PPRuNe Forums - View Single Post - Spanair accident at Madrid
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Old 4th Sep 2008, 17:57
  #1468 (permalink)  
lomapaseo
 
Join Date: Mar 2002
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Predictably this thead is going to swing back over to a single cause/blame whether it be engines, reversers or now taking off with the wrong configuration.

The professionals on this forum recognize the concept of the layers of swiss cheese between a single cause and an accident. albeit some want to always argue the primary cause is the first layer and that's all she wrote.

Again, the purpose of accident investigation is prevention, so of course the most important thing in all this is what is going to be done now along those lines.

I learned a long time ago that all one can do is minimize, you really can't eliminate many causal factors. Crew error like configuration botches have been with us for a long time and will remain with us forever. The issue then is to look at the various layers of cheese to find out what assumption under the regulations were made in the statistical error rate (including latent or hidden failures) in any of these layers. My tendancy is to identify that layer that is furthest out of wack with the design/certification assumptions as the one that needs the most attention.

So I will sit back and read this thread to see if anybody has identified failure rates of all the parts of the system (including crew) in this accident.
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