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Old 16th Oct 2008, 11:51
  #2188 (permalink)  
justme69
 
Join Date: Aug 2008
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Here is a scenario. Early flight first leg everything is ok. Then the second leg:
1) RAT fault on taxi out or just before T/O.
2) Returned to ramp, problem fixed, book is signed off and was acccepted by the flight crew.
3) Needed more fuel and decided everything was ok, taxied out.
4) Tired and in a rush, ran through a checklist and checked everything ok.
4) Lined up for T/O applied T/O power and then at VR the bird does not fly!!
Many conclusions from this forum, up to the investigative panel, judge, the company and indeed all of us. Blame everybody except...... Hmmm this swiss cheese or manchego, cheese lined up in a very subtle manner and everyone involved failed to see it? I would like to see how much of this report/ investigation is influenced by the liabilty and responsability involved ( ie Spanair).
I agree with everything except the "tired" and, to a reasonable extend, "in a rush" part.

The pilots had worked less than 40 hours a month. Consistently for the past 2 years. They had significant vacation periods as well.

They had only been working since 8 that morning, and had a 2 hours resting period right before this flight, and it was only "noon" on a flight that was going to take only 2:30h (3:30h if we account the delay). All in good weather and within the same timezone.

The whole issue with the RAT probe produced exactly a 1 hour delay from start to finish, hardly too much to induce an excesive need to rush.

Also, I do not believe that anybody was (particularly) "rushing" the pilots. Spain, for those few that perhaps don't know, is a country known worldwide for our relaxed pace.

Regardless, the pilots need to know that, no matter how much PAX or other factors may induce some (or a lot) need to "rush", they still need to follow the procedures adecuatly.

But indeed, from the point of view of the pilots, sans the "tired and rush" part, that is also what I think happened.

Once the CVR transcript is made public, perhaps we'll be able to see if they were carrying their job adequately and it was just a reasonable mistake (seems that way so far) or if they actually were engaged in too-lax, perhaps unaceptable behavior or if indeed they were overly tired or "rushed" for whatever unknown reason.

The responsability of Spanair (SAS, actually, they are wholly owned and managed) is also being investigated, but their SOPs seem to be according to worldwide regulations and manufacturer's original recommendations, their training and hiring programs on par or exceeding world standards, their safety record in 20 years impeccable, their safety culture on par with similar operators, their compliance with work conditions fully within western european regulations, ...

I fail to see how, other than not knowing the SOP was recommended (not required) to be changed to include more frequent TOWS tests on the MD-82, SAS could have any responsability for a licensed and experienced pilot's error (or errors), aided by a coincidental system malfunction that had been "serviced" by licensed technicians with significant experience.

CIAIAC's investigation may lean towards keeping happy manufacturer's or operators, but certainly I don't think anybody can (or should) suggest that the parallel judiciary investigation is biased and will not press charges against anybody or any company suspected liable for any voluntary wrongdoing.

Last edited by justme69; 16th Oct 2008 at 13:12.
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