On August 20, 2008 an MD-82 crashed after takeoff from runway 36 left at Madrid Barajas International Airport, Spain.
An interim accident report by the CIAIAC of Spain indicates that the leading edge slats and trailing edge flaps were not extended during takeoff. This reduced the airplane’s ability to achieve adequate aerodynamic lift. The report also indicates that no takeoff warning system (TOWS) annunciations were recorded by the cockpit voice recorder (CVR) during the takeoff roll. According to the airplane manufacturer, the TOWS should have annunciated a clear and audible aural warning when the throttles were advanced to takeoff power while the trailing edge flaps were not extended in a takeoff position.
The Spanish report contained several safety recommendations. The National Transportation Safety Board immediately issued five safety recommends to the Federal Aviation Administration (FAA):
Require that operators of Boeing DC-9 series, MD-80 series, MD-90 series, and B-717 airplanes include items in their preflight checklists to verify that a check of the takeoff warning system is accomplished before every flight. (A-09- 67)
Modify 14 Code of Federal Regulations Part 25 to include a certification standard that will ensure either that 1) the takeoff warning system (TOWS) cannot be disabled by a single failure or 2) if the system fails or has power removed while the airplane is operating on the ground, a discrete and clear annunciation of the loss of TOWS protection is provided to flight crews. (A-09-68)
Assess the history of pilot errors related to takeoff configuration and identify needed mitigating design elements; require inclusion of such design elements when determining current and future aircraft certifications. (A- 09-69)
Convene a meeting of industry, research, and government authorities, including international representatives, to develop guidance on industry best practices in operational areas (including checklist design, training, and procedures) that relate to flight crews properly configuring airplanes for takeoff and landing. (A-09-70)
Require operators to modify their takeoff and landing checklists to reflect the best practices identified as a result of the meeting recommended in Safety Recommendation A-09-70. (A-09-71) (NTSB)