Ryanair B738 at Alicante and Valencia on May 14th 2010, fuel emergency

Last Update: June 28, 2013 / 14:08:23 GMT/Zulu time

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Incident Facts

Date of incident
May 14, 2010

Classification
Incident

Airline
Ryanair

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

Spain's CIAIAC released their final report concluding the probable causes of the incident were:

The incident was caused by the crew’s inadequate decision-making process in opting to make a second approach, in the choice of alternate airport and in the flight parameters used en route to that airport, which resulted in the fuel amount dropping below the required minimum reserve fuel and in the crew declaring an emergency (MAYDAY).

The company’s fuel savings policy, though it complies with the minimum legal requirements, tends to minimize the amount of fuel with which its airplanes operate and leaves none for contingencies below the legal minimums. This contributed to the amount of fuel used being improperly planned and to the amount of fuel onboard dropping below the required final fuel reserve.

Another contributing factor was the wind information provided by ATC to the crew when preparing the approach to runway 28. This information, though accurate, did not give the crew a clear picture of the changing wind conditions, which would have facilitated their making more suitable decisions.

The CIAIAC reported that after landing the remaining fuel was measured and amounted to 956kg, 183 kg below required final fuel reserve of 1,139kg.

The operational flight plan had computed 8,123kg block fuel were needed, which was rounded up to 8,200kg. The captain decided to not take additional fuel - the CIAIAC explained that the captain can decide to carry an extra of 300kg without any explanation, adding more fuel would require an explanation on the voyage report. The OFP had computed a diversion to Valencia assuming 22 knots headwind, which resulted in a minimum diversion fuel of 2,259kg to land with the final fuel reserve of 1,139kg intact.

At the time of dispatch of the aircraft no significant weather had been anticipated by METARs or TAFs.

The crew consisted of a captain (27, ATPL, 6,835 hours total, 5,426 hours on type) and a first officer (22, CPL, 2,057 hours total, 1,902 hours on type). Following receiving ATIS the crew briefed for an ILS approach to Alicante's runway 10. Weather data reported to the crew indicated a tailwind component on approach to runway 10 above 200 feet AGL but calm winds on the runway. This weather scenario had been confirmed by previous arrivals reporting a speed increase while descending below 200 feet AGL.

The Ryanair Boeing was fully stabilized on their approach (Vapp was computed at 146 KIAS), descending through 180 feet AGL the indicated airspeed began to increase and after 20 seconds reached 162 KIAS, at which point according to pilot testimonies a windshear warning activated prompting the crew to initiate a go around. The aircraft reached a minimum height of 3 feet before climbing again. The CIAIAC reported that the cockpit voice recorder of that time was overwritten already by the remainder of flight, the flight data recorder did not show a GPWS (windshear) warning at that time.

Instead of having the Boeing fly the standard go around maneouver ATC vectored the aircraft to the west to avoid a loss of separation with slow traffic that had departed runway 10 just prior to the arrival of the Boeing. The controller suggested another approach to runway 10, which was accepted by the crew, 3 minutes later the crew requested another wind information for both runways, ATC responded both runways were now showing tailwind, winds at 2 knots. At this time the crew decided to attempt another approach to runway 28, remaining fuel at that time was 2,536kg with the minimum alternate fuel (including final fuel reserve) at 2,259kg. The crew held another approach briefing for a VOR approach to runway 28, then reported ready for the approach while in a hold at Magal.

The controller was busy providing instructions (in Spanish) to another aircraft on approach to runway 10. About a minute later the Ryanair crew again reported ready for the approach. The controller queried how long they could remain in the hold, the crew replied they needed to start the approach immediately or divert. The controller then queried (in Spanish again) with the other traffic whether that traffic could enter a hold, the other crew agreed. The controller finally cleared the Ryanair Boeing for the approach to runway 28, at that point the aircraft had 2,218kg of fuel remaining, 48 kg below diversion fuel plus minimum fuel reserve.

After establishing on the approach radial the aircraft was handed off to tower, tower reported the winds from 090 degrees at 15 knots, the crew queried the wind as approach had reported the wind near calm, ATC confirmed the wind from 090 at 15 knots prompting the crew to immediately go around and to divert to Valencia. At that point 1,932 kg of fuel were remaining, the FMC indicated the aircraft would land in Valencia with 1,300kg remaining.

The crew reported that the aircraft encountered three times the headwind anticipated by the operational flight plan (OFP), the fuel remaining indicated for landing by the FMC decreased to 1,200kg. When the crew became aware that they might land below final fuel they declared PAN. The approach to Valencia's runway 12 was continued, while turning final the fuel on board reduced to below the final fuel reserve remaining prompting the crew to declare Mayday. The aircraft landed safely on Valencia's runway 12.

An immediate measurement of fuel after landing showed 440kg in the left wing tank and 470kg in the right wing tank, total 910kg.

The CIAIC reported European Operation Regulations (EU-OPs) required: "The commander shall declare an emergency when calculated usable fuel on landing, at the nearest adequate aerodrome where a safe landing can be performed, is less than final reserve fuel." which was incorporated into Ryanair's standard operating procedures requiring:

"The commander shall make an urgency call (Pan x3) if he believes he will land with less than final reserve fuel (Ryanair policy).
- The commander shall declare an emergency when the calculated usable fuel on landing is less than final reserve fuel (EU-OPS).
- The commander shall make a mayday call (Mayday x3) when committed to making an approach and there is insufficient fuel to do a go-around."

