Spanair accident at Madrid [Archive] - Page 10

justme69

23rd Oct 2008, 07:21

An interesting article published yesterday:

Safety slip in Madrid crash also seen in U.S. - USATODAY.com (http://www.usatoday.com/travel/flights/2008-10-22-madridcrash_N.htm)

It talks of 55 voluntarily reported cases of bad takeoff configurations in the past 7 years or so in the USA alone. That's a lot more than I had found, that were around a dozen or so cases, but once I found it was pretty common, I didn't continue looking that closely. Most of them, of course, were catched in-extremis by the Take Off Configuration Warning Systems.

The Spanair pilots were of the few unlucky ones (together with Lanzarote and Reagan's cases, i.e.) that had an unnoticed TOWS failure shortly before they needed it the most. After so many years and so many million flights, I guess it was due to happen.

It comes to point to that, even with sufficient training, experience, safety culture, management, maintenance, etc, human error is still a piece of the puzzle that just can not be avoided and therefore needs as much help as possible from technology, etc.

But I don't think I'm saying anything new here. Traffic accidents, even by professional and experienced taxi/bus/truck drivers, happen every single day when humans in charge of vehicles make bad choices against everything they have been trained for. And no, most of them are not "careless" or "suicidal", they are just humans carrying their children to school everyday but don't even bother doing a basic visual check of all four wheels before entering the car. And constanly, driving schools, TV safety campains, police controls, improved vehicle designs, better roads and signage, etc, etc are reminding us to watch our speed, buckle up, not forget to turn on lights at night, etc, etc, etc.

And yet, we all do make those basic mistakes at times, putting our own lifes at risk against our better judgment for "unkown reasons".

BTW, does anybody know if there was ever an investigation report for the Indian Airways accident of Dic 17 1978 of B737 VT-EAL that explained why it tried to take off w/o slats and it crashed?

BOAC

23rd Oct 2008, 07:57

I have no knowledge of the MD and the effect of the A/G sensor, but it appears that the a/c was 'flyable' when stuck in the air mode. It appears the possible incorrect A/G state is not obvious on his a/c. IF the crash was caused by failure to configure correctly for take-off, then in my opinion it was not the MEL, the engineers or the TOWS failure that CAUSED the crash. That is a pilot's view. I know there will be howls of protest from the safety psychologists.

Certainly, having had an A/G stuck in 'Air' mode on landing in a 737-400 (Classic), it would be instantly obvious to crew that all was not right on that type.

I fully support the call for a 'look' at the MEL philosophy to ensure that possible causes for symptoms are checked/trapped in the 'comfort' of the manufacturer's tech office to take need to diagnose complicated systems away from the LAE, and I can easily see now how LAEs will be MOST reluctant to 'quick fix/dispatch' in future which will impact on airline programmes. I cannot, however, see how the possible dispatch of this a/c in 'Air mode' was a direct cause of the accident.

As we have seen, and know, it is by no means impossible for a fully serviceable and sounding TOWS to be ignored by crews, so we need to add this to Justme's list, making 4?

"At least it adds another layer to the cheese. Now 3 things would have to fail:
-The pilots missing a configuration error.
-The TOWS failing around that same time and not having been noticed on daily tests.
-The pilots missing the pre-takeoff TOWS test revealing the TOWS have become inop or the TOWS failing exactly in the few minutes (instead of up to 24h) between the check and the takeoff."

justme69

23rd Oct 2008, 08:05

As we have seen, and know, it is by no means impossible for a fully serviceable and sounding TOWS to be ignored by crews, so we need to add this to Justme's list, making 4?

Well, in that case, it would only make it a "one hole" cheese.

1) The pilots fail to set/verify the right takeoff configuration.

--- It doesn't matter if the TOWS fail or not, the pilots are going to ignore them.

They take off, and, if the conditions are not very favourable for a recovery (wind/weight/response time/engine thrust available/runaway length/pure random luck of the stall behavior/etc) they crash. That's it.

BOAC

23rd Oct 2008, 08:19

My apologies - I agree - I was trying to look at alternative routes through the holes to the same end, not related to this crash, and should have had 2.

1) The pilots fail to set/verify the right take-off configuration.
2) The pilots ignore a warning.

That is with a fully serviceable a/c, taking all questions of LAE actions and MELs out of the equation. This is where the last firewall needs to be.

justme69

23rd Oct 2008, 09:03

We indeed know of at least one case (LAPA), but possibly one or two more that weren't properly investigated, where that happened.

Also, please note that the MD-82 that suffered the accident wasn't in "air mode" strictly speaking.

Most of the indications for "air mode" come from the front wheel sensor, others from the back. But even the ones in the front are divided between the left and right "wheel". Each of those sensors feed between half-a-dozen and a dozen relays, which in turn feed the "correct state signal" to between 1 and 4 devices each.

The Spanair MD-82 probably had only one of those almost 20 front wheel logic electrical relays fail, one that ultimately only affected two devices: the RAT probe heater and the take off configuration alarm (the other two devices connected were redundantly serviced by the right wheel circuit). So only the TOWS and the RAT probe heater thought they were "on the air". The rest of the airplane thought it was "on the ground". The absolute only signs that the airplane had any failures whatsoever would've been: a RAT probe heater turned-on while on the ground and a TOWS that wouldn't have responded with sound to a bad configuration takeoff check. If none of those symptoms were noticed, nothing would've seemed wrong at all with the airplane, which otherwise was, of course, perfectly fit to fly.

It was almost out of luck that the pilots noticed the RAT heater on while on the ground, giving them and maintenance the only chance to figure something was wrong at all. But they missed that chance. Also, if a mandatory TOWS check would've been included in the checklists (and actually performed by the crew), the failure would've also been noticed. But unfortunately the whole RAT issue was pbbly also the "spark" that made them distracted and rushed and finally triggered the oversight on setting flaps and the tragedy.

The MAP MD-83 in Lanzarote had the whole set of relays from the left front wheel "disconnected" by a pulled circuit breaker. And still, because most of those devices are actually ventilation/air conditioning/etc and a good number are redundantly serviced by the right wheel circuit, the pilots still didn't notice the "air mode" logic that affected probably a dozen or so non-redundant devices. They forgot to set the flaps/slats as well and took-off with an effectively disconnected (but perfectly serviceable) configuration warning alarm, so they didn't realize anything was wrong until the airplane started to stall.

BOAC

23rd Oct 2008, 11:15

I'm with you, justme.

I am basically getting uneasy about posts like 777fly's, bubbers and others with suggestions that those involved (the crew and engineer) should have 'correctly diagnosed' the problem. (Leaving ?possibly? AB aside), an aeroplane - if correctly set up - will fly without any of these 'failsafes'. I just cannot see how blame can be attached to these poor folk for not understanding a complex logic system of switches and relays. The MEL system NEEDS to have been constructed with all this done in advance, surely? Certainly the limited tech info available to me in my seat on the ramp would in no way have allowed me to follow all the relay switching involved nor to be CERTAIN there was no other failure in the system that could heat the RAT sensor - and it really is not the pilots' job to do so either. The logical progression here is for me to insist on full access to maintenance manuals before I accept a signed off defect. NO - I am trusted to fly the a/c properly and I trust the engineers to fix it likewise.

sevenstrokeroll

23rd Oct 2008, 20:31

BOAC

if you TRUST everyone to do their job, including yourself, you will be dissapointed one day.

IF you are human, YOU will make a mistake. SO have even more layers of cheese (gosh I hate that analogy) may save your bacon.

The mechanics should have been better trained to recognize the reason the RAT was heated.

The pilots should have recognized it also.

the pilots should have been more thorough with checklists including placing hand on the flap lever until the gauge was correct.

AND KILLER ITEMS crossing the threshold are still vital.

I blame the airline and its training department for this accident.

AND VERY FEW THINGS should RUSH a pilot for takeoff. OK, maybe a nuclear bomb coming your way, but anything SHORT of that...take your freaking time!

justme69

23rd Oct 2008, 21:40

I blame the airline and its training department for this accident.

First, I'm guessing you mean that you blame them for not training the pilots and engineers to recognize a TOWS failure and not for failing to teach the pilots to properly go through the checklists and on how to lower the flaps, right? I think we can safely assume that any training facility in the first world would've made clear over and over the importance of checklists and the proper way to lower the flaps. The pilots complying with the training once it's over is another question. Spanair has been operating for 20 years and this was their first accident.

Second, I guess you mean them "in general", as most airlines and most training facilities in the world wouldn't probably have included a specific mention of the RAT probe heater problem having to do with a TOWS failure on an MD80. So you actually blame "most airline's training departments" in the world, right?

If your main objections are with the training, I'd like to raise the question of whose responsability the training is. A pilot is suppossed to have a license, like an architect or a doctor have a degree, that certifies he has enough knowledge to safely perform his job. Experience and additional training usually comes to the expense and will of the professional in question, not the people employing them.

If I want a safe building, I go to a good architect. If I want good health care, I go to a good doctor. I don't usually pay him to obtain the extra training in the next couple of years so that then he can work for me.

Any architect can build a simple house. Any doctor can diagnose a simple disease. Any pilot knows how to lower flaps and follow checklists.

Nothing prevented these pilots from taking extra classes, assisting to extra courses given out by Boeing on engineering, reading books and manuals, etc. They weren't required to do them, but if they thought their work conditions would've improved and their own lifes were at stake, why didn't they do it?

Pilots are now going to raise hell saying that they shouldn't be paying from their own pockets and on their own time for training that raises the safety of the airline operation. Try telling that to a doctor or an architect (or a police officer or mechanic or any other profession with some direct responsability on the life of clients or their own).

No doubts the airlines understand the need on certain industries of frequent refreshes and extra training, and that's why Spanair had twice the number of them required in the west. But that wasn't enough to stop their pilots from making the basic mistake of lowering the flaps.

And sure they failed to recognize the RAT/TOWS relation and probably very few (if any) training facilities in the world would've made that clear to the pilots/engineers, but in other cases such as MAP the RAT heater wasn't even noticed, as the problem is really only obvious in very specific conditions (checking RAT reading on hot weather after the power is applied to the systems for a while allowing the temperature to raise more than logical).

While better training to recognize TOWS/RAT relations may have saved this particular case (but not MAP's), it wouldn't have done anything if the temperature or taxi time in MAD would've been lower.

Better checklists with an additional TOWS test MAY have saved the day if the TOWS was inop already at the time of the test, though. I concur the airline/manufacturer could've done a better job at training to recognize systems failures through better manuals, better SOPs, requesting more checks, etc.

I've said it before. Better training never hurts, but I also think that it's each pilot's responsability to learn as much as he can about the machine he is driving past the point of "reasonable performance" that he obtains together with his license.

We all know that there are doctors that have graduated with straight A's and have taken many extra courses and have large experience, and doctors that have graduated with straight D's and spend all of their time playing golf.

Same with pilots. They are both suppossed to know how to do their jobs well enough not to make basic mistakes, like forgetting the flaps or not monitoring the heart rate. But the "Doctor House" could certainly save more lives that the "Doctor Partytime".

But even Dr. House makes a mistake every now and them and, if luck doesn't strike that day, ends the life of someone prematuraly. And he is the best on his field.

ZQA297/30

23rd Oct 2008, 22:17

Better training never hurts, but I also think that it's each pilot's responsability to learn as much as he can about the machine he is driving past the point of "reasonable performance" that he obtains together with his license.
The "reasonable performance" spoken of is in fact a legal requirement set by the authorities, and checked aggressively several times a year, not just at licence issue.
Things may have changed since I was flying, but if you flew a full roster-especially long haul, you barely had time to get over jet lag, much less attend kids functions, mow the grass, get the car serviced, and all the other things that eat up your time. You had 2 sim checks a year (requiring some level of preparation no matter how good you are), one route check, and a host of short courses in dangerous goods, firefighting, ditching, emergency equipment, security, etc, etc, etc.
Where on earth do you find the time (and money) to make yourself a "better pilot"? And who is willing to pay for this superior knowledge?

justme69

23rd Oct 2008, 22:29

I understand. That's why I wrote "reasonable performance" in quotes and mentioned the license issue for short.

I agree that, in general terms and in the west, training is already at a level where I don't think much more can be asked for. It never hurts to have more, but I don't think we can blame pilots for not having more or the industry for not providing more.

You said it yourself that you need to prepare and study for frequent tests and training sessions throughout your career even if you are good in your job.

Management can improve, I think that's true. I think that better scheduling, extra crews, less pressure, etc, are all good things for safety, but I also think that it has little to do with accidents like THIS PARTICULAR one, where a well trained, rested and not-particularly-rushed crew makes a very basic human mistake coupled with a too hard to diagnose failure to conclude in tragedy.

I think this particular type of accidents are the ones that can receive most benefits from better technology, rather than rely on better human knowledge (that comes from increased training, of course).

Or un-human pilots that just can not forget the simple task to set and verify the flaps no matter if it rains or hails. In that case, we don't need more training, or better SOPs, or better engineers, or better management, or more maintenance, or better work conditions, or better training departments, or even TOWS at all. We would simply need pilots that know how to lower the flaps (and the other couple of killer items) and ALWAYS make triple sure, for their own lifes, that they are set.

And who is willing to pay for this superior knowledge?

You are? Otherwise, you can die in an accident or, if you are a ground engineer (or a surgeon, or an arquitect), you could be put in prison for a long time for "provoking" one. If you think your work conditions and your knowledge are not good for your (or others) safety, you are suppossed to quit and do a different type of job, and NOT continue and put people in danger (including yourself). If the conditions are good but it's only training you lack to do your job properly, find the training quick and then it's all good. Or, again, just quit.

If the knowledge is there, fine, it saves the day. If it's not, I don't think it can be reasonably expected that all engineers make the RAT/TOWS connection inmediately or that all pilots should recognize the condition, besides it not helping at all in cases like MAP or in theoretical cases where the TOWS fail right before take off and right before anybody notices anything with the RAT or otherwise.

The guy writing the MEL and the SOP, on the other side, I do think that he should've made a better effort ... And I, personally, would've expected better from the maintenance technicians, but I do not blame them excessively for not taking the time to investigate the matters more througoughly.

I've already stated that my opinion, given the impossibility to trust the pilots to NEVER EVER EVER forget the killer items, is to improve the reliability of the warning systems by requiring more frequent tests by the crew, improving the design and improving the maintenance manuals to help recognize failures. That would help to assure that a warning is heard if there is a configuration mistake for whatever reason during takeoff. Any well trained crew would know what to do in that case.

A bad crew would just ignore it, but I don't think that anything can be done in that case except trying to find crews that have enough regard for their lifes to not forget flaps and not ignore warning alarms early during a "simple" takeoff.

sevenstrokeroll

24th Oct 2008, 00:18

justme69

it would appear that you are not a pilot. sure a pilot has a ''license'', but likely not a type rating...that would come with the job with the airline.

I learned to fly

Then I got hired at an airline which trained me on their type of airplane.

My airline flew the DC9/MD80.

My training department taught me how to recover from a stall right after takeoff.

My training department taught me that the RAT would be heated on the ground IF THE PLANE THOUGHT it was in the air.

MY airline's mechanics were taught this too.

MY plane's RAT was heated on the ground 3 times in 11 years of flying that type.

I BLAME THE AIRLINE(spanair) FOR NOT TEACHING< TESTING< the pilot's and mechanics in the same knowledge area that I was taught and tested in.

SIMPLE IS BETTER.

justme69

24th Oct 2008, 00:48

Seven,

I'm indeed not a pilot or anything remotely related. My background is in science and engineering.

I'm curious now as to what airline you were employed with, as I appreciate the extra safety of good professionals.

On the other side, how do you know your airplane had the RAT heater "erroneusly" on only 3 times during 11 years? You mean 3 times that you noticed, right? How many times do you suspect the RAT heater/inop TOWS went unnoticed in your airline in those 11 years by yourself or other pilots working with you?

Honestly and any wild figure will do. Do you think it was likely not noticed in 2 or 3 flights in all that time?

MAP concluded that they had their small fleet fly in that condition some 6 times in 3 months.

Does your company SOPS required a test for RAT probe heater on while on the ground? If not, how did you noticed? Because it happened to reach over 99º at the RAT and tripped an autothrust warning or simply because a routine look at the RAT showed an "impossibly high" temperature?

And did you just noticed the RAT heater on? Didn't you noticed an inop TOWS? Didn't your airline required a TOWS test before each flight?

If your airline wouldn't have taught you about the RAT probe heater problem being related to air/ground logic ... would you have still worked for them or deemed them "unsafe" and therefore refused to fly?

Smilin_Ed

24th Oct 2008, 00:55

My training department taught me how to recover from a stall right after takeoff.

These guys not only failed to set the flaps/slats, they then proceeded to pull the plane right up into a stall. Clearly they were thinking about something other than flying the airplane. They just jerked it off the deck and lost the bet that it would fly like that. :ugh:

sevenstrokeroll

24th Oct 2008, 01:14

justme69

I won't publish my airline here...let's call it security and leave it at that.

When I said my airplane, I meant MY AIRPLANE...the one I was on! The one I was flying. I have no clue how many times it happened at my airline or with that type of plane.

You check the RAT probe and the other various probes and their heating systems as part of the checklist at the gate. Seeing current on an amp meter while selecting RAT means SOMETHING IS WRONG.

