Avianca Flight 011

Avianca Flight 011

HK-2910X, the aircraft involved in the accident at Madrid Barajas Airport in August 1983.
Accident
Date	27 November 1983
Summary	Controlled flight into terrain due to pilot error and ATC error
Site	Mejorada del Campo, Madrid, Spain
Aircraft
Aircraft type	Boeing 747-283B
Aircraft name	Olafo
Operator	Avianca
IATA flight No.	AV011
ICAO flight No.	AVA011
Call sign	AVIANCA 011
Registration	HK-2910X
Flight origin	Frankfurt Airport West Germany
Stopover	Charles de Gaulle Airport Paris, France
2nd stopover	Madrid Barajas International Airport Spain
3rd stopover	Simón Bolívar Int'l Airport Caracas, Venezuela
Destination	El Dorado International Airport Bogotá, Colombia
Occupants	192
Passengers	173
Crew	19
Fatalities	181
Injuries	11
Survivors	11

Avianca Flight 011, registration HK-2910X, was a Boeing 747-200B on an international scheduled passenger flight from Frankfurt via Paris, Madrid, and Caracas to Bogotá that crashed on 27 November 1983. It took off from Charles-de-Gaulle Airport in Paris at 22:25 on 26 November 1983 for Madrid Barajas Airport; take-off was delayed to wait for additional passengers from a Lufthansa flight due to a cancellation of the segment Paris-Frankfurt by Avianca for operational reasons. The jet had been cleared to land at Barajas Airport, the first of two scheduled en route stops originating at Paris, with a final destination of Bogota, Colombia.

During the instrument landing system (ILS) approach to runway 33, the 747 crashed on a hill approximately 7.5 miles south east of the airport, killing 181 persons, including 19 on-duty and four off-duty crew members. The 11 surviving passengers were seriously injured. The cause of the accident was judged to be pilot error, having incorrectly determined the position of the plane. As of 2013, Avianca Flight 011 remains the second-deadliest aviation accident in Spanish territory behind the Tenerife airport disaster, and the deadliest accident in the history of Avianca.

Background

Aircraft

The aircraft involved in the accident while still operating with SAS

The aircraft involved was a Boeing 747-283B, registration HK-2910X, leased by Avianca in August 1982, having been previously owned and operated by Scandinavian Airlines System, SAS. The aircraft had been constructed in 1977, with number of construction (c / n) 21381/331, and counted on 20,811 hours of flight; at the time, it was a new aircraft and it was equipped with avant-garde systems and instrumentation for the time, with only six years of manufacturing. Because of the aircraft's rental status from SAS (HK-2910X was initially registered in Norway as LN-RNA), Avianca affectionately nicknamed the aircraft Olafo.

The aircraft was fitted with four Pratt & Whitney JT9D-70 engines; initially, the first Boeing 747 models normally carried JT9D engines, the -70 variant is particular due to the fact that very few were produced as they were part of a program of continuous improvement to a whole line of variants -7, specially developed to improve performance of the 747-200 and even several 747-300's, due to the introduction of Stage 3 noise emission regulations that compromised the maximum allowed gross weight of these aircraft by slightly reducing the thrust of the original design of the turbine. Only nine Boeing 747's were built with this engine configuration.

Crew

The captain was Tulio Hernández, who had been serving with Avianca for 35 years and had a record of 23,215 flight hours, including 2,432 hours on the Boeing 747. The first officer was captain Eduardo Ramírez, who had 4,384 flight hours, including 875 hours on the Boeing 747. The main flight engineer was Juan Laverde, who had 15,942 flight hours, including 3,676 hours on the Boeing 747. The back up flight engineer was Daniel Zota.

All crew members knew Madrid Barajas airport very well. Each member had navigated, took-off from and landed at Madrid Barajas International airport multiple times previously, respectively

There were 14 flight attendants on board. Sigrun Günther Platzöder (from Nürnberg, aged 41) was the purser. In addition, there were also four deadheading crew members.

