Crash of a Boeing 727-200 in Madrid: 51 killed

Date & Time: Dec 7, 1983 at 0939 LT
Type of aircraft:
Operator:
Registration:
EC-CFJ
Flight Phase:
Survivors:
Yes
Schedule:
Madrid - Rome
MSN:
20820
YOM:
1974
Flight number:
IB350
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
84
Pax fatalities:
Other fatalities:
Total fatalities:
51
Captain / Total flying hours:
8860
Captain / Total hours on type:
1919.00
Copilot / Total flying hours:
3474
Copilot / Total hours on type:
2840
Aircraft flight hours:
21525
Aircraft flight cycles:
19936
Circumstances:
Boeing 727-256 EC-CFJ of Iberia, operating scheduled flight IB350 to Rome, and DC-9-32 EC-CGS of Aviaco, operating schedule AO134 to Santander, crashed on runway 01/19 at Madrid-Barajas Airport. The Boeing 727 had been cleared for takeoff on runway 01 and was at V1 speed. The DC-9 had been cleared to proceed to the holding point at runway 01 through the outer taxiway. The accident occurred approximately at 09h39:29 on December 7, 1983. As a result of the impact and instant fire, the DC-9 aircraft was totally destroyed, dying the whole of its occupants, 5 crew members and 37 passengers. The Boeing 727 aircraft lost almost all of its left wing and main gear of the same side, sliding on the runway about 460 meters, until its final stop, remaining facing the opposite direction of takeoff, on the left edge of runway 01. As a result of the impact and of the spilling of fuel from the left wing, there was an almost instant fire at the time o the crash, which subsequently destroyed the aircraft. 34 passengers and 8 crew members out of the 84 passengers and 9 crew members, survived. 50 passengers and one assistance crew member died as a result of the impact and fire. The conditions of visibility at the airport were of daylight and intense fog.
Probable cause:
The cause of the accident was the unknown incursion of the DC-9 on the runway 01/19 when the Boeing 727 was on takeoff roll. The DC-9 was on the active runway because visibility conditions due to fog, by the zone where the aircraft was taxiing, impeded to the crew obtain sufficient visual references, to determine that, that was not the correct run that they should realize to reach the threshold of runway 01.
Final Report:

Crash of a Boeing 747-283B in Madrid: 181 killed

Date & Time: Nov 27, 1983 at 0106 LT
Type of aircraft:
Operator:
Registration:
HK-2910
Survivors:
Yes
Schedule:
Frankfurt – Paris – Madrid – Caracas – Bogotá
MSN:
21381
YOM:
1977
Flight number:
AV011
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
173
Pax fatalities:
Other fatalities:
Total fatalities:
181
Captain / Total flying hours:
23215
Captain / Total hours on type:
2432.00
Copilot / Total flying hours:
4384
Copilot / Total hours on type:
875
Aircraft flight hours:
20811
Aircraft flight cycles:
5800
Circumstances:
Following an uneventful flight from Paris-Roissy-CDG Airport, the crew was cleared to descent to Madrid-Barajas Airport runway 33. Once the altitude of 9,000 feet reached on descent, the crew was cleared to continue. At 0103LT, he was cleared to land on runway 33 and should complete a turn to the right. Following several errors on approach, the crew initiated a right turn prior to pass over the VOR, causing the aircraft to descent below the MDA. At an altitude of 2,247 feet and at a speed of 142 knots, the right main gear struck the top of a hill. Upon impact, the right main gear and the engine n°4 were torn off. Three seconds later, while in a 4,9° nose-up attitude, at a speed of 135 knots, the aircraft struck the top of a second hill. Then, six seconds later, the right wing struck the ground. The aircraft overturned and crashed upside down, bursting into flames. The wreckage was found 12 km from the runway threshold in an olive plantation. Eleven passengers (among them four members of the same family, father, mother and both children) were injured while 181 other occupants were killed, among them the Peruvian writer Manuel Scorza.
Probable cause:
Following a series of omissions and navigation errors on descent, the crew adopted a wrong approach configuration, causing the aircraft to descend below the MDA without proper visual contact with the runway until initial and final impact with the ground. The following contributing factors were reported:
_ Inaccurate navigation by the crew, which placed them in an incorrect position for initiating the approach manoeuvre,
- Failure of the crew to take corrective action after the GPWS alarm sounded in the cockpit,
- Poor crew coordination,
- Crew fatigue,
- Lack of ATC assistance during the last portion of the flight,
- Misinterpretation of ATC instructions on part of the flying crew,
- Lack of visibility due to the night.