I believe in being simple.

I don't think my airline was particularly good or bad at training. It was standard. Normal. routine

I have left jobs that I felt were unsafe. That was a moral choice and I ended up being harmed by the choice, BUT I STILL WOULD DO IT AGAIN.

IF I WERE THE JUDGE in this matter, I would check the training sylabus of SPANAIR and compare it to the major operators of this type of plane in the USA. See if all this is covered by spanair.

PM me if you like

justme69

24th Oct 2008, 01:20

Thanks for the reply, seven.

I'm still curious though, as if you noticed the amperimeter for the RAT probe indicating current on the ground, but I still not sure if you noticed the TOWS inoperative or not.

Were you required by the airline to test them before each flight?

Also, I'm curious if you ever found out, in those 3 occassions you noticed the RAT heater on, if it was due to faulty components or pulled c/b's.

Also, I guess you agree that all the training etc in the world wouldn't have helped if the TOWS become inoperative due to other reasons (i.e. actual TOWS electronic board failure) or if the R2-5 (i.e.) relay would've failed only a couple of minutes before the takeoff, right?

And do you think you could've saved this flight from a stall under the circunstances it happened?

Thanks again.

sevenstrokeroll

24th Oct 2008, 02:40

justme69

finding the ammeter showing current on the RAT would have stopped the checklist BEFORE we got to the TOWS check.

I honestly can't remember if it was the cb's or not...it has been a long time (more than 10 years).

all the training...would have prevented it because the slats/flaps would have been properly set...see previous posts on killer items and checklist useage.

I think any pilot who upon takeoff saw and heard the HUGE warning of STALL and had been trained to command: firewall power flaps 15 would have saved the plane.

again, check the sylabus of training for the pilots and mechanics. if the pilots and mechanics had not been trained, you have the culprit.

bubbers44

24th Oct 2008, 03:38

As said previously I have had the same problem on an MD80. Taxiing out noticed strobe lights were flashing, couldn't get power below flight idle but did not notice RAT temp or know TOWS was inop. I was able to fix the problem with aggresive brake application to compress the nose gear strut. Everything returned to normal. I then got in the maintenance books days later, and found out the air/gnd sensor on the nose strut was saying I was in air mode. I am smarter now and know the TOWS that night also was inop. That R2-5 relay or whatever was in air mode along with the TOWS. I didn't know it that night. I did have the flaps set but if I had not I would have had no warning. I don't think it would have ended up in a crash but it would have required more runway. Rotating to a normal deck angle and waiting for the aircraft to fly works for most airliners, over rotating can get you a tail strike or if in the wrong configuration, much worse.

justme69

24th Oct 2008, 03:44

Thanks again seven for clearing things up.

all the training...would have prevented it because the slats/flaps would have been properly set...see previous posts on killer items and checklist useage.

I was, of course, referring to a takeoff w/o flaps. If we agree that with training this can never happen, because the pilots will always remember to set flaps, then we don't need TOWS checks, training about the relationship of RAT probe heater to possible TOWS failure, better TOWS designs, better engineering, better MELS or even TOWS at all to avoid this type of accidents.

We just need to concentrate on training pilots to lower the flaps correctly.

But I thought we were already doing that.

And yet, sometimes, pilots forget to lower flaps (or landing gears, etc). Like Detroit's Nortwest or Delta's Dallas.

I thought all (sensible) airlines already teached their pilots to correctly follow checklists and make several take off checks of vital systems

The chief of operations for Spanair, Javier Muelas, claimed on TV that they established in their SOPS checks for the flaps 3 times before each take off (i.e. google translated short extract Versión traducida de http://www.salabriefing.es/nuke/modules.php?name=News&file=article&sid=1975 (http://translate.google.es/translate?u=http%3A%2F%2Fwww.salabriefing.es%2Fnuke%2Fmodule s.php%3Fname%3DNews%26file%3Darticle%26sid%3D1975&sl=es&tl=en&hl=es&ie=UTF-8) )

I haven't seen the current checklist at the time, but in old ones, depending how you look at it, they indeed indicate to check them twice, including one right before take off in big letters as the first item.

Can someone post a scan of Spanair's "current" MD-82 checklists before the accident?

So I'll ask again. Do you agree that, in the event of attempting to take off (w/o flaps), all the training recognizing RAT heater relation to ground logic wouldn't have helped in the event of a TOWS failure shortly before takeoff or one that was not related to ground logic (i.e. a blown loudspeaker)?

And do all the pilots here agree that simply firewalling a fully loaded MD-82 and quickly commanding flaps 15 would've almost for certain saved the aircraft from stalling (assuming a short-ish runaway and moderate tail wind) by just about any pilot?

I thought the aircraft would need some 15+ seconds to reach the correct speed on those conditions (fully loaded, tail wind) even if firewalled. That close to the ground, I thought you would need luck on top of good airmanship to keep the craft from crashing against the first thing that was more than a few meters tall (again, in a not grossly-long runaway).

Also, do pilots here think that the Spanair crew over rotated the airplane? How many of you would've done this:

You are taking off and there is no indication of anything wrong. VR is called. You start the rotation. You feel that it's a bit sluggish and the aircraft is not quite climbing as it normally does. Do you:

-Think you may have been too gentle and have a too shallow angle and pull up a little to help out

or

-Don't quite understand what's happening and just assume maybe you are a bit heavier than you thought (or the wind is playing you up, or you understimated your calculations, whatever) and let it run given available runaway until you get close to the end and then pull up more if still no possitive climb.

SPA83

24th Oct 2008, 07:51

The crew is an extremely fragile system whose level of performance, the ability to respond efficiently to a given situation depends on the quality of the environment in which it operates.

In aviation, some events may be described as “catastrophic” and are therefore recoverable with difficulty by the crew, engine explosion for example, others are more “simple” and therefore easily detected and corrected by an efficient crew (misreading a checklist or error handling of a device for example)

If the crew is under pressure, tired or weakened by the environment in which it operates, its performance may make it unable to cope with an event called “simple”.

So, what was the quality of the environment in which the crew was operating?

Furia

24th Oct 2008, 09:16

Smiling Ed. These guys not only failed to set the flaps/slats, they then proceeded to pull the plane right up into a stall. Clearly they were thinking about something other than flying the airplane. They just jerked it off the deck and lost the bet that it would fly like that

I am reading so much bull**** on this forum about this accident that I cannot belive this is a "profesional pilots forum". :yuk:

If we have learned something on this bussines is not to draw fast and easy conclusions.
Many wrong things happened that fatal day and we still do not know why.

The thing we do know for sure is that a lot of people died including the good professionals that were doing that flight.

I am reading here that pilots failed to check that the flaps and slats were lowered. Can somebody tell me how do you do that from the cockpit of an MD-82? So you move the lever of the flaps to the selected take off possition and the indicator shows you that. So what? unbuckle and walk to the passenger cabin to take a look through the window to check if they are deployed?

So far at least 2 things seem to have gone wrong on this tragedy.
The flaps and slats were not deployed despite "THE CREW READ THE CHECKLIST ITEM AND MOVED THE FLAP LEVER TO THE SELECTED TAKE OFF POSSITION" This information comes from the CVR and FDR and it is on the preliminary accident report.

So at first glance seems that they did their job. Reading and following the checklist.
However the flaps were not down and this as far as I know is a different system that the the TOWS.

Second issue was that once they selected take off thrust the "flaps/slats audio warning" should have sounded on cockpit and would have surely forced and aborted take off maneuver.

I have the priviledge of being a friend of the Captain of that flight and for me and for all the people that knew him he was a real professional besides being a great person.

The fact that on the first take off attempt after the long taxi from the terminal to the runway he detected the RAT probe temperature and decided to turn around should tell everybody that the crew was a professional one doing its job properly.
Some others maybe would just have took off with such RAT issue but not him.
They did their checklits throughly, detected the malfuntion of the overtemperature on the RAT and wisely retourned to the terminal in another long taxi. Careless crews do not do this.

Now comes the thing. We pilots follow specific protocols and procedures. We detect a malfuction, we report it to maintenance.
Maintenance investigate it and fix it or declare it "airworthy" according to MEL, Manual and company precedures.
So maintenace tell you the airplane is OK, they sign the books and declare it airworthy. So you get no more Warnings on cockpit and all appear to be functional.
What do you do?

When this tragedy happened many people claimed seein exploding one engine, they even ventured it was the left one. :suspect:

Now we are far away from that theory and we know more data.
But what we know for sure is that this accident happened not by a single error o malfunction. At least two different systems failed.
Flaps didn't lowered despite the lever being activated and the TOWS didn't worked either.
I am sure there were several other contributing factors that we do not know yet but that the combination of them made this accident happen.

When we have all the answers, it will be the time to determine who was responsible or not.
One things is speculate about possible technical scenarios that could have happened and another thing is blaming a dead person of being a careless jockey that endangered the live of hundreds. :=

captplaystation

24th Oct 2008, 09:59

Furia
I have read almost every post on this thread, but nowhere can I recall reading that either the FDR nor CVR made any reference to confirming that flaps were selected, merely that they were not deployed.
I recall that quality of CVR was poor and that the response to "flaps" was something vague like "OK" rather than the correct response,but I cannot recall that the report mentions anywhere an audible click or other mechanical noise confirming that the lever had been moved, nor a reading from FDR confirming lever movement ( if indeed that is measured as well as flap position )
Can you clarify where/what verifies that flaps were selected apart from "OK" ?

justme69

24th Oct 2008, 12:19

Furia is not correct in that the pilots activating the flaps handle is an established fact, confused probably by all the press reports (in Spain at least) that flat-out refuse to speak of even the possibility of human error but of "flaps failure". Nowhere there are indications about that. Of course you can read the CIAIAC report yourself here: Preliminary report A-032/2008 - CIAIAC - Ministerio de Fomento (http://www.fomento.es/MFOM/LANG_CASTELLANO/DIRECCIONES_GENERALES/ORGANOS_COLEGIADOS/CIAIAC/SPANAIR_2008/032_2008_Report.htm)

Indeed CIAIAC preliminary report point to the pilots, PERHAPS, going over the required checklist items and calling them ("ok"). Although PERHAPS not 100% according to regulations, but pretty close in the worst case, unofficially. The report doesn't say the CVR confirms the handles down (i.e. a noise is heard as it goes down) nor does the FDR have a way (AFAIK) of knowing the actual handle position (only the position of the flaps and slats, if working properly).

The flaps were down 11º on the first takeoff "attempt", but not on the second according to the FDR. The report states that the slats weren't likely out either (from recovered wreckage evidence), but CIAIAC lacks the confirmation by the FDR because it wasn't working quite right for the selected flight computer #2. Perhaps the QAR can "confirm" that now.

Regardless, the symptoms of the airplane stalling seem more consistent with a flaps and slats "deployment failure" than with only flaps, although both scenarios are possible, of course.

The report also says that they are trying to establish the procedures to try to determine the position of the flaps handle at the time of take-off. Nothing else.

The TOCWS, indeed, seems to have failed, as the configuration was incorrect (at least for the flaps) and the alarm didn't sound.

While we all still give the benefit of the doubt as to whether the flaps handle was lowered and both flaps and slats on both wings failed to deploy while the indicators for the slats properly lighted to the TAKEOFF position (while the rest of the lights remained off) and the analog dial indicators for both flaps signaled the correct 11º position, we all know that it is basically imposible and it is far more likely that the handle was never lowered, as it has happened many times before like in Nortwest, Delta, LAPA or MAP cases. Or, at least, even if it was lowered, that the indicators were never checked to be in the correct position. Either way, it would be a crew error. This action would've been carried out by the copilot in this case, rather than the pilot, it seems.

Also, the pilots noticing the RAT probe heater turned on came way late in the line up taxi roll for the first "takeoff attempt", pointing to probably having gone unnoticed until the temperature tripped over 99º, firing an autothrottle warning, rather than by reading the amp meter for the heater or doing a sanity RAT indication check early on, perhaps. I don't know if the SOP required such a test, but it wouldn't have been a bad idea that the crew checked the stuff anyway.

lomapaseo

24th Oct 2008, 12:46

The recent spate of news stories in the papers cites a NASA safety data source reported by pilots with similar events as the Spanair crash. I was particularly interested in the data comparison between the crew error vs the TOW error rate in this data refernced below.

From my initial view with such a high crew error rate we need a much lower TOW error rate to achieve the presumed level of safety in the initial design of the aircraft.

If this can not be done with system design then it has to be addressed with operational changes. I really don't see this as unique to a given aircraft model (see news article below). But I'm not willing to walk away from this as a one-off "it-can't happen to us"

Human error stubborn snag in airline safety - USATODAY.com (http://www.usatoday.com/news/nation/2008-10-22-insidecrash_N.htm)

From 2000 to the present, pilots reported 55 cases in which they attempted to take off without properly extending the flaps, according to the data. In nearly all cases, the warning horn functioned normally and prevented tragedy. But pilots — many surprised that they made such a critical error — say that stress, fatigue or interruptions to their routines caused them to make big mistakes.

captplaystation

24th Oct 2008, 13:33

justme69
Thanks for clarifying, that was indeed how I believed the "official" as opposed to the "press" version of events were.
No one wants to believe they, or someone close to them, is directly responsible for an event like this.
Unfortunately for Furia, his sadly departed acquaintance must shoulder some of the blame even if tech problems magnified the mistake from an incident to a fatal accident.
It would be interesting to run an anonymous poll to see what percentage of pilots have lined up & advanced the thrust levers without selecting flaps.
The results would open everyones eyes :eek:

sevenstrokeroll

24th Oct 2008, 13:44

IF you wanted to, you could stick your head out the DV window and see the slats/flaps.

I want it made clear. I didn't blame the pilots, I BLAME THE COMPANY THAT TRAINED AND TESTED THEM.
Is it remotely possible that the flaps were selected properly and the sleeve of the copilot moved it out of the detent and therefore up?

it is a very remote possibility, very remote.

But some bright guy might try it...maybe even his wristwatch caught the lever.

AMEandPPL

24th Oct 2008, 13:47

It would be interesting to run an anonymous poll to see what percentage of pilots have lined up and advanced the thrust lever(s) without selecting flaps

I'll be the first to admit to that. OK, it is only a C172, but the take-off performance is still degraded. Just feel a bit sheepish inwardly as you stagger into the air much more slowly than usual.

Furia

24th Oct 2008, 14:03

I do not want to exclude any posibility.
There is no video camera on the cockpit so we only have the CVR.

The oficial preliminary report states that the crew completed the checklist.
They say nothing about rushing items or missing items. Anyone that has flown in Barajas knows the long taxi to the runway so they should have not rushed any items anyway.

The report concludes the crew was performing the appropiate checklist.
No comments there, nothing was rushed, ommited or neglected, but still some people wonders if the pilots may have been doing some wrong

Seems that for some people here it is easier to assume that the crew was just reading a checklist but not doing their job rather to assume that a not uncommon flap/slat extension failure happened.

You must forgive me but without discarding any possibilities I prefer to think that if one pilot was challenged with the "Flaps and Slats" question and he positively answered "Flaps and Slats OK" he meant that.

If you want me to change my mind about that, demonstrate it otherwise.

justme69

24th Oct 2008, 14:36

Well, I don't want to get in an argument here, but if indeed the response to the checklist item flaps/slats was "OK", then that's your first evidence that the crew wasn't doing their job properly.

They should've answered with the degrees setting and the setting, like "11º/Takeoff", as trained and required by the SOP.

Also, it wouldn't be the first proven case in the history of aviation of a rotten response, but it would be the first one of a multiple system failure involving a very simple and reliable mechanism that developed into no less than 8 (4 for each wing) simultaneous failures (flaps actuators, flaps sensors, slats actuators, slats sensors), that resulted in a lighted indicator and an analog watch dial indications TAKEOFF for slats and 11º for each of the flaps when indeed both flaps were at 0º and the slats (likely) retracted.

If you choose to rather believe in someone saying "ok" rather than both needles of an ANALOG indicator gauge pointing "mysteriously" to 11º (while the flaps were at 0º) and a lighted indicator receiving power from TWO switches (one on each wing) closed by "something" in the place of the slats while the slats weren't actually there ... well, that's your choice and indeed it's a possibility.

But realistically, we all know what is far more likely.

Also, it has been proven in the past that crews failed to deploy flaps and slats in at least 4 more cases (Detroit, Delta, LAPA, MAP). So it is not so "unusual".

And the CIAIAC CVR preliminary analisys doesn't say the pilots completed the checklist, only that there is evidency of SOME ITEMS of the checklists being performed. Exactly, what it says is:

"The conversations of the cockpit voice recorder (CVR) revealed CERTAIN EXPRESSIONS corresponding to the before engine start checklists .... the normal start list, the after start list and the taxi checklist ..."

It doesn't say anywhere that the pilots called flaps/slats and the response was "ok", which still would've been a wrong response, but at least it would show that they were trying and they probably thought they had set it.

And UNOFFICIALLY, sources close to the investigation say that you can perhaps, with foreinsic CVR analysis help, indicate that indeed the pilot called flaps/slats and the copilot answered ok. But that's unofficial and would still not prove that the actual flaps and slats were commanded to deploy and the indicators verified, only that they thought they had set them.

