Aeromexico B762 at Madrid on Apr 16th 2013, tail strike on takeoff

Last Update: August 12, 2015 / 13:42:34 GMT/Zulu time

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Incident Facts

Date of incident
Apr 16, 2013

Classification
Accident

Airline
Aeromexico

Flight number
AM-2

Departure
Madrid, Spain

Aircraft Registration
XA-TOJ

Aircraft Type
Boeing 767-200

ICAO Type Designator
B762

An Aeromexico Boeing 767-200, registration XA-TOJ performing flight AM-2 from Madrid,SP (Spain) to Mexico City (Mexico) with 153 passengers and 9 crew, was rotating for takeoff from Madrid's runway 36L when the tail of the aircraft contacted the runway surface leaving debris behind. The crew continued the takeoff and climb, levelled off and descended after the oxygen masks were released, then entered a hold to burn off fuel and returned to Madrid for a safe landing about 90 minutes after departure. Two cabin crew received injuries, the aircraft sustained substantial damage.

An Air Europa Airbus A330 departing after the Aeromexico received nose gear tyre damage while departing over the debris left by the Boeing and needed to return, too, see Incident: Air Europa A332 at Madrid on Apr 16th 2013, damaged nose gear tyres on takeoff.

The airport reported two cabin crew received neck injuries (mainly bruises) from their seat belts as result of impact forces.

The airline confirmed the aircraft suffered a tailstrike on takeoff and returned to Madrid for a safe landing. The safety of passengers was not at risk at any time. The airline is cooperating with the investigation authorities.

Spain's CIAIAC is investigating the accident and resulting tyre damage incident.

An observer on the ground reported that the aircraft was rotating for takeoff about abeam of the fire station about 1900-2000 meters down the runway (runway length 4350 meters), the nose gear and main gear lifted off the runway but the aircraft did not climb, instead the tail contacted the runway for about 4 seconds before the aircraft started slowly to climb. The observer believed to have seen some smoke from the tail while it contacted the runway. Following the event the observer could not see any runway inspection.

A passenger reported the takeoff appeared normal initially until the aircraft began to rotate, the nose lifted up, however, nothing happened. The nose dropped again, then rose very sharply perhaps because of the runway end becoming visible. A sound of impact was heard from the back of the cabin followed by scratching sounds, that lasted for about 5 seconds, then the aircraft began to climb. During the initial climb the aircraft was shaking, the right wing dropped which the passenger, frequent traveller, perceived as unusual. The aircraft continued to climb heading north out of the Madrid area, no announcements were made. Passengers in the back of the cabin reacted confused and increasingly alarmed with no announcement made by the crew. Several minutes into the flight the passenger oxygen masks dropped (see photo below) together with the announcement "put on your mask and breath normally", the aircraft obviously stopped the climb and rapidly descended, a short time later an announcement "10,000 feet" was heard, cabin crew announced passengers could not remove their masks, the cockpit announced now they were returning to Madrid but provided no reason. The aircraft landed back in Madrid and taxied straight to the gate, the passengers disembarked normally. The passenger was able to see terrible damage to the tail of the aircraft, the right hand main gear tyres had deflated. The passenger had not seen any damage inside the aircraft. They were offered accomodation over night and were rebooked onto other flights via other European cities connecting to Mexico City the following day.

Air Traffic Control reported the aircraft climbed out without any comment, later into the departure climb the crew indicated they had cabin pressure problems and needed to return to Madrid. There was no mention of the possibility of a tail strike and no mention of injuries on board. The tower controller had not been able to see the tail contact the runway surface about 4km from his position, between the Aeromexico and Air Europa there were a few other departures without any problems.

On May 3rd 2013 Spain's CIAIAC reported the three flight attendants seated in the rear galley heard strange noises during takeoff. When they proceeded to inform the flight deck about the noises the flight crew already prepared to return to Madrid due to the cabin pressure problems at 14,000 feet. Then the passenger oxygen masks were released. The crew informed ATC about cabin pressure problems 22 minutes after departure. Two of the three cabin crew in the aft galley complained about neck pain. The aircraft received substantial damage to the lower fuselage including the near complete loss of both APU compartment doors. The Air Europa A332 departed 29 minutes after departure of XA-TOJ as 7th aircraft following XA-TOJ. The runway inspection following that departure recovered two metallic pieces of debris from the runway.

On Aug 12th 2015 the CIAIAC released their final report in Spanish concluding the probable causes of the accident were:

The accident occurred because the aircraft rotated at a much lower speed than necessary. Vr had been computed incorrectly during flight preparation based on the zero fuel weight rather than the takeoff weight. The error was not detected by the crew when the data were inserted into the flight management system.

Contributing factors were:

- recent introduction of a performance computation system (OPT) in the company
- experience of both dispatcher and crew was insufficient in this area
- Madrid did not have an OPT system installed yet, hence the data were transmitted in a way, that had not been defined.

The CIAIAC reported that the aircraft was preparing for departure when the OPT data were transmitted about 5 minutes prior to departure, however not in the way foreseen but in the way of an e-mail rather than the standardised output of the OPT program, that had been introduced in the company about 6 months prior to the accident. The OPT data would provide all data necessary to be input into the FMS directly. When the e-mail was compiled the main portions of the program output were copied into the text of the e-mail together with the results of the computations. The e-mail was cross checked the supplement first officer (49, ATPL, 13,428 hours total, 278 hours on type), the crew, captain (54, ATPL, 20,066 hours total, 149 hours on type) and first officer (41, ATPL, 11,696 hours total, 147 hours on type), subsequently entered the following data into the FMS:

V1: 118 KIAS
Vr: 118 KIAS
V2: 126 KIAS

The aircraft taxied to the departure runway, received takeoff clearance and following the routine call outs 80, V1, rotate the captain, pilot flying, rotated the aircraft, the aircraft however did not become airborne. The commander relaxed pressure on the controls to permit the aircraft accelerate some more, then the aircraft became airborne and climbed out. Surprised by the events the crew checked takeoff configuration but could not find anything out of the ordinary.

