A-037-2021 Final Report NM

Technical report
A-037/2021
______________________________
Accident on 31 July 2021 involving a Boeing

737-8AS aircraft, registration number EI-EPC,
while on approach to Barcelona Airport
Please note that this report is not presented in its final layout and
therefore it could include minor errors or need type corrections, but
not related to its content. The final layout with its NIPO included
(Identification Number for Official Publications) will substitute the
present report when available.
UNDERSECRETARIAT
CIVIL AVIATION
ACCIDENT AND INCIDENT
INVESTIGATION COMMISSION
Notice
This report is a technical document that reflects the point of view of the Civil Aviation Accident
and Incident Investigation Commission (CIAIAC) regarding the circumstances of the accident and
its causes and consequences.
In accordance with the provisions in Article 5.4.1 of Annex 13 of the International Civil Aviation
Convention; and with articles 5.6 of Regulation (UE) nº 996/2010, of the European Parliament
and the Council, of 20 October 2010; Article 15 of Law 21/2003 on Air Safety and articles 1 and
21.2 of Regulation 389/1998, this investigation is exclusively of a technical nature, and its
objective is the prevention of future civil aviation accidents and incidents by issuing, if necessary,
safety recommendations to prevent from their reoccurrence. The investigation is not pointed to
establish blame or liability whatsoever, and it’s not prejudging the possible decision taken by
the judicial authorities. Therefore, and according to above norms and regulations, the
investigation was carried out using procedures not necessarily subject to the guarantees and
rights usually used for the evidences in a judicial process.
Consequently, any use of this report for purposes other than that of preventing future accidents
may lead to erroneous conclusions or interpretations.
This report was originally issued in Spanish. This English translation is provided for information
purposes only.
ii
CONTENTS
Notice ........................................................................................................................... ii
CONTENTS ..................................................................................................................iii
ABBREVIATIONS ........................................................................................................ iv
Synopsis ...................................................................................................................... vi
1. THE FACTS OF THE INCIDENT .......................................................................... 8
1.1. Overview of the accident................................................................................. 8
1.2. Injuries to persons ........................................................................................ 13
1.3. Damage to the aircraft .................................................................................. 13
1.4. Other damage............................................................................................... 13
1.5. Information about the personnel ................................................................... 13
1.6. Information about the aircraft ........................................................................ 14
1.7. Meteorological information ............................................................................ 14
1.8. Aids to navigation ......................................................................................... 16
1.9. Communications ........................................................................................... 17
1.10. Information about the aerodrome .............................................................. 17
1.11. Flight recorders ......................................................................................... 17
1.12. Aircraft wreckage and impact information .................................................. 21
1.13. Medical and pathological information ........................................................ 22
1.14. Fire............................................................................................................ 22
1.15. Survival aspects ........................................................................................ 22
1.16. Tests and research ................................................................................... 23
1.17. Organisational and management information ............................................ 23
1.18. Additional information ................................................................................ 24
1.19. Special investigation techniques ............................................................... 26
2. ANALYSIS .......................................................................................................... 27
2.1 Analysis of the meteorological factors related to the accident. .......................... 27
2.2 Analysis of the coordination between the flight crew and cabin crew regarding
the turbulence. ........................................................................................................ 28
2.3 Analysis of the actions of the flight crew ............................................................ 28
3. CONCLUSIONS .................................................................................................. 29
3.1. Findings ........................................................................................................ 29
3.2. Causes/contributing factors .......................................................................... 30
4. OPERATIONAL SAFETY RECOMMENDATIONS .............................................. 30
ANNEX I: 737 FLIGHT CREW OPERATIONS MANUAL. TURBULENCE ......... 31
ANNEX II: 737 FLIGHT CREW TRAINING MANUAL. OVERSPEED ................. 34
ANNEX III: FLIGHT DATA .................................................................................. 35
iii
ABBREVIATIONS
 ‘ “ Sexagesimal degrees, minutes and seconds

C Degrees Celsius
AEMET Spanish State Meteorological Agency
AFDS Autopilot Flight Director System
ARM Armed
ASR Airport Surveillance Radar
ATC Air Traffic Control (in general)
ATIS Automatic Terminal Information Service
ATPL Airline Transport Pilot Licence
CAS Calibrated Airspeed
CRM Crew Resource Management
CPL Commercial Pilot Licence
CVR Cockpit Voice Recorder
E East
FCOM Flight Crew Operating Manual
FCTM Flight Crew Training Manual
FL Flight Level
ft Feet
g Normal acceleration
GMFF ICAO code for Fez Airport
h Hours
hPa Hectopascals
IF Intermediate Fix
IFR Instrument Flight Rules
ILS Instrument Landing System
kg Kilograms
km Kilometres
kt Knots
L Left
LEBL ICAO code for Josep Tarradellas Barcelona-El Prat Airport
LNAV Lateral Navigation
m Metres
MCP Mode Control Panel
No. Number
N North
NM Nautical Mile
ICAO International Civil Aviation Organisation
PA Public Announcement
PF Pilot Flying
PFD Primary Flight Display
iv
PM Pilot Monitoring
QAR Quick Access Recorder
Altimeter subscale setting that indicates elevation while on the ground
QNH
(precision setting indicating elevation above mean sea level)
R Right
RW Runway
SAT Static Air Temperature
SEP Safety and Emergency Procedures
Information regarding the meteorological conditions on route that could
SIGMET
affect the safety of aircraft operations
SPD Speed Mode
STAR Standard Terminal Arrival Route
TAF Terminal Aerodrome Forecast
TCP Cabin Crew
UTC Coordinated Universal Time
VMC Visual Meteorological Conditions
VMO Maximum Operating Speed
W West
v
Technical report
A-037/2021
Owner Ryanair Designated Activity Company