The alleged response of "OK" (instead of 11º/Takeoff) could also mean that the copilot understood a different item to be checked instead of the flaps/slats and replied to that, while the pilot calling the item didn't verify or requested the proper response.

Bis47

24th Oct 2008, 14:50

Hello !

justme69
I've said it before. Better training never hurts, but I also think that it's each pilot's responsability to learn as much as he can about the machine he is driving past the point of "reasonable performance" that he obtains together with his license.
I fully agree … and not only to learn more about the machine, but also about other very important aspects of his job. It is part of the required « enthousiasm » that is a character of good pilots. It is pure « airmanship ». If you are interested, I recommend « Flying kow-How » and « Flying the weather » by Robert N. Buck (Macmillan).

However, not all the pilots have the proper culture to progress by themselves in the several « improvement » paths. That is the reason every airline has a « training » department, even if they don’t provide basic training or type rating. Instructors, chief instructors, head of operations … should have - collegially - the required culture, experience, airmanschip and information (error reporting litterature) to design an appropriate « continuous improvement » program.

It is nowaday recognized that the initial type rating could not provide all the in-depth kowledge of an aircraft. You have to build that in-depth kowledge by adding layers of kwowledge above layers of training and operational experience. With proper supervision an progressive checking.

The fact is that there is litlle or no « standard » about that continuous improvement of competency and airmanship. Its rests upon the shoulders of the chief pilots and instructors.
So each time you hear « Our airline is fully complying with the standards » … it means NOTHING.
Or , in fact, it means : « we are satisfied with minimum standards » L

justme69

I think this particular type of accidents are the ones that can receive most benefits from better technology, rather than rely on better human knowledge (that comes from increased training, of course). 1. Obviously, MacDouglas and Boeing should have done better ...

2. Better human knowledge (of the aircraft systems and other safety related toppics) doest not come from « more » training, it comes from better training … Better training is given by better instructors, using appropriate tools and a better syllabus. You don't need the latest multi-million simulator to train better pilots, what you need is :
- first class instructors (instructors with extra airmanship, instructors who think ) – not the kind of « repetitors » that are so frequent among sim instructors …
- selected pilots … applicants selected and trained not for their parents wealth, but for their smartness and enthousiasm for flying.

When airlines used to train their future pilots ab-initio and for free , their first objective was to select « the right stuff » ;) .

Only a very limited percentage (5% or so) of applicants made it to the right seat of an airliner.
Today, training is given by commercial subcontractor, and paying trainees are indeed « customers ». You won’t reject customers …
Selection is a joke. It is just a selection by the money … So, only a very limited percentage of applicants are rejected in commercial FTO’s and TRO’s.

3. Better technology can help … to some extend. Airbus was supposed to provide that cutting edge technology improvement towards flight safety. You think they made it ?

Actually, the best improvement in flight safety came with the introduction of CRM and scenario based recurrent training. A real improvement from the previous « macho » philosophy. Still a long way to go (at least with Spannair) :
- A properly CRM trained crew member would "never ever ever" accept a sloppy challenge and response check list. (Just considering it as an insult ...)
- A properly scenario trained crew would know better about stress and distractions …

justme69
I've already stated that my opinion, given the impossibility to trust the pilots to NEVER EVER EVER forget the killer items, is to improve the reliability of the warning systems by requiring more frequent tests by the crew, improving the design and improving the maintenance manuals to help recognize failures.
I do not agree with the "more frequent test" remedy.
The main business of a pilot is not to test again and again his parachute … The main business of a pilot is to make sure not to have to use that last ressort safety net.
Before take off, there are much more important items to check, rechek and cross-chek … The system tests should really be kept to the minimum (I agree with a test during the prestart scan ... as a normal pilot habit!)
But, once the aircraft starts moving, chek list should be restricted to the killer items, and to those items that were impossible to set/check while the aircraft was at the stand.

sevenstrokeroll
I BLAME THE AIRLINE(spanair) FOR NOT TEACHING< TESTING< the pilot's and mechanics in the same knowledge area that I was taught and tested in.
I fully agree.
For the same reason that the maintenance manager has to report to justice, I think the chief pilot and a few other managers should be involved as well.

An airline his supposed to have a strong structure garanteeing safe operation :
- a trainging departement and a flight ops department working in close relationship. They are supposed to be headed by very competent and experimented « responsible managers »
- a quality manager, a quality system and a safety officer working in close relationship, and coordinating/supporting other managers efforts.
- scheduled quality management meeting, examining audit reports and propositions for improvement.

Let us not forget the triple mission of the quality system :
- make sure that mandatory standards are complied with. We know that lobbying by short sighted cost conscious airlines have reduced those standards to a level well below what was previously in force by first class airlines. Just a paper work challenge ...
- seek for continuous improvement above those bare minimums. It means of course … see at it that the "responsible managers" really work in that direction ! A very exciting challenge indeed, provided that all the managers are willing to play and that they have the time and smartness to be honnest players.
- keep the top management "in the loop".

It is a fine structure ...
But that structure did fail ...well before the crew entered the airplane that day.
There was a latent defect somewhere ...

justme69

24th Oct 2008, 15:30

BIS,

I agree with most of the points you raise. When we post here, we all obviously try to be brief and shortcut our explanations a bit.

So just to clarify, when I said "increased training" I meant "more, better training". I disagree that knowledge doesn't come from "more" training but only from "better" training. I think that it comes from both, but that's just semantics.

When I said "more frequent TOWS checks" I meant more than just once a day and whenever pilots changed or were away from the cockpit for a long time. In more practical and specific terms, I meant "once a day by maintenance and shortly before each takeoff by the crew". Obviously TOWS check is an important safety measure, as shown in this an other cases, second to killer items, of course, but not far behind, lacking a better solution (i.e. technologically super-reliable TOWS which gives a big and clear indication when it fails)

I fully agree with the "right culture" against the "macho" culture. I think there is a LOT of that in Spain at least (Iberia, Spanair, Air Europa, Binter, Air Comet, etc). I have no problems pointing fingers where I think they are due.

I, nonetheless, disagree that training or "corporate culture" in those companies promote or condone this kind of behavior, but SOME pilots engage on it right away shortly after their license/rating is granted.

Firing someone with a powerful union behind is not easy or cheap in Spain. And with closed-door cockpit policies, other than consistently spying on your own pilots through CVRs and QARs I don't know how they can figure out the good apples from the bad.

I'm all in for planting videocameras in the cockpits and have one person in the airline reviewing everyday random flights and suspending pilots left and right. But I can see hell being raised by them and their unions, so it probably won't happen and the "machos" will continue to dominate the skies.

I have two relatives that are in the aviation industry. One is an ATC and the other is an airline captain for a major airline in Spain. The horror stories he tells me of while travelling around in jumpseats are not for the faint of heart.

DISCLAIMER: Obviously there are very fine, top of the line worldclass pilots in Spain. But we have ALL seen what some less stellar ones do around here. And not only here, of course. Look at the CVR from LAPA or Delta (etc, etc) in similar accidents for much much worse.

And on the good side of news today, all survivors have left the hospitals in Madrid, although one of them would still need local medical supervision for a while. All 17 PAX and 1 avan crew member that survived have been able to recover favorably.

agusaleale

24th Oct 2008, 15:44

I encourage you to see a movie, Whisky Romeo Zulu, from Enrique Piñeyro, former pilot of LAPA. The movie has its name as it was the LAPA plane, LV-WRZ
I don´t know if there is any version of it in English, but those who know spanish will appreciate it.
The case of the LAPA plane was not only about pilots forgetting to put the flaps/slats and not giving attention to the TOWS (that in that case worked fine).
It infoms precisely the many layers of swiss cheese that were aligning in that company that lead to the disaster.

Besides all, we are forgetting the particular circumstances of that day, the copilot in charge of the take off knew that he would be fired or offered an administrative work; also a press comunicate from the sindicate pronouncing some facts about the risk in the operations in Spanair (that never saw the light as a consecuence of the accident)...

justme69

24th Oct 2008, 16:08

I have seen the movie and considered it too biased. But what would you expect from a movie made by a pilot unionist.

Otherwise, except for a couple of times when I thought it was being overly one-sided, it raised many vaild issues to public awareness that basically shows the caos in Argentinean civil aviation industry.

And all of you are going to excuse me, but I still fail to see how management or training etc can have much to do with a basic, simple human mistake like not lowering flaps.

I would understand that undertraining and generally unsafe practices unsupervised could lead to pilots making mistakes during complex maneuvers or extreme situations.

But something as basic as lowering the flaps handle while taxiing on the ground for 20 minutes by a rested, non-overworked crew?

Isn't every single pilot in the (first) world taught to never ever skip the checklists, do them right, and never forget the flaps/trims/spoilers/landing gear/etc like a million times?

How come when they fail to do that is NEVER their fault but "the company" for not firing them/training them (even) better?

I guess I have a question to make.

When is a pilot's mistake ONLY his fault and nobody elses? Never?

In that case, congratulations to all of you who are pilots. You can never fail because when you do, it's not your fault, it's somebody elses that apparently is human, unlike you.

sevenstrokeroll

24th Oct 2008, 18:57

the whole point is this:

if you are taught to use a checklist, but don't...it is vital that you be found out ...but if the management doesn't look for problems, they won't be found.

I would like to listen to the CVR and try to hear the movement of the flap handle into the detent. Or the actual movement of the slats...I've heard them at idle thrust when selected.

I would also like to know if the CVR picked up the stall warning horn.

I think the crash would have been more survivable if the use of the ''snatch'' rotation had been discouraged. Waiting for the plane to ''fly'' off might have given a better chance of surviving the crash. rolling off the end, right on centerline certainly would be better than slipping off the side into a ravine.

I wish that spanish judge would chat with me.

Bis47

24th Oct 2008, 19:27

justme69
When I said "more frequent TOWS checks" I meant more than just once a day and whenever pilots changed or were away from the cockpit for a long time. In more practical and specific terms, I meant "once a day by maintenance and shortly before each takeoff by the crew"
I’m not type rated on the MD’s …
As far as I know, the actual procedure for testing the TOWS is to advance thrust levers while the flaps are up or the airbrakes are out.
Nobody wants to do that while taxying, and nobody wants to be in an abnormal condition « shortly » before take off … just to test the warning system !
But this is so easy to perform (at least partially) before start, that I don’t see any reason not to perform it before each start up. (Let it be a partial check : the airbrakes « out » condition would not be checked …)
« First flight of the day » checks are a pity … A test is either important and then it is wise to make an habit of checking those systems before each flight … or that test is not really so important, and then let us forget about it and concentrate on more important items directly affecting safe operation.
Then, giving a look at the RAT indication before departure would give a clue about air/ground mode if the reading is abnormaly high. And there are other good reasons to observe that instrument shortly before departure ...
There are other ways to improve proper take-off configuration set-up :
- do it as soon as practicable, as a priority action. Say - typically - just after push back …
- keep the taxi checks to a strict minimum
- ask for before take-off check list before calling « ready for departure » and keep that check list short ! … By the way, a captain should silently review the killer items just for himself before asking for the check list (IMHO – and that is my personal private safety net, my « pride » not to be saved be the check list).

Justme69
I, nonetheless, disagree that training or "corporate culture" in those companies promote or condone this kind of behavior [macho culture], but SOME pilots engage on it right away shortly after their license/rating is granted.

Firing someone with a powerful union behind is not easy or cheap in Spain. And with closed-door cockpit policies, other than consistently spying on your own pilots through CVRs and QARs I don't know how they can figure out the good apples from the bad.

I'm all in for planting videocameras in the cockpits and have one person in the airline reviewing everyday random flights and suspending pilots left and right. But I can see hell being raised by them and their unions, so it probably won't happen and the "machos" will continue to dominate the skies.
It is part of the chief pilots responsibilities to see at it that a « macho culture » does not survive in the company. Many tricks are available during sim checks to have macho's regain some humility ...
Yes, spying crew as much as practicable is a chief pilot duty … and a common practice by top companies. Crews are aware that recorders are going to be checked, either by their chief pilot or by state inspectors …
Firing an undisciplined pilot is difficult, or expensive ? Try an accident !
In any way, that will hold true for the first firing, less so for the second one … and then, there will no longer be any need to fire somebody ...

Justme69
And all of you are going to excuse me, but I still fail to see how management or training etc can have much to do with a basic, simple human mistake like not lowering flaps.
I do excuse you … You cannot realise the accident prevention intricaties and subtilities if you are not « in charge » in the real world …

justme69

24th Oct 2008, 20:21

Thank you, Bis

Just for the record, I do understand some of the "subtleties" involved, like checking the RAT reading and RAT air intake anti-ice heater having more to do than simply showing potential air/ground logic faults. The autothrottle computers would appreciate having the correct temperature readings for the calculations.

I do not know if the MD80 have alarms for when the heater fails while on the air, but I know some similar (but more vital) devices like the pitot do.

Again, for short, I guess I didn't specify that by testing TOWS shortly before takeoff, I meant right before the engines are started is close enough if that's the most convinient time to have the flaps up and move the throttle to switch activate position w/o bothering/endangering anyone.

"Overnight" daily checks done by maintenance are, from my point of view, a good thing as it provides with a less stressful and rushed enviroment in which an engineer expert rather than a pilot can test systems more deeply. Some times, I understand other systems are better tested while flying and/or performed by the crew.

And I do understand that a better managed, very supervising company, where knowledge is spread and advanced during time, etc, etc, can strongly contribute to a safer operation where a "simple", "silly" mistake like forgetting to lower the flaps is LESS LIKELY to happen.

I guess I didn't make myself clear. My problem is with "inmediately" blaming the company/management with something that COULD be the sole fault of the pilot. Granted it's not always the case. Perhaps even not the most common, I concur.

My problem is with those that do not believe that the pilots EVER can do anything wrong because, if they do, it's only because other humans working in the airline, regulatory bodies, or at Boeing, or at a maintenance subcontractor made them.

My problem is with those that think that fogetting to set of the flaps at least 55 times in the USA in the past 7-8 years (voluntarily reported), means automatically that in all cases tons of airlines must have crappy training, bad safety culture and poor supervisory skills, and they should all be put in jail for that. Except the pilots, who simply "followed along" blinded from the dangers of not lowering flaps.

We are all humans and we all make mistakes. As long as pilots only forget to lower flaps once in their career, I'm ok with that. I can not, in good faith, demand for much better. Hopefully, when they do, the TOWS won't be inoperative. I can, though, reasonably demand for a better TOWS than the one involved in this case.

alatriste

24th Oct 2008, 20:30

Furia,
According your hyphotesis:

1 After start checklist was properly performed. Therefore:
i) Flap/slats were selected according TO performance calculation
ii) Slat secuence was checked as: disgree/TO/disagree-auto/disagree/TO
iii) Flap position indicator was checked to agree with selected flaps (both)
iv) Slats T/O light was checked to be ON and all other slat advisory lights
to be OFF.
v) Auto slat fail caution light on annunciator panel was checked as off.

2) Take off briefing during taxi was performed and flapp setting was checked.

3) Take off inminent C/L was properly performed and so:
Flap/slat position was verify( needles + light) during final/killer items check

Even though procedures comply 100% with SOPs, in FACT flap/slats were not deployed.
This scenario being true, I guess no MD pilot all over the world might trust this machine and the MD fleet should be grounded inmediately.

justme69

24th Oct 2008, 21:22

Now, to be honest, I'm appalled at the aviation industry for a couple of things that were permissable 30 years ago but I no longer think they should be today.

Granted I haven't seen the operations inside a cockpit on large airliners (some small commuter planes don't even have cockpit doors) for a while, but last I saw say only 9 years ago or so (Spanair, Aviaco, Alitalia, Usairways I remember specifically), and they still were holding a crappy piece of folded paper as their checklist, going through the items from my point of view faster than neccessary.

I know that checklists are computerized in some airplanes, specially new ones, and I understand that older types like the MD80 don't have that luxury.

But would it be too much to ask to print out some decent (instead of crumbled) checklists and asks the pilots to put checkmarks on the items or use a little lighted electronic board to check them off as descibed before in this thread?

Also, while I was reviewing old Spanair checklists I noticed how the most important item was in the first position in larger type. Well, because of this, I did miss the Flaps/Slats in the inminent takeoff checklist on the first look, subconsciously thinking it was a header rather than an item. I'm not a pilot, though, so I guess I'm excused.

Frankly, I thought the whole checklist system was far below anything needed since the invention of the inkjet/laser printer. The typeface, colors, etc. It can all be done so much better by a 12 yo (I'm exaggerating, of course).

Also, from the checklists I have seen carried out, most of the time it looks like one pilot is simply reading and the other setting/verifying, with the first one taking whatever the second one says for granted while he concentrates mostly in taxing rather than double checking (except for crosschecks, usually).

And last, very few times I have seen a pilot actually truly checking the flaps indicator while lowering the handles. The one flying during landing would call "flaps 20" and the other would lower the handle and inmediately answer "set" w/o ever looking at the indicator. This always caught my attention. Sometimes the one lowering the handle wasn't even looking at the position it was (actually looking out the window), just trusting it was the right detent by the "feel".

