Various A332, A320, B738, CRJX at Madrid on May 27th 2018, wind shear and go arounds cause losses of separations involving a total of 8 aircraft

Last Update: February 22, 2021 / 23:58:11 GMT/Zulu time

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Incident Facts

Date of incident
May 27, 2018

Classification
Report

Aircraft Registration
CS-TNQ

Aircraft Type
Airbus A330-200

ICAO Type Designator
A332

Madrid Airport had been operating in a North Configuration (landings on runways 32L and 32R, departures on runways 36L and 36R) when between 20:47L (18:47Z) and 20:54L seven arriving aircraft went around due to changing weather conditions causing windshear (loss of speed). At 20:54L the airport therefore decided to change the configuration to the southern configuration (landings on runways 18L and 18R, departures on runways 14L and 14R). This lead to a complex traffic scenario leading to a number of losses of separations involving 8 aircraft.

On Feb 23rd 2021 Spain's CIAIAC also released their English translation of the final report (Editorial note: the following is still based on the initial release of Feb 6th 2020 and is unmodified).

On Feb 6th 2020 Spain's CIAIAC released their final report in Spanish only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a Spanish only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).

The report concludes the probable causes of the incidents occuring in the Madrid Control Zone were:

The separation losses were caused by a complex operational situation in the Madrid control zone.

Contributing factors were:

- unavailability of weather information tools covering the entire control zone of Madrid
- sudden change in weather conditions, in particular intensity and direction of wind
- the time needed to make the decision to switch runway configuration.

The CIAIAC reported in the aftermath of the go arounds and switch of airport configuration the first loss of separation occurred around 21:36:59L (19:36:59Z) when the separation between two aircraft reduced to 200 feet vertical and 0.8nm horizontal:

A TAP Air Portugal Airbus A320-200, registration CS-TNQ performing flight TP-1018 from Lisbon (Portugal) to Madrid,SP (Spain) with 166 passengers and 6 crew, was on final approach to runway 18R descending through 4100 feet at about 160 knots over ground.

An Air Nostrum Canadair CRJ-1000 on behalf of Iberia, registration EC-LJS performing flight IB-8399 from Alicante,SP to Madrid,SP (Spain) with 80 passengers and 4 crew, was on final approach to runway 18L descending through 3900 feet at about 170 knots over ground.

A minute after that closest point of approximation, just before touchdown, the separation between the two aircraft was 300 feet vertical and 0.8nm horizontal.

The second loss of separation occurred around 21:52L (19:52Z) when the separation between two aircraft reduced to 325 feet vertical and 1.2nm horizontal.

A Ryanair Boeing 737-800, registration EI-FZR performing flight FR-2083 from Birmingham,EN (UK) to Madrid,SP (Spain) with 170 passengers, was on final approach to runway 18R descending through 3400 feet at about 170 knots over ground and continued to just before touch down.

An Air Nostrum Canadair CRJ-1000 on behalf of Iberia, registration EC-LJR performing IB-8825 from Turin (Italy) to Madris,SP (Spain) with 93 passengers and 4 crew, was on final approach to runway 18L descending through 2900 feet at 140 knots over ground and continuing to just before touch down, when the closed point of approximation between the two aircraft occurred at 325 feet vertical and 1.2nm horizontal.

The third loss of separation occurred around 21:58L (19:58Z) when the separation between the aircraft reduced to 0 feet vertical and 0.9nm horizontal.

An Iberia Airbus A320-200, registration EC-LYM performing flight IB-3635 from Birmingham,EN (UK) to Madrid,SP (Spain) with 169 passengers and 6 crew, was on final approach to runway 18R descending through 2500 feet MSL at 140 knots over ground, the crew had been requested to maintain minimum speed due to preceding traffic.

A Ryanair Boeing 737-800, registration EI-FTY performing flight FR-7156 from Dublin (Ireland) to Madrid,SP (Spain) with 176 passengers, was on final approach to runway 18L descending through 2500 feet at 150 knots over ground having caught up with the preceding Iberia A320.

The fourth loss of separation occurred at 22:03L (20:03Z) when the separation between the two aircraft reduced to 400 feet vertical and 1.0nm horizontal.

An Air Europa Boeing 737-800, registration EC-LXV performing flight UX-9076 from Arrecife,CI to Madrid,SP (Spain) with 136 passengers and 6 crew, was on final approach to runway 18R descending through 3300 feet at about 140 knots over ground.

An Air Europa Airbus A330-200, registration EC-LVL performing flight UX-1062 from Milan Malpensa (Italy) to Madrid,SP (Spain) with 208 passengers and 10 crew, was on final approach to runway 18L descending through 2900 feet at 120 knots over ground.

The CIAIAC analysed that although METAR and SPECI reports were available for the aerodrome, the exact times of the wind changes could not be determined as a SPECI is not being issued for a sudden wind change. Based on METAR at 19:00Z and the fact that the first go around occurred at 18:45Z, the wind change must have occurred before 18:45Z. The supervisors of Madrid Aerea Control and Madrid Aerodrome consulted with each other mentioning the presence of a storm and decided to wait for 5 minutes in case the winds would change again. Madrid tower consulted with the weather forecaster who explained these were convective currents with variable directions which would last for about one hour. At 18:54Z the decision was made to switch the aerodrome configuration.

