PRCTICA 3 - INVESTIGACIN DE

ACCIDENTES

GP444 accident in Reus

Accident on 15 December 2016

at Montroig, 17 km from Reus Airport (LERS). Catalonia, Spain.
to the Boeing 737-800
registered EC-DAV
operated by Ganxet Airlines

David Asensio Ortiz de Pinedo

Savina Pal Santaulria
Josep Maria Roca Genovs
Abel Sardaa Sambola
15th of December, 2016 Eduard Padrell Casals
Investigacin de Accidentes, Prctica 3 15/12/16

INDEX
1. Introduction
2. Synopsis
3. Factual Information
3.1. History of flight
3.2. Injuries to persons
3.3. Damage to aircraft
3.4. Other damage
3.5. Personnel information
3.5.1. Pilot. Pilot Monitoring.
3.5.2. Co-pilot. Pilot Flying.
3.6. Aircraft Information
3.7. Meteorological Information
3.8. Aids to Navigation
3.9. Communications
3.10. Aerodrome Information
3.11. Flight Recorders
3.12. Wreckage and Impact Information
3.13. Medical and Pathological information
3.14. Fire
3.15. Survival Aspects
3.16. Organizational and management information
4. Analysis
4.1. Loadsheet Information
4.2. Weather Information
4.3. Bird Strike
4.4. Staff Information
5. Conclusions
6. Safety Recommendations
7. Bibliography

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1.INTRODUCTION

We will proceed to make the final report of an accident created by us providing the
necessary clues so that the colleagues who are listening can ask appropriate
questions to find out what has happened. For that, each of us will have a role in the
accident, this is how we have assigned them:

- 2 survivors: JM Roca and David Asensio

- Director of the airline: Eduard Padrell
- Maintenance Manager: David Asensio
- 3 witnesses: Savina Pal, JM Roca, Abel Sardaa
- Air Traffic Controller: David Asensio
- Flight Dispatcher: Savina Pal
- Investigator in charge: JM Roca
- Reporter: JM Roca, David Asensio, Abel Sardaa, Eduard Padrell

During the presentation we will consider as if our colleagues should discover what
has happened, the reasons why the accident has occurred, and then proceed to
explain analysis and conclusions. Thus, our companions will know if they were right
or not.

At the same time, we will draft the final accident report here below.

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2. SYNOPSIS

AIRCRAFT Boeing 737-800

REGISTRATION EC-DAV

DATE AND TIME 15 December 2016; 12:05 UTC

OPERATOR Ganxet Airlines

PLACE Montroig, 17 km from Reus Airport

(LERS). Catalonia, Spain.

TYPE OF FLIGHT Commercial Air Transport - Charter

PERSONS ON BOARD Captain (PM), co-pilot (PF), 4 cabin

crew, 90 pax.

CONSEQUENCES AND DAMAGE Aeroplane heavily damaged;

56 passengers fatally injured; 5 serious
injured; and minor injures to 28
passengers and 1 cabin crew.

In 15 December 2016, a 737 departed from Reus Airport. 15 minutes later, it crashed
near Montroig. Most of the crew and passengers were fatally injured, and only few
survived.
The airplane took-off with incorrect trim tab as a result of an error in the loadsheet
made by the flight dispatcher.
The crew departed with tailwind and flex takeoff power. Shortly after takeoff they
crossed with a flock of birds. Crew did not give importance to any of these elements.
The aircraft continued with the departure, but realising that they could not clear the
mountains, the captain diverted the plane to the left.
The turn nearly induced a stall, that was counteracted by the captain.
Nevertheless, the plane impacted with the terrain.

The investigation concluded:

-The dispatcher was under pressure and did not check the loadsheet to save
time.
-The captain was focusing his attention on the novel first officer and did not
fulfill his responsibilities. He did not check the loadsheet and allowed a
dangerous takeoff.
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-Crew did not give enough importance to the effects of a possible bird strike.
-The jammed elevator prevented the plane from flying safely inside the
expected flight envelope.
-The lack of efficiency from the elevator caused the plane to not be able to
recover from the stall.