Not to mention the "macho" pilots who would go down fast and high and straight to flaps 30 after a 180 at 70º roll... (or who knows what angle, I'm bad at estimating these things, but at least 45º), but that's another story and the exception rather than the rule.

These are the words of Spanair's chief of operation, Javier Muela, extracted from an interview and translated by me:

In relation to procedures for checking the takeoff devices he said: "from the time the engines are started until take off, the takeoff configuration is tested up to three times, specially the flaps and its indicators, to make sure it's the correct one" .... "This triple check is even more effective than a TOWS check recommended by the manufacturer, which nonetheless is made during the first flight of the day or, in consecutive flights, if the crew changes or if they have left the aircraft".

He said that the first (TOWS) check was done (should've been done by the pilots) in the previous flight from Barcelona and again in the next one, Madrid-LPA, where the airplane remained for over 2 hours in the stopover, as the crew had left the cockpit for a long time, so "the crew made (should've made) another (TOWS) check upon entering the cockpit".

They weren't required to check the TOWS again for takeoff after the Return to Gate due to the RAT "problem", as they had not left the airplane and (theoretically) had tested them already for that flight (about 1 hour before, if the SOP was followed). This does not follow Boeing's recommendation of testing them before each (attempt to) takeoff. Spanair has since changed the SOP and now requires a TOWS check for the MD's before each takeoff, not just upon both pilots entering a cockpit.

Because the CVR only records the 32 minutes prior to the accident, and the airplane suffered the "RAT heater problem" delay and long taxi times in excess of 15 minutes each way, a lot of the data for analyzing previous crew actions can not be properly known.

agusaleale

25th Oct 2008, 01:02

Justme
These are the words of Spanair's chief of operation, Javier Muela, extracted from an interview and translated by me:

In relation to procedures for checking the takeoff devices he said: "from the time the engines are started until take off, the takeoff configuration is tested up to three times, specially the flaps and its indicators, to make sure it's the correct one" .... "This triple check is even more effective than a TOWS check recommended by the manufacturer, which nonetheless is made during the first flight of the day or, in consecutive flights, if the crew changes or if they have left the aircraft".

If this statement is true, then we have a clue. It is very possible that the TO configuration was checked only once.
If so, we can presume that the pilots were used to do this only one time, not three times, so the procedures were not followed, and in this case we can talk of poor management and training, as nobody noticed what they were doing.

justme69

25th Oct 2008, 04:06

While I personally think that it's not easy at all to "catch" pilot's bad behavior, specially if it is only sporadic, I'm all for forcing airlines to install voice/image recording devices in the cockpits that last longer than the 32 minutes of the CVR which, best case scenario, would only allow to evaluate pilot's behavior for the landing part of the last flight.

That way airline supervisors can figure out what goes on behind the locked doors of the cockpit and catch bad apples before their actions becames a danger. Don't we all agree that this would be an easy, cheap and really effective way to monitor progress and compliance of crews with training?

After all, the last 8 large accidents with victims in the US have all been due to human error. This was Spain's worst accident in a long time, the first one with victims in Madrid in 25 years and the first one for Spanair in 20. Over 65% of aviation accidents are due to human error as the primary cause.

In that case, those within the company in charge of supervising could also be held responsables for repeated risky conducts of the pilots under their supervision/training.

It looks a bit like "who watches the watchman" to me, though.

So a pilot (consistenly, lets make this easy) fails to do his job as trained and the person that hired/trained him is to blame. Therefore, they failed too and all "four" go to jail. And it's OK to end it there. We don't need to hire someone to supervise that the supervisor is actually supervising the pilot, or that the trainer is actually properly training the pilots.

And if we establish such a position in an airline, then when a pilot fails, we send to jail also the supervisor for failing to catch him and the supervisor of the supervisor for failing to notice that the supervisor that failed to catch the pilot wasn't doing his job correctly.

I'm all for that too.

But why stop there? I would put a smiley face if the matter wasn't serious.

While I would totally understand the chief pilot/chief of operations/training of Spanair being charged by a judge if he never allowed the pilots to know how to properly deploy the flaps and how to follow the checklist, or if he had knowledge that they weren't routinely following the proper procedures, I don't see how he can be responsable if he never found an indication of that being the case and the training included more than sufficient information on the importance and proper procedures of flaps deployment.

threemiles

25th Oct 2008, 04:42

I don't think it would have ended up in a crash but it would have required more runway. Rotating to a normal deck angle and waiting for the aircraft to fly works for most airliners, over rotating can get you a tail strike or if in the wrong configuration, much worse.

You would only have noticed that something is wrong as soon as you had left the ground effect. Until then you would have used the same Vr and therefore required almost the same amount of runway to get the wheels off. Bouncing back to the runway is certainly not an option once the iron lady tells you stall especially when the plane starts rolling unexpectedly. What makes you sure, you would have saved the day?

Bis47

25th Oct 2008, 07:11

Hello!

Justme69
My problem is with those that think that fogetting to set of the flaps at least 55 times in the USA in the past 7-8 years (voluntarily reported), means automatically that in all cases tons of airlines must have crappy training, bad safety culture and poor supervisory skills,

I'm among those that think that [...]
Yes sir, that is the real world.
Tons of lifetime examples ...
Demonstration?
Let it be given by a sharp occasional observer ;) :
Frankly, I thought the whole checklist system was far below anything needed since the invention of the inkjet/laser printer. The typeface, colors, etc. It can all be done so much better by a 12 yo (I'm exaggerating, of course).

Also, from the checklists I have seen carried out, most of the time it looks like one pilot is simply reading and the other setting/verifying, with the first one taking whatever the second one says for granted while he concentrates mostly in taxing rather than double checking (except for crosschecks, usually).

Now, to be honnest, taxying is not the best time for Challenge and Response check list ... So the necessity to restrict it to very essential items.

In short, there is a real need to improve the useability of check list, as well as to promote a good "tempo" for calling "Check list!".

- subtilities/intricaties of accident prevention
- need for smart people ...

Please, don't take me wrong, I do appreciate "strong" safety devices ... but I hate seeing them used as an argument to dispense with "strong" crews, witch is the modern tendency ...

justme69

25th Oct 2008, 07:53

Hi Bis,

I think that, deep inside, we agree more than we disagree.

What I was trying to say is that I object to those that state, in cases similar to this, that they do NOT blame the pilots but the airlines for these accidents.

A pilot is a grown adult and knows very well that he is not doing his job right when he doesn't follow checklists as trained. The fact that nobody has caught him acting that way, doesn't mean that he is not responsable and, like a child, is not liable for his own actions.

Other people in the system may have also failed in their responsability (to catch and fire him), but you can't say: "I don't blame the pilots, I blame those who trained him", when those who trained him DID teach him correcly how to follow checklists and how to lower flaps and how important it was to do it right.

I'm ok with "I blame the pilots and I ALSO blame those who trained him". In most cases.

But to pretend a pilot is always "blame free" because, if he does something wrong knowingly and against his training, it's still some supervisor working at the airline's fault for not catching him ... hmmm.

No matter what he does, he is never responsable.

If he doesn't lower the flaps because he was never taught how to do it right, it's because he wasn't trained better.

If he was very well trained on how to lower the flaps and all its safety implications but he still didn't comply/made a mistake, it's because he was hired/never caught/not fired on time.

I'm obviously missing something in that line of thought.

But anyway, as I've said before, "whose fault" is not the most important part but "what can be done to fix it".

At this point, I vote for a (much) better TOWS design, a (slighty) improved checklist system, a (?) better maintenance manuals/MEL/etc and to plant AV cameras on the cockpits with 8h recording time digital DVRs (total cost $200) that are reviewed often by the airline to make sure pilots make good use of the training.

Improved training, as I've said before, can never hurt either.

agusaleale

25th Oct 2008, 09:50

Justme wrote

While I personally think that it's not easy at all to "catch" pilot's bad behavior, specially if it is only sporadic, I'm all for forcing airlines to install voice/image recording devices in the cockpits that last longer than the 32 minutes of the CVR which, best case scenario, would only allow to evaluate pilot's behavior for the landing part of the last flight.

That way airline supervisors can figure out what goes on behind the locked doors of the cockpit and catch bad apples before their actions becames a danger. Don't we all agree that this would be an easy, cheap and really effective way to monitor progress and compliance of crews with training?
...In that case, those within the company in charge of supervising could also be held responsables for repeated risky conducts of the pilots under their supervision/training.

...
So a pilot (consistenly, lets make this easy) fails to do his job as trained and the person that hired/trained him is to blame. Therefore, they failed too and all "four" go to jail. And it's OK to end it there. We don't need to hire someone to supervise that the supervisor is actually supervising the pilot, or that the trainer is actually properly training the pilots.

...

I am certainly suprised if airlines don´t do this.
I work in a non critical job(such as pilots do) and I am strictly supervised daily.
I fully agree with you !!

justme69

25th Oct 2008, 12:19

I am certainly suprised if airlines don´t do this.
I work in a non critical job(such as pilots do) and I am strictly supervised daily.
I fully agree with you !!

Well, if pilots don't want to be responsable for their mistakes, and the responsability must be found on those who train/supervise/hire them, then they must allow those people to closely monitor them at all times, obviously, and be willing to cheerfuly accept all corrective measures for any and every mistakes noticed.

Personally I don't think it's that great of an idea, as it would be like if I had someone constanly looking over my shoulder while I work. But then again, I do accept responsability for my own mistakes and don't blame my college professors when I fail to do correctly what they have taught me.

SPA83

25th Oct 2008, 12:55

Justme69, don't forget the camera in the airline management's desk...

justme69

25th Oct 2008, 14:06

Justme69, don't forget the camera in the airline management's desk...

I'm all for that too. But who watches that camera?

Because the person that is watching the manager's camera, probably needs another one too to be monitored. And somebody to watch the person watching it.

Or perhaps, each adult professional should be reasonably left alone and be held responsable for his own mistakes.

When management/training makes a mistake, they should be held responsable. When a pilot doesn't lower the flaps as instructed, I do not believe that this would be the case (generally, in airlines that teach safety to good standards). Training obviously encouraged him to follow the checklist properly. That he didn't do it it's not due to management (under reasonable circunstances).

A different story is when a complex or caotic situation arises that is indeed due to bad training or bad management.

But a simple one like not following checklists correctly by a rested crew that is not "incredibly pressed" (and even if they are, a pilot needs to know that no matter what, for his own life, he can not stop to try to follow the checklists to the best of his abilities) and has been trained on how to do it properly, I still fail to see how it can be directly related to irresponsable management/training.

Somewhat related, maybe. *Necessarily* directly related, no.

And even if it is directly related, unless the pilots were actually trained and encouraged to not follow checklists (and they complied? Isn't that accomplicement?), that doesn't exempt pilots from the error's responsability.

It merely extends the responsability to include both, the pilot and the management/training.

That's my objection. In a case like this, of a reasonably good airline with reasonably good safety and resonably good training and reasonably good working conditions, a sentence like this can not be said: "I do not blame the pilots, I blame the training/management departments in the airline".

I have no objections with: "I blame the pilots and I also blame the airline", until more information can be had to see to what extend training on correctly following checklists or really bad work conditions were factors.

I think a scenario for this accident where the pilots had no responsability at all for their actions and it was all the fault of other workers (be Boeing engineers, SAS management or Spanair's training subcontractors), is very unlikely.

I have already stated, that besides the pilots, in this accident, in my opinion, there are many other factors and the people that produced them, that SHARE some (small) responsability (maintenance, Spanair's SOPs, CIAIAC, civil aviation authorities, MEL, Boeing, etc). And I have already said that, depending on more information from the CVR to see to what extend they were careless, I do not blame the pilots for what it looks could just have been an "honest" oversight.

All this, of course, assuming the pilots neglected to lower the flaps under the known conditions and the TOWS didn't work due to a recent unnoticed failure.

captplaystation

25th Oct 2008, 21:07

Don't remember anyone asking the question, did this flight have to respect a CTOT ( slot time) on it's 2nd departure, as that for sure adds a degree of stress/urgency to the start-up & taxi phase. Of course, in MAD, taxy time is never short time wise, but people can sometimes become very wound up, concentrating only on reaching that R/W before expiry of the slot to the exclusion of everything else ( cabin secure/ de-ice hold over time etc) I have seen it too often, and that could provide an explanation ( but not an excuse) for the rushed / skipped / screwed-up checks.
With apologies to anyone who feels otherwise, the F/O may be the one who lowers flaps, but the guy with the 4 stripes is in charge and ultimately responsible for the safety of the aircraft. If they tried to take-off with no flaps I can't see how anyone else can carry the can. Sure McDonnell Douglas the Spanair engineers ( and by failing to find out about/implement the cx before each T/O the Chiefs of Spanair) made it easier to turn an omission into a tragedy, but finally the "blame" if as a society we absolutely have to identify the "culprit", lies firmly on two guys who have paid the ultimate price for their mistake.
This thread is going round and round in circles now, surely it is time to realise the simple facts. Pilots are human, they make mistakes, when they do lots of people can die, they are included in this toll so don't want to make mistakes.
Designers Regulators and Managers don't have this immediate exposure to death, but they too make mistakes. The Pilot is always the one left holding the Baby, sometimes it slips from his hands. Everyone says how did he drop it? less people ask why did you hand it to him covered in soap and wrapped in cellophene. This is the nature of the profession of Pilot, you can die, you can kill others. Some will villify you, a few will understand, a few will even try to defend you and find excuses for your mistakes.
Finally, Sh@t happens, and you are the last link in a very long chain so expect to be blamed whether you were good or bad and whether you survive or not.

justme69

25th Oct 2008, 22:10

I agree.

But remember that, if you are handed out a soap-covered baby and you accept it, it is certainly to great extend your responsability to not drop him. If you don't want the responsabilty and want it to remain with the person handing you out the baby, don't babysit. Choose another profession.

But if the baby handed out to you only had a small band-aid in the forehead, and you dropped him with fatal consecuences, don't blame exclusively the person handing it out because he had a previous minor head injury.

Sure, "without the previous band-aid" the baby had more chances to survive the drop. But he probably would've perished even w/o it anyway if you dropped him like that, and he certainly would've survived just fine with the small band-aid if you didn't drop him.

There are times the responsability is 100% with the "handler" and 0% with the "parent" (i.e. the baby was in perfect condition and you just were overly careless). There are times when it's 80%-20%. There are times when it's 1%-99%. But there are very few times when it's 0%-100% (it would be irresponsible and liable to accept a baby you know is gonna fall w/o remedy -- you would only be excused if you had a gun pointing at you and forced to accept him).

I'm quitting now. This baby analogy is giving me the goosebumps.

BOAC

26th Oct 2008, 11:25

if you TRUST everyone to do their job, including yourself, you will be dissapointed one day. - sorry for the delay - been a bit busy.

I agree, I have been and no doubt will be again, and sadly a lot of folk were indeed 'dissapointed' that day. I insist, however, there has to be trust in the system - are you so certain of you and your crew's abilities that you don't think the pax should be checking your fuel loads or approach speeds (or flap settings, come to that) or are you exempt from this - you need to confirm the engineers' actions but the pax just have put up with you? It appears you benefitted from an unusually deep airline systems training regarding the RAT heater which I doubt is universal.

I would still maintain that before this incident there were not many MD drivers who knew the A/G gotchas we have discovered here, and that it is unreasonable to attach blame to them, or to the LAE who 'fixed' the defect if HIS/HER training (including the MEL) also turns out to be inadequate. Indeed I suspect this thread has been invaluable in that respect.

It still looks as if the a/c would have taken off safely if correctly configured despite the rectification actions. Whether or not a crew should be trained/able to recover a stall following mis-configured flaps, I prefer not to comment.

bubbers44

26th Oct 2008, 13:03

You would only have noticed that something is wrong as soon as you had left the ground effect. Until then you would have used the same Vr and therefore required almost the same amount of runway to get the wheels off. Bouncing back to the runway is certainly not an option once the iron lady tells you stall especially when the plane starts rolling unexpectedly. What makes you sure, you would have saved the day?

We did a no flap takeoff in the sim at SNA (5700 ft) to demo this using flap 11 V speeds. We lifted off late but even with the flaps up did not have any control problems. Of course we didn't over rotate knowing what that would do to controllability with no flaps. The Spanair pilots didn't have the luxury of knowing their flaps were up at rotation.

Bis47

26th Oct 2008, 13:24

Hi Just You!

justme69
I think that, deep inside, we agree more than we disagree.
Not only inside ! It is just that I wanted to add a "plus" here and there to your most valuable posts ...

What I was trying to say is that I object to those that state, in cases similar to this, that they do NOT blame the pilots but the airlines for these accidents.

Generally speaking, pilots are "without pity" against their colleagues ... except in public, and especially when those colleagues died due to their own mistakes.

Blaming dead pilots seems indecent ... In fact they already paid for their mistakes ...

And, it is not "fair" either ... Because pilots are human being, and as such, they do mistakes. Every day ... They will put the flaps to 11 instead or 15 ... or things like that. They will set up wrong frequencies, wrong heading bugs ... Not too serious, and almost every time, they will correct by themselves, or be saved by the other pilot, or by the check list, or by a "back up" safety device (TCAS ...) or by sheer luck .

Human failability is a part of the safety equation ...

When the mistake ends up in a fatal accident, it means that the pilots made an error, of course, but also that all the accident prevention program failed.