Operator: Ryanair Designated Activity Company
Aircraft: Boeing 737-8AS, registration number EI-EPC
(Ireland)
Date and time of accident: 31 July 2021, 14:00 h1
Site of accident: On approach to Barcelona Airport
Persons on board: 6 (crew members), 172 (passengers)
Type of flight: Commercial air transport – Scheduled – With
passengers
Phase of flight: On route - Normal descent
Type of operation: IFR
Date of approval: 30 March 2022
Synopsis
Summary:
On Saturday 31 July 2021, the Boeing 737-8AS aircraft bearing registration number EI-
EPC left Fez Airport (GMFF) in Morocco and made its way to Josep Tarradellas
Barcelona-El Prat Airport (LEBL) in accordance with Standard Terminal Arrival Route
(STAR) MATEX 2E. It was scheduled to land on runway 07L.
During the descent, the flight crew observed the presence of cumulonimbus on the
weather radar and asked ATC to adjust the flight’s intended track in order to avoid the
cloud. The captain then informed the cabin crew of the possibility of turbulence during
the approach and asked them to proceed to secure the cabin.
The aircraft continued its descent and entered an area of undetected turbulence that
lasted for around two minutes, during which time the aircraft’s speed increased until it
approached the maximum operating speed (VMO). In order to reduce speed, the pilot
flying (PF) disengaged the autopilot and pitched nose up. Vertical acceleration of +3.09
g was recorded at that moment. One second later, he moved the control column in the
opposite direction, lowering the aircraft’s nose and recording vertical acceleration of -
0.18 g.
While this was happening, the cabin crew members were on their feet and beginning the
task of securing the cabin. As they did not have enough time to sit down or secure
1
All times referenced in this report are local time. The UTC is 2 hours less.
vi
themselves, they were thrown against various parts of the cabin and fell to the floor. After
the aircraft had passed through the area of turbulence, one of the cabin crew members
asked the flight crew to request an ambulance upon arrival at the airport, as two of the
cabin crew members had been incapacitated.
Upon landing at Barcelona Airport, the injured cabin crew members were attended by
the airport’s medical service. In addition to the injured cabin crew members, one
passenger also suffered head wounds. All of the injured parties were taken to hospital.
The investigation has concluded that the probable cause of the accident was the series
of actions taken by the PF to prevent the aircraft from exceeding the VMO while it was
flying through an area of turbulence. This resulted in vertical acceleration that injured a
passenger and two cabin crew members.
After carrying out an internal safety investigation into the accident, the operator
reinforced the flight crew’s training on the subject of turbulence and overspeed.
Additionally, among other measures, it proposed to publish the lessons learnt from this
event in its operational safety publications, and to include the event as a case study in
its crew training activities. All of these measures are considered appropriate, and no
safety recommendations are proposed.
vii
Technical report A-037/2021
1. THE FACTS OF THE INCIDENT
1.1. Overview of the accident
On Saturday, 31 July 2021, the Boeing 737-8AS aircraft bearing registration number EI-
EPC travelled from Fez Airport (GMFF) in Morocco to Barcelona/Josep Tarradellas-El Prat
Airport (LEBL). There were 178 people on board: two pilots, four cabin crew and 172
passengers2.
After studying the meteorological information provided by the flight dispatcher, the flight
crew concluded that the aircraft would probably encounter turbulence during the descent
into Barcelona and informed the cabin crew accordingly.
The cockpit was occupied by the captain, in the capacity of pilot flying (PF); the co-pilot, in
the capacity of pilot monitoring (PM); and an off-duty pilot from the same operator, who was
sitting in the observer’s seat.
The flight proceeded as normal and at 13:53:09 h, after 59 minutes in the air, the aircraft
began its descent towards Barcelona Airport. The autopilot and autothrottle were engaged.
The aircraft proceeded to the MATEX point in order to follow the MATEX 2E STAR and land
on runway 07L.
2
It was the third of four flights that the crew had been assigned for that day.
8
Image 1: Extract from the STAR to runway RWY07/L/R at LEBL
The autopilot’s vertical mode was MCP SPD3 and the autothrottle was in ARM4 mode. The
aircraft descended to FL200, which had been selected on the MCP5 altitude selector.
As ATC had delayed the start of the aircraft’s descent, in order to comply with the altitude
restrictions of the STAR the flight crew had gradually increased the speed selected in the
MCP while keeping the throttle at idle, thereby increasing the rate of descent.
The descent took place under tailwind conditions, the intensity of which at the time was 70
kt.
As they were descending through FL280, in the section between MATEX and BL028 points
of the MATEX 2E STAR the flight crew observed the presence of cumulonimbus on the
weather radar and asked ATC to adjust the flight intended track in order to avoid the cloud.
Consequently, at 13:57:32 h the aircraft adjusted its heading 14º to the left, to fly on a
heading of 065º.
3 In MCP SPD mode, the AFDS sets the pitch positions that are required in order to maintain the speed that
has been selected in the MCP.
4
In ARM mode, the autothrottle servos are inhibited, allowing the pilot to move the thrust levers manually. It
is the mode that is activated after the RETARD mode, whereby the autothrottle sets thrust at idle.
5
The pilot uses the MCP (Mode Control Panel) to instruct the autopilot to perform certain actions.
9
Subsequently, at 13:58:03 h (approximately 25 minutes before the estimated landing time),

