP.pdf5.92 MB