Since it is too late to improve the pilots, it's time to look at the system!

A pilot is a grown adult and knows very well that he is not doing his job right when he doesn't follow checklists as trained. The fact that nobody has caught him acting that way, doesn't mean that he is not responsable and, like a child, is not liable for his own actions.

Many pilots are not of that kind of reasonnable, wise, humble, persons ... If they do it their own way, they think they are doing a better job ... (sometimes, it could be true ... cfr those pilots silently reviewing killer items while lining up). Pilots are gods, you know ...

In big, safety conscious companies, it tooks a pilots generation to fully appreciate the benefits of a good CRM "spirit" ... God is no longer infaillible, a baby copilot can save the day!

Other people in the system may have also failed in their responsability (to catch and fire him), but you can't say: "I don't blame the pilots, I blame those who trained him", when those who trained him DID teach him correcly how to follow checklists and how to lower flaps and how important it was to do it right.

Ok, pilots are humans, they do mistakes. Every day ... They will put the flaps to 11 instead or 15 ... or things like that. They will set up wrong frequencies, wrong heading bugs ... Not too serious, and almost every time, they will correct by themselves, or be saved by the other pilot, or by the check list, or by a "back up" safety device (TCAS ...).

When an accident happens : "pilot error" - most of the times. Or : ATC error. Or : hardware failure (wing spar, rudder, fuel tank explosion ...).

Do you blame a cargo door for failing?

No, you want to investigate why that cargo door failed, and ultimately put the blame (and the responsibility) on the shoulder of those persons who ultimately approved the design, with the full knowledge it was flawed ... (Consider the infamous DC10 cargo door problem : the cargo door initial design system was flawed, the "design supervision people" caught the flaw and refused to approve the flawed design ... But the head of the FAA finaly approved it, after a minor correction ...

So when a crew proceed to take off without flaps and ends up into flames, the big questions are :

1. Understanding how such a mistake did happen ... and that is in fact looking at the system around the pilots, putting blame on some flaws of that "error prevention system".
2. How to improve things ...

Of course, recognizing the fact that the pilots made an error is crucial ... because it opens the question : how came they made that mistake?

But "blaming" the dead pilots ... is too indecent, unfair, useless.

I'm sure that, despite my poor english, we understand the nuance between "admitting the fact of a pilot error" and blaming a dead pilot for making an error ...

For myself, I admit many errors, and I blame myself for those errors. I also improved a lot as a pilot looking at my own errors, at other pilots errors, and - with very great interest - looking at students errors ...

When the day comes when we have acces to CVR transcript, I think that we all shall learn a lot about "how to make a big mistake" ...

rattler46

26th Oct 2008, 17:18

(Sorry, dont find a "Quote" button, so just highlighting it it manually):

Quote Rattler46:
Think of it a a court martial, keeping up the spirit while performing to the public, plenty of room still and nothing perjudicary stated with just the accusation. /EndQuote

Quote Similin_Ed: If I have misread the above quote, I apologize, but at least in the U.S., courts martial are real courts and they are deadly serious. Courts martial have been established by acts of congress under The Uniform Code of Military Justice. They are not show trials for the sake of public opinion. Convictions in courts martial are the same as convictions in any other federal court and the punishments awarded, including imprisonment and death, are very real./End_Quote

Sorry if that came along the wrong angle: By no means did I want to disqualify court martials in any way, I fully understand they are real courts (I am ex mil myself).

What I wanted to express with my post was that the inquisitionary juridical system in Spain (I live here, just FdR) with an "instructional" judge heading the *criminal* (and none else) investigation has some similarities to court martials in as that you can get accused of just about anything fairly easily (and much easier than in traditional common law "civil" criminal procedures) as long there is just a hint of "reasonable suspicion" of a criminal responsability, more or less along the lines of "...better be on the safe side...".

AFAIK (at least in Germany, where I served 8 yrs), about 95% of the court martials, long before oral trial, terminate w/o accusation (i.e. no formal charges brought against the defendants), from what I understand this is the same in an instructed criminal investigation case in Spain, as said in the name, this is an investigation and nothin more, after all.

FWIW, Rattler

TyroPicard

26th Oct 2008, 22:32

justme69
While I personally think that it's not easy at all to "catch" pilot's bad behavior, specially if it is only sporadic, I'm all for forcing airlines to install voice/image recording devices in the cockpits that last longer than the 32 minutes of the CVR which, best case scenario, would only allow to evaluate pilot's behavior for the landing part of the last flight.

That way airline supervisors can figure out what goes on behind the locked doors of the cockpit and catch bad apples before their actions becames a danger. Don't we all agree that this would be an easy, cheap and really effective way to monitor progress and compliance of crews with training?

I don't agree at all! Do you really think management have the time to watch or listen to a tape of every departure to catch "bad apples"? A waste of their time and talent. So hire people specifically for the task - can you imagine how well they would do such a boring, repetitive job?
Good SOP's, training and self-discipline are part of the solution - but we are all human.

ZQA297/30

26th Oct 2008, 22:38

Sorry, can't resist.:E
Do you really think management have the time to watch or listen to a tape of every departure to catch "bad apples"? A waste of their time and talent. So hire people specifically for the task - can you imagine how well they would do such a boring, repetitive job?
You mean like the airport security people?

agusaleale

27th Oct 2008, 08:06

TyroPicard:
I wouldn´t do it in that way. I´d only record certain parameters of the flight just to introduce them in a program. It would gave me lots of useful information to evaluate the behaviour of the pilots. May be it´s already in use ....in this case forgive me for my appreciation.

justme69

27th Oct 2008, 08:45

Well, if "blame" from the pilot's actions is consistenly going to be put in management, and I was one in an airliner, I would no doubt put a couple of "video ipods cameras" recording audio/video for several hours in cockpits and retrieve them "at night".

Then, I would hire someone to spend the whole day fast-forwading through to the important maneuvers (take-off, landing), going to normal motion when he suspected the crew was acting up.

And I would personally review a few of the "tapes" myself, at least one operation (i.e. takeoff) of each of my crews a month.

Just knowing that the cameras are there, would make a lot of pilots realize that "their system" is not better than the "checklist", i.e., or that looking at the flaps gauge is not optional.

The alternative is to have a system where the pilot is only nominally supervised (during training excercises, tests, QAR, inspectors) like we have now and, when he screws up for not following the training, it's probably only his "fault", not ONLY that of the ones that "didn't catch him not following trained procedures".

PJ2

27th Oct 2008, 12:16

agusaleale;
I wouldn´t do it in that way. I´d only record certain parameters of the flight just to introduce them in a program. It would gave me lots of useful information to evaluate the behaviour of the pilots. May be it´s already in use ....in this case forgive me for my appreciation.
That's what FOQA/FDA - Flight Data Analysis programs have been doing, in some cases (BA) for over fourty years, in other cases a few years.

A QAR - Quick Access Recorder records the same if not many more parameters than the crash recorder. It is analyzed by specialists, usually a small group of pilots designated for the task or an independant company, and the de-identified reports are provided to the airline's management.

Now, it is far, far more complex than this, so I might suggest you google, "FOQA" as a good place to start.

Data analysis is, as you suggest, proactive, and is looking for both trends and incidents/events. In many arrangements, calls to the crew are made not by management but by the pilots' own peers usually through an agreement with the airline. The program is extremely effective in discovering what the airplanes and crews are doing on a daily basis.

PJ2

justme69

27th Oct 2008, 13:15

A couple more witnesses declared in front of the judge in charge of the investigation today. Nothing really new. You can skip this post.

The worker in charge of fueling the airplane before the RTG declared how much he put in an hour before departure, etc. He also declared that his co-worker, who was the one to later add more fuel after the RTG (and who will declare later), told him about the anti-collision lights being on while on the ground.

Nobody has strictly said what lights they were talking about, but the prior mention of this situation to the police was that he noticed the lights "on top and underneath the airplane", leading to believe that he didn't mean the wing's strobes.

It was said here by those familiar with the MD80 that those lights, as oppossed to the strobes, turn on and off only through a manual switch in the cockpit.

Having them on during the refueling while they were parked and right after the "repairs", probably only means that they never turned them off when they stopped the airplane to have it serviced.

The press, of course, is already jumping to the conclusion that the airplane was in "air mode" and that provoked the accident.

The witness also declared that he co-worker did talk to one of the pilots, who stepped outside of the airplane to give him instructions on the amount of fuel, etc.

Not related, but some may be interested in this article:
Airliner Repair, 24/7 | Flight Today | Air & Space Magazine (http://www.airspacemag.com/flight-today/Airliner_Repair_247.html)

ZQA297/30

27th Oct 2008, 22:57

Maybe I'm wrong, but I get the impression that justme69 feels that the aviation industry has been asleep at the helm in scientific analysis of aviation safety.

As PJ2 says.
Data analysis is, as you suggest, proactive, and is looking for both trends and incidents/events. In many arrangements, calls to the crew are made not by management but by the pilots' own peers usually through an agreement with the airline. The program is extremely effective in discovering what the airplanes and crews are doing on a daily basis.

TEM, FOQA, etc, have been in use for more than a decade, along with several other equally important programs.
The Flight Safety Foundation is a good source of links to what has been, and is, going on.
Here is link to one (of many) TEM articles:
http://www.flightsafety.org/pdf/tem/tem_dspt_12-6-06.pdf

Bis47

28th Oct 2008, 07:32

Some time ago (1 year?) the Ryanair boss made it public that he would fire any crew that would be caught as not being stabilized on final below 1.000 ft. (?)

I guess he meant it. :D

A pilot has to be bold ...
An airline manager too.

justme69

28th Oct 2008, 08:10

They need lots of that in Iberia.

Aviation Video: Airbus A340-300 - Iberia (http://www.flightlevel350.com/Aircraft_Airbus_A340-300-Airline_Iberia_Aviation_Video-9163.html)

Anyway, I indeed do not know much about FOQA and similar programs, but got up to speed and read a couple of articles, like Avionics Magazine :: FOQA: Training Tool, And More (http://www.aviationtoday.com/av/categories/maintenance/1224.html)

Looks like it's slowly (not as fast as some people here seem to think) catching up with airliners and starting to become effective, specially with newer aircrafts where extensive computer use makes it easier to monitor many parameters.

I doubt it has made much in-roads in ATR's or MD-80's of small airliners, but maybe it'll get there.

Putting miniature solid state "mini-QARs" that in many cases even upload the information wirelessly (or manually on memory/PCMCIA cards) is a good idea and provide quite a bit of monitoring over flight performance to be then analysed by software and supervisors.

Still, crew "attitude" in their work place (closed cockpit) monitoring could still get a helping hand from similar solid state recording that shows the audio/video of the performance.

As I said, I'm not "all in" for spying on the pilots, but I'm also not "all in" for blaming the managers for "letting them do" unsafe practices they have not been encouraged to do during training.

This FOQA thing seems to be another great tool for increasing safety and a step in the right direction, but one that is quite recent, not as widely used yet, not 100% effective (but pretty good) and not too expensive.

So I'm all for a lot more of it.

Do you think that if such a program was being used on this MD-82 over at Spanair it would've prevented the accident?

Obviously, not necessarily, unless it was able to indicate that this particular crew was often not following all the checklists items like they should, which is likely not the case. They obviously (I'd like to think), never before neglected to lower the flaps or set any other important item from the checklist. But a video showing them rushing through items or not checking them properly would've raised a red flag.

FOQA can probably not detect, i.e., that a crew is hardly ever visually checking flaps/slats indicators when they activate the handles. A video showing how they lower the handles w/o hardly even looking at the handle itself and quickly moving to another item is a clear indication, though.

agusaleale

28th Oct 2008, 09:40

justme69

28th Oct 2008, 13:28

Never been to Ecuador, but indeed I hear Quito is usually an airport with challenging landing conditions.

Nonetheless, the number of accidents in the airport doesn't seem greater than some others in equal or even "worse conditions" and, behold, Iberia is right there on the recent A340-600 landing accident in Quito, that prompted Ecuador goverment to suspend operations of Iberia (and only Iberia) in that airport for a while, until Iberia could "guarantee" that their operations there wouldn't endanger anyone.

Ecuador's Dirección de Aviación Civil required from Iberia a security plan that included a commitment from the company to guarantee the "professionalism and permanent training of the pilots in that company". All they had to do is watch the (leaked) airport security camera video and figure it out, as it was later confirmed in the preliminary report by the investigators (landed high and fast ... the rest, the landing gear damage, lack of reverser deployment, etc, as contributory factors).

We won't talk about the evacuation fiasco in that case, or the previous blown tires a few months before in August on the same runaway by another Iberia A340.

Easy or hard airport, it wasn't my intention to finger point a particular airline or a particular airport. It was just an example. Many airlines could benefit from less risky pilot's behavior.

And Iberia or Spanair are not exceptions.

I hope the usual disclaimer is not needed on how Iberia/Spanair has many world class pilots and that a few rotten apples exist in any airliner in the world. And that accidents happen to good pilots as well. And that I'm not implying the pilots in the Quito accident didn't do everything they could but it just didn't work well for them. This was Spanair first accident with victims in 20 years and Iberia has moved 500 million passengers in 40 years with only 4 accidents with victims.

PJ2

28th Oct 2008, 19:33

justme69:
Do you think that if such a program was being used on this MD-82 over at Spanair it would've prevented the accident?
From the moment the airplane departed for the second time after it's return to the gate? - No.

But that is not what FOQA programs do. I believe you now have a better comprehension of FOQA. It's a good start but there is much, much more to such a program than can be gleaned by reading a few articles - the subtleties are enormous, the variations on how to do FOQA well are wide and the protections for crews also vary widely. Some (the Asians, typically, but now, apparently, others in Europe) use a pilot's data to punish rather than learn. Such a stupid approach to safety has it's own long-term reward and is universally discouraged under a Just Culture approach to flight safety but some owners/managers want instant solutions and remain largely ignorant that they are in the business of aviation.

What FOQA does is to identify trends and highlight incidents. In this, the program is extremely successful. Association pilots may call crews to learn more about the event because the program does not use the CVR data, does not record ATC transmissions, does not know what the weather was, does not know if the cockpit was sterile, (the TAM accident A320 cockpit was not - there was a female scream just as the aircraft went over the edge of the airport boundary and into the buildings across the street), and does not know what transpires between maintenance people and the cockpit crew on the ground.

The program uses exactly the same data as the crash recorder does. It is from the exact same sources - primarily the ARINC 429 and 717 - designated standard aircraft data busses although other ARINC standards are employed especially on the 787.

This is a crucial fact mainly because I have seen an airline dismiss some very serious "FOQA data" because, they said, it "wasn't from the DFDR and so they couldn't act on it". Using this as an excuse to continue operations when a different action was indicated is a grave misapprehension of what FOQA is, what the data sources are and how such actions may place the organization legally in harm's way. "Knowing and not acting" is the same as acting with intentional negligence.

What FOQA also does is put the lie to those management people who harbour and broadcast their illusions that their operation is completely safe, does not make mistakes and that their standard is second to none. Such is simply ignorant wishful thinking but is popular at safety board meetings where the tough issues don't have to be dealt with and no senior manager gets "branded" or otherwise thought that his/her department isn't the safest possible. That "safety is first" is simply another illusion. It is not. Cost is first and it is extremely difficult to change that world-view. The usual "intervention" is an accident, a pattern which repeats itself so often that safety people can always be found doing thus: :ugh:

I continue to hear reactions such as astonishment when I describe what we are seeing in the data - raised eyebrows and "not our pilots!!" are typical of the reactions, followed by dismissal of the data in some very serious incidents in which most of the details may go unreported to the regulator but not unobserved by FOQA and, by reports, to management.

All these facts stated, the program itself is one of the most significant improvements in safety analysis in the last fourty years. British has been doing this kind of work since the late fifties and many enlightened airline managements brought in FOQA programs as computerization made such possible and cheaper.

Often, FOQA is only taken seriously after an accident. That is the case at QANTAS after Bangkok, Air Transat after their Azores diversion, US Airways etc. Other carriers "get it" right away and do FOQA properly. Most are somewhere in between. The program is accepted worldwide, more or less, by almost all pilots because the intention is not "big brother" - the intention is to remain as informed as possible about what the fleet is doing and how the fleet is being flown. As such, it is a proactive approach to flight safety.

Now - to respond directly to your question, justme69, a FOQA program can tell both the pilots' association (if there is one) and management (if the deidentified data is shared with them, and it must be for due diligence requirements), depending upon how long the data is kept and who examines it on a daily basis, it can tell you if any of the fleet taxiied out with the slats/flaps retracted and it can, depending on the programming of the LFL, (Logical Frame Layout - a "map" of parameters and their values), tell you whether the takeoff warning horn sounded.

It can tell you how many times it happened, where and what the rate per nnn number of flights is, etc - once the data is available, it can be analyzed using graphing and statistical techniques.

It cannot "predict" an incident or accident but no one can. What it can do is point to heightened risk or the need to discuss an unreported incident with a crew, (using the pilots' peers, NOT management!).

In fact, many FOQA programs record over a thousand parameters, many more than the the aircraft's DFDR or FDIMU. So a very detailed picture (and, with suitable software, an animation) may be built of each flight the aircraft takes.