the captain informed the cabin crew of the possibility of turbulence during the approach and
asked them to proceed to secure the cabin.
Directly afterwards, at 13:59:18 h ATC authorised the aircraft to descend to FL80 and, if
flight conditions permitted, to proceed to ASTEK6. This was accepted by the flight crew.
At 13:59:24 h, the PF extended the speed brakes. The tailwind component was 58 kt.
At 14:00:07 h, two minutes after the captain had spoken to the cabin crew and while
descending through FL180, the aircraft entered an area of turbulence. At that time, the
speed selected by the flight crew in the MCP was 320 kt, while the aircraft’s CAS was 325
kt. The engines’ N1 was at idle.
Over the next 29 seconds, the speed selected in the MCP was reduced to 308 kt. During
this period, the aircraft’s CAS ranged from 306 kt to 329 kt. Fluctuations in vertical
acceleration of between +0.50 g and +1.36 g were recorded, with changes that, on
occasion, reached up to 0.7 g within the space of one second7.
At 14:00:37, while descending through FL170, the aircraft’s CAS suddenly increased, going
from 322 kt to 334 kt within the space of one second.
In his statement, the captain explained that the PFD’s speed trend vector had started to
show large oscillations. In his view, the level of turbulence had become severe. He stated
that the flight was under VMC conditions.
In the captain’s opinion, the autopilot was unable to maintain the correct speed, so he
decided to disengage it to avoid exceeding the VMO (340 kt). At 14:00:38 h, he disengaged
the autopilot. An increase of +48 lb was then recorded with regard to the amount of force
applied to the control column.
One second later, at 14:00:39 h, the pitch angle had increased from -1.8º to +6.2º, reaching
vertical acceleration of +3.09 g.
After applying a force of -51 lb to the control column in the opposite direction, at 14:00:40
the pitch angle was reduced to -1.6º, with vertical acceleration of -0.18 g.
Meanwhile, the cabin crew members had begun their preparations to secure the cabin and
were at the rear of the aircraft. Two and a half minutes had passed since the captain had
made his call. The senior flight attendant, who was issuing a turbulence warning to the
passengers, was in the rear galley along with two other cabin crew members. The fourth
6
ASTEK is the intermediate fix (IF) of the ILS approach to runway 07L. It is positioned at 12 NM, at the end
of heading 07L.
7
Changes in the accelerometer’s readings of between 0.5 g and 1.0 g at the aircraft’s centre of gravity indicate
moderate turbulence. Changes in the accelerometer’s readings of 1.0 g and above at the aircraft’s centre of
gravity indicate severe turbulence.
10
cabin crew member was at row 29, attending to a passenger request. Suddenly, all of the
cabin crew members were thrown against different parts of the cabin and fell to the floor.
Activation of the AFT ENTRY DOOR8 Master Caution light was recorded at 14:00:41 h. The
co-pilot stated that he noted the activation of said light.
For the next 21 seconds, the aircraft remained practically level at FL170 and the force
exerted on the control column varied between +32 lb and -36 lb. Positive pitch angles were
recorded, while the CAS began to fall.
At 14:01:00 h, the CAS was 283 kt and the aircraft resumed its descent.
At 14:01:30h, while descending through 15,900 ft, the autopilot was re-engaged.
At 14:02:24 h, the aircraft exited the area of turbulence.
At 14:03:53 h, ATC authorised the aircraft to descend to 3,000 ft and maintain 250 kt to
ASTEK as number 1 and to ILS Z for runway 07L.
8
This light was activated when the senior flight attendant was thrown against the door.
11
1 13:56:00 FL310 CAS 290 kt The aircraft overflies MATEX.

2 13:57:32 FL270 CAS 305 kt The aircraft begins its diversion onto a heading
of 065º.
3 13:58:03 FL250 CAS 314 kt The captain warns the cabin crew of likely
turbulence during the approach.
4 13:59:18 – 13:59:24 FL210 CAS 318 kt ATC authorises the aircraft to proceed to
ASTEK and the speed brakes are extended.
5 14:00:07 FL180 CAS 325 kt The aircraft enters the area of turbulence.
6 14:00:38 FL170 CAS 334 kt Autopilot disengaged; vertical acceleration of
+3.09 g.
7 14:01:30 FL160 CAS 289 kt Autopilot re-engaged.
8 14:02:24 FL130 CAS 296 kt The aircraft exits the area of turbulence.
9 14:04:21 FL90 CAS 276 kt Call from the cabin crew, advising that crew
members have been injured.
10 14:04:53 FL80 CAS 259 kt The flight crew contacts ATC to request an
ambulance upon arrival
Image 2: Path of the aircraft during the descent
At 14:04:21 h, one of the cabin crew members called the flight crew to inform them that two
cabin crew members had been injured and that an ambulance would be required upon
arrival.
At 14:04:53 h, the flight crew contacted ATC to request an ambulance upon arrival at
Barcelona.
After landing at Barcelona/Josep Tarradellas-El Prat Airport, the injured cabin crew
members were attended to by the airport’s medical service. In addition to the injured cabin
12
crew members, one passenger also suffered head wounds. All of the injured parties were
taken to hospital.
1.2. Injuries to persons
Injuries Crew Passengers Total in the Others

aircraft
Fatal
Serious 1 1 2
Minor 1 1
Unharmed 4 171 175
TOTAL 69 172 178
1.3. Damage to the aircraft
The aircraft did not sustain any damage.
1.4. Other damage
There was no other damage.
1.5. Information about the personnel
1.5.1. Information about the captain
The 29-year-old captain had an ATPL (Airline Transport Pilot Licence) issued for the first
time on 29 April 2019, with a B737 300-900 rating and an instrument flight rating, both valid
until 30 April 2022.
His Class 1 medical certificate was valid until 7 June 2022.
As of 31 July 2021, he had amassed a total of 4,041.77 h of experience.
With regard to his training, amongst other items, he had received specific training in the
following:
• Recovery from overspeed while cruising, on 15 April 2021.

• Procedures upon entering an area of severe turbulence, recovery from overspeed
and awareness of g-load factor, on 10 April 2019.
• Effective communication and coordination within and outside the cockpit and with
other operational personnel and ground services, on 13 April 2019.
9
The crew comprised two flight crew and four cabin crew.
13
1.5.2. Information about the co-pilot
The 26-year-old co-pilot had a CPL (Commercial Pilot Licence) issued for the first time on
7 March 2018, with a B737 300-900 rating and an instrument flight rating, both valid until 31
March 2022.
His Class 1 medical certificate was valid until 1 December 2021.
As of 31 July 2021, he had amassed a total of 1,692.8 h of experience.
With regard to his training, amongst other items, he had received specific training in the
following:
• Recovery from overspeed while cruising, on 10 April 2021.

