Report
Summary report of the experts appointed by the judge investigating the crash of MD82 Spanair EC-HFP, which occurred on 22 August 2008 that killed 154 people.
The experts concluded that the accident resulted from a series of errors that attended sequentially or simultaneously causing the accident. The report is especially tough on the TMA and is aimed primarily at them, the drivers, the manufacturer and aviation authorities.
MAINTENANCE
For Aircraft Maintenance Technicians will be a before and after following the crash of a Spanair MD.
The responsability of the signing of a relevant charge of flight and the resolution of an incident must be pondered before being released on-premise or on-time economy.
In this regard, the report notes that maintenance "did not identify the cause of the damage and sent the wrong plane, invoking paragraph 30.8 of the MEL" prevailing approach to reduce the delay against the decision of the fault.
According to experts the TMA at no time came to identify the cause of the fault and they sent the wrong plane. The mechanics work "focuses directly to find support in the MEL to defer repair, without trying to approach the location of the cause that produced the fault and its remedy."
The report makes clear that the manuals were written "in a misleading or uncertainty in the performance of maintenance." Even recognizing that the documentation called "incorrectly" fuse and disconnected the favored technique to tackle the "wrong way" the fault.
In any case, it ensures that material "does not introduce new risk factors to the operation" after disconnecting the fuse Z29.
PILOTS
In aviation referred to human error and therefore the flight operation is designed to avoid mistakes of the pilots. But do not allow the failure of any essential equipment, and by MEL flight is prohibited by the label NO-GO if any of the equipment or automation stops working properly.
The pilots were unaware that the alarm of misconfiguration for takeoff (TOWS) did not work and there is an unacceptable situation: at the time of the accident, pilots fail to determine the cause of the plane not sustained. That is, it crashed without knowing what happened.
There are criticisms against the pilots for failing to properly perform checklists. The cabin is not kept sterile and conversation about topics unrelated to the transaction with a third person distracts the crew due attention and concentration.
In addition, the deactivation by the TMA system auto engine thrust (TRS) casts doubt on the drivers and distracted their attention repeatedly, from leaving the platform until you reach the runway threshold.
MANUFACTURER AND AUTHORITIES
There was an amazing coincidence precedent: in 1987 there was the accident in Detroit threw an MD82 that 154 people, the same as in the case of Spanair, and whose origin was a mistake wheelseat flaps on takeoff, taking off the TOWS, as in the flight JK5022.
After the accident in Detroit, the Federal Aviation Administration (FAA) has recommended changing the system to have a visual warning if the TOWS was not receiving electricity, but Boeing did not act and MD remained unchanged in the message system to takeoff.
To the experts that the alarm system "admits failure modes that should be incompatible with the significance" of that device. That is, it's so important you should take extra security measures.
Moreover, after the Detroit accident analysis by the manufacturer sent a telex to all the companies operating the MD to modify their operating manuals with the corrections recommended by the NTSB.
There is a security issued by the U.S. authorities or the European or Spanish as required by law "to ensure it reaches all operators (present and future) and applied effectively," the recommendation, which would become an obligation.
Iberia received a notification from the manufacturer because it operated the MD, but Spanair, as it was years later. The manufacturer despite the recommendation sent to the companies, did not modify the aircraft's operational manual, so Spanair documentation did not include recommendations in its operating manual.
The report concludes that "the TOWS failure in EC-HFP accident could have been avoided if, following the accident in Detroit, had dealt decisively with the modification of the system design."