It takes a very experienced person who is also an active pilot with the airline to interpret the data successfully. Such a job cannot be handed over to the cheapest intern available because mistakes in interpretation will most assuredly be made. If the airline actually takes the data seriously and acts upon it, correct interpretation is fundamental.

I hope this helps - truly, a book could be written on doing FOQA properly and well.
PJ2

agusaleale

29th Oct 2008, 01:35

PJ2:
Thanks for your information, it´s a great instrument the system itself. It is very helpful.

Do you know in the case of Spanair, if there was such a thing?

PJ2

29th Oct 2008, 04:42

No, I don't know if Spanair has or ever had a FOQA program. However, information regarding the existence of such a program usually finds it's way into these threads long before now, (loooooooooooonnnngggg before now) so it appears to me that they don't have such a program. I believe Iberia does but am not sure.

Given the nature of such programs and their importance to SMS, [Safety Management Systems] approach to flight safety, perhaps some airline managements would find it easier and "safer", (for the corporation) NOT to know what their fleet is doing.

In comparison with the return on investment, (safety, maintenance, airframe loads, fuel efficiencies), such programs, employed intelligently and thoroughly, are relatively cheap. One may conclude these days that the airline which has no such program in place is either ignorant of it's business and responsibilities, doesn't have a safety culture worth the name or the executive has made the [quiet] decisions that it does not want to know what it's fleet is doing. Those that have the program but don't use (or believe) the data and seem to have it "on the books as a box tick" fall into the same category. An airline which employs flight data in a manner discussed here recently regarding a firing does not have a safety culture, it has a culture of blame and punishment which discourages safety reporting and learning.

Such an approach works for a while but building systems based upon knowledge as opposed to being based upon punishment yields better, and more targeted results. Human factors are by far the largest single cause of an aircraft accident and learning about them through data analysis then finding ways to reduce/prevent them seems a more effective way to handle this most difficult of causes to fix. At least fifty-five takeoffs without slats/flaps were attempted/reported. How many more are hidden in the data? Airlines that don't have a FOQA Program and the appropriate events for such incidents will never know until the day an accident occurs.

Kicking tin only prevents the second accident. Not all incidents are reported, especially in a blame-and-punish culture. FOQA, used as intended, can tell an airline, more specifically it's pilots, about the first "accident" that, but for one layer of cheese almost happened. That way everyone quietly learns and headlines, lawsuits that put airlines out of business don't happen and most important of all, crews and passengers live.

Same goes for FOQA - it is almost like a free ride - a get-out-of-jail program. It can tell an airline where, when, and how the near-accident happened so it can do something before the next time. FOQA can tell an airline's management where it's soft underbelly is and equally important, it can tell an airline and it's pilots where it's strengths in training and SOPs are. But it must be used with complete integrity, honesty, knowledgeable support from the CEO on down and cannot be used to punish pilots for mistakes. That's what training and standards are for.

adlerman

29th Oct 2008, 10:10

read in the news of the manslaughter charges on the ground crew,poor guys!
They will be feeling bad enough without having the finger pointed directly at them,sure they had a part in this tradgedy,but they are not the ones who did not set the lever !

agusaleale

29th Oct 2008, 12:02

Your news arrive a bit late, they have more than 10 days old...:ugh:

SPA83

29th Oct 2008, 15:21

http://nsa03.casimages.com/img/2008/10/29/081029042200676773.jpg (http://www.casimages.com)

PJ2

29th Oct 2008, 15:44

SPA83;

The Reason "Swiss Cheese Model" is well known and understood and is even being challenged these days as "limited". For it's time, it's greatest value was moving an extremely recalcitrant (hesitant, with an attitude) community off the "pilot error" excuse for an aircraft accident and into a way of considering systemic causes far removed (physically) from the actual accident. The concept was revolutionary at the time and still serves a purpose in terms of continuing to educate those who stubbornly stick to old notions about causes and how to fix them. A blame-and-punish culture and the increasing willingness to criminally prosecute rather than learn is a formula for repetition. If we examine the fatal accident rate since the late '60's, a dramatic drop is easily seen and the "curve" is almost flat at the moment, there being great difficulties in cracking the final barrier to solving the "human factors" issues. This is where Reason's model came in some twenty years ago.

Today Reason's theory has "morphed" into more sophisticated notions about causal chains. The concept and increasing reality of a "Just Culture", not limited to aviation by the way, has taken these understandings to greater and I think more helpful levels. One writer among many excellent authors is Sidney Dekker who has written, "The Field Guide to Understanding Human Factors", and "Just Culture", both well worth reading in concert with Jim Reason's work. I recommend them highly as one way into next steps after Reason. I know there are others.

As mentioned above, the accident rate has somewhat stabilized and is proving difficult to reduce. That means that any increase in traffic, (I realize present economic circumstances mitigate against such increase but we all know economics is cyclical) will bring a corresponding increase in the number of fatal accidents which causes will likely be human error.

FOQA, LOSA, AQP and a supporting cast in an enlightened management are ways forward. The trend to blame-and-punish will keep the accident rate where it is because no learning ever resulted from punishment. We could argue that lawsuits alone have forced improvements in aviation and to a certain extent that's true but the cost has been, and continues to be, extremely high in human as well as economic terms. It seems slightly more efficient and intelligent to use the best means possible to forestall and otherwise prevent accidents through knowledge rather than a rolled newspaper or worse, "jail time for the perps".

FiveGirlKit

29th Oct 2008, 15:56

The reason for the AD is
"In August 2008, a McDonnell Douglas DC-9-82 (MD-82) airplane crashed while attempting to take off from runway 36L at Madrid's Barajas International Airport.
Although the preliminary report issued by Spain’s Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC) did not identify the probable causes of the accident, it states that the data recordings suggest the flaps/slats were not set for takeoff and the Take-Off Warning (TOW) did not occur.
After a similar accident in 1987 where it was concluded that the flaps/slats were not set for takeoff and the TOW did not occur, McDonnell Douglas recommended all MD-80 series operators conduct a check of the TOW system before engine start prior to every flight. It has been found that some operators’ procedures no longer reflect the initial intent of the recommendation made by McDonnell Douglas as the check is performed less frequently.

A defective TOW system could let an improper take-off configuration undetected to the flight crew and result in loss of control during the initial climb. As a consequence, to ensure that all operators of MD-80 series airplanes perform the TOW system check before every flight, this Airworthiness Directive requires an update of the Airplane Flight Manual (AFM) to make the frequency mandatory.
The AD also extends to the DC-9 and 717-200 aircraft as the design of the TOW system is common to all three types."

Link to the AD EASA Airworthiness Directives Publishing Tool (http://ad.easa.europa.eu/ad/2008-0197)

justme69

29th Oct 2008, 20:11

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:

http://ad.easa.europa.eu/blob/easa_ad_2008_0197.pdf/AD_2008-0197_1

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.

PEI_3721

30th Oct 2008, 02:00

Have I missed something here?
Is this AD perhaps a bit like ‘closing the stable door … ’ given evidence of previous events.

If the check is carried out correctly and the TOCW proven to be serviceable, but the nose ground–air switch changes state during taxi, and in combination with a failure to select flap, then an accident could still occur. This scenario is very similar to this accident:-
Previous work on the nose leg, possible mal-aligned switch during maintenance, or a design weakness where the switch is opened when the aircraft is loaded at aft cg.
Is there a time delay before the TOCW is reactivated if the switch is remade? Does the nose leg rise at aft cg as power is applied during the takeoff run? Have operators deliberately chosen to load aft cg to aid fuel burn in the current economic situation?

Given the above, how does the AD “reduce the likely hood of this type of accident”, or “improve the consistency of pre-flight safety drills”?
Hopefully the “further action in light of the on-going investigation” will resolve the issues above.

bubbers44

30th Oct 2008, 02:26

Loading fuel aft is how you increase fuel efficiency. Just don't overinflate the nose strut. Testing the TOWS before engine start each time should eliminate 99% of departures with TOWS inop.

justme69

30th Oct 2008, 06:44

Just a quick note to clarify that, for whatever reason, the CIAIAC is strongly suspecting the failure of the R2-5 relay as oppossed to the strut gear sensor (as in a case described in this board) or the Left ground control circuit breaker (as in MAP case).

The main reason is probably the lack of evidence that the 30+ devices connected to the front wheel logic, including the 20 or so exclusive to the left wheel, failed the ground/air mode and, more importanly, that the Flight Data Recorder recorded a change of state from ground to air coming from the front wheel left sensor circuit on R2-12 shortly after VR was called, signalling a correct detection of the front wheels leaving the ground by the left wheel sensor circuit, to which R2-5 is also connected.

The R2-5 relay could have had an intermitent malfunction (i.e. a loose electrical connection, etc) and this would've only ultimately affected the ground/air logic for only two devices, the TOWS and the RAT probe anti-ice heater (because the other two "devices" also connected to R2-5, the AC x-tie & the radio rack venting were redundantly serviced from the right wheel sensor circuit through R2-8 and R2-4).

Most of this, especulation on my side.

SPA83

30th Oct 2008, 07:45

http://nsa03.casimages.com/img/2008/10/30/08103008482176260.jpg (http://www.casimages.com)
The aircraft is on the ground but R2-5 is in flight mode

safetypee

31st Oct 2008, 23:22

EASA AD No.: 2008 - 0197
The wording in the required action – the check, is a type of SOP, and might not be the best example of creating a SOP or additional safety defense.
The check assumes that the flaps are up before the TOCW is tested – this is not stated. If the flaps were inadvertently down for the check, and another part of the TOCW in error e.g. mis-set trim, then this might open a hazardous sequence of events, but no less likely than in this accident, i.e. after taxing-in due to a RAT fault and flaps are selected up after the test – before the next start. The test has been successful (mis-set trim), but might not prevent an accident, e.g. failed ‘intermittent relay.
This emphasizes the need for careful wording in checks, an understanding and memory of the reason for the check, and correct execution of the check. All of these should be associated with training or documentation, as without them there may be more possibilities for error, similar to those which supposedly occurred in the accident.

The check might be seen as a ‘band-aid’, or just another line of defense which adds complexity to the operation (the check takes time in an environment where crews could be hurrying), or it becomes another opportunity for error - forgetting.
An alternative is to provide a more robust defense, probably improving something which already exists, but where an investigation identifies a weakness e.g. a more reliable TOCW system, or a TOCW system failure warning (cf AMC CS 25.703 ). Solutions in this area could also suffer added complexity or more opportunity for error, but robustness and resilience in defense are often quoted as being more effective than a check.

I recognize that it is easy to pick holes in proposals and, in hindsight, seek a safety solution that focuses on the most recent accident. The skill in safety management might be that of identifying and managing the risks of the ‘holes in the solutions’, or choosing the better generic solution(s) addressing the causes underlying this particular or a similar accident. Apparently, the causes (why) in this accident have not yet been identified.

Note the CS 25 text re hazards of crew familiarity with a warning in normal operations (the check) vs their reaction to a warning in the failure case, where the familiarity of the warning during the check might decrease its effectiveness in a failure condition – human performance and limitations, etc.

bubbers44

1st Nov 2008, 01:31

This before start check of TOWS only says the system is working and the annunciator works. It can not be tested for all the faults like trim, speedbrakes and flaps, only that something is wrong. Flaps are always up during this check so that is the fault giving the warning most of the time. Hopefully this warning will never be needed again since we are aware of the possibility of failure of the system and the importance of checking flap setting lining up with the runway.

Bruce Waddington

1st Nov 2008, 04:15

PJ2,

You state "As mentioned above, the accident rate has somewhat stabilized and is proving difficult to reduce."

Very true!

Tony Kern's premise in his book 'Flight Discipline' is that although we know the right thing to do (CRM, Human Factors, SOPs, Training, etc) we often lack the discipline to carry it out. On the jacket cover he states that "A skilled pilot without flight discipline is a walking time bomb."

Personal experience tells me that one of the most difficult tasks an aviator faces is to be consistently disciplined. Failure in this tremendously important area has in too many circumstances caused loss of life and property.

best regards,

Bruce Waddington

Joetom

1st Nov 2008, 04:51

A little drift, but.

Which aircraft hav the lowest rate of T/O (actual or attempt) or T/O warn config due pilot test on Airbus due to Slat/Flap incorrect settings ?

Do Airbus pilots report if test picks up a config prob ?

Does the Airbus config test record findings to any data recording device ?

I guess the answer to my last question could be a big factor to answer to my middle question !

The latest AD mentions a previous event that resulted in a crash, what about all the other non crash events of this type getting into the air with incorrect Slat/Flap settings !

My thoughts still with all involved.

justme69

1st Nov 2008, 07:07

Joetom,

I'll let the questions about the airbus takeoff configuration warnings to someone who knows the answers.

About how often this type of incidents/accidents happens: quite a bit.

Read the thread a couple of pages back. There has been at least 6 accidents with victims (LAPA, India, Northwest, Delta, Lufthansa, Spanair).

There've been at least 3 take-offs w/o flaps/slats that managed to stay in the air long enough to escape a crash. In none of them the warning worked (bad switch @DCA/pulled circuit breaker @ACE/not reported). In some cases, i.e. the flaps were noted retracted after the stall alarm and quickly commanded, in others just engines firewalled and nose down while flying on ground effect until the speed was increased.

It seems there have been voluntarily reported some 55 cases in the USA alone in the past 7.5 years of attempted clean takeoffs, almost all of them "catched" by the Takeoff Config Warning System, of course.

It seems like it happens "quite often". A couple more cases, probably not reported, have unofficially been told in this thread by a couple of pilots.

There've been also at least 6 instances of known cases "after the facts" of flights that took off with unnoticed inoperative TOWS alarms (but the configuration was just fine, so nothing happened).

All this, probably, just the tip of the iceberg.

If in the past say 25 years or so there has been at least 7 known take-offs in which the crew didn't set the configuration and the alarm didn't sound (I'm not counting LAPA where it did sound nor India Air, which it wasn't reported), I guess we could factor that it's common enough so that once every 3-4 years someone forgets to set the flaps &/or slats at exactly the same time the TOWS is not working, although it not always ends up in a crash, but could've easily if the conditions weren't favourable for a recovery.

Bis47

1st Nov 2008, 07:42

Note the CS 25 text re hazards of crew familiarity with a warning in normal operations (the check) vs their reaction to a warning in the failure case, where the familiarity of the warning during the check might decrease its effectiveness in a failure condition – human performance and limitations, etc.

This is a real issue ...
It is a training issue, and also a "generic philosophy" issue.

The "generic philosophy" issue is a matter of projecting one self in the near future when performing a test, or checking a set up.

If you just do the test to make sure the TOWS is operational, you have only checked the nuts and bolts, you missed to check the human part.

I you chek the TOWS while projecting your self at the beginning of the take-off roll, and imagine that you hear that warning ... you just have to end the test (by retarding the thrust levers) while imagining yelling "ABORT" ...
It would be a good idea to add that word "abort" to the test procedure , and a good opportunity to remember that "any warning before xx knots, we abort"

Training issue ...
Well, see to it that this "projection philosophy" becomes an habit ...
Take full advantage of sim training to enforce the principle "any warning ... etc"
Take advantage of such sim training to enforce first officer assertivity ... (have the captain ignore voluntary such a warning ...)
Take full advantage of the failure pannel ... and rent the simulation device with the most comprehensive one.

alf5071h

1st Nov 2008, 23:38

“More training – better training”
More, or better training might be identified with the need to link knowledge with know-how (tacit knowledge), which is difficult to teach and best gained from experience.
The industry promotes a ‘no error’ operational philosophy, yet humans learn from error. Similarly the lingering blame culture restricts the number of error reports and restricts opportunity to learn from others.
Pilots can be taught the fundamentals of the TOCWS and the ground-air switching logic, but in order to associate them in situations when a probe overheats requires skills of critical thinking:- how is the situation understood and/or related to the next operation, what if, comparison, association, accurate memory recall, etc.
These skills are essential in aviation, and generally acquired from being in the relevant situations – experience.
Thus for a probe failure, full understanding of the situational aspects might require a pilot to have experienced ‘the specific failure’. However, probes can fail for many reasons – with or without TOCWS implications, that’s one reason we call maintenance to determine the nature of the failure;- CRM, use all available resources, provided that they too have the required knowledge and know-how.
The MMEL DDG (Dispatch deviation guide) should be the documented reference for allowing and managing these failures, but MELs may not consider human error, and probably not combined with other errors.

Following this line of argument, then it might be unreasonable to expect pilots to know the specific association between TOCW / ground-air switch / probe.
Flight crew are seen, and see themselves as the last line of defence, which breeds personal responsibility, but there are limits to the practicality of this.
The regulations (#2104) might suggest that system design should limit the dependency on pilot’s knowledge (and vulnerability to error), which argues for improved system integrity. If this was not the intent of the regulation then this accident identifies a mismatch between what the regulation (CS 25) assumes about a pilot’s knowledge and that required by JAR-FCL (training); a gap in the regulations which the operational industry fell into.

