Source IAA:
The Irish Aviation Authority (IAA) released their result of their investigation into the fuel emergencies concluding:
- The aircraft in all three cases departed for Madrid with fuel in excess of Flight Plan requirements.
- The Crew diverted to Valencia with fuel in excess of the minimum diversion fuel depicted on the Flight Plan.
- Diverting with fuel close to minimum diversion fuel in the circumstances presented on the evening in question was likely to present challenges for the crew. Initial holding was to the Southwest of Madrid which increased the diversion time to the alternate.
- The Crew declared an Emergency in accordance with EU-OPS when the calculated usable fuel for landing at Valencia was less than final reserve.
- The Met conditions in Madrid were more significant than anticipated by the Crew when reviewing the Met Forecast. Consequently the additional fuel carried was influenced by the forecast.
- Operations into a busy airport such as Madrid in Thunderstorm conditions with the associated traffic levels can add significant delays to all traffic.
- Air Traffic Control in Valencia was under significant pressure with the number of diversions arriving in their airspace.
The IAA quoted internally published Ryanair Fuel Policies: "Operational considerations may dictate the carriage of fuel in excess of flight plan fuel, even when not tankering. This is a matter for the exercise of the Captain's discretion. The Commander may carry up to 300kg more than FPL/Block fuel without explanation, actual plog fuel +300 kg, rounded up to the nearest 10 kg. Where departure fuel is more than 300 kg in excess of flight plan fuel an explanation for the uplift shall be recorded on the Voyage Report".
AESA (Spain's Aviation Safety and Security Agency) inspectors pointed out that with the southerly runways in use at Madrid delays would regularly occur due to extensive vectoring and holding. They would consider to put a requirement into place requiring operator to carry additional fuel in such cases similiar to requirements for London Heathrow. The inspectors also took note of the crew comments regarding the air traffic management by Valencia ATC.
The IAA reported regarding the flights:
Flight FR-2054
The total planned fuel was 5887 kg including a planned diversion to Valencia. The captain however chose to take 6500 kg aboard due to the southerly runway configuration and the likelihood of cloud buildups north of the aerodrome of Madrid. The captain expected to be sent into holding east of Madrid, closer to Valencia in case of diversion.
Inbound to Madrid the aircraft was vectored to runway 18L, the crew declined vectors to position TAGOM however due to a thunderstorm cell in this location. The aircraft was therefore offered runway 18R, the captain took control due to weather. The crew became visual with runway 18R about 25nm out.
After being fully stabilized for the approach 18R the aircraft encountered a windshear prompting a windshear warning from the GPWS, the crew therefore initiated a go-around in compliance with standard operating procedures.
During the go-around the aircraft was struck by lightning and a "Window Overheat" master caution illuminated. The relevant checklists were completed while climbing the aircraft to 10,000 feet southwest of the aircraft as instructed by air traffic control.
The captain decided to divert to Valencia when 2900kg of fuel were remaining. ATC vectored the aircraft to Valencia around weather adding 40-50nm to the route to Valencia.
On initial contact with Valencia the air traffic controller appeared overloaded and did not respond to numerous calls. Subsequently the aircraft was kept high on the approach profile by ATC vectors and was cleared to a holding fix at which point the captain declared emergency and was cleared for an immediate approach. The aircraft was still too high however and further vectors were needed. The aircraft landed at 21:08Z and was escorted to the apron by fire trucks. The aircraft had 1029kg of fuel remaining with a required final reserve of 1104 kg.
Flight FR-5998
The total flight plan fuel for the sector Stansted-Madrid had been 8917kg, the captain chose to take 9200kg on board to have some additional margin in case the southerly runways would be in use at Madrid.
The aircraft was descended early for an approach to Madrid's runway 18R, CBs were shown on the weather radar. While on Madrid Approach frequency the crew did not receive detailed weather information despite request, the crew was only advised that departures had been suspended but arrivals were still continuing.
About 18nm out the captain decided to discontinue the approach detecting serious weather approaching the runway from the south and the two aircraft ahead went around. The aircraft was vectored to the west with ATC being extremely busy. The aircraft was cleared to RESBI to enter a hold but was unable due to the weather. When the fuel remaining dropped to 2900 kg the captain decided to divert to Valencia, the vectors to Valencia added 40-50nm to the route.
While reporting on Valencia approach the air traffic controller confused Ryanair and Lan Chile aircraft and was generally overwhelmed. The crew was advised they were number 6 for the approach with a 10 minute delay. This information resulted in an estimate of 1200kg of fuel remaining for landing prompting the captain to declare emergency. The aircraft was subsequently sequenced number 3 behind an Easyjet and Lan Chile who had declared Mayday too.
The aircraft landed safely at 21:20Z and was escorted to the apron by emergency services. The aircraft had 1160 kg of fuel remaining with 1119 kg of final fuel reserve required.
Flight FR-5389
The total flight plan fuel for the flight from Skavsta to Madrid was 11,928 kg, the captain chose to take 12,720 kg on board.
The aircraft was vectored for an approach to Madrid's runway 18R and was advised to expect a holding inbound. The crew noticed weather south of the aerodrome and thus declined vectors to intercept the approach due to significant weather cells all around the aerodrome. The crew requested a go-around to the east of the aerodrome, which was clear of weather, ATC replied "standby", then cleared the aircraft to proceed to the west and climbed to FL140.
The crew requested to divert to Valencia when the fuel load had reduced to 2600 kg, with a minimum diversion fuel of 2588 kg. The aircraft was cleared to MADUX and enter a hold, another aircraft on frequency was advised a holding time of 35 minutes, which prompted the captain to declare emergency. The aircraft was then cleared directly to the localizer from the north and landed safely at 21:29Z with fuel of 1229 kg remaining (required final fuel reserve 1090kg).