The CIAIAC annotated: "The EU OPS regulations do not use the terms MAYDAY or PAN, nor is the “urgency” concept fully explained; therefore, emergency declarations are not associated with their use. The ICAO addresses urgency and emergency messages in Annexes 2 (Rules of the Air) and 10 (Aeronautical Telecommunications), an extract from which is shown in Appendix F. Annex 6 (Operations of Aircraft) does not explicitly cover these terms. It is this Annex that is transposed in the EU OPS, but only in connection to fuel in EU OPS 1.375."

The CIAIAC analysed that the aircraft had arrived at Alicante with 12 minutes maneouvering fuel until the minimum diversion fuel was reached, hence there was sufficient fuel to attempt a second approach. However, between first and second approach 22 minutes elapsed which brought the aircraft to below minimum diversion fuel remaining.

The CIAIAC analysed: "When the aircraft reported to Alicante approach that it was ready for the approach, the controller was busy giving instructions to other traffic. The fuel remaining on the aircraft at that time was the minimum diversion fuel to the alternate (Valencia). When the aircraft was cleared and started, one minute later, the VOR approach maneuver to 28 from MAGAL, its fuel remaining was 2,218 kg, or 41 kg below minimum diversion to Valencia. This decision to make a second approach with fuel just below the minimum diversion is within the scope of regulation EU OPS 1.375 on in-flight fuel management (see Appendix A) considering prevailing conditions for making a safe landing with at least final reserve fuel. In conclusion, the captain’s decision to attempt a new approach in Alicante was based on the fuel remaining and on the wind information that he was given. Had he had a more accurate picture of the weather situation, he probably would have made a different decision, such as proceeding to the alternate without attempting a new approach."

The CIAIAC analysed that the weater data (METARs) at Alicante did not reflect the unusual weather conditions present from about 4 hours before until one hour after the approaches by the Boeing 737. The tower log showed a number of aircraft reporting windshear on departure and arrival with 5 arriving aircraft going around due to windshear. ATIS at that time also made reference only to variable winds from 080 to 160 degrees. No warning of windshear was included.

The CIAIAC stated: "The wind information that Alicante approach reported to RYR 9ZC as it was preparing for the approach to runway 28, though exact and correct in reporting a tailwind component at the threshold of said runway, did not give the crew a clear idea of how strange and unpredictable the wind conditions were. ... In contrast, the other crew that had agreed to let RYR9ZC through to make its second approach, and which was communicating in Spanish, received a more detailed explanation of what has happening that was more useful to its decision-making process."

The CIAIAC thus annotated: "The fact that English was not used in the communications kept RYR 9ZC from understanding the more explicit and colloquial information that was being given to the other aircraft. That is why it would be convenient that, when aircraft converge at the same airport and whose crews speak different languages, English be used so that all have the same information and all benefit from the information provided to other crews."

The CIAIAC analysed: "The flight to Valencia was direct at FL 80 and 220 kt, parameters far from those recommended by Boeing to maximize range for a given amount of fuel. The OFP reflects the fuel required for the alternates but makes no reference to the criteria, i.e. the optimum altitude and speed, used in this calculation, meaning the relevant parameters are not directly known to the crew. Had this information been included in the OFP, the crew could have made better decisions in terms of the optimal flight parameters. As a result, a safety recommendation is issued in this regard."

The CIAIAC analysed that according to EU-OPs the captain should have declared MAYDAY upon the second go-around in Alicante, not PAN. The CIAIAC stated: "In this case, the crew’s urgency declaration through the use of the PAN PAN code was not understood by approach and tower controllers at Valencia, who even joked about whether he had said PAN PAN or TAM TAM, and who admitted not knowing what to do next." and continued: "A check of the ATC recordings shows that the pilots of RYR 9ZC spoke English fluently, since both were British, but it was difficult for controllers (whose native language was different) to understand. An analysis of the recordings reveals a high number of repeated transmissions and also more lack of precision than desired in the transcription of these recordings."

Safety recommendations issued as result of the investation suggested AENA should improve ATIS to facilitate relevant and significant information created by sudden changes even if not deemed important enough to create a SPECI or TREND report, a change to modify Ryanair's operational flight plan to show real time, computed fuel fuel and optimum flight parameters to alternate airports, a revision to the operational manual to clarify the use of PAN and Mayday, Ryanair introduce as part of practises and procedures to "at least when operating outside domestic airspace, and especially in emergency situations, its crews speak English adapted to the so-called “operational level”, using standard phraseology as much as possible and speaking slowly and clearly enough so that they may be easily understood by all of the parties involved." Two more safety recommendations were released to ICAO to clarify the use of PAN and Mayday as well as reconsidering the fuel related emergency declarations in order to avoid the improper use of "minimum fuel" to become a standard declaration.
Incident Facts

Date of incident
May 14, 2010

Classification
Incident

Airline
Ryanair

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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