“What can be learned?”
Investigations of accidents in complex systems can usually determine ‘what’ happened quite quickly; finding out ‘why’ things happened is much more difficult. Blame, should not – must not, enter these phases of investigation, and is normally an issue for the lawyers, but this segregation is not always made.
Perhaps the most disappointing aspect of the the investigation so far, is that the ‘why’ aspects appear to be missing. Perhaps the jump to the legal national requirement (blame) has eclipsed the need to determine ‘why’; a pity as it is this understanding from which the industry might learn.

It is interesting to relate what is known about this accident with the causes of the recent financial ‘crash’. (cf New Scientist 25 Sept “The blunders that led to the banking crisis.”) Although the banking collapse is seen as an industry wide issue, the reasons for failing apply equally to an individual organization, bank or operator.

“The crisis did not come without warning.” Were the outcomes of previous MD 80 accidents and incidents sufficiently heeded? What action was taken by the continued airworthiness process, the manufacturer, and operators?

“By definition they are rare, extreme events, so all the [math] models you rely on in normal times don't work any more, " What assumptions have been made about aircraft system failure in the MD 80 and opportunities for error? Did these change with in-service experience?

“… each liquidity crisis is inevitably different from its predecessors, not least because major crises provoke changes in the shape of markets, regulations and the behaviour of players.” Was the Spanair operation towards the ‘end of the chain’ where previous experience, knowledge, or requirements may not have been passed on? Or if available the information not used due to a lack of awareness of the severity / frequency of the problem?

“…wrongly assumed that two areas of vulnerability could be treated in isolation, each with its own risk model. When the two areas began to affect each other … there was no unifying framework to predict what would happen, " Something for aviation to learn? MMELs rarely consider combined interactions in systems and / or human vulnerability.

“These models typically assume that market prices will continue to behave much as they have in the past, and that they are reasonably predictable. Statistical models based on short time series of data are a terrible way to understand [these kinds of] risks.
The banks had set great store by their use of statistical models designed to monitor the risks inherent in their investments. The models were not working as well as hoped - in particular that they were ignoring the risks of extreme events and the connections. The real risk, … turns out to be a cycle of drops." Complacency? Drops – small incremental changes in normal procedure, moving away from the assumed safe standard and so become the norm. Are these changes identifiable with FOQA, LOSA, etc, and are these safety tools based on the correct norm – risk, certification / training assumptions?

“… each bank had been content to use a measure called "value at risk" that predicted how much money it might lose from a given market position ("What do we stand to lose?") . In aviation, is this synonymous with an insular approach to flight safety – not sharing safety information, not considering the experiences of other operators?

“Statistical models have proved almost useless at predicting the killer risks for individual banks, and worse than useless when it comes to risks to the financial system as a whole. The models encouraged bankers to think they were playing a high-stakes card game, when what they were actually doing was more akin to lining up a row of dominoes.
Banks should be careful not to assume that they have it right and the rest of the world has it wrong. And regulators - who have lately allowed themselves to be blinded by science - should have no qualms about shutting down activities they do not understand. We shouldn't need another warning.” Cf Revisiting the Swiss Cheese Model of Accidents. (www.eurocontrol.int/eec/gallery/content/public/documents/EEC/note/2006/13_Swiss_Cheese_Model.pdf)

[USA Today] – Alan Greenspan … was "shocked" to discover, as a once-in a-century financial crisis spread, that his bedrock belief that financial firms could police themselves turned out to be "flawed."
"I made a mistake in presuming that the self-interests of organizations, specifically banks and others, were such as that they were best capable of protecting their own shareholders and their equity," "… a flaw in the model that defines how the world works."

Hopefully not an epitaph for aviation SMS and devolved regulatory oversight.

lomapaseo

2nd Nov 2008, 02:07

alf5071h

While there is a lot of good words in what you wrote, I do feel that it is too wordy and reaches too far in comparison with a well regulated system such as aviation with a far less regulated trust me approach of the financial sector.

The issuer of the MEL does have a responsibility to assume a degree of other errors. Typically a probabilistic approach should treat this based on experience with all known faults in asimilar machine. However such assumptions can not imagine statistically improbable combinations of human error where no such subtantiated reports have been presented from history.

Of course I am not privy to all the facts surrounding this latest accident still under investigation. But I am drawn to the so called newly released NASA data suggesting that numerous incorrectly configured aircraft takeoffs have been attempted and some even in the presence of failed TOWs systems.

Is this the failure of a system by itself? or is this a failure of communication between the user and the MEL writer.

I'm not ready to discect this further at this time because I don't even know if the MEL writer or Span Air had any idea of the results of the NASA study beforehand. Sometimes safety related studies are kept even private from the manufacturer and the users.

PJ2

2nd Nov 2008, 17:43

lomapaseo;

I have to say I'm 100% in agreement with alf5071h in an examination of common factors in both "accidents", (if you will).

I say this because done improperly, (under-resourced, data ignored, lack of coordination and/or honesty with POI), SMS is the de-regulation of safety - it is handing over monitoring and self-governing processes to those who's interests are contrary to conservative, (regulated, overseeing) approaches to flight safety.

The processes are exactly the same. Certainly the details, complexities, risks and outcomes are different but the principles are the same: When no one is watching management will compromise, cut corners, attempt to make the organization look good with candy-coated safety-board reports, ignore the warnings from FOQA/FDA, ASR and other safety programs in favour of commercial, profit-oriented/cost-controlling priorities.

It is not a matter of what Diane Vaughan called "ammoral calculation" - an intentionally-negligent act by management. The processes under the de-regulation of safety "feel" and "seem" natural and sufficient such that the notion of "compromise" does not even arise in the safety dialogue or if it does, the "deviance is normalized" to the point where it is acceptable.

Three main factors, (I know you know/understand this...I'm writing for all readers), are at work as the "new" standard is entrenched as "normal": Time, new managers with little/no experience (plus bean-counter pressure) and "success" - the "new, lowered standard has not resulted in a reduction in safety". Ignoring safety data or at least dismissing it as "suspect" provides comfort to such processes.

In terms of finance, all these factors were at work prior to the current world economic crisis and, in principle, they are at work at airlines right now - I have seen them, (and the consequent commercial decision-making), first-hand and have asked why FOQA data was ignored. The question itself was ignored and nothing has changed.

The factors and the pathways are as clear as a brightly-lit road and it was a matter of time until the sub-prime crisis back-flushed into the banks and out onto the streets. As we know, the seeds of aircraft accidents are similarly sown months and more likely years before the accident.

"Kiting" financial instruments is illegal for individuals but America's corporations and banks do it all the time with impunity. In flight safety work, "kiting" equates to finding compromise within the legal documentation such as the MMEL and the SMS audit process such that the operation may continue without apparent risk, all the while such risk laying buried in a stream of seemingly rational operational decisions.

The difference between the causes of this financial collapse and the increased potential for an accident under SMS is a matter of degree, not principle. Historically speaking, the roots of the present crisis may be found in "neoliberal" economics from about 1970 onwards where de-regulation, privatization of profit and socialization of risk which has morphed into the mad drive for pure profit at the expense of all sound financial principles. Nixon withdrew the US from the Bretton-Woods agreement, under tremendous pressure from corporations, in 1999 Clinton repealed the Glass-Steagall Act of 1933 which permitted banks to engage in currency speculation among many other non-traditional banking activities and to create "value" through loans and home purchases by those who couldn't afford it.

Though not in the same league or playing field, these processes equate directly with SMS's first principle with is self-regulation, self-auditing and an absent regulator. We already have seen the results in the US in the FAA's "difficulties" when it's oversight of Southwest, United and other airlines was found wanting.

In my view, these similar principles will lead to similar outcomes - that's all that's being stated, not that Transport Canada is going to listen or change course and not that any airline is going to listen. To me and obviously to others, there are significant lessons for the airline industry both in Canada and the US from the greatest financial crash since 1929 and I think alf5071h hit the nail on the head.

glad rag

2nd Nov 2008, 19:40

Cracking post PJ2 straight to the root of the problem..:D

Bis47

3rd Nov 2008, 07:12

+1 :ok:

Very pertinent analysis

Tyres O'Flaherty

3rd Nov 2008, 11:17

In aviation is there a similar move to a ''Professional'' managerial class that hasn't necessarily a background ( deeper understanding ) in the industry ?.

This is one of the obvious precursors to the current disaster in the finance/business sector.

Very ''clever'' people making apparently ''clever'' decisions about older practises that were there for a good reason.

Bah

captplaystation

3rd Nov 2008, 13:02

Not a similar move, but a quite long standing trend already. Many management types knew zero about aviation before becoming involved, and are very diligent about maintaining that status as they ignore all the good lessons of the past 60 or so years to preach the profit-above-all mantra. :=

agusaleale

4th Nov 2008, 09:59

Alf posted:

...
Thus for a probe failure, full understanding of the situational aspects might require a pilot to have experienced ‘the specific failure’. However, probes can fail for many reasons – with or without TOCWS implications, that’s one reason we call maintenance to determine the nature of the failure;- CRM, use all available resources, provided that they too have the required knowledge and know-how.
...

You already know that in the case of the LAPA flight: even though the TOW sounded all time, the pilots ignored it.

The comission who studied the accident stated that the pilots were not familiar with such kind of alarm, they had not enough experienced it before just to understand that they had to stop.

You are damn right...!

alf5071h

7th Nov 2008, 00:05

PJ2 (#2369 SMS aspects) I believe that we agree on the fundamentals of the problem, but for clarification I prefer to use ‘devolved regulation’ to describe the modern implementations of a State’s safety oversight responsibilities, instead of the generic SMS. There are many values in the concept and processes of SMS when used by an organization or individuals.
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern. Many other concerns have been outlined, but additionally the relative ‘remoteness’ of the regulator can reduce their knowledge-base and the opportunity to communicate knowledgably with other operators (and other countries). These are essential qualities in the process of continued airworthiness.

Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?

Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.

More words, more questions. However, in a supposedly well regulated industry (possibly over regulated) who will seek answers relating to this accident. Hopefully the independent investigation team, providing that they are really intent on identifying a ‘root’ cause (as above) and providing the industry with something which will improve safety; something that I doubt that the lawyers will do.

philipat

7th Nov 2008, 07:47

It seems to me that this thread has PROBABLY, despite the variable quality of inputs over the pages, highlighted several highly important issues regarding Crew disciplne and various technical weaknesses with the MD8X series, including the TOCW system architecture.

I don't know, but it seems to me that the deceased and families are owed a little more of a sense of urgency than that being presently demonstrated by the various investigations in terms of reaching conclusions and being proactive in addressing same?

Yes, the relay problems are known and have already been communicated by Boeing to operators. Yes the need to check the TOCW warning ahead of EVERY departure was ADVISED (But not received by some carriers who received the aircraft AFTER the advisory. Are there others?) Yes, the failure to deploy slats/flaps was previously known and officially communicated.

But, ASSUMING, there is already enough data to confirm the PPRuNe conclusions, and I concede that this is speculative, perhaps in the extreme, I just wonder why more is not being done by this stage to re-visit and reinforce some of the earlier advisories.

My thoughts and prayers remain with the deceased and their families. I believe they deserve better.

bsieker

7th Nov 2008, 08:55

I have prepared a preliminary Why-Because-Analysis of the accident.

It is based mostly on information kindly provided by people on this thread, many thanks for that.

If you've never heard of this method the website about Why-Because Analysis (http://www.rvs.uni-bielefeld.de/research/WBA/) is highly recommended.

A PDF file (http://www.causalis.com/index.php?id=29&file=1A16B0&no_cache=1&uid=43) of the analysis of the case is available for download at the Causalis (http://www.causalis.com/) publications (http://www.causalis.com/publications/reports.html) website.

Besides studying the graph I recommend reading the annotations in the provided detailed factor list.

Comments, either private or public, are very welcome.

Bernd

BOAC

7th Nov 2008, 09:01

One very quick one you can correct is the runway was 36L

bsieker

7th Nov 2008, 09:14

Thanks for the quick reaction.

One very quick one you can correct is the runway was 36L

Fixed.

Hydroman400

7th Nov 2008, 12:16

Philipat, do you not consdier the AD issued by EASA is a prompt step in the right direction even without the CIAIAC final report? If your comment is aimed more at design changes to the TOWS/TOCW then I am afriad this will take a while longer........

PJ2

7th Nov 2008, 19:25

alf5071h;

Thank you for your thoughtful response which takes the dialogue even further along an important road of understanding.
Re, There are many values in the concept and processes of SMS when used by an organization or individuals.
I couldn't agree more. I think SMS, as conceived, is a far better system than "blame/enforcement". But I do not believe (and have seen evidence for this) that it is being done, "as conceived. Assumptions such as the efficacy of a two-day course on SMS for all managers, and having all the "right" documentation in place, (the importance of documentation vice taking actual action is a very big issue in aviation management today - documents are cheap - action can be very expensive).
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern.
The issues in the United States with Southwest and United indicated that this concern was a reality. I believe the same conditions exist in Canada but have yet to be discovered.

Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?

Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
All excellent questions which demand responses. Coordinating same such that effective changes may be brought about is, as we know, much more difficult. Some questions have ready, and good answers. Others, such as those dealing with certification, may not.
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.
I have seen this first-hand and know that this circumstance exists even today and it causes great concern. When something is discovered in the data, conveyed to the appropriate internal airline departments and then is dismissed for "reasons", can occur even under SMS when there is little or no oversight and the documenation isn't followed and the audit processes do not reveal, or worse, tolerate such a weakness.

The non-use of FOQA/FDA data for example, by dismissing it when "inconvenient", (commercially), or worse, that the data is somehow not to be believed and is "wrong", is a real factor which governs operational decisions even now. Either the regulatory authority takes steps to protect safety information under SMS, and further, states that data from QARs used in FOQA/FDA programs is "the exact same" data as from the DFDR or such programs may as well stop and the money saved.

So I hear what you are saying and I agree that we view both SMS and the problems associated, in roughly the same way. For me, the term "devolution" may not reach far enough to describe some of what is happening, but be that as it may, the key is, the regulator is, in some countries anyway, beginning to examine what SMS means and, more to the point, what is being missed.

The risk in a non-robust SMS environment is, when no one is watching and there is little "danger" of discovery, commerical decisions can, depending on many factors, take priority over operationally safe decisions, which, because of such "success", can further result in the "normalization of deviance" and a continuance of the practice beyond the perview of the regulator. While that was/is always a possibility, under SMS, trust and integrity are absolutely fundamental keys that must be first demonstrated and then continuously proven to the regulator by the carrier. That is the only way SMS can work. The regulator who only "audits the audits" and not the air carrier's actions (which may or may not have been followed through on), may not discover a systemic weakness until an accident occurs, caused by quite different circumstances/pathways than the industry has experienced thus far.

bubbers44

8th Nov 2008, 03:06

Quite a long winded recital but they forgot the flaps. The warning system didn't work and they crashed. It will happen again if they don't fix it. Simple as that.

atceng

8th Nov 2008, 07:09

Factor list item no.39, 'Maintenance personnel de-activate rat probe heating'.

This is NOT exactly what they did,and is crucial to the causality and mindset leading to the accident.

They seem to have switched off a power supply ONE of the functions of which was to supply the rat probe heating.
They appear to have failed to consider the effect of loss of power to the other systems powered by the same supply,or considered that the lack of power to these systems did not constitute a MEL .infringement.

It is vital in a maintenance regime to consider the effects and consequences on other systems of ANY action taken,and to be sufficiently conversant with the whole system to properly analyse the effects overall.

I write this after 50+ years in designing and maintaining industrial control and safety systems,and I still approach any 'link it out/switch it off for now' fault solutions with great fear and trepidation and endless what else will it affect mind searching.

rolling

8th Nov 2008, 10:25

well said bubbers 44

bsieker

8th Nov 2008, 12:43

atceng, thanks for the feedback.

They seem to have switched off a power supply ONE of the functions of which was to supply the rat probe heating.
They appear to have failed to consider the effect of loss of power to the other systems powered by the same supply,or considered that the lack of power to these systems did not constitute a MEL .infringement.

Interesting. I'd like to know where this information comes from.

To clarify:

In the MD80 flight manual that I have seen, the RAT probe heater has a dedicated circuit breaker, called "Z29".

The problem is not that disabling the heater also disabled other systems (for all I know it didn't), but that the fact that the heating was operating on the ground was a symptom of something else wrong. And this "something else", most likely a failed relay, also influenced other systems. Most importantly it inhibited the Takeoff Warning System.

It's all in my graph. Some further information is buried in the annotations in the "Factor list Details". The annotations help clarify a lot of the factors in the graph, but were left out of the graph proper in order to limit its size.

Although the CIAIAC preliminary report wasn't quite on time, nor is it the best preliminary report I've seen so far, I still assume, also taking into account justme69's take on it, that the information it contains is established beyond reasonable doubt:

[...] opened the electrical circuit breaker that connected the heating element.

Bernd

philipat

8th Nov 2008, 12:43

Quite a long winded recital but they forgot the flaps. The warning system didn't work and they crashed. It will happen again if they don't fix it. Simple as that.

That was my point entirely.

philipat

8th Nov 2008, 13:01

Quite a long winded recital but they forgot the flaps. The warning system didn't work and they crashed. It will happen again if they don't fix it. Simple as that.

To anyone who enjoys Saturday Night Live, to quote Oscar, they should:

1. Fix
2. It
3. FIX IT

Who?

Them.