• Recovery from overspeed and awareness of g-load factor, on 23 January 2019.
• Effective communication and coordination within and outside the cockpit and with
other operational personnel and ground services, on 1 February 2018.
1.6. Information about the aircraft
• Make: Boeing
• Model: 737-8AS
• Year of manufacture: 2011
• Serial number: 40312
• Registration number: EI-EPC
• Maximum take-off weight: 66,990 kg
• Number of engines: 2
• Type of engines: CFM56-7B26
• Information about the owner and operator: The aircraft has been registered in the
Irish Aircraft Register in the name of Ryanair Designated Activity Company since 23
March 2011.
The aircraft has an Airworthiness Certificate and an Airworthiness Review Certificate, valid
until 22 March 2022.
After the accident, an inspection was carried out as specified in the Aircraft Maintenance
Manual for severe turbulence. No anomalies were found.
The aircraft’s VMO is 340 kt.
1.7. Meteorological information
1.7.1 Local meteorological conditions
The ATIS for Barcelona Airport at 12:00 UTC on the day of the accident was:
14
31/07/2021 12:00:16 ATIS_ARRIVAL LEBL INFO ARR Y TIME 1200 ILS Z APCH
EXPECTED RWY IN USE FOR ARR 07L AND FOR DEP 07R TRL 75 REMAIN ON TWR
FREQ AFT LDG CTN RNAV APCH TRANSITIONS IN USE FM IAF CHECK FMS EXPECT
1E APCH TRANSITIONS FOR RWY 07L WIND TDZ 140 DEG 6 KT VRB BTN 110 AND 180
DEG CAVOK T 25 DP 16 QNH 1010 NOSIG10
The TAF for Barcelona Airport issued at 11:00 UTC on the day of the accident indicated a
likelihood of storm activity from 14:00 UTC onwards:
TAF LEBL 311100Z 3112/0112 13010KT 9999 FEW020 TX29/3114Z TN20/0106Z PROB40
TEMPO 3114/3121 VRB20G35KT 3000 TSRA SCT020CB BECMG 3117/3120 34005KT
PROB30 TEMPO 0100/0106 BKN014 BECMG 0110/0112 20010KT
SIGMET number 4 issued by the weather monitoring station in Valencia was:
LECB SIGMET 4 VALID 311100/311500 LEVALECB

BARCELONA FIR/UIR FRQ TSGR FCST WI N4008 W00026 – N41 E00005 – N4133
E00123 – N4058 E00155 – N3946 E00111 – N4008 W00026 TOP FL460 STNR NC
The SIGMET message indicated

a forecast of storms between
11:00 UTC and 15:00 UTC in the
area delimited by the red
polygonal line (see the image on
the right), which comprised the
aircraft’s arrival and approach
path
Image 3: Area in which storms were forecast, as delimited in

