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Old 16th Oct 2008, 09:14
  #2184 (permalink)  
justme69
 
Join Date: Aug 2008
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I tend to agree with the need for "smart people".

If Boeing would've been "really smart" instead of "by the bare minimun of the book", they would've:

-Designed (or retrofitted) a TOWS that was easier to diagnose. One that, i.e., when it failed, gave a nice warning instead of the same sign as a "configuration ok for takeoff" (silence).

-Made absolutely sure all airlines in the world, in the absence of a better, more reliable, easier to diagnose TOWS, at least knew about it and was following the recommendation of making tests every flight.

-In the absence of all the above, they would've at least have made better maintenance instructions available on how to deal with a probe RAT heater that turns on while on the ground, so that less "smart" engineers can not confuse the instructions of "faulty"-heater=MEL is just fine.

If Spanair would've been really smart, they would've hired a smart chief pilot that, eventually, after studying TOWS for so many years (Spanair's been flying for 20y), would've realised that a TOWS check each flight was good safety operation to follow and needed to be included in the SOP.

If the pilots would've been really smart, they would've realised after so many years the same thing with the TOWS and run tests, required or not by the SOP, prior to each flight.

If the ground engineers would've been really smart, they would've realised the heat probe problem was actually the symptom of a larger problem, not the problem itself.

But, with the exception of the pilots that were (theoretically) the only ones to make a flat-out mistake (who knew they had to lower the flaps, who had been well trained to lower the flaps and yet, they didn't), everybody simply "followed the book to the bare minimun" and that was enough to avoid the prevention of this accident.

It's arguable that the ground engineers followed or not the instructions "by the book", but as others have written here, "the book", if not very clearly written and covering all posibilities down to the "T", allows for some interpretation that can be "less smart" than it was intended to. It's not the first case of a pilot, a copilot and two engineers agreeing that an item was OK to MEL when it actually wasn't (strictly or as performed).

So much for the safety of "stupidly" following a book that can be miss-interpreted as valid for 3-4 (smart or not so smart?) people ...

Here is part of the judge's reasonings in his proceedings:

-He believes there is strong evidence that the airplane could've fall at the flying conditions from a stall induced by the flaps and slats not being deployed.

-He believes there is strong evidence that the TOWS alarm didn't warn the crew of the configuration error.

-He can read from the maintenance manual that it shows that the RAT heater and the TOWS receive power (on a reverse logic) from the same relay R2-5.

-That there is a possibility that the RAT heater problem was a manifestation of a multi-system malfunction affecting the TOWS, and that such condition was not found by the maintenance technicians.

-He estimates that those actions could constitute criminal neglicency with the result of 154 charges of involuntary manslaughter and 18 of involuntary negligent lesions.

-He requests the two technicians and Spanair's chief of maintenance to report to court to declare as accused parties.
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