Some safety recommendations were assessed, like:

- Better training to increase crew decision making capabilities to avoid danger
situations.
- Develop and apply a specific procedure for Reus airport in case of presence
of birds and implement an alert system to notify pilots about the appearance
of birds.
- Always check the important items (like loadsheet) and not apply penalizations
to flight crew if the are late.
- Put another pilot in the cockpit to perform the function of teaching and
monitoring novel pilots.
- In case of bird strike, is better to land and revise the aircraft before continuing
the flight.

Recreation of our accident (the plane in the photo is not a 737). Source: The Baltimore Sun

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3. FACTUAL INFORMATION

3.1 History of flight

Thursday 24 December 2016, the Boeing 737-800 registered EC-DAV operated by

Ganxet Airlines was programmed to undertake charter flight GP444 between Reus
(Spain) and London Stansted (England), with the callsign GPI21B.

6 crew members (2 flight crew and 4 cabin crew) and 90 passengers were on board.
It was the first flight of that day.

The takeoff from Reus took place at 11:50h UTC from runway 25. The co-pilot was
Pilot Flying (PF).

Co-pilot was low experienced and was being teached during the flight by the
commander (Pilot Monitoring - PM).

The runway in use was 07 but the crew decided to take-off on runway 25 despite the
tailwind because they were inside limits according to their calculations.

The plane was carrying the players from Reus Deportiu football team that had to play
at Wembley. The crew were under pressure to arrive in time.

The flight dispatcher made an error when completing the loadsheet.The plane was
loaded in a way that the center of gravity was out of limits and the trim calculation
was incorrect.

The trim tab adjustment set by the flight crew was incorrect.

This was not noticed by the pilots because the commander was busy teaching the
new first officer and did not revise the loadsheet.

The takeoff run was performed in flex mode (higher temperature and less power
available). A higher amount of pitch and deflection from the elevator was required.

There was no apparent problem during the rotation and first sector of climb. When
the plane was arriving to 733ft (500ft AGL) a flock of birds crossed from west to east
in front of the plane.

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Pilots alerted ATC about the presence of birds. Affirming that none of them had
impacted the plane because the engines were operating normally and no impact was
sensed. They decided to continue.

A bird had impacted the horizontal stabilizer, partially blocking the elevator. It could
not be extended to its operative maximum.
The crew was performing an ARBEK2R and they were heading to the mountains of
W point (Falset). The crew noticed that rate of climb was not as the necessary
amount and it started to decrease.

At 12:00h UTC the DONT SINK alert was triggered by GPWS.

The captain took control of the plane and applied maximum power and maximum
pitch up.

The stuck elevator failed to provide the required pitch angle.

The crew saw that they were heading to the mountains and the rate of climb was not
high enough to avoid them.

The captain made an abrupt turn to the left, but it was so strong that it put the plane
in a situation close to the stall. The stick shaker was activated.

The captain lowered the nose to increase airspeed and the plane came out of the
stall. But the elevator had not enough efficiency to recover the nose attitude to climb
again.

The plane impacted with the ground at 12:05h UTC, slid over the belly and it
separated in two parts.

The remains spread over a distance of 5 kilometers near the municipality of

Montroig.

The passengers and the cabin crew that were on the tail survived. The crew and
passengers that were on the front section died almost all of them. Injured
passengers were distributed between both sections.

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3.2 Injuries to persons

Injuries

Fatal Serious Minor/none

Crew members 5 1 0

Passengers 57 4 29

Others - - -

3.3 Damage to aircraft

Aircraft heavily damaged.

3.4 Other damage

Only environmental damage to the forest.

