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ASN Wikibase Occurrence # 218535
Last updated: 3 September 2019
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Date:08-AUG-2017
Time:09:35 UTC
Type:Silhouette image of generic B789 model; specific model in this crash may look slightly different
Boeing 787-9 Dreamliner
Owner/operator:American Airlines
Registration: N825AA
C/n / msn: 40644/517
Fatalities:Fatalities: 0 / Occupants: 240
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Madrid TMA -   Spain
Phase: En route
Nature:International Scheduled Passenger
Departure airport:Madrid-Barajas Adolfo Suárez Airport (MAD/LEMD)
Destination airport:Dallas/Fort Worth International Airport, TX (DFW/KDFW)
Investigating agency: CIAIAC
Narrative:
The Boeing 787-9 aircraft, registration N825AA, had taken off from runway 36L at the Madrid-Barajas Airport as flight AA37 to the Dallas-Fort Worth Airport, United States.
The Cessna 172M aircraft, registration EC-IEO, had taken off from the Madrid-Cuatro Vientos Airport on a Z flight plan to the Burgos Airport. Its callsign was ACR31. After taking off, and in IFR conditions, it had been cleared by ATC to fly direct to Burgos at 11000 feet. It was leveled at that altitude at the time of the incident.
The Boeing 787 aircraft had been cleared to climb to FL240 and to follow standard instrument departure (SID) ZMR1L. Shortly after passing point MD44 in procedure ZMR1L, the traffic collision avoidance system (TCAS) on the Boeing 787 aircraft issued a resolution advisory (RA) due to a
reduction in separation with the Cessna 172. At that moment, the B787 was at 10900 ft and climbing to FL240.
The crew of the B787, AA37, reported the situation to the control center while operating the controls to initiate a descent. For their part, the crew of the other aircraft, ACR31, had visual contact with the B787, realized it was descending and decided to make an evasive climb maneuver.
These actions resulted in a quick resolution to the conflict situation, after which both aircraft continued their flights, reaching their destinations without further incident.
The investigation has determined that this incident occurred because the executive controller focused his attention on resolving a conflict in another part of the airspace under his control, while forgetting to track and resolve a potential conflict that he had previously identified.
The following factors are deemed to have contributed to this incident;
- A conflictive flight plan for aircraft ACR31, which violated restrictions on the airway and that brought it into conflict with takeoffs and landings at LEMD.
- Poor reception on the dedicated line to LEGT, which forced the executive controller to take over the tasks that the planning controller had been doing.
- The conflict alert on the SACTA system did not activate early enough for the executive controller to take action before the conflict situation involving the aircraft occurred.

Sources:

CIAIAC

Safety recommendations:

Safety recommendation REC 34/18 issued by CIAIAC to ENAIRE
Safety recommendation REC 35/18 issued by CIAIAC to ENAIRE

Accident investigation:
cover
  
Investigating agency: CIAIAC
Status: Investigation completed
Duration: 1 year and 3 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
25-Nov-2018 12:54 harro Added

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