What happened
On 21 July 2004, a Spanair McDonnell Douglas MD-83, registration EC-FTS, departed Alicante Airport for Palma de Mallorca. Approximately three minutes after takeoff, while climbing through 5,400 ft, the captain identified a failure in the left engine. The crew immediately notified Air Traffic Control (ATC) and declared an emergency to return to Alicante.
During the approach, the crew attempted to execute the in-flight engine failure checklist three times. However, the process was interrupted by communications from ATC and the necessity to focus on the landing phase. The aircraft landed on runway 10 and taxied to a stop via taxiway C4. After ATC informed the crew of a visible fire in the left engine, the crew ordered an evacuation. During the evacuation, 19 passengers and one firefighter sustained minor injuries. While the tailcone emergency exit was activated, the inflatable evacuation slide failed to deploy.
The investigation
The CIAIAC investigation examined the engine's condition, the crew's performance, and the effectiveness of the emergency procedures. Investigators performed a disassembly of the left engine, which revealed that no actual fire had occurred within the engine core, despite the visual reports from ground personnel. The investigation also reviewed the cockpit voice recorder and flight data recorder to evaluate the crew's management of the emergency and the impact of ATC communications on their workload.
Findings
- The engine failure was caused by the simultaneous or near simultaneous fatigue failure of two stator vanes in the 8th stage of the High Pressure Compressor (HPC).
- The crew did not complete the engine failure checklist due to task saturation and interruptions.
- There was a lack of effective task sharing in the cockpit, as the copilot was managing both communications and the engine failure procedure.
- The operator's engine failure procedure was found to be ambiguous, specifically regarding how to determine if an engine is "damaged" or "undamaged."
- The tailcone slide failed to deploy upon activation.
Safety action
- The investigation issued a recommendation for Spanair to review its in-flight engine failure procedure to ensure pilots can use objective parameters for quick assessments.
- A recommendation was made to improve training regarding task sharing during emergency situations in CRM and simulator courses.