3.5 Personnel information

3.5.1 Captain. Pilot Monitoring

Male, 53 years, Spain.
ATPL from 31 January 1984.
B737-800 type rating revalidated on 19 October 2015.
Class 1 medical valid until 23 December 2017.
12950 flying hours, 3100 on type, 650 as a captain

3.5.2 Co-pilot. Pilot Flying

Male, 23 years, Portugal.
Frozen ATPL from 20 December 2013.
B737-800 type rating revalidated on 16 February 2015.
Class 1 medical valid until 20 March 2017.
480 flying hours, 50 on type.

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3.6 Aircraft information

Manufacturer Boeing

Type 737-800

Serial number 135

Registration EC-DAV

Entry into service 05/02/2009

Airworthiness certificate N1332 of 13/05/2016 issued by EASA

Airworthiness review certificate T512ARC4034/2016 of 23/06/2016

valid until 11/06/2017

Utilisation since last maintenance 6 hours and 3 cycles

(72h check on 10/12/2016)

Utilisation as of 15/12/2016 12,305 hours and 3,954 cycles

3.7 Meteorological information

LERS 151200Z 07006G14KT 120V050 4000 FEW030 15/10 Q1022

The METAR showed tailwind on the runway 25, 6 kt intensity and gusting wind of
14kt. Despite this, they took-off from RWY 25. Maximum tailwind component of
14kts; 737 is limited to 15kts tailwind as a very maximum.

3.8 Aids to navigation

In radar contact through all airspaces.

Transponder: Mode S Enhanced Surveillance
Radio contact with ATC.
VOR, DME, NDB and ILS at Reus airport.

3.9 Communications

The plane was in contact with ATC during all the time.
The pilot reported the presence of birds to ATC.
After this, no further communications was established.

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3.10 Aerodrome information

ICAO/IATA: LERS / REU

AD administration: Aena
Approved traffic: IFR/VFR
Elevation: 71m / 233ft.
Runway 07/25: 8068ft x 148ft (asphalt pavement of category PCN 39/F/B/W/T).
Lighting: Edge, ALS.
Runway 25 precision approach with ILS CAT I available.
Airport: V: 0600-2200 PS 1 HR PPR
I: 0700-2100 PS 1 HR PPR
Fuelling: HR AD. AVGAS 100LL, JET A-1.
Handling: HR AD
Security: HR AD
De-icing: No
ATS: V: 0545-2220, I: 0645-2120
Fire category: 7.
MET office: Reus MET. HR AD. METAR: Half-hourly. TAF: 24 HR. TREND: No.

3.11 Flight recorders

Two flight recorders. Both were damaged:

-FDR: Flight Data Recorder. 25 hours of recording capacity of approx. 600

parameters.
Information extracted from FDR showed that the position of the trim was not
compatible with a safe takeoff and safe flight envelope.
It was recorded the activation of different alerts and the reactions of the crew.

-CVR: Cockpit Voice Recorder. 2 hours capacity in standard quality and 30

minutes in high quality.
The CVR recorded the confusion between the flight crew. The pilots were busy trying
to realise what had happened and did not communicate with ATC. There was an
evidence lacking of situational awareness.

3.12 Wreckage and impact information

Mountainous terrain, next to Vilanova dEscornalbou. Montroig municipality.

Accident coordinates: 410638.6N 05519.1E

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SIte of the impact and flight path. Source: Google Maps

3.13 Medical and pathological information

Both pilots were fit and in healthy conditions to fly. Both had the class 1 medical
certificate.

3.14 Fire

No evidence of fire in flight.

Fire at ground after the accident as a consequence of the inflammation of fuel in the
tanks during the impact.

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3.15 Survival aspects

The airplane was fragmented in two parts. The part nearer to the tail separated from
the rest of the aircraft shortly after the impact.

The frontal part, including the wings, caught fire when the wings fuel tanks fractured
during the impact igniting all the fuel (the plane was fully loaded because it had just
taken-off). This, added to the forces during the crash, killed almost all passengers
that were in the frontal and middle section of the plane.

At 12:20 UTC the firefighters arrived to the crash site. While some firefighters fought
the fire, the police and the rest of firefighters evacuated in ambulances the survivals
to the Hospital Sant Joan de Reus and Hospital Joan XXIII in Tarragona.
The most critical ones had to be evacuated by helicopter.