the SIGMET
For its part, AEMET provided the investigation with a weather report in which it concluded
that the meteorological conditions on 31 July 2021 during the aircraft’s approach into
Barcelona Airport at 12:15 UTC were characterised by the presence of wind shear,
originating from the gust fronts of the storm formations located in the vicinity of the airport.
1.7.2 Meteorological information extracted from the QAR data
Data on outside temperature, wind speed and intensity were extracted from the QAR for the
period in which the aircraft crossed the area of turbulence.
10
The runway in use for landing was 07L. Wind intensity was 6 knots, with a direction of 140º, varying between
110º and 180º. Visibility was greater than 10 km, with an absence of clouds below the CAVOK reference
height and an absence of cumulonimbus and tower-shaped cumulus clouds. The temperature was 25°C, with a
dew point of 16°C. The QNH was 1010 hPa.
15
During this period, changes were recorded in wind direction and intensity, along with
oscillations in the figures for static air temperature (SAT). These variations are shown in the
following graphs:
Image 4: Graph showing the variation in SAT with altitude in the area of turbulence
Image 5: Graph showing the variation in wind direction and speed in the area of turbulence
1.8. Aids to navigation
N/A.
16
1.9. Communications
The most relevant communications between the flight crew and ATC are detailed in section
1.11. There were no reports of turbulence from other aircraft or ATC; however, requests for
track deviations from aircraft to avoid storm clouds were heard on the frequency.
1.10. Information about the aerodrome
Josep Tarradellas Barcelona-El Prat Airport (ICAO code LEBL) is located 10 km south-west
of the city of Barcelona. Its elevation is 4 m and it has three runways: 02/20, 07L/25R and
07R/25L. The coordinates of its reference point are as follows: 41º17'49" N, 002º04'42" E.
At the time of the accident, the daytime non-preferred configuration was being used, i.e. the
Easterly configuration, with parallel runways. Consequently, flights were landing on runway
07L.
1.11. Flight recorders
This section presents all of the information taken from the flight recorders (CVR and QAR),
along with the information from the air traffic services, from the moment when the aircraft
began its descent from its cruising altitude of FL380 to the moment when it landed.
1.11.1 Descent
At 13:50:47 h, when the aircraft was flying at FL380, the flight crew asked ATC for
authorisation to begin the descent. ATC delayed the aircraft’s descent for the next two
minutes before finally authorising it to descend to FL330. This was then selected by the
flight crew using the MCP altitude selector. With the autopilot and autothrottle engaged, the
flight crew carried out the descent in ARM/LNAV/MCP SPD modes11.
Via the MCP speed selector, the pilots selected a speed of 240 kt/0.76 Mach, which they
increased as the aircraft descended.
The flight crew commented on the impossibility of complying with the restriction on
overflying the MATEX point at FL250 or lower, owing to the delayed authorisation of the
descent.
The weather radar was being used.
At 13:53:51 h, the aircraft was authorised to descend to FL310, which was then selected by
the flight crew using the MCP altitude selector. The pilots continued to increase the aircraft’s
speed in order to increase the rate of descent.
11
The AFDS flight mode indications are expressed as follows: AUTOTHROTTLE MODE/ LATERAL
MODE/ VERTICAL MODE.
17
At 13:54:51 h the aircraft was authorised to descend to FL200, which was then selected by
the flight crew using the MCP altitude selector. The speed selected had been increased to
270 kt, while the CAS was 268 kt. The tailwind component was 70 kt.
At 13:56:00 h, the aircraft overflew the MATEX point while descending through FL310.
At 13:57:10 h, the flight crew requested a heading of 065° to avoid a cloud formation. The
request was approved by ATC.
At 13:58:03 h, the captain called the cabin crew to inform them that they may experience
turbulence during the approach and that they should begin to prepare the cabin for landing.
At 13:58:54 h, while descending through FL220, the aircraft was authorised to descend to
FL150, which was then selected by the flight crew using the MCP altitude selector. The
speed selected had been increased to 320 kt, while the CAS was 317 kt.
At 13:59:18 h, the aircraft was authorised to proceed to ASTEK if flight conditions permitted.
This was accepted by the flight crew. The aircraft was 64 NM from the touchdown zone.
At 13:59:24 h, deployment of the speed brakes commenced, during the descent through
FL200. The tailwind component was 58 kt.
At 13:59:33 h, the aircraft was authorised to descend to FL80, which was then selected by
the flight crew using the MCP altitude selector.
1.11.2 Flight through the area of turbulence
At 14:00:07 h, while descending through FL180, the aircraft entered an area of turbulence
that lasted for approximately two minutes, until 14:02:24 h. During this period, the speed
selected was 320 kt, while the CAS was 325 kt.
From the start of the turbulence to the disengagement of the autopilot
Over the next 29 seconds the speed selected was reduced to 308 kt. During this period, the
aircraft’s CAS ranged from 306 kt to 329 kt. Fluctuations in vertical acceleration of between
+0.50 g and +1.36 g were recorded, with changes that, on occasion, reached up to 0.7 g
within the space of one second.
18
Image 6: Flight parameters from the start of the turbulence to the disengagement of the
autopilot
At 14:00:36 h, while descending through FL170, the CAS was 322 kt and the speed selected
was 308 kt.
One second later, at 14:00:37 h, the CAS increased to 334 kt. The pitch angle was -1.8º.
Interval in which the autopilot was disengaged
At 14:00:38 h, the disengagement of the autopilot was recorded. The force on the control
column increased to +48 lb. Vertical acceleration increased to +3.09 g: the highest amount
recorded during this period.
One second later, at 14:00:39 h, the pitch angle was +6.2º, the force on the control column
was -51 lb, and the CAS was 328 kt. Vertical acceleration decreased to -0.18 g: the lowest
amount recorded during this period.
At 14:00:41 h, the Master Caution light was activated.
For the next 21 seconds, the aircraft remained practically level at FL170 and the force
exerted on the control column varied between +32 lb and -36 lb.
Positive pitch angles were recorded, while the CAS began to fall. At 14:01:00 h, the CAS
was 283 kt and the aircraft resumed its descent.
19
Image 7: Flight parameters for the interval in which the autopilot was disengaged
The captain stated that he did not want to exceed the VMO and that he was going to
temporarily disengage the autopilot.
From the re-engagement of the autopilot to the aircraft’s exit from the area of turbulence
At 14:01:30 h, while descending through 15,900 ft, the autopilot was re-engaged.
During this period, vertical acceleration reached a maximum of +1.31 g and a minimum of
+ 0.68 g, with changes that, on occasion, reached 0.4 g within the space of one second.
At 14:02:24 h, the aircraft exited the area of turbulence.
20
Image 8: Flight parameters for the period from the re-engagement of the autopilot to the aircraft’s
exit from the area of turbulence
1.11.3 Approach and landing
At 14:03:53 h, the aircraft was authorised to descend to 3,000 ft and to ILS Z for runway
07L at Barcelona Airport. ATC informed the flight crew that it was number 1 and that it could
maintain 250 kt until ASTEK.
At 14:04:21 h, TCP (cabin crew member) 2 called the cockpit and informed the flight crew
that TCPs 1 and 4 had suffered injuries and would require an ambulance upon arrival at the
airport. At 14:04:53 h, the flight crew contacted ATC to request an ambulance upon arrival
at Barcelona.
Throughout the rest of the flight, the cabin crew updated the pilots with regard to the
condition of the injured cabin crew members. In turn, the pilots passed this information on
to ATC.
The aircraft landed on runway 07L at 14:12:01 h.
1.12. Aircraft wreckage and impact information
N/A.
21
1.13. Medical and pathological information
We have found no evidence to suggest that the actions of the cabin crew or flight crew were
affected by any physiological or disabling factors.
1.14. Fire
There were no signs of fire during the flight or after the impact.
1.15. Survival aspects
The cabin crew was comprised of four crew members. According to their statements, 20 or
