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Old 21st Oct 2008, 14:17
  #2233 (permalink)  
justme69
 
Join Date: Aug 2008
Location: Canary Islands, Spain
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Were the mechanics responsible for the aircraft taking off with no flaps?
Well. If we IMAGINE a FICTICIOUS scenario where:
-A) The pilots were trained (and allowed by SOP/regulations) to blindly trust the TOWS would catch any configuration mistakes and
-B) The mechanics KNEW (or should've known if they were doing their jobs right) the TOWS were broken and yet didn't do the proper repairs ...

... then yes. They would be responsable. If they would've fixed the TOWS, the pilots wouldn't have taken off with no flaps.

But this is a FICTICIOUS scenario.

I guess for some people it wasn't clear that my position in the previous post was a THEORETICAL position.

I do NOT believe that the mechanics are responsable for the accident.

I do believe that they could've done a better job diagnosing the failure and perhaps that would've saved the day. But I don't know to what extend their actions or lack of REQUIRED ones actually contributed to the outcome.

So, again, if I must say, so that it becomes clear for everyone, I PERSONALLY believe that the contributing factors were the ones I'm listing below. If the CVR recording proves the pilots were more distracted than reasonable (i.e. the LAPA case), then that would shift my opinion even further. Same thing if they were following checklist in that "fast and furious" automatic way I have seen done many times in the past, where the pilots would answer non-standard things, put off some items to come back to them later from memory, etc, etc. That's not the way they were trained and encouraged to do it.

If you have NEVER seen a pilot carrying out a checklist way too fast like it was some kind of race, and you have ALWAYS seen them following the items carefully, writing checkmarks to each item, pointing to the instruments as they read the answers, etc ... then good for you. Please let me know the name of the airline so I can book safer flights for my family.

-The copilot: he was the one in charge of lowering the flaps/slats. He was also the one doing the takeoff maneuver. Although he had been working on the MD-82 for about 2 years and had some +1000h of experience on that aircraft, he can be considered somewhat of a rookie. W/o the exact CVR transcript and actually recording, I don't know how much of his mistake was the result of a "legit" oversight or of a "careless" attitude. Nonetheless, on him goes 50% of the "blame" at this point in MY opinion.

-The pilot: his +10 years of experience and +10000h of flytime should make him now better than trust a "rookie" copilot without double checking the important stuff. For me, he holds another 40% of the "blame".

-The other "highly contributing factor", the failure of the TOWS, from my point of view, COULD be considered an "act of God". Although in this particular case there were other circunstances, the TOWS could've theoretically have failed EXACTLY 1 minute before takeoff. TOWS is an electrical machine. There is NOTHING anybody can do to avoid failure 100.00% of the time. With that kind of design, whenever it fails is up to "God", no matter what maintenance or anybody does. If they allow that type of design to exist in an airplane, failure can occur at any time whatsoever w/o ANY warnings. I'm pretty sure the pilots kind-of-new that, but we all prefer to think it will never happen to us. We all know that, at any time, the brakes in our cars can fail. But we know it's so rare that this happens, that we trust them like if the were never going to fail. Until they do.

-In THIS particular accident, the other 10% of the blame is spread among all those that could've made the TOWS less likely to fail or the pilots less aware than optimal about the importance of correct takeoff configuration (i.e. a SOP requesting to triple check killer items, etc).

Say something like 6% of the "fault" would go to Boeing for not making a better TOWS design/better diagnosis/better maintenance manuals/better spreading the frequent TOWS test recomendations, a 1% to the person in Spanair responsable for failing to include the latest recomendations on the SOP or a SOP with a killer item double check right before takeoff, a 1% on the technicians for not taking a better look at the consecuences of their "repairs" and a 2% to the rest of the people/companies/regulatory bodies/CIAIAC/training systems/etc that allowed the plane to fly with pilots that overtrusted their TOWS (the pilots didn't even tested them prior to this flight, which wasn't even required in their SOP, indicating that they trusted them more than they should've. Somebody should've warned them better of the real danger.)

That's my PERSONAL opinion so that I'm not accused here of defending other positions I do not.

And, of course, I may be wrong and/or there maybe other contributing factors which I failed to mention or which contribution to this accident may be more relevant than I estimate. Again, this is a "rough" PERSONAL opinion, nothing more. I RESPECT that others may have the view of this matter were the "blame" is almost the opposite reverse to my OPINION, and they think that the pilots only have a small percentage of the "fault" and other factors (training, regulations, pressure, etc) are the main culprits. I don't agree, but I respect the view.

And finding "who/what is at fault" is the least important part. The "how can this situation be improved" is more important.

Personally, I think that, no matter how much training, how much experience, how much required procedures (i.e. double and triple checks on the checklists), human error can never been "ruled out" from the equation. Sure better SOPs and checklists can be developed to reduce the chances, though, and better training never hurts.

But I think that technology has a lot to say in cases like this. The TOWS can certainly be made much better nowadays w/o much trouble or expense, so why not start there?

I see no point on not making (all) TOWS nowadays something like this.
When takeoff thrust is applied on the ground or a CONFIG button is pressed as part of the checklist, the TOWS should run a quick self diagnosis, tap all positive sensors and reply:

-A distinctive "musical tone" with the words OK in "happy tone" by i.e. a female synthetic voice (i.e. LA-LA-LEE- "Configuration OK")

-A distinctive alarm tone with the name of the failing configuration in serious tone by a male synthetic voice (i.e. OOOORRGG - Slats - OOOORRGG - Flaps - etc)". This alarm tone would also be used in case of an autodiagnosis fail (i.e. "OOOORGGG - TOWS failure" when a stuck sensor or other condition is detected)

-When silence is "heard", the pilots should notice something familiar is missing and hopefully will conclude the TOWS didn't work for whatever reason (i.e. blown loudspeakers, sound amplifiers, logic board, lack of power, faulty "air mode" ground logic). They should consider aborting the takeoff if they can or be extra alert if they are past V1 when they notice, as they don't have a working electronic watchdog for any unnoticed configuration problems/mistakes there might have been.

I know this is not as simple as it may sound, specially in 30+ year old airplanes, and that too many alarm tones etc can also distract from ATC communications or other more important alarms (fire, etc), or even that the pilots could still try to take off without TOWS "approval" (i.e. LAPA) but I still think that technology can be one of the easy, cheap, effective ways of reducing the likehood for this type of accidents.

Last edited by justme69; 21st Oct 2008 at 15:51.
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