Accident

The flight originated in Frankfurt and stopped in Paris before heading to Madrid. It took off from Paris at 22:25 on 26 November 1983. It was dark at the time of the accident, the meteorological conditions just before the crash consisted of a visibility of 5 miles, and the wind was calm. About 20 minutes prior to the impact the aircraft had obtained meteorological information on the weather conditions at Barajas from Avianca. The first contact with Spanish air traffic controllers took place at 23:31. At 00:03 the aircraft contacted Barajas again and was cleared to land on runway 33; this was the air traffic controller's last contact with the aircraft. The accident took place in the township of Mejorada del Campo, approximately 7.5 miles southeast of the Madrid Airport. The time of the accident was approximately 00:06 on 27 November 1983. The plane hit three different hills on its way down during the crash, with the third hill being the final impact. The debris of the airplane was widely scattered as a consequence of the three impacts. The crash killed 158 passengers, 19 crew members and 4 off-duty crew members. 11 were seriously injured. Of the injured people, nine were ejected out of the airplane, a few of them with their seats still attached, and two claimed to have exited the aircraft by themselves. The aircraft was completely destroyed by the impact and ensuing fire. The aircraft was equipped with a digital flight data recorder and a cockpit voice recorder, both of which were recovered on the day of the accident in good condition.

Investigation

The crash was investigated by the Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC). The CIAIAC (Commission of Investigation of Accidents and Incidents of Civil Aviation) is the official organization in charge of carrying out the investigation of aviation accidents and incidents that occur in Spanish territory. This commission was notified of the accident at 1:40 am, so following the procedure indicated by ICAO, it reported the accident to the countries of registration and manufacturing of the aircraft, which were Colombia and the United States, respectively.

The accident report was issued by the CIAIAC with the code A-042/1983, entitled "Technical Report of the Accident Suffered by the Boeing Aircraft 747-283B, Registration HK-2910, at 12 KM. of the Madrid-Barajas Airport on November 27, 1983  ". This document is the official verdict of the competent authorities, as a result of the research carried out by said body and in accordance with ICAO regulations for this type of events.

Geographical location

The crash site in Mejorada del Campo is an agricultural area with limited access by rural roads; no different victims were presented to the aircraft occupants who died after the impact. Due to the way the Boeing 747 crashed, it was destroyed on the third impact, caused by three hilltops. The third impact caused the aircraft to rollover, break apart, and subsequently. The emergency services reached the crash site 20 minutes after being notified of the accident. It took two hours to extinguish the post crash fire.

Flight recorders

The final report indicates that the Flight Data Recorder (FDR) recorded 64 parameters during the last 5 minutes of flight, while the Cockpit Voice Recorder (CVR) had four recording channels (however, only one was useable):

a) Communications between the captain and ATC.

b) The conversations between the crew members captured by their headset microphones.

c) Communications between the first officer and ATC.

d) Audio captured by the Cockpit Area Microphone (CAM).

The CAM channel was the only one that could be analyzed by the authorities, due to the other three being ineffective.

Medical and pathological information

The primary causes of the death of the 181 fatalities were the multiple injuries of the impact, the fire and production of toxic gases, or a combination of both; the survivors were passengers who were fired from the plane during the first two impacts, along with two other occupants who escaped on their own in the only part of the fuselage that did not collapse with the overturn, before the plane started to burn after the third impact

"As a result of the third impact of the aircraft and the inverted position in which it collided with the terrain, the chances of survival were greatly diminished.

All this coupled with the immediate fire, prevented the number of survivors was greater. 

(...)

Of the studies conducted it has been proved that 35% of the victims died as a result of fire, 30% died from polytraumatisms and the the remaining 45% died from a combination of disability caused by trauma and aspiration of toxic gases due to the fire."