30 minutes before landing the captain called them and asked them to proceed to secure the
cabin12. He also mentioned that there might be turbulence during the approach, although
he did not specify how intense it would be.
The captain’s call was taken in the rear galley by TCP 2, who passed the information on to
TCPs 1 and 3, who were also in the rear galley.
They had just started to secure the cabin. TCP 1 was in the process of making a passenger
announcement (in English) warning the passengers of turbulence; however, he/she had to
interrupt the announcement when the aircraft experienced - as the cabin crew described it
- severe turbulence, which affected the crew members in various ways.
• TCP 1 was standing up in the rear galley, issuing the passenger warning. His/her
head hit the ceiling of the aircraft and he/she fell to the floor, between door L213 and
the left-hand jump seat. During the fall, he/she also hit the door. TCP 1 was left
unable to breathe and with severe pain in his/her back. TCP 2 moved him/her to the
outer left-hand jump seat; however, he/she was unable to sit down correctly as
he/she had suffered a spinal fracture. TCP 1 remained in the same position for the
remainder of the flight.
• TCP 2 was also standing up in the rear galley. Although he/she cannot recall it
happening, he/she believes he/she must have been thrown against the door or the
galley. TCP 2 then managed to sit on the outer right-hand jump seat, although
he/she was unable to fasten the harness. TCP 2 suffered bruising and other lesions.
Subsequently, he/she was able to assist TCP 1 and move him/her from the floor to
the outer left-hand jump seat. TCP 2 remained seated with the senior flight
attendant.
• TCP 3, who was also standing up in the rear galley, was thrown against the
equipment above the right-hand jump seat, and then against the galley. TCP 3
suffered bruising and other lesions. TCP 3 sat down in the inner right-hand jump
12
According to the operator, the normal procedure for securing the cabin begins 15 minutes before landing.
13
Door L2 is the rear left door of the aircraft.
22
seat and fastened the harness. TCP 3 also had to take care of his/her colleagues,
TCPs 1 and 4, who were unable to perform their functions.
• TCP 4 was at row 29, attending to a passenger request, when he/she fell down and
was thrown against the toilet door. With the help of TCP 3 he/she was able to sit in
the outer right-hand jump seat and fasten the harness. TCP 4 remained there for
the rest of the flight.
The following diagram shows the position of each cabin crew member, marked with a light
grey circle. The position of the passenger who suffered serious injuries is marked with a
purple circle.
TCP #2
TCP #4 TCP #3
TCP #1
Image 9: Diagram showing the position of the cabin crew members and the passenger who was injured
during the event
When the event occurred, all of the passengers were seated. The injured passenger was
sitting in seat 29 E. When the aircraft landed, the cabin crew advised that the passenger
had been injured.
As TCPs 1 and 4 were incapacitated, TCP 2 assumed the role of senior flight attendant.
TCP 2 called the captain to request an ambulance and informed him that two cabin crew
members were injured. The ambulance was waiting for them when the aircraft landed. The
medical team entered the aircraft in order to attend to the crew and passenger, who were
subsequently taken to hospital in the ambulance.
1.16. Tests and research
N/A
1.17. Organisational and management information
N/A.
23
1.18. Additional information
1.18.1. Meteorological information supplied to the crew during flight preparation
The meteorological information supplied to the flight crew during flight preparation was
similar to that detailed in section 1.7.1 of this report. The captain explained that he based
the likelihood of encountering turbulence during the approach on the forecasts warning of
storms in the area and in the vicinity of Barcelona Airport.
Additionally, the operational flight plan between Fez and Barcelona airports indicated wind
shear of between 3 and 4 units at the STAR points. The operator explained that wind shear
of 3 units or above indicates a likelihood of moderate turbulence.
1.18.2. Boeing’s turbulence and overspeed procedures.
The 737 Flight Crew Operations Manual (FCOM) drawn up by Boeing sets out the
procedure for operating the aircraft in the event that turbulence is encountered while flying.
Annex I of this report includes an excerpt from this document.
The FCOM explains that in the event of light or moderate turbulence, the autopilot and/or
the autothrottle may remain engaged, unless their performance is unsatisfactory. There may
be temporary speed variations of between 10 and 15 kt
In the event of severe turbulence, the FCOM states that the use of autopilot is optional and
recommends adjusting the aircraft’s speed to 0.76 Mach or 280 kt and maintaining its
attitude with the wings level, thereby permitting variations in altitude. It warns that the control
systems should not be subjected to sudden large inputs.
The 737 Flight Crew Training Manual (FCTM) drawn up by Boeing sets out the procedure
for operating the aircraft in the event of overspeed. Annex II of this report includes an
excerpt from this document.
The FCTM for the 737 NG/MAX recommends that in the event of unexpected overspeed,
the flight crew should keep the autopilot engaged, unless it is clear that the autopilot is not
correcting the overspeed event.
The FCTM also warns that disengaging the autopilot to prevent or reduce the severity of an
accidental overspeed event can result in abrupt changes to the pitch angle.
1.18.3. Ryanair Operations Manual: Turbulence Procedure.
Section 8.3.8.3 of Ryanair Operations Manual Part A, which addresses the subject of
turbulence, states the following:
Flights shall not be planned through areas with severe turbulence. The procedures are
included in FCOM Volume 1 and in the SEP.
24
ATC must be notified of severe turbulence. Additionally, an ASR must be filled out and a
note made in the aircraft’s technical logbook.
1.18.4 Coordination procedures in the event of turbulence
The operator’s Operations Manual Part A describes the procedures for coordination
between the flight crew and cabin crew when turbulence is expected during the flight. It also
explains how to act in the event of unexpected turbulence.
If the flight crew anticipates the possibility of passing through areas of turbulence during the
flight, it must inform the cabin crew accordingly. Although the procedure does not include a
standard message for communicating this information, it does stipulate that the following
terms be used when communicating the level of turbulence: LIGHT, MODERATE and
SEVERE, when referring to said turbulence. Each of these levels is associated with a series
of actions to be carried out by the cabin crew, ranging from continuing their activities with
caution, to ceasing their activities immediately.
The operator’s procedures state that if the information provided during flight preparation
predicts that the aircraft will be flying through areas of turbulence, this information must be
communicated to the cabin crew before the flight begins. Once in the air, the flight crew
must communicate with the cabin crew in order to inform them of the possibility of passing
through an area of turbulence. The flight crew will also activate the fasten-seatbelt sign.
The procedure specifies that the cabin crew should not wait to receive a warning from the
flight crew in order to cease their activities, in the event that the level of turbulence is such
that they need to cease their activities and sit down. In particular, the procedure specifies
that in the event of suddenly and unexpectedly encountering moderate or severe
turbulence, the senior flight attendant must instruct the rest of the TCPs to go to their seats
and issue a passenger warning instructing passengers to remain seated and fasten their
seatbelts.
In the event of severe turbulence, the cabin crew must sit down in the nearest available
seat, even if it is a seat intended for passengers.
1.18.5 Actions taken by the operator after the event
After the event, the operator carried out an internal safety investigation, the outcome of
which was the provision of additional simulator and line training for the flight crew on the
subjects of overspeed and flying through turbulence.
It also considered14 the following measures:
• A debriefing on the event for the cabin crew.