When the aircraft climbed through 10,000 feet, which marks the end of sterile cockpit requirement, a flight attendant located in the rear of the cabin contacted the cockpit and reported unusual noises and a bump during takeoff. A few moments later the cabin altitude alert activated and the passenger oxygen masks were automatically released. The crew donned their oxygen masks, descended the aircraft to 11,000 feet and removed the oxygen masks. The company approved landing above maximum landing weight, without dumping fuel, and the aircraft landed without further incident on runway 18L. While taxiing towards the apron tower informed the crew that debris off the aircraft was found on the runway. After the aircraft arrived on stand, tyres deflated due to the brakes temperatures triggering the tyre fuses.

There were no injuries.

The CIAIAC analysed that the correct speeds would have been:

V1: 152 KIAS (instead of 118 KIAS)
Vr: 156 KIAS (instead of 118 KIAS)
V2: 161 KIAS (instead of 126 KIAS)

The CIAIAC analysed that OPT data had been computed on the base of the zero fuel weight, however, when the e-mail was compiled, the correct takeoff weight data were inserted and transmitted together with the zero fuel weight performance data making it impossible to the crew to detect the mismatch of data, as the performance data appeared to have been computed for the takeoff weight.

As result of the accident the company prohibited transmission of data in any other way but direct output of the OPT program until all stations received the OPT equipment directly.

The CIAIAC analysed that upon reaching 118 KIAS, the computed Vr, the rotation began and within 5 seconds reached 8.8 degrees nose up, at that point the indicated airspeed was 134 knots still insufficient to become airborne. A second later the main gear lifted off and reached a maximum height of 4 feet while the pitch increased to 14.1 degrees nose up, the main gear touched down again however causing the tail strike (maximum pitch angle with main gear touched down and oleos not compressed is 13.1 degrees nose up) bringing the pitch down to 13 degrees. The controls were slightly relaxed, the aircraft accelerated to 141 KIAS then the pitch angle was increased again reaching 15 degrees nose up at 142 KIAS, stick shaker activated for two seconds and a second time for two more seconds. The aircraft reached 19 degrees nose up pitch accelerating through 148-150 KIAS at 47 feet AGL, then the backpressure on the controls was relieved some, the aircraft accelerated into normal speed range.

The CIAIAC analysed that the crew attempted rotation 32 knots below necessary rotation speed and did not disengage autothrust although required by procedures and did not release the back pressure and lower the nose as necessary to correct. Instead engine power was increased against FCOM recommendation (to prevent further increase of the pitch angle). Considering all the data available, the CIAIAC continued, it can be concluded that the crew failed to recognize the low speed situation and instead increased the pitch to 19 degrees where a maximum of 13.1 degrees was permitted before a tail strike would occur.

The CIAIAC analysed that the presence of a tail bumper would not have prevented the damage, but would at least have alerted the crew to the tail strike occurrence. Cabin crew were adament to not violate the company procedures of sterile cockpit up to 10,000 feet, permitting exceptions only for observations that would prevent the safe conduct of the flight. Neither cabin crew thought their observation was indicative of a problem preventing the safe conduct of flight. The general manager of the airline made clear that the possibility of intercom always existed to communicate abnormal situations in the passenger cabin, that could cause an emergency situation.

While the master caution activated and 3 seconds later the cabin altitude alert activated, the crew initially levelled off at FL170 to work the checklists but continued the climb to FL190, then advised ATC that they could not maintain this level due to cabin pressure problems and began to descend again, in about that time the passenger oxygen masks deployed. The crew realized the oxygen masks had been released by the illumination of the related cockpit switch and decided to return to Madrid, however, performing a normal descent rather than an emergency descent.

The CIAIAC analysed that the crew was not aware of the tail strike and did not detect the possibility of a tail strike, hence air traffic control was never informed about the possibility of debris on the departure runway. The tower controller had observed the aircraft climbing out and did not notice anything out of the ordinary, hence the presence of debris on the runway was not anticipated until another aircraft hit the debris during their departure roll.

Metars:
LEMD 161500Z 18004G15KT CAVOK 25/07 Q1021 NOSIG
LEMD 161430Z 19004G18KT 130V260 CAVOK 25/08 Q1021 NOSIG
LEMD 161400Z 23004KT 120V280 CAVOK 25/08 Q1021 NOSIG
LEMD 161330Z 19006KT 130V290 CAVOK 25/12 Q1022 NOSIG
LEMD 161300Z 21006G18KT CAVOK 24/10 Q1022 NOSIG
LEMD 161230Z 21006G17KT 160V280 CAVOK 24/10 Q1022 NOSIG
LEMD 161200Z 17005KT CAVOK 23/12 Q1022 NOSIG
LEMD 161130Z 18002KT CAVOK 23/09 Q1023 NOSIG
LEMD 161100Z 22002KT CAVOK 22/11 Q1023 NOSIG
LEMD 161030Z 21001KT CAVOK 21/11 Q1023 NOSIG
LEMD 161000Z 19003KT 140V250 CAVOK 19/11 Q1023 NOSIG
Incident Facts

Date of incident
Apr 16, 2013

Classification
Accident

Airline
Aeromexico

Flight number
AM-2

Departure
Madrid, Spain

Aircraft Registration
XA-TOJ

Aircraft Type
Boeing 767-200

ICAO Type Designator
B762

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