The supervisors of Madrid Control Zone believe that tower delayed the decision to switch the aerodrome configuration. However, the weather data on the monitor available to the control tower did not allow to make that decision. Therefore the CIAIAC recommends to improve the coordination of ATC services and weather forecasters as well as the weather observers at the aerodrome.

The switch of configuration occurred in a critical situation. The switch takes about 10 minutes until operations have been re-established in a standard way. Sector assignment and some technical problems further complicated the switch. Therefore CIAIAC recommends that the decision making to switch the runway configuration should also involve the supervisor of Madrid's TMA.

The CIAIAC analysed that following the switch the ATC sector controllers at Madrid TMA had to physically swap their places in order to continue working the approach and departure sectors. The CIAIAC recommends that the controllers should simply switch from approach to departure and vice versa keeping their places.

The CIAIAC analysed that it was not recorded when the pre-alert of the storm affecting the aerodrome was triggered. With the SPECI issued at 18:19Z the airport had to react however and reduced the capacity from 52 to 42 aircraft within the next 2 hours. It follows that ATC had to enter alert status with the issuance of the SPECI. The airport reduced its capacity further to 38, then 20 and finally 0 aircraft for an hour. This placed additional burdens onto the controllers who, besides ensurig maintaining proper separation of the aircraft, needed to transmit available information to the aircraft such as causes for delay, estimated delays and weather information at diversion fields. The standard operation procedures by the ATC operator were generic and did not consider the operational and geographical context of Madrid aerodrome.

The CIAIAC analysed that the range of METAR and TAF data was 8 kilometers. Data outside that range were not collected and were not available to the ATC supervisors. ATIS was prepared automatically based on METARs and TAFs. However, ATC can manually modify ATIS messages. During the event ATIS was changed manually to include the information about moderate windshear, later severe windshear. The switch of runway configuration was relayed on ATIS only 5 minutes after it happened. The CIAIAC recommends as result that due to the current weather products available to the aerodrome do not include observations like lightning, storm etc. outside the 8km range to complement those with products covering beyond the 8km range.

The CIAIAC analysed that in 3 of the 4 losses of separation the aircraft interecepted the localizers with less than 2nm horizontal separation. These separations were further reduced by the inability of the aircraft to comply with the speed restrictions imposed by AIP or ATC instructions. Nonetheless, the CIAIAC analyses that the ATC actions were the "most appropriate tactial actions" in order to mitigate the critical situation. Each crew of the aircraft involved in the losses of separations was advised by ATC that the other conflicting aircraft was intercepting the localizer of the parallel runway.

Six safety recommendations were issued to the ATC provider, two to the weather service provider.

Similiar situations had occurred in Spain before, see News: Thunderstorms in Madrid on Jul 26th 2012, landings, diversions, fuel emergencies and Ryanair and News: Fog in Barcelona on Dec 23rd 2012 overwhelmes ATC: "Let the aircraft land and put them on taxiways, carpark, roof ... but on the ground!".

Metars:
METAR LEMD 272130Z 06004KT 020V110 9999 FEW045 BKN070 16/13 Q1015 NOSIG=
METAR LEMD 272100Z 12009KT 9999 FEW045 BKN070 17/12 Q1015 NOSIG=
METAR LEMD 272030Z 12009KT 080V150 9999 FEW047CB BKN070 17/12 Q1014 NOSIG=
METAR LEMD 272000Z 13012KT 9999 FEW047CB BKN070 18/13 Q1014 NOSIG=
METAR LEMD 271930Z 13012KT 9999 FEW047CB BKN070 18/13 Q1013 NOSIG=
METAR LEMD 271900Z 12007G17KT 9999 VCTS FEW050CB BKN070 20/12 Q1013 BECMG NSW=
METAR LEMD 271830Z 30011KT 270V330 9999 VCTS FEW050CB BKN070 22/10 Q1012 TEMPO TS=
SPECI LEMD 271819Z 29011KT 270V330 9999 VCTS FEW060CB BKN070 22/10 Q1012 TEMPO TS=
SPECI LEMD 271815Z 29011KT 9999 FEW060CB SCT075 22/10 Q1012 NOSIG=
METAR LEMD 271800Z 27011KT 9999 FEW060 SCT075 23/09 Q1012 NOSIG=
METAR LEMD 271730Z 27013KT 9999 FEW060 SCT077 23/10 Q1012 NOSIG=
METAR LEMD 271700Z 28009G20KT 240V330 9999 FEW060 SCT077 25/10 Q1011 NOSIG=
Incident Facts

Date of incident
May 27, 2018

Classification
Report

Aircraft Registration
CS-TNQ

Aircraft Type
Airbus A330-200

ICAO Type Designator
A332

This article is published under license from Avherald.com. © of text by Avherald.com.
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