Spanair Flight JK5022: Lessons on Accident Causal Chain

Spanair Flight 5022

Location: Barajas Airport, Madrid, Spain
Date: 20 August 2008
Aircraft Type: Boeing MD-82
POB: 162
Crew: 10
Fatalities: 154
Survivors: 18


Spanair Flight JK 5022 , which started its journey in Barcelona, was on its way from Madrid to Gran Canaria when it crashed just after take off from Barajas Airport. The aircraft, christened "Sunbreeze", registration EC-HFP, broke into at least two parts which were engulfed by subsequent explosion. It was the first fatal accident for Spanair (part of the SAS Group) in the 20-year history of the company, and Spain's deadliest aviation accident in 25 years. [1]

According to the airline, the flight was already more than one hour late, due to a technical issue with the plane (a sensor reporting excessive temperature in an air intake, and the temperature sensor was de-activated on the ground) that forced the first takeoff attempt to be aborted as there were failure signals while taxiing away from the terminal. The aircraft was inspected and then tried to take-off for the second time, which ended in the catastrophe.

Aviation Crash Videos

Part 1 of 3

(Video embedded from YouTube on 19 August 2009)

Part 2 of 3

(Video embedded from YouTube on 20 August 2009)

Part 3 of 3

(Video embedded from YouTube on 20 August 2009)


Spain's Civil Aviation Accidents Commission concluded in its report that systems failure and pilots' error combined to cause the crash of the Spanair Boeing MD82. The aircraft's flaps and slats were not extended as the aircraft was preparing for takeoff, but this was not noticed during the pilots' routine pre-departure check and the automatic on-board system designed to warn the cockpit crew of such a situation did not alert the error.

"The aircraft had the standard procedures and check lists in force… which included the selection and confirmation of the correct configuration for takeoff," the report said. "The pilots used these procedures as a reference, but for some reason — whether an interruption from the aircraft's first return to the terminal due to a mechanical problem, pressure due to time delays or faults in the cabin crew's work methods —, these were not strictly followed," it added. [2]

Lessons from the Accident

This unfortunate accident exemplifies Reason's Swiss Cheese Model in which the causal sequence of human failures that leads to the mishap or error includes:

  • active failures as shown in the cockpit video recorder (CVR) when the pilots went through the final checks before taking off but omitted to check lights and flaps after starting the engines;
  • latent failures where the early warning system (TOWS) which should have detected the incorrectly positioned wing flaps, failed to alert the crew to the problem
  • contributory factors for unsafe acts - although the pilots followed procedures, the fact that the initial take-off was interrupted and the plane had to return to the hangar, upset the chain of safety procedures, which, combined with pressure to take off quickly and make up for lost time led to the crew overlooking important safety issues.[3]

In the aftermath of the accident, both Spanair and the aircraft manufacturer, McDonnell Douglas (Boeing), have revised their safety procedures and now require the TOWS system to be checked before every single flight.

The Commission for the Investigation of Civil Aviation Accidents and Incidents (CIAIAC) recommended an annual international aviation conference to revise check lists, crew training and improvements in work methods to ensure that crews correctly configure their aircraft before takeoff and landing.

Tragically, the circumstances of the Spanair Flight 5022 crash was similar to the 1987 crash of Northwest Flight 255 in Detroit, coincidentally 154 people also died in the accident due to incorrect flap settings and involved the same type of aircraft.

It was determine by the National Transportation Safety Board "that the probable cause of the accident was the flightcrew's failure to use the taxi checklist to ensure the flaps and slats were extended for takeoff. Contributing to the accident was the absence of electrical power to the airplane takeoff warning system which thus did not warn the flightcrew that the airplane was not configured properly for takeoff. The reason for the absence of electrical power could not be determined." [4]

Want to know more?

Northwest Airlines Flight 255
This page shows Northwest Flight 255 failures leading to the accidents similar to Spanair Flight 5022.
Swiss Cheese model
An overview of Reason's accident causation model.

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