• Inclusion of the event as a case study in the CRM training activities.
14
As of the date of publication of this report, Ryanair has confirmed to the investigation that two of the three
measures have been implemented.
25
• Inclusion of the event in the operator’s publications promoting operational safety.
1.19. Special investigation techniques
N/A.
26
2. ANALYSIS
Several factors have been analysed in relation to this accident: those relating to the
meteorological conditions during the flight and in the area where the accident occurred; the
coordination between the flight crew and cabin crew; and the actions of the flight crew.
2.1 Analysis of the meteorological factors related to the accident.
Analysis of the meteorological information supplied to the flight crew
The meteorological forecasts supplied to the flight crew prior to beginning the flight
predicted storms in both the Barcelona area and in the vicinity of the airport. Additionally,
the operational flight plan between Fez and Barcelona airports indicated wind shear of
between 3 and 4 units at the STAR points, which meant it was likely that the aircraft’s
descent and approach would take place within an area of turbulence.
The captain concurred with the assessment, and he informed the cabin crew accordingly.
Analysis of the meteorological conditions in the area of the accident
The flight crew were following the MATEX 2E STAR, and had the weather radar connected,
when they detected a storm formation in the section between MATEX and BL028 points. In
order to avoid entering the storm, they asked ATC to divert them 14º to the left. According
to the captain, this gave them a sufficient margin of separation from the cloud. He also
stated that they were in VMC and the air was stable.
There had been no reports of turbulence; however, requests for track deviations from
aircraft to avoid storm clouds were heard on the frequency.
According to the flight crew, a few moments later the aircraft began to pass through an area
of turbulence. The crew’s statement concurs with the data obtained from the QAR, which
show significant changes in vertical acceleration as well as variations in outside temperature
and wind intensity, direction and speed. From the moment the aircraft entered the area of
turbulence to the moment the autopilot was disengaged, the level of turbulence varied from
light to moderate, with variations in vertical acceleration that, on occasion, reached 0.7 g
within the space of one second. During this same period, the aircraft’s speed underwent
fluctuations that reached a maximum of 12 kt within the space of one second, moments
before the disengagement of the autopilot.
With regard to the period after the disengagement of the autopilot, it has not been possible
to determine the level of turbulence, as the actions applied to the control column contributed
to the variations in vertical acceleration that occurred while the autopilot was disengaged.
During this period, changes in vertical acceleration reaching 3.2 g were recorded within the
space of one second, coinciding with changes to the pitch angle and the level of force
exerted on the control column.
27
During the period after the autopilot was re-engaged, the level of turbulence was light, with
variations in vertical acceleration that, on occasion, reached 0.4 g within the space of one
second.
2.2 Analysis of the coordination between the flight crew and cabin crew regarding
the turbulence.
During the pre-flight briefing, the flight crew informed the cabin crew of the likelihood of
encountering turbulence during the descent into Barcelona. According to the statements of
both the pilots and the cabin crew, the captain also informed the passengers of this
likelihood in his passenger announcement.
Once the aircraft had begun to descend, and after deviating in order to avoid entering a
storm cloud, the captain called the cabin crew to inform them that they might encounter
turbulence during the approach and that they should start to secure the cabin. During this
call, the captain did not specify the level of turbulence (light/moderate/severe), nor did he
indicate how much time the cabin crew would have to secure the cabin.
At the time of the captain’s call, the estimated remaining flight time was approximately 25
minutes. In other words, he asked the cabin crew to start preparing to secure the cabin
earlier than usual (normally the request is made 15 minutes before landing), as he
anticipated having to cross an area of cloud - whose associated turbulence might affect the
passengers and cabin crew - during the approach. The message did not communicate a
sense of urgency with regard to securing the cabin; however, the request to begin
preparations was issued early, as a precaution, so that the cabin would be secure for the
approach.
Barely two minutes after the captain called to inform the cabin crew of the likelihood of
encountering turbulence during the approach, the aircraft entered an area of turbulence that
had not been detected by the flight crew. According to the TCP, they were starting to secure
the cabin when they were suddenly thrown against various parts of the galley and cabin,
and then fell to the floor. From their perspective, it was a sudden encounter with severe
turbulence in which they did not have enough time to sit down or even grab onto any
elements within the cabin.
2.3 Analysis of the actions of the flight crew
Because ATC had delayed the aircraft’s descent, the PF increased the speed selected in
the MCP as the aircraft descended, to increase the rate of descent. Subsequently, the flight
crew was authorised to proceed to ASTEK, which shortened the route to the touchdown
area and kept the aircraft positioned above the descent profile. The tailwind component was
58 kt. The PF extended the speed brakes to continue increasing the rate of descent.
According to the pilots, they had managed to avoid the storm cloud and were under VMC.
Thus, the aircraft entered an area of undetected turbulence with its speed brakes extended
and at a CAS of 325 kt.
28
The PF reduced the speed selected to 308 kt; however, the area of turbulence caused
changes in the aircraft’s calibrated speed, which fluctuated between 306 kt and 329 kt.
Some 30 seconds after entering the area of turbulence, the aircraft’s speed suddenly
increased from 322 kt to 334 kt. According to the PF, the speed trend vector was showing
large oscillations and he saw that the autopilot was not correcting the changes in speed.
The PF disengaged the autopilot and pitched nose up, to reduce speed. During this
manoeuvre, vertical acceleration of +3.09 g was reached. One second later, the pilot
performed the opposite action, lowering the aircraft’s nose. This resulted in vertical
acceleration of -0.18 g, representing a change of 3.2 g within the space of one second.
Although the VMO was not exceeded in this instance, the manufacturer recommends that in
the event of unexpected overspeed, the flight crew should keep the autopilot engaged,
unless it is clear that the autopilot is not correcting the overspeed event. It also warns that
disengaging the autopilot to prevent or reduce the severity of an unexpected overspeed
event can result in abrupt changes to the pitch angle.
The PF explained that, in his opinion, the turbulence had become severe. Under such
conditions, the manufacturer recommends reducing speed to 280 kt. The aircraft reached
speeds near to 280 kt during the period in which the autopilot was disengaged.
After carrying out an internal safety investigation into the accident, the operator reinforced
the flight crew’s training on the subject of turbulence and overspeed. Additionally, among
other measures, it proposed to publish the lessons learnt from this event in its operational
safety publications, and to include the event as a case study in its crew training activities.
All of these measures are considered appropriate, and no safety recommendations are
proposed.
3. CONCLUSIONS
3.1. Findings
• The pilots had been given training on the subject of overspeed and flying under
turbulent conditions.
• After analysing the meteorological information for the flight, the captain informed the
cabin crew of the likelihood of encountering turbulence during the descent into
Barcelona.
• There were no reports of turbulence from other aircraft or ATC.
• The fasten-seatbelt sign remained switched on throughout the flight, in line with the
operator’s COVID procedures.
• The aircraft’s crew visually observed certain cloud formations and performed a
visual manoeuvre to avoid them.
• The captain warned the cabin crew of the possibility of turbulence during the
approach and asked them to begin their preparations to secure the cabin.
29
• Two minutes after the captain spoke to the cabin crew, the aircraft entered an area
of undetected turbulence.
• The aircraft’s speed suddenly increased to 334 kt, although it did not exceed the
VMO (340 kt).
• In order to avoid exceeding the VMO, the PF disengaged the autopilot and pulled on
the control column, lifting the aircraft’s nose. He then moved the control column in
the opposite direction, i.e., pushing it, which brought the aircraft's nose down.
• During this manoeuvre to avoid exceeding the VMO, vertical acceleration reached
+3.09 g, and one second later fell to -0.18 g.
• The cabin crew, who prior to that moment had been standing up, fell to the floor.
Two of them were incapacitated for the remainder of the flight.
• When the aircraft landed, the crew advised that a passenger had been injured and
had suffered wounds to his head.
• The aircraft involved in the accident did not report any turbulence to ATC.
Commission Implementing Regulation (EU) 923/2012 of 26 September 2012 and
the Air Traffic Regulation stipulate that moderate or severe turbulence must be
reported by means of a special air report.
3.2. Causes/contributing factors
The investigation has concluded that the probable cause of the accident was the series of
actions taken by the PF to prevent the aircraft from exceeding the VMO while it was flying
through an area of turbulence. This resulted in vertical acceleration that caused severe
injuries to a passenger and two cabin crew members.
4. OPERATIONAL SAFETY RECOMMENDATIONS
The measures proposed by the operator are considered appropriate, and no operational
safety recommendations are proposed.
30
ANNEX I: 737 FLIGHT CREW OPERATIONS MANUAL. TURBULENCE
31
32
33
ANNEX II: 737 FLIGHT CREW TRAINING MANUAL. OVERSPEED
34
ANNEX III: FLIGHT DATA
35
36

