Just as a reminder of where the focus needs to be:
The Boeing checklist, printed on the chartclip that is affixed to the steering wheel in the B-767 and B-757 contains only the really important items:
Landing SPEEDBRAKES ARMED
The warning system is just there to alert the pilot in case he has forgotten to set the mentioned items in the correct configuration. Having items in the wrong configuration is not the fault of the warning system.
(This is not written as accusation of the deceased pilots. If the final outcome of the accident investigation proves that the high lift devices were not properly configured for take-off, well, to err is human, it is as simple as that).
Location: Correr es mi destino por no llevar papel
And who or what is going to test the " 'TOWS Untested' warning system"?
ECAM - takeoff memo has a line: T.O CONFIG.......TEST (with 'test' in cyan) which turns into green T.O CONFIG NORMAL when test is pressed. My takeoff checklist has three items: 1. checking that entire take off memo has turned green 2. checking actual config on E/WD 3. checking the state of AC packs, and it's done by both pilots.
OTOH, ATR has a similar TOWS to MD80 and I had to test it with flaps retracted, before each and every flight per company policy.
Seems like a quick advancing of throttles asking for take off flaps should verify TOWS working. Simple and flows with the initial taxi procedure. It would have saved all of those lives. In their case apparently no one asked for take off flaps so may have not worked. Interupted normal flow as they had can really mess up a routine. I always tried to start from scratch when an interuption of our normal routine made us backtrack on our checklist.
and yes, there should be a big frickn light that says: AIR MODE GROUND MODE and all planes should have this
Yep, and those two lights should be on a big toggle switch, so that the pilot can always tell the computer that it is wrong, and toggle the mode to the one that is correct. (to keep the pilot from messing with that switch, each use should be recorded in the computer as a system fault and trigger an investigation within the company)
I’ve been reading this thread from post No.1, I’ve been posting in a similar thread on a Russian pilots’ forum. I’ve been always eager to participate in any major accident thread out there. But it probably takes a real-life involvement in an accident to realize how inappropriate, how leisurely, careless and “just-posting-for-fun-while-sipping-my-nice-hot-tea-and-not-giving-a-damn-to-be-honest” all these discussions are.
I came back from Perm (Boeing 737-500 crash) more than a week ago. But everything I saw and everything I felt is still with me. I saw relatives sitting and crying just a table away from us while we were eating and talking. I’ve been at the crash site, I’ve looked down the hill, I’ve looked across the railway, I’ve looked to the left where the wreaths and the plaque are, I’ve walked around the wreckage area, I’ve come across a kid’s shoe, a cell phone, a belt, a backpack, a book, an album “Watches”, a CD with English audio course. It hurts. That kid’s shoe will stay with me forever. No, there were no body fragments, no blood, no hairs, nothing like that but I think it would not give me so much pain as did those signs of life, those things still breathing with life, still belonging to someone. Seeing this makes you silent, makes you shut up. Makes you respect what you’ve seen with your silence.
It also makes you respect the work of investigators you’ve seen. It was the first (and I hope the last) time I saw how they work and I am probably too emotional but watching their work filled me not just with respect or admiration but with something more than that. Worship is the right word, I think. Serious, dedicated, thorough, intent, professional is how they look when you watch them work. Now when I look at this thread and other threads like this the contrast is stark.
Please, let us honor the relatives, let us honor the work of the investigators, let us honor the gravity of the event with our silence and let us wait patiently and silently for the official report.
This is not preaching. Me being there did not make me more special or better or cleverer than everybody else, it just made me say what I have just said. And I really feel the urge to spread these words to you and to share what I’ve seen and felt with you.
Your allowed your view. It's tainted by your first view of an accident. There are many on here who have seen more than one, and at closer quarters than you did. The thread is still valid. People are free to choose what they post. The moderators will moderate.
Xolodenko, Even though I appreciate your emotive words, I think that the whole thing it to save lives and learn from the experience. Don´t you think that many of the pilots who follow this thread may have changed their own procedures; understanding minimally what´s happened contributes for aviation safety. And think about how many lives may have been saved since pilots follow this and other aviation forums and threads, where accidents and many other questions are questioned. These are very good reasons for continue with this thread respectfully.
We all respect and care for the victims. I don't really appreciate suggestions that, out of respect for the victims, all we should all do is NOTHING AT ALL until some "experts" tells us "officially" what THEY think happened and then take it as the absolute truth. Whatever they feel we don't need to know, they can then just not share with the world and keep it secret.
