Last Thursday, the Plenary of the Congress approved the Opinion issued by the Parliamentary Commission of Inquiry set up to investigate the causes of the crash of flight JK5022 on 20 August 2008 at Madrid-Barajas Airport, in which 154 people died. The Opinion was issued on 20th of April, after three years of intense work with the aim of “determining the causes and possible responsibilities for the accident of Spanair flight JK 5022 but, above all, to prevent future accidents with the maximum rigour and commitment”.
The 169-page report includes a series of conclusions on the events that contributed to the fatal outcome, describing one by one the failures in the safety chain. Among these conclusions, it is worth highlighting those concerning the actions of the pilots, so far the only ones identified by both the Commission for the Investigation of Civil Aviation Accidents and Incidents (CIAIAC) and the Madrid Court of First Instance No. 11 as being directly responsible for the accident.
The report analyses the environment and the business climate in which the pilots had to carry out their work. “The pilots – the report states – in view of the flight delay, acted under pressure due to the commitment made by the airline through an advertising campaign to refund tickets in the event of delayed departures, linked to the presentation of a staff redundancy programme on 8 August 2008 which affected more than 1,200 employees of the Company. It is reasonable to deduce that this factor caused them not to adjust the flaps and slats check, the second time they took to the runway”.
Furthermore, it explicitly points out to what extent the failure of the Take Off Warning System had an influence in the accident: “The TOWS, which should have warned them of the incorrect configuration of the aircraft, did not work. This is undoubtedly the determining factor in the safety chain. Had this alarm worked, the pilots would have aborted the take-off and the tragedy would not have occurred”.
The conclusions also go on to analyse other factors that contributed to the accident, such as the automatic extension of the airworthiness certificate and the disconnection of the Z-29 circuit breaker that feeds both the RAT heating probe and Relay 2-5 (which was ultimately what failed during take-off, preventing the TOWS alarm from sounding). In addition, it analyses the failures in the emergency plan deployed after the accident, which led to the delay in assisting the victims.
Finally, it points directly to several of the political leaders who held specific positions in the Ministry of Public Works, such as the then Minister Magdalena Álvarez, the Director General of Civil Aviation Manuel Bautista and the Director of Air Navigation Carmen Librero.
The opinion, which aims to contribute to improving air safety in the future, also makes 13 recommendations to be considered. These include: the creation of a multimodal body for the investigation and prevention of accidents with multiple victims; the recommendation to the Ministry of Transport, Mobility and Urban Agenda to draw up a report on the various preventive actions carried out by the public institutions involved in aviation safety since 2008; and the review of existing healthcare protocols in regional and local administrations, airlines, Civil Protection and Aena, and the carrying out of drills.
It is also recommended, among other measures, the creation of a Flight Safety Foundation; an Aviation Flight Inspectors Body within the State Aviation Safety Agency (AESA); the referral of the contents of the investigation carried out by this commission to the State Attorney General’s Office; to declare the 20th of August as the National Day for the Victims of Air Disasters and their Families; and the promotion of the reform of the Law of the Central Courts of Instruction to allow for the investigation of accidents with multiple victims of any means of transport.
Towards a true Just Culture
This is the first time that it has been stated so explicitly to what extent business pressure can be a determining factor in aviation safety decisions. All aviation institutions have always advocated the need to move towards what is known in the industry as “Just Culture”. This concept refers to a non-punitive working culture, in which professionals can make their safety decisions solely on the basis of safety criteria, regardless of business or economic criteria such as punctuality.
Sepla therefore welcomes the fact that this opinion, drawn up by a commission of the Spanish citizens’ representative chamber, identifies “pressure” as a determining factor in the accident. Air crews, and in particular pilots, are ultimately responsible for the safety of the flight, and the success of the flight depends on their work. It is therefore vital that they take their decisions in a totally free manner, outside and independent of any other criteria other than safety.
Finally, Sepla recalls that, 13 years later, the name of the two pilots of the accident, Antonio García Luna and José Antonio Mulet, whose responsibility for the accident was unjustly placed on their shoulders, has been cleared, at least in part.
- Read the full Opinion here(Spanish)