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Old 29th Oct 2008, 20:11
  #2326 (permalink)  
Join Date: Aug 2008
Location: Canary Islands, Spain
Posts: 240
EDIT: ooops, sorry, I didn't notice the post above as I was typing this one.

Well, as a first "lesson learned" and in an attempt to reduce the likehood of this type of accidents, EASA (European Aviation Safety Agency) has published this directive today:


together with this press note:

"Following the preliminary report of the Spanish Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC) on the 20 August 2008 accident of a Spanair McDonnell Douglas DC-9-82 (MD-82) at Madrid's Barajas International Airport, as well as the Agency's own evaluation of DC-9/MD-80 family service history, EASA is today publishing an Airworthiness Directive (AD) concerning the DC-9/MD-80 family of aircraft.

The Airworthiness Directive requires an update of the Airplane Flight Manual (AFM) to include a mandatory check of the functionality of the Take-Off Warning system (TOW) before engine start prior to every flight. This system provides warning in the case of the flaps and slats not being correctly set, thus alerting the crew of an improper take-off configuration. This action is being taken as a precautionary measure to improve the consistency of pre-flight safety drills.

To ensure that the TOW check is a part of all operators’ pre-start checks for every flight, a recommendation for an Operational Directive (OD) affecting the same aircraft types is simultaneously being issued by the Joint Aviation Authorities (JAA) to their members, after consultation with EASA. The JAA are currently responsible for remedial action related to air operations, until the EASA Implementing Rules on air operations are in force.

At the present time the cause or causes of the non-functionality of the TOWS system of the Spanair MD-82 have not yet been established. EASA is continuing to work closely with all parties involved in support of the CIAIAC investigation team and will consider any further action in light of the on-going investigation."

Theoretically, and according to Spanair's chief of operation declaration, the SOP demanded a TOWS test for this flight as well, as the crew had left the cockpit in Madrid for a significant amount of time. Although there is serious doubt the crew performed the test, the chain of events should've been this in this case:

-Crew tested TOWS and RAT heater
-Relay failure occurred during taxi (it had been happening intermitently for up to 24h)
-Aircraft lined up for take-off
-RAT probe heater was noted on through excessive RAT readings / autothrottle warning
-Returned to gate and engines off
-Heater was "repaired" (disconnected by MEL)
-Aircraft lined up again, this time w/o testing the TOWS as it had already been tested for THIS FLIGHT and the pilots (incidently not even the PAX) had left the aircraft for any significant amount of time (as per Spanair's SOP which met standards but didn't follow Boeings updated recommended procedure after Detroit)
-The aircraft attempted to take-off with an unnoticed inoperative TOWS and the crew (likely) neglected to set flaps/slats for the maneuver.

The directive is now clear in that tests should be made required before each engine start, which theoretically happens quite close to takeoff time, for all the operators that still didn't include such recommended procedure.

Last edited by justme69; 30th Oct 2008 at 03:43.
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