Investigation

The investigation reveals that the flight was performed under normal circumstances, without any anomaly or failure in the aircraft or its maintenance, nor in the ground equipment (radio aids, antennas, radars, etc). Problems of weather conditions or visibility were ruled out, and there was effective communication to the crew about them. Therefore the study focused on the analysis of conversations and communications of the crew in order to establish the human factors that affected the development of the accident.

In fact, despite the technical problems presented in the analysis of the cockpit voice recorder, most of the crew's communications with the different air traffic controllers during the last phase of the flight could be reconstructed, contrasted with the external registers (ie, with the available recordings of the communications maintained by the different controllers), and the operational data recorded in the digital flight data recorder.

These reveal that the crew omits the communication of being passing over the navigation point of Pamplona, ​​and the First Officer apparently has problems when selecting navigation frequencies or determining distances, which are corrected by the Commander; Although this was not a contributing factor, it is a factor that allowed understanding the nature of the accident.

Chronology

23:46:30 GMT

Flight 011 requests to descend to Madrid Centro (Madrid-ACC). They are authorized to go down from FL370 to FL190, to descend after FL190 to 9,000ft. Six minutes later (23:52) they contact Madrid Approach (APP) communicating their passage through Barahona (BAN) and asking to omit the Castejón navigation point (CJN) to go directly to the VOR of Madrid (Campo Real or CPL).

During this period the recovery of cockpit conversations shows that captain Hernández seemed to doubt and rectify on several occasions the readings that the First Officer makes of the navigation chart, including the insertion of frequencies and navigation coordinates into the flight computers (INS or Inertial Navigation System).

23:58:30 GMT

When the aircraft was approaching 9,000 ft, the crew make the approach check to Runway 33; it is at this moment when the first officer determines that, after losing 4,000ft (altitude assigned by Madrid APP), the interception altitude of the ILS marker is 2,300ft, when in reality it was 3,200ft (confusing the thousands with hundreds, better said the position of 2 and 3); despite the fact that on previous occasions the captain had verified the information provided by the First Officer, this time he gives this information as valid and does not verify it in his own letter. It means that they looked for the ILS locator signal with reference to an altitude 900ft lower than that indicated on the approach chart.

00:03:29 GMT

Madrid Approach announces that flight 011 approach CPL and gives the radio frequency of Madrid Torre; the crew acknowledges the information, dismisses and changes frequency. It is at this moment when, missing 5.8 NM to reach CPL, the aircraft makes a turn to go to MA, a radio aid located in the vicinity of the External Marker of Runway 33 of Madrid-Barajas Airport; In this regard, the report indicates:

"Immediately after saying goodbye to the APP aircraft, it started a turn to the right, when it was about 5.8 nautical miles from CPL, which ended 37 seconds later, heading towards MA of 283.7 degrees, altitude 3,802 feet, speed of 165 knots and approximately 4.8 nautical miles of CPL. The captain started the turn before he reached CPL, probably because he no longer had distance reference DME to CPL, or because there might be an accumulated error in the INS, which makes him believe he is closer to CPL; the ambiguous position information given by Control could help set this idea or the possibility of some visual reference through two layers of clouds."

— 

This moment is crucial in the chain of events, because it summarizes the factors that influenced the accident: altitude below the established limits and minimum safety of the area, initiation of a maneuver ahead of time; captain Hernández also orders the landing gear to be lowered prematurely (according to the procedure indicated) to reduce the speed of the aircraft, although its speed or descent rate was within normal limits; it is not possible to determine then that the crew had rush to land, but it is indicated as an error within a pre-established sequence of operations. A momentary disconnection of the autopilot is also recorded during the turnaround that occurs in advance.

00:04:17 GMT

"..., the autopilot is reconnected at the same time as the turn ends, and from this moment on, the aircraft started a continuous descent, probably because the Commander, when reconnecting the autopilot, forgot to put the altitude mode selector in altitude hold position (Altitude Hold), or because coming mentally to reach 2,382 feet in MA, continued a voluntary descent by manually acting on the autopilot rise-descent control."

