Aeromexico B762 at Madrid on Apr 16th 2013 - Final report

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...since the original report on PPRUNE was/is closed

"http://www.pprune.org/rumours-news/512718-aeromexico-b762-madrid-apr-16th-2013-tail-strike-takeoff.html"

Spain's CIAIAC final report released...with summary here...

Accident: Aeromexico B762 at Madrid on Apr 16th 2013, tail strike on takeoff (http://avherald.com/h?article=460db38a&opt=0)

...bad...bad...bad :suspect:

[Hotel Tango]

:eek: For a pretty heavy flight from Madrid to Mexico City I am astounded that the extremely low V1 and Vr speeds of 118 KIAS didn't ring any alarm bells. We're not talking about just a slight discrepancy here.

[MrSnuggles]

Direct link to report here:

16-abril-2013. XA-TOJ. Boeing B-767-200. Aeropuerto de Madrid-Barajas - 2013 - Investigación - CIAIAC - Órganos Colegiados - Ministerio de Fomento (http://www.fomento.gob.es/MFOM/LANG_CASTELLANO/ORGANOS_COLEGIADOS/CIAIAC/INVESTIGACION/2013/010_2013_FINAL.htm)

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For a pretty heavy flight from Madrid to Mexico City I am astounded that the extremely low V1 and Vr speeds of 118 KIAS didn't ring any alarm bells. We're not talking about just a slight discrepancy here.

...yeppers....astounded is a nice descriptive...those yokels bent a plane because they couldn't/wouldn't/didn't do the math...just friggen pitiful:sad:

[atakacs]

Hotel Tango: my thoughts exactly. 40000+ h in the cockpit but no one raising an eyebrow on those figures? Amazing

[LostThePicture]

As an aside, no runway inspection performed after an incident of that nature, resulting in damage to another aircraft? Seems a bit negligent...

LTP

[Una Due Tfc]

Tower was 4km from the impact point and the crew didn't report anything unusual to ATC. Nobody on the ground knew there had been a tailstrike until the Europa hit the debris.

The fact it wouldn't pressurise...did they breach the bulkhead?

[Hotel Tango]

LTP, I think that's because nobody knew until the Air Europa had its problem. And even at that time the AMX crew were still not aware of it themselves (other than an apparent pressurization problem).

[LostThePicture]

Ah, well that all makes more sense then. I retract my apparent criticism. Thanks for the clarification.

LTP

[Doors to Automatic]

Even the geekiest armchair MSFS "pilot" would raise an eyebrow at a 118kt VR in a wide-body - especially on such a long flight!

One is left wondering how on earth some of these accidents in aviation can possibly happen! :ugh:

[Tiennetti]

I don't know if they had any previous experience on wide-body, but despite almost 40k hours of experience, the three together barely reach 500h on type...

EDIT: in the report they call as a factor that pilots will often use low weights during sim sessions. Those weight will give Vspeeds similar to the one registered that day. Very low experience on type, paired with a training phase in the sim where the speeds used were normally in the low-120ish range, so nothing strangein their mindset

[Doors to Automatic]

Even so as a captain of a 767 you should have an idea of ZFW, Fuel weight and payload and the rough relationship with take-off speeds? It is fundamental.

For a couple of years I was involved with a company which operated a 737-800 fixed-based simulator (usually used by cadets for pre-sim assessment practice). Now I have no real-world experience of flying jets but even I know that the ballpark take-off speed is in the 140-150kts range.

If I was in a real one I might be out by 4-5 kts if I did no prep but not 40!!!

[atakacs]

Tiennetri: thanks for pointing that out. I wonder about crew roasters at Aeromexico - 500h seems really low. But even me, being a complete amateur PPL, would have questioned those take off figures...

[Mr Good Cat]

I don't know if they had any previous experience on wide-body, but despite almost 40k hours of experience, the three together barely reach 500h on type...

EDIT: in the report they call as a factor that pilots will often use low weights during sim sessions. Those weight will give Vspeeds similar to the one registered that day. Very low experience on type, paired with a training phase in the sim where the speeds used were normally in the low-120ish range, so nothing strangein their mindset

Exactly.

If they were all used to seeing similar OPT results for their previous type (maybe 737 or 320?) then the scene was set for this situation.

Not unlike the Melbourne A340 incident where the crew were used to seeing a figure of 250t instead of 350t (due to mixed fleet flying) and the error didn't register in their minds.

[TDK mk2]

I'm always amazed when so called professional pilots post on here critisizing fellow professionals and inferring that they would never make such a mistake. Very easy to do, but I'd bet money this crew got trapped by a number of different factors, as has been inferred above, into making the error(s) that led to the outcome. As for the ones who have never operated commercial jets, stick to commenting on subjects you know something about.

True negligence in these kinds of situations is rare and declaring it without a proper investigation into an incident is contrary to just culture, and I would say safety in general.

[Hotel Tango]

I'm sorry TDK, but they had to input the data into the FMS. About to depart in a heavy B767 on a direct flight to Mexico I think that my 10 year old grandson would have questioned a Vr speed of 118 KIAS. Of course these errors are not deliberate acts but they are nevertheless difficult to comprehend. Forgive me if I sound alarmed by an experienced crew making such an error, whatever the reason might be. And as you should know, it would take a relatively light A320 or B737 to achieve those figures too by the way. I'm not criticizing anyone, but simply, as already stated, astounded that it went unnoticed. The outcome could have been a lot worse as in the MK Airlines B747 in Halifax in October 2004.

[F-16GUY]

While I recognize the fact that one starts off with zero hours on type, is it normal company procedure to compile the entire cockpit crew of pilots with low time on type?

Captain 149, hours on type.
First Officer 147, hours on type.
Supplement First Officer, 278 hours on type.

For all I know the +40K hours this crew had between them, could have been in a type that is operated in a totally different way.

Thoughts anyone?

[bubbers44]

We never just kept rotating past tail strike attitude until airborne. Has training changed in the last ten years to just keep rotating past tail strike attitude at Vr?

[Tinribs]

Bubbers is so right
We never just kept rotating but stopped at the expected unstick pitch and waited, only if hitting the far hedge began to look likely did we pitch up more and take the consequences

F16 er
We had a rule about low hours in both seats, green on green, but that ended after 50 hours on type

[RAT 5]

Guys: I think you are missing a very salient point. As an ex-B767 captain I agree with all your comments about smelly something fishy with those speeds. Indeed on any a/c that you are familiar with. This comment has been made about other such incidents. However, back to the salient point. This flight was from Madrid to Mexico. I assume, therefore they had flown from Mexico to Madrid. Therefore they should have had similar weights and correct speeds for their east bound flight and known what to expect. The return flight should have been a mirror of their recent flight and thus fishy smell should have been abundant. Total type experience; previous sim experience; etc. etc. red herrings, and still smelly. It seems there are too many pilots today who do not think; do not have ball park gross error checks in their everyday habits; do not have a'feel' for what is correct. Back to training. This problem will become more prevalent with the computerised performance calculations, i-pad etc. Little heed paid to "what do I expect" and then see what you get. There's too much an attitude of accept what you see. It's a computer, it must be correct. Ouch, and Oh my gawd.