B738, en-route, northeast of Lanzarote Canaries Spain, 2018
B738, en-route, northeast of Lanzarote Canaries Spain, 2018
Summary
On 10 February 2018, soon after a Boeing 737-800 en-route to Fuerteventura had begun its cleared descent from FL370 to FL130, the controller changed the clearance limit to FL360 after noticing a previously overlooked potential loss of separation with traffic below at FL350. The attempt to level off as instructed resulted in a mismanaged manual intervention which led to an upset lasting about a minute during which a passenger carrying a small child fell and sustained serious injury. The significant delay in getting the injured passenger to hospital after landing led to systemic deficiencies in airport medical assistance being identified.
Description
On 10 February 2018, a Boeing 737-800 (EI-EKI) being operated by Ryanair on an international passenger flight from Edinburgh to Fuerteventura as RYR8421 and in the cruise at FL370 requested and was given descent clearance to FL130 but upon beginning this descent, the controller instructed the aircraft to stop at FL360. The attempt to achieve this involving manual flight path control resulted in a brief period of abrupt changes in vertical acceleration during which one of the passengers fell and sustained a serious leg injury. Subsequent hospitalisation on arrival was significantly delayed.
Investigation
Once notified of the Accident several days after it had occurred, an Investigation by the Spanish Commission for the Investigation of Accidents and Incidents (CIAIAC) was commenced. This notification delay meant that relevant data from both the CVR and FDR had been overwritten, however the operator was requested to provide a copy of the QAR data used for OFDM purposes and did so. All relevant ATC recorded data were also available. It was noted that the aircraft crew had consisted of a 38 year-old Captain of Italian nationality and a 29 year-old First Officer of British nationality and that the ATS sector involved had been the ‘RNE’ sector of the Canaries’ TMA.
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