A-037-2021 Final Report NM

Uploaded by

Copyright:

Available Formats

A-037-2021 Final Report NM

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A-037-2021 Final Report NM

Uploaded by

Copyright:

Available Formats

Technical report

Accident on 31 July 2021 involving a Boeing

 ‘ “ Sexagesimal degrees, minutes and seconds

Owner Ryanair Designated Activity Company

Date of approval: 30 March 2022

1. THE FACTS OF THE INCIDENT

1.1. Overview of the accident

Image 1: Extract from the STAR to runway RWY07/L/R at LEBL

Subsequently, at 13:58:03 h (approximately 25 minutes before the estimated landing time),

At 14:02:24 h, the aircraft exited the area of turbulence.

1 13:56:00 FL310 CAS 290 kt The aircraft overflies MATEX.

Image 2: Path of the aircraft during the descent

1.2. Injuries to persons

Injuries Crew Passengers Total in the Others

1.3. Damage to the aircraft

The aircraft did not sustain any damage.

1.4. Other damage

There was no other damage.

1.5. Information about the personnel

1.5.1. Information about the captain

His Class 1 medical certificate was valid until 7 June 2022.

As of 31 July 2021, he had amassed a total of 4,041.77 h of experience.

• Recovery from overspeed while cruising, on 15 April 2021.

1.5.2. Information about the co-pilot

His Class 1 medical certificate was valid until 1 December 2021.

As of 31 July 2021, he had amassed a total of 1,692.8 h of experience.

• Recovery from overspeed while cruising, on 10 April 2021.

1.6. Information about the aircraft

The aircraft’s VMO is 340 kt.

1.7. Meteorological information

1.7.1 Local meteorological conditions

SIGMET number 4 issued by the weather monitoring station in Valencia was:

LECB SIGMET 4 VALID 311100/311500 LEVALECB

The SIGMET message indicated

Image 3: Area in which storms were forecast, as delimited in

1.7.2 Meteorological information extracted from the QAR data

1.8. Aids to navigation

1.10. Information about the aerodrome

1.11. Flight recorders

The weather radar was being used.

1.11.2 Flight through the area of turbulence

From the start of the turbulence to the disengagement of the autopilot

Interval in which the autopilot was disengaged

At 14:00:41 h, the Master Caution light was activated.

At 14:02:24 h, the aircraft exited the area of turbulence.

1.11.3 Approach and landing

The aircraft landed on runway 07L at 14:12:01 h.

1.12. Aircraft wreckage and impact information

1.13. Medical and pathological information

1.15. Survival aspects

1.16. Tests and research

1.17. Organisational and management information

1.18. Additional information

1.18.1. Meteorological information supplied to the crew during flight preparation

1.18.2. Boeing’s turbulence and overspeed procedures.

1.18.3. Ryanair Operations Manual: Turbulence Procedure.

1.18.4 Coordination procedures in the event of turbulence

1.18.5 Actions taken by the operator after the event

It also considered14 the following measures: