2008 Spanair Flight 5022 Crash Causes Still Undetermined

By George Potter


Photo by Andres Rueda

The Barajas international airport just outside of Madrid, Spain, is one of Europe’s busiest airports. With four lengthy runways and extensive passenger and cargo terminals, the facility is considered to be the country’s most important air traffic hub, as it is situated almost directly in the geographic centre of the Iberian Peninsula.

Barajas handles national and international commercial and private air traffic 24 hours a day–some 80 national and international airlines of regular and charter passenger and cargo. Nearly 50 million passengers used the airport in 2010, making it Europe’s fourth most important airport. Last year, the airport handled more than 433,000 take-offs and landings.

THE CRASH

At midday, August 20, 2008, Spanair flight 5022, Madrid to Las Palmas de Gran Canaria, a McDonnell Douglas MD 82 aircraft, initiated take-off after having aborted its scheduled take-off nearly one hour previously. The cancelled take-off was apparently attributed to a malfunction of a heat sensor, which was disconnected by a mechanic prior to the second take-off attempt. As the twin engine jetliner rolled along runway 36L gaining speed for lift off, “something happened” just as the aircraft became airborne. It subsequently veered away from the runway, impacted, and broke into several pieces which came to rest in a ravine between two parallel runways. The spilled fuel ignited, spreading fires over and around the sections of the airframe and passengers. There were 172 persons onboard (162 passengers, six flight crew members, and four deadheaded personnel, i.e. those who had not paid for tickets). In total, 146 died as results of impact injuries and/or burns on the scene, six more died en route to hospitals, and two more died later in hospitals. Only 18 people survived; many had been ejected from the aircraft, seats and all.

POST-CRASH

On July 29 of this year, the Spanish government’s Civil Aviation Accident and Incident Investigation Commission (CIAIAC) determined that the pilot and co-pilot committed a series of errors that, combined with mechanical malfunctions and annulments, ground crew faults, and even airline management decisions, all contributed to the crash.

This incident is quite well known throughout the airline world and, in fact, bears similarities with several other aviation incidents: Northwest Flight 255, Delta Flight 1141, Mandala Flight 091, and LAPA Flight 3142. In all of these incidents, failure to deploy flaps and slats were influential in causing the crashes, and these failures were caused by flight deck crew errors. However, in the case of the Spanair crash, the Commission has determined that the ground crew was negligent in handling the heat sensor problem, although they state that the malfunction of the heat sensor itself was not a decisive factor.

The following factors were cited:

  • Pilot and co-pilot negligence in not verifying flap and slat deployment because of anxiety caused by the delay of departure;
  • A cell phone conversation that distracted the co-pilot at a critical point in time;
  • The presence of an unauthorized person in the cockpit;
  • Malfunction of the TOWS (Take Off Warning System) that did not warn the pilot or co-pilot of the nondeployment of the flaps and slats;
  • Serious “malware” infections to the airline’s central computer system that caused numerous operational problems, including failure to inform the flight crew of several serious problems affecting this particular aircraft; and
  • Airline management’s apparent lack of supervision of ground crew technical training.

The basic cause of the crash was the failure to deploy the flaps and slats, hydraulically actuated extensions of the wings that facilitate lift-off. Apparently, both the pilot and the co-pilot did not verify flap and slat deployment at three distinct pre-takeoff standard operating procedure checklist positions. What still remains a mystery is why the TOWS did not function.

FIRE AND RESCUE RESPONSE

A factor that hampered fire and rescue response to this incident was the overgrowth of vegetation, including many full grown trees along the creek between runways 36L and 36R. The creek, however, helped to reduce the severity of the burns of several survivors. Apart from the severity of the fuel and airframe fires, the crash also provoked a problematic wildland fire.

The Barajas airport fire brigade was the first to respond to the crash. The entire shift responded from the facility’s three fire stations: 25 firefighters, including the department’s chief, staffed seven major crash tenders, two tankers, a structural fire engine, and command vehicles. The Madrid municipal fire service dispatched 15 engines and some 45 firefighters, and the Madrid regional fire service also sent pumpers and more than 25 firefighters. Fifty-seven ambulances and rescue vehicles were also mobilized; they were staffed by municipal and regional medical emergency responders, civil defence personnel, and private ambulance company personnel. Two helicopters were also deployed, aiding greatly in communications from above the scene as well as in combating the wildland fires.

Initial command structure was practically nonexistent until well into the incident when command staff from the multiple emergency services plus the various police agencies on scene got together and established an operating incident command structure.

The Barajas airport fire brigade is staffed by 160 career firefighters who can mobilize nearly 50 additional airport employees trained in emergency situation backup actions when needed. The airport has mutual-aid agreements with the Madrid city fire service and the Madrid regional fire service, which can provide numerous human and material resources when needed, as in this incident. Over the course of the past 10 years, these public fire services have intervened in several severe incidents at the airport, including two terrorist bombings.

This incident, as well as so many other aircraft crashes over the past few years, demonstrates the fallacy of the International Civil Aviation Organization’s (ICAO) mandate on occupant rescue and evacuation organized by cabin crew members. The six flight crew perished in the crash. Someday, sometime, and somewhere, a crash will affect “somebody” who could have been rescued by airport emergency response personnel, had they been present. At this time, the airport fire services have a primary mission of: approaching the affected aircraft, applying foam around and on the aircraft, and extinguishing fires that may threaten the aircraft. There are far too many airport fire departments around the world that have adequate or even more than adequate foam-delivery capabilities of vehicles staffed by one or two firefighters.

George H. Potter is a practicing fire protection specialist who has lived in Spain for the past 45 years. He served as an Anne Arundel County, Maryland, volunteer firefighter with the Riva Volunteer Fire Department and the Independent Hose Company in Annapolis and as an ambulance driver with the Wheaton (MD) Rescue Squad. He served six years in the United States Air Force as a firefighter, an apparatus driver/operator, and a crew chief. He has been involved in fire protection system installation, mobile fire apparatus design, and construction and fire safety training. He is a Spain-certified fire service instructor and a hazmat specialist, and is a member of the Board of Governors of the Spanish Firefighters’ Association (ASELF).

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