If myself or my daughter would've been in that airplane (and she actually had just flown round trip on Spanair from the Canary Islands to Madrid on an MD-82 the week before the accident), I would not want to have "no news whatsoever until a final investigation concludes, possibly years from the accident".
Actually, I would be doing exactly what I'm doing. Trying to spread as much information as possible so that people I trust know better than me could help me understand what happened, tell me who (if anybody) is at fault, and what is gonna be done so that it doesn't happen to others.
I even think that, if I found a thread like this, I would be most grateful to all, experts and "inmature afficionados", for each sharing their views, experiences and speculations. I rather visit this forum than hit "refresh" on CIAIAC's website only to find that, as it happened in Lanzarote's case, after 15 months all you can read is:
A single paragraph that, basically, says nothing at all on why or how 150 people had their lives hanging from a string that day. That's the "offical investigation" (so far) in a case where they had an intact plane, the crew was alive and a company investigation that concluded the likely cause 10 months ago.
Because the Madrid accident actually had a large number of victims and initiated a judiciary investigation, the CIAIAC is going to take it a bit more seriously and the burocrats that run it (some of them not very bright, by the way, it's my personal opinion) are going to meet tomorrow to vote on the agreement of the current preliminary report to be then published. They were required by international safety organizations and their own regulations to have done that two weeks ago. The report, in its current state, although still missing some important information, at least is brave enough to point out the causes of the accident and appropiate action.
Even worse is the pitiful show put on by the press, where they've run headlines such as: "Turbulences caused the accident", "An engine fire caused the accident", "A wing malfunction caused the accident", "A wrong repair by a technician caused the accident", "Spanair's procedures didn't follow Boeing recommendations and caused the accident", "The airplane reverser was broken and could've caused the accident", "The plane had a miriad of malfunctions and still tried to fly", "The RAT probe heater was broken ... and it's needed to make sure the engines don't freeze on the air", "The airplane's flaps had failed a few days before ... and maintenance did 'nothing'", "The probe repair deactivated vital systems for the take off", "The airplane crashed because it thought it was in air mode on the ground", "The flight was overweight", "Spanair didn't check take off devices", ...
If I was family of the victims, I would be angry at the press for such careless "wide" speculations that large population take as "truth". On the other side, a "small", private forum of professional pilots, under the "Rumours and News" chat room, I don't see why they couldn't make speculations probably 10 times better informed than some newspaper reporter decides to print.
I understand some people feeling offended by comments on this thread. That is fine. All they have to do is not read/participate in it. They can also express their view that they are feeling offended by it. Fine. But we already know that some people feel this way. We don't need to be reminded over and over. We understand, politely disagree, and each is free to stop reading it or continue posting on it under their own moral standards.
Only 7 survivors remain hospitalized in Madrid. The state of 2 of them is not made public by desire of their families. Out of the other five, they are all evolving favourably, with two remaining in serious condition, one of which is still in intensive care and assisted respiration. I wish for their prompt and complete recovery.
To the families of all those that perished in this tragic accident, my deepest condolences.
US judge orders Boeing to release information on Madrid crash plane Submitted by Sahil Nagpal on Tue, 10/07/2008 - 09:56. Source: www.topnews.in
Madrid - A US judge has ordered aircraft maker Boeing to hand over all available technical information on the MD-82 jetliner that crashed in Madrid on August 20, killing 154 people, Spanish press reports said Tuesday. A US law firm has filed a complaint against Boeing and its subsidiary McDonnell Douglas in the name of 18 families that lost members in the accident. The judicial proceedings started Monday in the US state of Illinois, where Boeing has its headquarters. Ribbeck Law Chartered was initially seeking technical information on the plane in order to decide how to proceed, lawyers representing the law firm were quoted as saying. The lawyers want to find out which company made the wing flaps that were not deployed on take-off and may have contributed to the accident, according to a preliminary report by an investigating commission that was leaked to the Spanish press. The flaps help to lift aircraft on take-off. If the flaps were not made by Boeing or its subsidiaries, the court case could be extended to the company that manufactured them, lawyers said. Judge Ronald Davis gave Boeing six weeks to provide the requested information.
xolodenko wrote: I’ve been reading this thread from post No.1, I’ve been posting in a similar thread on a Russian pilots’ forum. I’ve been always eager to participate in any major accident thread out there. But it probably takes a real-life involvement in an accident to realize how inappropriate, how leisurely, careless and “just-posting-for-fun-while-sipping-my-nice-hot-tea-and-not-giving-a-damn-to-be-honest” all these discussions are.