— 

00:05:42 GMT

"... the first officer says: "The locator seems that if it is, it is wrong. I hope." This suggests that they think they were closer to MA than they actually were, maintaining the descent regime, with the intention of reaching MA at the height they had set at 2,382 feet, instead of at 3,282. feet of the approach chart."

— 

00:06:05 GMT

The Ground Proximity Warning System (GPWS) activated and made several "whoop whoop pull up" alarms. This system works with the data collected from the instruments and the detection of an Altimeter Radar, and is designed to alert crews about potentially dangerous collision situations against the ground or obstacles. It is a critical warning that indicates to pilots of Avianca Flight 011 that the aircraft is on a collision course with either the ground or water. The data collected from the flight recorders reveal that the crew did not take any corrective action that would allow the alarm to go off, that is, the crew did not avoid an eminent collision despite receiving a critical alarm for 15 seconds.

00:06:19 GMT

Fifteen seconds after the GPWS activated, at a recorded speed of 139 knots (257 km/h; 160 mph), with a heading of 284º, a vertical speed of -1,016 ft per min, at an altitude of 2,249 ft (MSL), with the landing gear deployed, and the flaps set to 20º, the aircraft impacted the ground. The main landing gear right and a wing tip sliced a tree in half. There is an instantaneous acceleration and retraction of the spoilers (in the armed position), which indicates that the warning systems of the Boeing 747 acted as if it were an unsafe takeoff. Three seconds later, the aircraft impacted the ground a second time, causing the crew to lose control. The now-uncontrolled aircraft then crashed into the ground a third time and exploded, with the fuselage breaking apart. A post-crash fire erupted from the wreckage.

Conclusions of the CIAIAC

*a) The captain and the crew were adequately qualified and experienced.

• b) The Controllers were adequately qualified, experienced and physically well.
  
• c) The aircraft had the Certificate of Airworthiness, Certificate of Registration and Certificate of Maintenance valid. The records show that it has been maintained in accordance with the authorized maintenance program.
  
• d) The navigation and approach aids worked correctly, according to the verifications carried out.
  
• e) There is no evidence of malfunction in the ATC radar and communications equipment.
  
• f) In the investigation, no evidence of abnormality was found in the operation of the engines and systems of the aircraft.
  
• g) The weight and centering of the aircraft was within the established limits.
  
• h) Between Barahona and the beginning of the turn towards MA, the crew did not do the necessary procedures, so they made an incorrect navigation.
  
• i) The crew flew below the minimum of the sector, more than one minute, before entering the protection zone of CPL.
  
• j) The crew removed the train out of sequence, in advance, according to the ILS approach procedures, and before starting the turn towards MA.
  
• k) The crew made the turn towards MA and continued its flight until the impact, without verifying the distance to CPL, nor having captured any signal from the ILS approach system; leaving only the ADF bearings.
  
• l) The captain accepted, without checking, the erroneous altitude of MA overrun given by the first officer.
  
• m) The captain did not take the correct corrective action when the GPWS alarms activated.
  
• n) The ACC Controller transferred the aircraft to APP, at a different time and place than agreed.
  
• o) The APP Controller, when making the traffic transfer, did not give precise position reference, neither to TWR nor to the aircraft.
  
• p) The APP Controller transferred the aircraft to TWR, without receiving confirmation from the crew that they had intercepted any assistance for the approach or had visual reference.
  
• q) The APP Controller did not maintain the radar surveillance due to not having communicated to the aircraft "finished radar service."
  
• r) The wording and communication procedures used, both by the controllers and by the crew, did not comply with those recommended by ICAO."
  — CIAIAC, Committee of Investigation of Accidents and Incidents of Civil Aviation.
  