Crash of a Douglas DC-10-30CF in Málaga: 50 killed

Date & Time: Sep 13, 1982 at 1200 LT
Type of aircraft:
Operator:
Registration:
EC-DEG
Flight Phase:
Survivors:
Yes
Schedule:
Madrid – Málaga – New York
MSN:
46962
YOM:
1977
Flight number:
BX995
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
381
Pax fatalities:
Other fatalities:
Total fatalities:
50
Captain / Total flying hours:
16129
Captain / Total hours on type:
2119.00
Copilot / Total flying hours:
6840
Copilot / Total hours on type:
2165
Aircraft flight hours:
15364
Aircraft flight cycles:
4008
Circumstances:
Takeoff acceleration was normal, failure was not detected on engines, systems or structures. The crew registered a strong vibration at or close to V1. The captain felt how this vibration was highly increased as he began rotation, consequently rejecting the takeoff at a speed between VR and V2. Physical evidence shows how detachment of the tread of a tire of the nose gear, retreated, began before the aircraft had reached V1. The reject of takeoff began where there were another 1,295 meters (4,250 feet) of runway left. The aircraft crossed the runway end at a speed slightly over 110 knots, colliding with an ILS concrete building, breaking the metal fencing of the airport, crossing a highway, causing damage to three vehicles on the same, colliding then with farming construction. Engine number three detached after impact with the ILS building. Approximately three quarters of the right wing as well as the right horizontal stabilizer were detached as a result of the impact with the afore mentioned farming construction. The fuselage also ran over the construction with which the right wing collided. The aircraft stopped 450 meters (1,475 feet) away from the end of runway 14, and approximately 40 meters (130 feet) off to the left from the centerline. Neither the passenger department nor the cockpit showed damage that could impede survival when the aircraft stopped. Fuel was spilled off the right wing, from the time it collided with the farming construction, and the fire began in the rear of the fuselage. The fire destroyed the aircraft completely. There were 381 passengers and 13 crew members on board. 333 passengers and 10 crew survived, and as a result of the fire subsequent to the impact, 47 passengers and three assistant crew members died.
Probable cause:
The Commission determines the cause of the accident to be the fractional detachment of the retread of the right wheel of the nose gear, originating a strong vibration which could not be identified by the captain, leading him into the belief that the aircraft would become uncontrollable in flight, and thus deciding to abandon the take-off over VR. The decision of aborting the take-off, though not in accordance with the standard operation procedure, is in this case considered reasonable, on the base of the irregular circumstances that the crew had to face, the short period of time available to take the decision, the lack of training in case of wheel failure and the absence of take-off procedures when failure other than that of the engines occurs.
Final Report:

Crash of a Canadair CL-215-1A10 near Cañaveruelas: 4 killed

Date & Time: Mar 2, 1981 at 1120 LT
Type of aircraft:
Operator:
Registration:
UD.13-2
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Torrejón - Torrejón
MSN:
1013
YOM:
1969
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was completing a training mission out from Madrid-Torrejón AFB. After performing a scooping mission on Lake Embalse de Buendía, the twin engine airplane crashed in unknown circumstances near Cañaveruelas. All four crew members, three pilots and a mechanic, were killed.
Crew:
Lt Fernando Esteban Baturone,
Lt Aurelio Gil Laso,
Alf Eduardo Javier Moreno Jiménez,
Sgt Santiago García García.

Crash of a Canadair CL-215-1A10 near Beniarrés: 2 killed

Date & Time: Oct 12, 1980
Type of aircraft:
Operator:
Registration:
UD.13-13
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
1053
YOM:
1977
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was engaged in a fire fighting mission over the Sierra d'Aitana. After its load of water was scooped, the airplane struck trees and crashed onto a hill located in Beniarrés. Both crew members were killed.

Crash of a Beechcraft C90 King Air in Salamanca

Date & Time: Oct 1, 1980
Type of aircraft:
Operator:
Registration:
EC-CHB
Flight Type:
Survivors:
Yes
MSN:
LJ-623
YOM:
1974
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances at Salamanca-Matacán AFB while completing a local training mission. There were no casualties.

Crash of a Learjet 35A in Palma de Mallorca: 4 killed

Date & Time: Aug 13, 1980 at 2156 LT
Type of aircraft:
Operator:
Registration:
EC-DFA
Survivors:
No
Schedule:
Madrid - Palma de Mallorca
MSN:
35-196
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
While on a visual approach to runway 24, the crew failed to realize his altitude was too low when the airplane struck the slope of a mountain located 8 km short of runway. The aircraft was destroyed by impact forces and all four occupants were killed.

Crash of a Lockheed C-130H Hercules near Las Palmas: 10 killed

Date & Time: May 28, 1980 at 1025 LT
Type of aircraft:
Operator:
Registration:
T.10-1
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Madrid – Tenerife – Las Palmas
MSN:
4520
YOM:
1973
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The crew was completing a flight from Tenerife to Las Palmas where 70 soldiers should embark. The descent to Gando Airport was initiated from the west in marginal weather conditions. In limited visibility due to clouds, the four engine airplane struck the slope of Mt Hoya del Gamonal located about 17 km northwest of the airport. The aircraft was destroyed and all 10 occupants were killed. For unknown reasons, the crew initiated the approach from the west over the island instead of flying along the northern coast of the island.
Probable cause:
Controlled flight into terrain.