It took 4 hours to completely extinguish the fire because the priority was to rescue
the survivors.

The fire damaged the aircrafts documentation and some evidences, but fortunately,
it did not affect the black-boxes that were located in the tail.

3.16 Organizational and management information

Ganxet Airlines (GPI) was set up in 2006. The Air Operators Certificate (AOC), valid
on the date of the accident, was issued by AESA on 15 October 2007.

As of the date of the accident, GPI was operating 6 Boeing 737-800 and undertaking
flights from Reus bound for many countries in Europe. Ganxet Airlines employed
about 46 flight crew and 72 cabin crew.

Employment is performed by direct entry after a selection process that consists of an

interview and a flying test in a simulator.

Up to the date of the accident, the company had not registered any significant
incident and all the company and planes documentation was legal, correct and up to
date.

The company has an approved maintenance program that ensured all the planes
were in an airworthiness condition.

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4. ANALYSIS

4.1. Loadsheet Information Loadsheet made by us from Ganxet Airlines

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The loadsheet was made by the flight dispatcher during the 25 minutes walk-around
in Reus Airport, he did not check that the ZFW and the TOW were out of balance
(centre of gravity limit), as it can be seen marked in red. So, the T/O Stab Trim Units
were out of range for the safe in-flight operation for that flight; but the Captain did not
notice that when the flight dispatcher delivered the document. He just reviewed it
quickly and signed it as it was inside takeoff allowance limits.

Then, the flight departed with an incorrect set of trim tab for take-off. That affected
the elevator negatively. There was no alert of incorrect take-off configuration
because despite the trim being incorrect, it was still inside the safe take-off limit.

This failure itself was not enough to produce the accident, but added to the other
factors that have been listened, led to the catastrophic result.

4.2. Take-off

This is the METAR the day and hour the aircraft was performing the departure:

LERS 151200Z 07006G14KT 120V050 4000 FEW030 15/10 Q1022

The crew decided to takeoff from rwy 25, as it was quicker for them to perform the
SID. The active runway was 07. Despite maximum tailwind component for the
737-800 is 15kts, a takeoff with a component of 14kts tailwind is not safe and nearly
a violation.

This was one of the multiple causes of the plane crash that occurred, and the
visibility was not the best to perform a flight unless you are familiarized with the area.

Take-off with tailwind will result in the use of much more runway to get enough lift for
flight (it takes distance to nullify the tailwind before any headwind is obtained for lift).
Climb angle is also reduced. Think about obstacles! A five knot tailwind increase
take-off distance with 25% and a ten knot tailwind with about 55%.

We need to take into account that the takeoff was made with flex mode (higher
temperature and less power available). A higher amount of pitch and deflection from
the elevator was needed, so this two facts (weather and flex mode) were part of the
cause of the accident.

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4.3. Bird Strike

Quickly after the departure, pilots alerted ATC about the presence of birds. Affirming
that none of them had impacted the plane because the engines were operating
normally and no impact was sensed. They decided to continue the flight.

A bird had impacted on the horizontal stabilizer, partially blocking the elevator. It
could not be extended to its operative maximum.

A bird strike is strictly defined as a collision between a bird and an aircraft which is in
flight or on a takeoff or landing roll. The term is often expanded to cover other wildlife
strikes - with bats or ground animals.
We use to associate this kind of occurrences with damage on engines, even though
it can be dangerous for other parts of the aircraft, for example, high lift devices in this
case.
Bird strikes are common and can be a significant threat to aircraft safety. For smaller
aircraft, significant damage may be caused to the aircraft structure and all aircraft,
especially jet-engined ones, are vulnerable to the loss of thrust which can follow the
ingestion of birds into engine air intakes. This has resulted in a number of fatal
accidents.
Bird strikes may occur during any phase of flight but are most likely during the
takeoff, like this case, initial climb, approach and landing phases due to the greater
numbers of birds in flight at lower levels. Since most birds fly mainly during the day,
most bird strikes occur in daylight hours as well.
One of the keys of this accident was the damage on the elevator caused by the
impact with birds and the crew not giving enough importance to this incident.