Cause

The CIAIAC made the following conclusion:

PROBABLE CAUSE: "The pilot-in-command, without having any precise knowledge of his position, set out to intercept the instrument landing system (ILS) on an incorrect track without initiating the published instrument approach maneuver; in so doing he descended below the sector minima until he collided with the ground. Contributory factors were:

• a) Inaccurate navigation by the crew, which placed them in an incorrect position for initiating the approach maneuver;
• b) Failure of the crew to take corrective action in accordance with the operating instructions of the ground proximity warning system;
• c) Deficient teamwork on the flight deck;
• d) Imprecise position information supplied to the aircraft by APP;
• e) The APP controller, in failing to inform the aircraft that radar service had terminated, did not maintain a proper watch on the radar scope."
  — (CIAIAC)

There was no evidence of any anomalies in Paris prior to this flight. The crew had stayed in the city 72 hours after arriving on flight AVO10 on the first day, 24 November 1983. The investigation also determined that the pilot-in-command and crew were properly licensed and qualified, as were the air traffic controllers. The aircraft carried a valid certificate of airworthiness and a registration and maintenance certificate. The airplane was maintained in accordance with the prescribed maintenance program, and the navigation and approach aids were checked and found to be functioning correctly. In addition, there was no record of malfunctions in the controllers communications or radar equipment, and no evidence was discovered of defects in the aircraft engines or systems.

The crash is the 12th hull loss and 8th fatal accident of a Boeing 747, the second-deadliest aviation accident in Spanish territory (behind the Tenerife Airport Disaster), the deadliest accident in the history of Avianca and any other Colombian airline.

Victims

Nationality	Passengers	Crew	Total
Colombia	126	19	145
Argentina	10	0	10
Peru	9	0	9
Mexico	7	0	7
United States	5	0	5
Uruguay	4	0	4
Netherlands	3	0	3
Australia	2	0	2
Bolivia	2	0	2
Cuba	2	0	2
Ecuador	2	0	2
United Kingdom	2	0	2
Canada	1	0	1
Chile	1	0	1
France	1	0	1
Germany	1	0	1
Italy	3	0	3
Switzerland	1	0	1
Panama	1	0	1
Brazil	1	0	1
India	1	0	1
Sweden	1	0	1
Jamaica	1	0	1
Japan	1	0	1
Spain	1	0	1
Venezuela	1	0	1
El Salvador	1	0	1
Guatemala	1	0	1
Total	169	23	192

Among the passengers who boarded Flight 011 of Avianca, were invited to the "First Meeting of the Hispano-American Culture" outstanding writers and critics of culture, invited by the Colombian president of the time, Belisario Betancur. Among others, they include:

• Jorge Ibargüengoitia – Mexican novelist
• Ángel Rama – Uruguayan writer, academic, and literary critic
• Rosa Sabater – Spanish pianist
• Manuel Scorza – Peruvian novelist, poet, and political activist
• Marta Traba – Argentine writer and art critic

Aftermath

As of 2018, Avianca still operates Flight 011, a daily flight from Madrid to Bogota, using a Boeing 787 Dreamliner.

See also

• Japan Airlines Flight 123
• Korean Air Flight 801 
• American Airlines Flight 965 
• Air Inter Flight 148 
• List of accidents and incidents involving commercial aircraft 
• Prinair Flight 277

External links

External images

Pre-Crash photos of HK-2910 at Airliners.net

Photo of the crashed airliner from AirDisaster.com

• Report from the Ministry of Infrastructures, Spain – Civil Aviation Accident and Incident Investigation Commission (in Spanish).
• Transcript of the cockpit voice recorder (CVR)
• Accident description at the Aviation Safety Network

Fatal error: The format of the coordinate could not be determined. Parsing failed.

Category:Airliner accidents and incidents caused by pilot error Category:Airliner accidents and incidents involving controlled flight into terrain Category:Aviation accidents and incidents in 1983 Category:History of Madrid Category:Aviation accidents and incidents in Spain Category:Accidents and incidents involving the Boeing 747 Category:Avianca accidents and incidents Category:1983 in Spain Category:Adolfo Suárez Madrid–Barajas Airport Category:20th century in Madrid Category:November 1983 events

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