I Write: We all have a great respect and care for the victims. Pilots who reads this thread will be better pilots, how many times have we not heard of pilots who forget to put down the flaps, then think of all the times in which we have not heard about this, because of the TOWS have warned the pilots. I am sure that pilots flying MD80 and have read this thread, thinking "flaps" before take off. It is very likely that some investigaters reading this thread that he / she will have information which may help to solve the problems of the accident, or get a different approach to the real problem.
Hopefully, a tread as this can save human lives. It's just my opinion
CIAIAC vocal members are meeting right now and will decide on the publication of the current preliminary report draft, likely later today.
It will presumably include indications from the CVR that the pilots did (try to) follow the checklist. Although the audio is particularly bad and it can not always be 100% conclusive, it is believed they did go over the flaps/slats items and said they were "ok".
Obviously they weren't reading the indicators properly, as the FDR and other evidence shows the flaps weren't extended at that time or later.
It will still point out to a failure of the SOP to require testing TOWS on each flight as the main point that must be changed to improve safety. Other operator's SOPs don't include this recommendation either, so it's important that it's made mandatory worldwide. Needless to say, Spanair has already changed the SOP a few days after the accident.
Being a preliminary report it can not include final conclusions or recommendations.
Justme69, thanks for your always informed and excellent posts, without them I would have been unable to get such a full picture of the event & for sure we have all had our awareness raised by it.
Re your last post, does anybody know if there could be any link between the TOWS disablement & the flap indications? Whilst I agree that it's SOP failure not to have the TOWS check in the system, it has also been known for pilots to read & call an action yet not actually look to ensure things are what they should be - another SOP failure.
I'm reluctant to suggest that these guys failed to follow SOPs thoroughly but does anybody know what training / SOP standards were/are like in Spanair? It's certainly an area I'd want to look at if I were investigating this.
Incidentally, Spanish media reports that Spanair have lost 11 million Euros worth of business since the crash. A reminder of that excellent saying, "If you think safety is expensive try having an accident." Given the SEPLA letter that preceded this event, I hope Spanair (& other airline's) management reflect on just how good their, "cost saving & efficiency measures," have been.
Last edited by Southernboy; 9th Oct 2008 at 08:48.
DISCLAIMER: This whole post ASSUMES that the crew failed to correctly deploy the flaps/slats. This still hasn't been proven, so it must be taken as purely speculative and not based on facts.
Others could answer more authoritatively than I could. But, to the best of my knowledge and in my personal opinion, I'm sure there is no "electrical/mechanical" link between TOWS being disabled by the lack of energy from R2-5 and flaps AND slats indicators failing in any way. The indicators in the instrument panel (flaps degree watch dial and slats takeoff lighted indicator) are mechanically set.
From the manual:
The flaps indicator contains dual, superimposed pointers and a dial which is graduated in degrees of flap travel. Each outboard flap is linked to a separate flap position transmitter that operates one of the dual pointers. The pointers respond to actual flap movement rather than flap control handle movement and will normally move in unison.
To take off, respond to challenge question for flaps slats with the degrees setting and "TAKEOFF".
The flap takeoff selector wheel should be in the stowed position for 11° or 15° flap takeoffs. When departing with other flap settings, rotate the flap takeoff selector wheel until the required degrees of flaps are indicated. Note: Flap settings between 13 and 15 degrees are designated, “Do Not Use,” and will not be selected for takeoff.
Move the flap/slat handle to the appropriate detent. Observe the slat TAKEOFF light is on, SLAT DISAGREE, AUTO SLAT, and SLAT LAND lights are out and flap position pointers indicate the required flap setting. Note: When extending the flaps to a dial-a flap detent, if the detent is passed, the flap/slat handle must be retracted beyond the detent and re-extended to the takeoff detent.
