PPRuNe Forums - View Single Post - Spanair accident at Madrid
View Single Post
Old 16th Sep 2008, 20:27
  #1766 (permalink)  
Join Date: Jul 2003
Location: An Island Province
Posts: 1,116
bia botal re #1778, “… it has been proved time and again that it takes 7 holes in the swiss cheese to cause an accident. Ground/air CB pulled and flaps not set are but two …”

It would be interesting if you could provide a link or reference for your assertion.
Nevertheless, looking at the detail and considering latent conditions as well as active failures then it may be possible to identify many holes:
CB pulled (no config warning), + was this procedure approved (error/violation), + CB not checked.
Flaps not set, + not checked by setter (lever and gauge), + flaps not checked by checker (lever and gauge).
+ Possible poor practice of calling ‘set and checked’ – management/training oversight, + possible poor checklist design / SOP wording.
+ Possible rush / hurry (ill discipline – training/personality, or human weakness – natural wish to satisfy passengers), + possible distraction (human weakness, or weak training – start checklist again, or poor discipline – company culture), etc, etc.

As with most accidents the path to the event is riddled with holes, the key features are those which cause the critical holes to line up (the contributors to the accident), the failure to close holes which are a potential accident path, or the failure to detect an already open path. And of course in hindsight, the failure (of everyone) to report these weaknesses (open holes) so that they could either be closed or be mitigated with suitable defences.
alf5071h is offline