4.4. Staff Information

-Captain. Pilot Monitoring

Male, 53 years, Spain.
ATPL from 31 January 1984.
B737-800 type rating revalidated on 19 October 2015.
Class 1 medical valid until 23 December 2017.
12950 flying hours, 3100 on type, 650 as a captain

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-Co-pilot. Pilot Flying

Male, 23 years, Portugal.
Frozen ATPL from 20 December 2013.
B737-800 type rating revalidated on 16 February 2015.
Class 1 medical valid until 20 March 2017.
480 flying hours, 50 on type.

As stated earlier, the captain of the aircraft was an experienced pilot, with many
hours. In contrast to the co-pilot, who had low experience. This could mean that the
captain was paying more attention to the execution of the co-pilot than to his own
functions, such as in the case of not checking the loadsheet or looking for the
allowed tailwind limit.

So, even if both were in full physical capacity, had no mental problem or restriction
on the medical certificate; their attention may not was 100% focused.

Damage to the horizontal stabilizer similar to our crashed plane. Source: Pelicanparts

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5. CONCLUSIONS

1. The flight dispatcher was wrong with the distribution of weights, leaving the
aircraft out of bounds and without realizing such an error, delivered the
loadsheet to the flight crew. He was under pressure to deliver the plane on
time.

2. The flight crew had a series of judgments that were decisive:

a. Performing the take-off while being nearly outside wind limits, using the
opposite runway to the operative.
b. The captain was not completely focused on his tasks and checked the
loadsheet incorrectly, without seeing that it was off balance limits, so
he configured the aircraft with an erroneous trim tab setting.

3. A flock of birds was moving towards the aircraft when it was taking off, and
one of these birds hit the horizontal stabilizer of the aircraft, leaving the
elevator damaged. The crew did not give enough importance to this factor, not
taking corrective actions

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6. SAFETY RECOMMENDATIONS

1. If you look at the navigation charts of Reus airport, you can observe that there
is no specific procedure or alert on the appearance of birds. Even so, this is
an airport where there are usually these kinds of incidents. It would be
advisable to establish some corrective security measures reduce birds
affluence to the airport (like an environmental study); to establish procedures
that must be followed by an aircraft after having a bird strike or alert about
birds presence in the vicinity of the airport with NOTAM's as far as possible.

2. The flight dispatcher should have verified that the loadsheet was out of limits,
as it has a table on the same sheet that indicates the possible balance range
for the given weight (TOW and ZFW). If he or she delivered the loadsheet with
that error was because did not make a check, and that is an operative failure
that should be notified to the handling company so that it does not happen
again. This kind of thing never have to be done in a rush. Despite being in a
hurry, is always better to depart late rather than to have an accident.

3. The commander should had been more attentive to his own tasks and if he
had any doubts about if the co-pilot was sufficiently trained to exercise his
function, he should have communicated it to the airline rather than carry more
responsibility and set aside his obligations.
- He should have checked the loadsheet properly and seen that another
track (the operation) was more suitable for take-off that day.
Put another pilot in the cockpit to perform the function of teaching and
monitoring novel pilots.

4. Company should provide a better training to their crew to improve their

decision making. It was not acceptable to takeoff with tailwind and flex takeoff
power. This kind of acts should be forbidden by the operations manual and
company policy.

5. In case of a highly possible bird strike, despite not having sensed an impact,
is always better to land and revise the plane before continuing the flight.

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7. BIBLIOGRAPHY

1. http://weather.uwyo.edu/ weather information / METAR

2. GermanWings 9525 Final Report by BEA (Bureau dEnqutes et dAnalyses

pour la scurit de laviation civile). Structure Guidance

3. AIP Spain LERS information

4. Google Maps Location information and coordinates

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