Embraer 145 descends below safe altitude during approach to Madrid

Casualties unknown • Aprox. Madrid (Madrid), ES

An Embraer 145 flight from Luxembourg to Madrid narrowly avoided terrain impact after a communication error led the crew to descend below minimum safe altitudes.

What happened

On August 4, 2011, an Embraer 145 LU, registration LX-LGX, operated by Luxair, was performing a scheduled international passenger flight from Luxembourg International Airport to Madrid-Barajas Airport. During the approach phase, the aircraft was cleared by the RES sector controller to descend to 10,000 feet. However, the crew erroneously acknowledged a descent to 5,000 feet.

As the aircraft continued its descent, it breached the minimum altitudes specified by the Standard Terminal Arrival Route (STAR) and the minimum radar vectoring altitude. The aircraft reached a minimum altitude of 6,290 ft before the Enhanced Ground Proximity Warning System (EGPWS) issued "TERRAIN TERRAIN" and "TERRAIN PULL UP" alerts. The crew immediately disengaged the autopilot and initiated a climb to escape the terrain. The situation was only realized by air traffic controllers after the crew reported they were maintaining 7,000 feet due to nearby mountains.

The investigation

The investigation examined flight data from the Quick Access Recorder (QAR) and communications between the crew and two ATC sectors (RES and AIS). The investigation established that the aircraft had been flying below the required procedure altitude for approximately four minutes and below the minimum radar vectoring altitude for three minutes without detection by the crew or controllers.

Investigators also reviewed the ATC procedures and the capabilities of the SACTA surveillance system. It was noted that while the system includes a "Minimums Alert" function, this feature was not enabled at the time of the incident. Furthermore, the investigation looked into the specific roles of the planning controllers at the approach control station, finding that their exact tasks were not explicitly documented.

Probable cause

The incident was caused by the crew descending below the minimum altitudes specified in the arrival procedure and the minimum radar vectoring altitude. This was triggered by a faulty readback where the crew acknowledged 5,000 feet instead of the cleared 10,000 feet, an error that was not corrected by the controller. Contributing factors included the use of non-standard phraseology by ATC and the failure of both the crew and controllers to detect the altitude deviation.

Frequently asked questions

What happened in the 2011-08-04 Embraer ERJ-145LU accident near Aprox. Madrid (Madrid), ES?

An Embraer 145 flight from Luxembourg to Madrid narrowly avoided terrain impact after a communication error led the crew to descend below minimum safe altitudes.

What aircraft was involved and where did it happen?

The accident on 2011-08-04 involved a Embraer ERJ-145LU, registration LX-LGX, at Aprox. Madrid (Madrid), ES.

What was the probable cause of the accident?

The incident was caused by the crew descending below the minimum altitudes specified in the arrival procedure and the minimum radar vectoring altitude. This was triggered by a faulty readback where the crew acknowledged 5,000 feet instead of the cleared 10,000 feet, an error that was not corrected by the controller.…

Investigation report by the Spanish Civil Aviation Accident and Incident Investigation Commission (CIAIAC). Original record: https://www.transportes.gob.es/recursos_mfom/2011_043_in_eng.pdf. This page is a structured re-presentation; facts and quotes are in the Comision de Investigacion de Accidentes e Incidentes de Aviacion Civil (CIAIAC), Spain - Ministerio de Transportes y Movilidad Sostenible.

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