Crash of a Boeing 727-64 in Tenerife: 146 killed

Date & Time: Apr 25, 1980 at 1321 LT
Type of aircraft:
Operator:
Registration:
G-BDAN
Survivors:
No
Site:
Schedule:
Manchester - Tenerife
MSN:
19279
YOM:
1966
Flight number:
DA1008
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
146
Captain / Total flying hours:
15299
Captain / Total hours on type:
1912.00
Copilot / Total flying hours:
3492
Copilot / Total hours on type:
618
Aircraft flight hours:
30622
Circumstances:
Dan-Air flight 1008 took off from Manchester Airport (MAN) at 09:22 UTC en route for Tenerife-Norte Los Rodeos Airport (TFN). After an uneventful flight, the crew contacted Tenerife North Airport Approach Control at 13:14, informing them that they were at FL110 and at 14 nautical miles from the TFN VOR/DME. Approach Control replied, "Dan Air one zero zero eight, cleared to the Foxtrot Papa beacon via Tango Foxtrot November, flight level one one zero expect runway one two, no delay." The Dan Air crew repeated the clearance and requested meteorological information, which was given as: "OK runway in use one two, the wind one two zero zero five, visibility six from seven kilometres clouds, two oktas at one two zero metres, plus four oktas at two five zero metres, plus two oktas at three five zero metres, November Hotel one zero three, temperature one six, dew point one, and drizzle." Approximately one minute later Approach Control told the aircraft to descend and maintain FL60. Receipt of this message was acknowledged by the aircraft, whereupon the controller immediately requested it to indicate its distance from the TFN beacon. The crew replied that it was at 7 NM from TFN. At 13:18:48 UTC the aircraft notified Approach Control that it had just passed TFN and that it was heading for the 'FP' beacon. The controller then informed them of an unpublished hold over Foxtrot Papa: "Roger, the standard holding over Foxtrot Papa is inbound heading one five zero, turn to the left, call you back shortly." Dan Air 1008 only replied "Roger" without repeating the information received, which was not compulsory under the ICAO regulations in force at the time of the accident. Almost one minute later, the aircraft the crew reported: "Dan Air one zero eight, Foxtrot Papa level at six zero, taking up the hold" and Tenerife APP replied: "Roger". Instead of passing overhead FP, the flight had passed this navaid at 1.59 NM to the South. Instead of entering the 255 radial, the Boeing 727 continued its trajectory in the direction of 263 degrees for a duration of more than 20 seconds, entering an area with a minimum safety altitude (MSA) of 14500 ft. The co-pilot at that point said: "Bloody strange hold, isn't it?" The captain remarked "Yes, doesn't isn't parallel with the runway or anything." The flight engineer then also made some remarks about the holding procedure. Approach control then cleared them down to 5000 feet. The captain then remarked: "Hey did he say it was one five zero inbound?". It appears that at this moment the information received on the holding flashed back to the Captain's mind, making him realize that his manoeuvre was taking him to magnetic course 150 degrees outbound from 'FP', whereas the information received was "inbound" on the holding, heading 150 degrees towards 'FP'. The copilot responded: "Inbound yeh". "I don't like that", the captain said. The GPWS alarm sounded. The captain interrupted his left hand turn and entered a right hand turn and ordered an overshoot. They overflew a valley, temporarily deactivating the GPWS warning. The copilot suggested: "I suggest a heading of one two two actually and er take us through the overshoot, ah." But the captain continued with the turn to the right, because he was convinced that the turn he had been making to the left was taking him to the mountains. The captain contacted Approach Control at 13:21: "Er ... Dan Air one zero zero eight, we've had a ground proximity Warning." About two seconds later the aircraft flew into the side of a mountain at an altitude of approximately 5450 ft (1662 m) and at 11.5 km off course.
Probable cause:
The captain, without taking into account the altitude at which he was flying, took the aircraft into an area of very high ground, and for this reason he did not maintain the correct safety distance above the ground, as was his obligation. Contributing factors were:
a) the performance of a manoeuvre without having clearly defined it;
b) imprecise navigation on the part of the captain, showing his loss of bearings;
c) lack of teamwork between captain and co-pilot;
d) the short space of time between the information given and the arrival at 'FP';
e) the fact that the holding was not published" (Spanish report)
UK authorities agreed in general with the report, but added some comments to give the report 'a proper balance':
1. the information concerning the holding pattern at FP, which was transmitted by ATC, was ambiguous and contributed directly to the disorientation of the crew;
2. no minimum safe altitude computed for holding pattern;
3. track for holding pattern at 'FP' is unrealistic.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Bilbao

Date & Time: Aug 26, 1978
Registration:
G-BAEI
Survivors:
Yes
MSN:
421B-0259
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach, the twin engine airplane went out of control and crashed on the Getxo golf course located approximately six km short of runway 12 threshold. The aircraft was destroyed and all four occupants were injured.