On the ground, it is normal for the AUTO SLAT light to come on momentarily when the flap/slat handle is moved from up/ret to any setting commanding a mid-slat position. The AUTO SLAT light comes on to indicate slats have momentarily moved to the fully extended position during a self test of the system. The AUTO SLAT FAIL light will come on to indicate system failure
Takeoff Warning System
The takeoff warning system provides an aural alert if certain parameters are not properly set for takeoff. The system requires normal electrical power. When the airplane is on the ground, any one of the following conditions will cause the aural warning system to sound: Either throttle is (or, on airplanes with Service Bulletin 31-34 incorporated or production equivalent, both throttles are) advanced for takeoff and the FLAP/SLAT handle (after being positioned to the takeoff flap setting) is not in agreement with the value set in the FLAP window of the TAKEOFF CONDTN computer, or the horizontal stabilizer is not set within the green-band area of the LONG TRIM indicator, or the slats are not extended, or the spoiler handle is not in the retract detent, flaps extended beyond 26º, or the parking brake is set.
The first settings of flaps AND slats (mid, 11º) are set mechanically, and the possibility of failure is almost zero. Also, in this flight, the flaps did deploy correctly (as recorded by the DFR) some 45 minutes earlier when they first tried to take off (before they returned to gate).
Even if they BOTH (flaps and slats activation) failed for whatever reason, another mechanically linked independent indicators read back the position and informs the pilots positively (there is virtually zero chance of this also failing) the position of both wing's slats and the angle of deployment of both flaps. If the actual flap or slat doesn't physically hit the sensor/push the dial sensor that signals its position, there is virtually zero chance that the indicators would show the correct setting while the device actually being in the incorrect position.
If both, the flaps and slats weren't out before take off, there is virtually no other explanation than the crew failed to properly read all the indicators that would've signaled the faulty condition.
It's not so "incredible" that a pilot could forget to deploy necessary systems (i.e. landing gears, brakes, flaps). After all, it was proven to have happened in Detroit's Northwest case, in Buenos Aires' LAPA case, in Lanzarote MAP case, and no less than 8 others "unofficial" (read this thread) cases. Human error is the main cause in over 60% of aviation accidents.
Actually, the Take Off Warning System was put into airplanes by manufacturers precisely because crews weren't correctly checking that vital systems were in the correct configuration 100% of the time. If one could trust that pilots ALWAYS checked thoroughly things like "landing gear down" or "speed brakes armed" or "flaps down", then things like TOWS wouldn't be needed at all.
Spanair is part of the Star Alliance, and performs sharecode flights with United Airlines, Air Canada, Scandinavian Airlines and Lufthansa. This was actually also Lufthansa's flight LH2554 for some passangers.
Standards of training and operation on Spanair, a Scandinavian Airlines company, were very high, as far as I've been able to study. Way over world average, I'm told by people I trust. On par with western european countries, which are above those of, i.e., the USA. SAS moves over 3.5 million passengers a month.
Boeing had reviewed just recently Spanair procedures and issued certificates of quality, declaring their procedures excellent. Spanair has twice the recommended number of pilots training refreshes in the first world. Their SOP called for up to 3 checks of take off configuration and a TOWS test at the beginning of the day or when pilots changed or were absent from the cockpit for extended periods.
Pilots unions will ALWAYS complain for fewer working hours, more free training, less work pressure, more investment in security and maintenance, zero MEL items, etc, etc. This is obviously normal. It will still not prevent pilot error, and at some point the line has to be drawn.
You can read about the pilots in previous posts, but basically they had reasonable training/experience (9 years in the company, +7000 hours on the MD, the copilot, in charge of the take off and of lowering the flaps, 2 years and +1000 hours on the MD), they weren't overworked (under 40 hours a month, consistenly in the prior months), etc, etc.
Truth be told, the copilot knew he was probably going to lose his job in less than a month, although Spanair had agreed to hire him in a lesser position if he so wished. There was even talk of a "disgrunted employee" sabotage earlier on:
... which the judge doesn't really buy as the TOWS failure would seem to be casual.
Unemployment benefits in Spain are substantial, so the copilot had, at VERY LEAST, 60% tax free of his full salary available for 8 months without the need to work, plus an additional substantial one-time penalty payment if he was fired before his contract expired, likely equivalent to at LEAST two full months of pay.
In western europe, unions (air controllers, pilots, airport personnel) like SEPLA are constantly "complaining" and demanding even better work conditions although they are already above average and among the best in the world. Spanair was about to fire 1100 workers (they finally fired 950 recently), so no wonder everybody was upset and complaining. But this has little to do with "forgetting to deploy the flaps", or improperly following checklists for which you are well trained.
I'm sure the crew didn't do it right. But I'm also sure they were very well trained to do it perfectly and weren't particularly pressed to do things otherwise. They simply made a mistake (hypothetically).
