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ASN Wikibase Occurrence # 241060
Last updated: 14 November 2021
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Time:14:54 LT
Type:Silhouette image of generic B735 model; specific model in this crash may look slightly different
Boeing 737-524
Registration: LY-KLJ
MSN: 28923/3060
Fatalities:Fatalities: 0 / Occupants: 65
Other fatalities:0
Aircraft damage: None
Location:Madrid-Getafe Air Base -   Spain
Phase: Landing
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:Madrid-Barajas Adolfo Suárez Airport (MAD/LEMD)
Destination airport:Kaunas International Airport (KUN/EYKA)
Investigating agency: CIAIAC
On 5 April 2019, the crew of a Boeing 737-524 aircraft, registration LY-KLJ, was preparing for a planned flight from the Madrid-Adolfo Suárez Madrid Barajas Airport (LEMD) to the Kaunas Airport (EYKA) in Lithuania.
During the pre-flight inspection, they identified a fault in the captain’s automatic flight system, so both pilots, with help from a company engineer, reviewed the Minimum Equipment List (MEL) and verified that it allowed dispatching the aircraft with this equipment inoperative.
They decided to proceed with the flight and after receiving the relevant clearance, took off from runway 14L at 14:15:26.
During the climb, several faults occurred with the first officer’s automatic flight system, which eventually became inoperative at 14:17:32, so the crew decided to return to the departure airport while flying without assistance from the automatic flight systems.
Spain’s air traffic control manager, ENAIRE, reported that shortly after takeoff, the crew declared an emergency but did not report the exact nature of their problem.
At 14:20, the operations supervisor informed the approach controller that he was transferring him an aircraft that had just taken off from Madrid-Barajas whose crew had declared an emergency and wanted to return to the airport.
Based on information provided by the controller, he cleared the runway 18R localizer by diverting two aircraft, AC/1 and AC/2, which were on approach to this runway.
He also instructed them to adjust their speeds to maintain the required separation as much as possible, both to each other and to those that were already positioned at the localizer.
The traffic that declared an emergency did not lower its speed properly and crossed the two localizers at 250 kt behind a third aircraft.
The controller then corrected the approach vector he had initially provided so that the aircraft could intercept the localizer for runway 18L (180º heading).
The crew ended up going around at 14:23:10. The controller asked if they had problems with the speed, since he did not know the nature of their emergency, but the crew again requested vectors to land.
Because of its position, the aircraft had to climb to maintain the minimum altitude, but the controller saw that it was not climbing.
He could not turn it toward Casas de Uceda because there were aircraft at the runway 18R localizer and it would have had to continue toward heading 360º to try to intercept it from behind.
Twice he informed the crew that they were below minimums and instructed them to climb, but they did not carry out this instruction, since the aircraft was at 4,400 ft and entering an area where the minimum was 6,700 ft.
It turned to 220º at 220 kt and positioned itself behind A/C 2, which was at the other localizer.
It managed to intercept the localizer 11 NM out, at an altitude of 4,300 ft and a speed of 170 kt.
At 8 NM out, it had not acquired visual contact with the runway. Its speed was 150 kt. It remained at the localizer, and the controller transferred the aircraft to a colleague who was on the final approach sequence just before the aircraft reached a distance of 4 NM from the DME.
At a distance of 2.5 NM DME, it changed localizers and the controllers realized that it had gone around again. It was 14:33:58.
When the aircraft declared the emergency, the airport activated the local alert and the airport firefighters were standing by to respond to any situation during the landing on runway 18L.
After two failed landing attempts, the aircraft was diverted by air traffic control to the Getafe Air Base (LEGT) in Madrid, where it landed on runway 23 at 14:53.
There were no injuries and the aircraft was not damaged.

Causes/Contributing factors:
The investigation has determined that the incident was caused by the problems the crew had operating the aircraft in instrument flight conditions after losing both of the aircraft’s automatic flight systems.



Accident investigation:
Investigating agency: CIAIAC
Status: Investigation completed
Duration: 1 year and 5 months
Download report: Final report


Photo of LY-KLJ courtesy

Larnaca - International (LCLK / LCA)
9 November 2019; (c) Derek Gaynor

Revision history:

08-Sep-2020 17:40 harro Added

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