Although they had a delay in the flight due to the RAT probe "acting up", another plane was already called in and available. You can listen to Spanair operation requesting the change of registration plane for this flight and a delay. They already had a gate (C49) with personnel already present to unload the passengers and reload them. The return flight for this plane wouldn't even require a time change. Cattering was already on the move.
But the technicians figured, with the full knowledge of the pilot, that the issue was probably minor, and they got it quickly "fixed". In exactly 1 hour from scheduled time, they had taxied to T2, "fixed the problem", taxied to T4 and were again ready to take off in the runway. And there was no huge need to "rush". Delays of 1 or 2 hours are so common nowadays, that they are the staple of the norm.
The malfunction probably made them distracted. But it was still their job to complete the checklist as trained and not forget the flaps.
I do not believe that Spanair was putting more or less pressure than other western airlines on unsafe practices or that they were implementing cost-cutting measures that significantly reduced safety. Even if they were, what does it have to do with pilots forgetting to deploy flaps/slats? If they have a license to fly a MD-82 I'm sure they have been trained on how to do it right.
The TOWS inoperative is not the pilot's fault, but nothing prevented them from checking the TOWS system if they so wished. It's (basically) as simple as pushing the handles to takeoff, listening to the alarm, and quickly putting them back.
I do feel that Boeing is a bit to blame for not making a better TOWS design and for not making sure the SOP's were requesting frequent TOWS tests worldwide. I do feel that Spanair is a bit to blame for not making sure their SOPs reflected the very latest safety measures recommended, even if they weren't mandatory and they were never told about their existence. I do feel that Boeing also deserves more blame for not making maintenance manuals more clear on implications of "faulty" RAT heater. I also feel that Spanair's technicians deserve a bit of blame for not figuring out in 2 days what was going on with the plane.
Although it's not proven and it is totally speculative, the crew may also possibly be to blame for not testing the TOWS in the earlier flight from Barcelona, this time as required by Spanair's SOP. And, of course, they would carry the burden of most of the fault for failing to properly check if the flaps and slats were correctly placed.
CIAIAC vocal members finally voted today to unanomously approve the preliminary report with a few changes. Those changes will be written within the next days (Friday, most likely). It will then be available from their web page:
Thanks for that Justme; informative as ever. However whilst I accept many of your points re the accident & you are probably about right as to the main reasons, it still leaves us with the question why well trained experienced pilots made such an elementary mistake? Yes we know pilots do but there is usually one of the other well known factors involved, stress, time pressure, distraction, fatigue or whatever; you are saying none of these applied.
One things I would query is this line, "If they have a license to fly a MD-82 I'm sure they have been trained on how to do it right." We all know it isn't as simple as that. If the atmosphere - safety culture - in which you work is not robust & non standard methods are accepted then it builds a basis for cutting corners. I have worked in airlines where the paperwork was legal but it was a box ticking culture and good solid training was minimal in order to keep the show on the road & costs under control. We all had licences to fly our types but always felt under trained. You are clear that was not the case here & I must accept that as I know nada de nada about the company. However there's world of difference between good training, adequate training & just legal requirements, so I remain curious why such well qualified experienced pilots did - or did not - what they did, there are always reasons in the background & they are ones we really need to understand.
Lets face it neither humans nor machines function perfectly all the time. Humans doing repetitive tasks sometimes "see" what they are accustomed to seeing, or are expecting to see, especially if momentarily distracted. That is why most airplane systems and procedures have warning system and cross-check redundancy. TOWS, and challenge and response, for instance.
If machines could be trusted to fly aircraft without human back-up, the economic and and efficiency benefits would have had them doing so from long ago. So we have to put up with pilots.version 001.
Years ago at a Royal Aeronautical Society Air transport course I attended, there was a very informative lecture by a gentleman from the AAIB in which he demonstrated how easily a human mind can be programmed to commit stupid errors, and misread simple indications. Layouts, language, and a host of other small details can set traps that even the most experienced and qualified pilots fall into.
Human engineering is still in its infancy, but hopefully that will change soon. The closest example of a perfect human died a couple thousand years ago, although we do have a few pretenders on this forum.
May be possible that the pilots somehow got confidents about the TOWS when testing it that morning, and later the same system turned against them when not working. I mean, if the confidence in the system may have produced that prior to the take off, the checklist has been done in a relaxed way.