FIX IT

forget

8th Nov 2008, 14:16

Could anyone point me to the post which had a jpeg of the Relay schematics. I've looked everywhere. Has it gone?

glad rag

8th Nov 2008, 14:19

"The Circuit breaker for the RAT heating supplies the RAT heating. That is it, full stop, dead end, nothing further. There is absolutely no connection to any other system including the take off warning."

So the (as found on pprune) "guilty" :rolleyes: were actually guilty of nothing more than de- energising an authorised cct to enable dispatch, working against the clock and (most likely) being denied authority to further fault find due to the aircraft being manned and on the line, a practice that occurs dailly around the globe.

So lets just forget trying to find scapegoats and approportion the blame where is belongs.

Belgianboy

8th Nov 2008, 14:31

As I don't have knowledge of the relay system of the MadDog, I refrain to post so far.

To the best of my knowledge, the purpose of our exercize is neither to blame people nor to find a scapegoat, but, to assist in improving the system and to try, at least if feasible, to avoid similar accidents in the future.

Lately, they were lot of talks regarding denergizing the system or just isolating the heater of the RAT probe.

To clarify the matter and to avoid nonsense talk, I would suggest that people familiar with the wiringl on boad of this craft and/or the ones who supplied the diagrams should revert and summarize their findings in plain language for the average laymen supported by enclosed diagrams.

Thks in advance for the effort.

Willy

bubbers44

8th Nov 2008, 15:10

Forget,

The relay schematic in on page 97, post 1935. R2-5 failed in air mode on the ground.

justme69

8th Nov 2008, 15:49

I may not be the most appropiate person to do this summary, but unless someone has time to expand on the topic, this is the "simple" scenario.

-The front landing gear controls many of the ground/air logic through two sensors (right and left wheel).

-Each one of these two sensors "signals" (energizes) a circuit (left or right) depending on their ground/air position. When the wheels have weight and the strut is compressed=on the ground. Or the wheels don't have weight/strut decompressed=front wheels are off the ground. It can happen that a strut is "overinflated" (not properly regulated) and the sensors don't quite reach the closed position (strut is not compressed-down enough) even while on the ground. It could also happen i.e. if the airplane is out-of-balanced overloaded in the back and has no weight in the front. This doesn't seem to have been the case on this flight (read below). Also, the aircraft was almost at maximun takeoff weight, so certainly all wheels were supporting a heavy load.

-Each one of this left&right circuits "signals" (powers) aprox. between half a dozen (right wheel circuit) and a dozen (left wheel circuit) relays.

-Each one of these relays "signals" (powers) between 1 and 4 devices (TOWS and other warnings, heaters, ventilation, lights, cabin pressure, etc).

-Some of these devices receive "power" (signal) from two different relays at the same time from both, right and left wheel circuits. As a result, if the relay that powers it (or the whole circuit for the whole wheel) "fails", it would still work as long as the other wheel's circuit is ok. Those devices are "redundantly" serviced, and therefore would still work correctly even if one relay or one whole circuit (left/right) "fails" (i.e. is disconnected, etc) or one wheel sensor "fails".

-One relay in the left wheel circuit (R2-5) was responsable for both, the TOWS and the RAT probe air intake anti-ice heater. It also powered two other "devices" (AC x-tie/Radio vent), but those two were redundantly serviced from another relay in the other (right) wheel circuit.

-The only circuit servicing the RAT heater and the TOWS was the "left wheel" one. The only relay servicing the RAT and the TOWS was the R2-5. They were NOT redundantly serviced.

-In the same "left wheel" circuit, another relay, R2-12, MAY (someone please confirm) be the one responsable for signaling the Data Flight Recorder the ground/air mode state. The Data flight recorder DID detect and record a change in logic state between ground/air at the appropiate time (shortly after rotation was called). As a result, it is likely that the whole "left wheel" circuit was working (relays R2-308, R2-283, R2-5, R2-125, R2-58, R2-212, R2-3, R2-2, R2-240).

-But since the RAT heater could have only received power if the R2-5 relay thought it was in "flight mode", it was probably malfunctioning (i.e. stuck/blown, electrically shortcutted/opened to the sensor, otherwise malfunctioning). The same fact would've made the TOWS inoperative in all likehood.

-Assuming an R2-5 malfunction, no other systems would've been affected except for the TOWS and the RAT heater.

-The technicians pulled Z29 circuit breaker which only disconnects the RAT probe heater, w/o affecting other systems. They interpreted the MEL allowed for this. That would've "taken care" of the only problem reported by the pilots: "The RAT heater is on while on the ground", by turning it off completely and allowing the a/c to fly since there was no danger of ice formation in such hot weather and destinations.

The technician's actions, while not the smartest in the world, probably complies sufficiently with their jobs requirement. The interpretation to disconnect a "working" (but could be considered "erratic") device as being part of the MEL is up to semantics and interpretation. The only thing the MEL really says is that the airplane can fly with the heater inoperative if the weather and other conditions are met.

Also, nobody had told them anything about a non-working TOWS, that the crew presumably were required to check prior to all this.

Certainly maintenance guys could've put two-and-two together. Although I'm sure "nobody overly pressed them" to do a quick-and-dirty job (i.e. another airplane, transfer busses, gate, personnel, flight plan, etc were all ready for a new plane to be used for that service w/o an overly significant delay), certainly I'm sure they felt that for the comfort and interest of the passengers and the airline it was better just to quickly disconnect such a non-significant "problem" and take care of it later.

Should have not the pilots forgotten to deploy the flaps/slats exactly at that time, nothing would've come of it. I'm sure soon enough (although indeed probably not until another return flight at "night", potentially w/o TOWS unless the crew performed a test), it would've gotten noticed/fixed.

But it had to be on a hot day, with tail wind, with a virtually MAX gross that both issues aligned while a somewhat rookie (2 years, 1000h) copilot was in charge and random stall bad "luck" had them roll right a bit too much, enough to miss the runaway's course making recovery nearly impossible. The nose-up attitude tendency of MD-82 under stall didn't help, I'm sure.

So the short-short version would be: only the TOWS and the heater were "not working". The technicians disconnected only the heater. Nobody (pilots or technicians) noticed the TOWS were also not working, nobody tested them after all this, and nobody made the connection between both conditions being in all likehood closely related.

SPA83

8th Nov 2008, 16:03

http://nsa03.casimages.com/img/2008/11/08/081108060622526954.jpg (http://www.casimages.com)

forget

8th Nov 2008, 16:04

Here's a simplifed schematic of R2-5.

http://i21.photobucket.com/albums/b270/cumpas/RAT2.jpg

SPA83

8th Nov 2008, 16:06

http://nsa03.casimages.com/img/2008/11/08/081108060903141826.jpg (http://www.casimages.com)

safetypee

8th Nov 2008, 17:17

bubbers44, et al; re “… they forgot the flaps. The warning system didn't work and they crashed. It will happen again if they don't fix it” (#2382).
‘They’ the crew, were operating in conditions where there are opportunities for error, and ‘they’ the crew, are error prone, as are all humans.
Your simplistic view implies blame; although you may not have intended this. This may be a result of oversimplification.

You also refer to those (they) who fix ‘it’; – which ‘it’, the TOCW (the operating conditions) or the human susceptibility to error. Who are these people, what are their responsibilities, and are these responsibilities of similar magnitude as those of the crew? Thus should they proportionally share the burden of this accident?

If the TOCW system had been fixed after previous accidents then this accident might have been avoided. Checks were introduced, but these did not circumvent error. Are they, the people at higher level who decided on checks vs a fix, to be blamed? No, but as with the crew and all of us there is a shared responsibility for safety.

How many Ppruners contributing to this thread knew about the poor working conditions (TOCW problems), how many of us have erroneously failed to select flap (on any aircraft) … how many have reported these issues, and if reported who took action and checked the result?
Not blame (after the event), but responsibility before the event; this isn’t simple.

Stanley Eevil

8th Nov 2008, 17:31

Lets cut to the chase here .... the crew ****ed up, didn`t set the flaps, presumably paid lip service to formal checklists that should have revealed the error and crashed - end of!

glad rag

8th Nov 2008, 18:51

Excellent diagrams, I presume they are relevant to type/mark??

One thing, coil supply is 115AC via CB B 1-23 (anyone got a relay schematic??)

ta.

FE Hoppy

8th Nov 2008, 18:53

Love your work but this is a no brainer. As had been said. The crew forgot the flaps. An absolutely vital item in normal procedures. They payed lips service to a checklist designed to catch their previous mistake.

There are standards which need to be maintained in aviation. Finding excuses for gross negligence does not help safety one iota.

PJ2

8th Nov 2008, 20:05

FE Hoppy, bubbers44, Philipat - re:
They payed lips service to a checklist designed to catch their previous mistake.
That the crew screwed up is plainly obvious and tells us nothing new nor does it inform anyone about how to prevent the next human error. If that's all there was to this accident, the thread could have finished on page 1, liberal loads of kapoc notwithstanding. The question begged however, is "Is that all there is to this accident - the crew screwed up, end of story?"

Perhaps I have misunderstood your intent: Do you consider the broad input from those discussing safety factors, safety (preventative) programs, system design features, safety cultures, interpretations of MELs and last of all what crews themselves could have done to prevent this and at least three other accidents of the same cause (plus 55 reported incidents in which the airplane did not crash) all as unnecessary, superfluous and irrelevant to causes and that discussion should have stopped with the above statement of fact?

If so, then how does Philpat's entreaty to "fix - this", a statement with which I'm sure we all agree, get actioned once and for all? Much as we all would like it, crews (pilots/maintenance) can't be just told/implored to "follow SOPs" and that's the end of it. I know from previous posts you don't dismiss investigation or safety programs, so what am I missing?

bubbers44

8th Nov 2008, 22:03

B1-23 is shown in the above schematic. It would affect all of the relays, not just R2-5 so it was operating normally. The FDR sensed nose gear oleo extention on take off and would not have let engine power go below flight idle taxiing. They would have noticed that because I had it happen one night when the nose strut was overinflated.

safetypee

8th Nov 2008, 23:55

FE hoppy I hope that you agree that a central theme of modern flight safety is that human error cannot be completely eliminated; it can only be minimised or the effects mitigated.
At some point an error will occur. A key aspect of TEM is to ensure that this error is detected (if it cannot be avoided), or does not occur in combination with some other critical feature, or that the outcome is manageable.
I agree that checklists can help, but why only checklists, why not use technology to prevent / detect an error in parallel with the crew. Why not increase normal takeoff speeds so that an inadvertent flapless takeoff might be controlled? These, like most things in aviation, are judgement calls, and are generally in the process of certification – communal experience.

The crew appears to have suffered an error – why; this aspect has yet to be revealed.
Our commercial industry chooses to crew with two pilots, where one might monitor the other. This accident involves one of those rare situations where both pilots suffered simultaneous, or near simultaneous error – there was a safety time span from checklist action until takeoff to detect the error, why were there failures in these aspects?

In this accident it is not up to us to determine if the crew (or others) did all that they could have done in the prevailing circumstances, we should not – we cannot determine negligence. It might be impossible to establish the mental processes which the crew employed; it is difficult to establish intent, knowledge, perception, bias, or belief, etc, which could have affected behaviour from a FDR or CVR.
However, we can at least consider other aspects which could affect the circumstances which might have influenced the crew.
It was not my intent to identify excuses, only the circumstances, which based on current information point towards weaknesses in the TOCW system.

Was it just chance that the crew encountered error provoking circumstances at the same time as the TOCW was at its weakest; if so the danger is that we might ‘blame’ chance, because as has been stated other crews have suffered checklist errors (flaps) without an accident. Chance is not good enough for our industry, thus there is the need to search deeper into the communal experience – the ‘model’ of safety, which like in the financial crash, might be flawed.

Perspectives on Human Error. (http://csel.eng.ohio-state.edu/woods/error/app_cog_hand_chap.pdf)

Punishing People or Learning from Failure? (www.hufag.nl/archief/huf03_dekker.pdf)

Human error: models and management. (http://bmj.bmjjournals.com/cgi/reprint/320/7237/768)

Human reliability. (http://en.wikipedia.org/wiki/Human_error)

Joetom

9th Nov 2008, 03:02

A couple of points.

Nose gear air/ground sense, people have mentioned left wheel and right wheel sensors, is it correct to say, when the the nose oleo extends to a said extension that two sensors(may be 1+2 or L/H+R/H sensors) config the airplane into the air mode and talking of L/H or R/H wheel sensors can confuse people ?

Most MEL's I have seen mention a set of conditions/checks that may be required to allow use of the said MEL item, for the MEL item in question, do MEL's have any conditions/checks(apart from weather) ?

Some comments on hear mention that engineering should of researched more about the pilot's reported defect, should this be the case, then every item in the MEL should have the conditions that engineering should check every possible interconnection before using the MEL, and I guess the conditions should also ask the pilots to do the same !

Always worth remembering, engineers often work alone and do not have another person sitting next to them to talk over any issues, even cabin crew use two staff to check if doors are in auto/man mode, also engineers hours of work and sleep patterns are not well regulated to say the least.

Sounds like lots of learning from this accident, lets hope all the lessons are put in to practice to save lives in the future.

My thoughts with all involved. Joetom.

sevenstrokeroll

9th Nov 2008, 03:04

I've watched this thread from day one.

now I've seen it all...increase take off speeds to allow for takeoff without flaps/slats.

ok, and now you increase the chance of tire failure.

I am sorry this accident happened. BUT, if you want a safe airline it costs money.

It means a dedication and honor of the highest type. It means that the CEO must create a culture of SAFETY FIRST.

But how can this be when the modern airline CEO doesn't know a trim handle from a suitcase handle. ;0

so, let's quit talking crazy...just do it right.

lomapaseo

9th Nov 2008, 03:35

I sense the outspoken masses would like somebody to blame and this thread closed so we could get on with waiting for the next accident to start another 100+ page thread.

So OK your brief vote is cast. But if history is repeated "those that choose not to participate" can rest assured that their comments have been noted.

For myself, I haven't figured out how to apportion blame, nor what to do while waiting for the next accident. So I shall continue to read this thread for pearls of wisdom.

BOAC

9th Nov 2008, 07:21

We will never agree, SC, but as a professional pilot on a professional pilots' web forum (and I have NO idea what you are), I have to re-arrange your post:-

APPARENT primary cause: Crew failing to select flaps and failing to perform check lists (as yet, as far as I know, unproven - and no-one has stated that the a/c could not have operated satisfactorily with the defect)

Contributing Factors:

Possible technical defect resulting in failure of a warning system - apparently not understood by those who write the maintenance books, nor the engineer or crew.

Possible commercial pressures - the ever present need to operate a company in profit or slide gently down the wall. 'Acceptable accident rate' (defined by 'regulators' in many walks of life) being a 'derivative' of this. If this was a contributor I have no doubt that Spanair will learn the consequences.

I doubt many Spanair pilots - or management - even know what CHIRP is, so you should leave that off your list as irrelevant in this accident. Please define for us a 'defective aircraft'. Are you suggesting the DDM/ADD call-it-what-you-will system be scrapped? As for unions 'criticising an airline'.................

Out of this thread come lessons: pilots must review their operating procedures; manufacturers and airlines need to ensure that maintenance procedures are thorough; it is encumbent on those who can to ensure that this particular 'hole' is plugged. I suppose the 'word I dare not utter' is REGULATION. It is how we get these things achieved that is important.

PJ2 - "If that's all there was to this accident, the thread could have finished on page 1" - I strongly disagree!

philipat

9th Nov 2008, 07:23

PJ2:

If so, then how does Philpat's entreaty to "fix - this", a statement with which I'm sure we all agree, get actioned once and for all? Much as we all would like it, crews (pilots/maintenance) can't be just told/implored to "follow SOPs" and that's the end of it. I know from previous posts you don't dismiss investigation or safety programs, so what am I missing

Your inputs are always informative, intellegent and pragmatic and I have nothing but respect. I will stand corrected as necessary. I think I actually made my point in the earlier referenced post, but to summarise, the issues I saw were as follows:

It is taking far too long to reach a sensible conclusion, balancing the consequences of being too quick or too slow.
Boeing should ensure that all operators of MD8X aircraft are compliant with TOCW check requirements ahead of EVERY TO in the light of this and several prior incidents. Has this been done and, if not, why not?
Boeing should ensure that the MMEL addresses the relay issues involving the RAT probe. Has this been done and, if not, why not?I understand that there are legal issues and that these these issues have already, largely, been communicated to lines. However, it still seems to me that the set of circumstances involved would justify repetition for the sake of clarity and the possible saving of lives in future.

Wise (Retired) pilots such as yourself have already concluded that, as good airmanship, a final check of the "Killer items" whilst lining up for TO, whilst not required as an official check, makes very good sense. If I were a pilot I would have learned from this thread that this can save your own life and those of passengers. Why is this not a formal final check? Many lines also now mandate that Flaps be deployed after push back and before taxi commences. Why nor ALL lines?

Those are my only issues and, as I said, I am learning from this and stand ready to be corrected.

SPA83

9th Nov 2008, 07:49

latent cause COMMERCIALISM
last events:
-bad troubleshooting
-Crew failing to select flaps and failing to perform check lists

BOAC

9th Nov 2008, 08:05

SC - any chance you can illuminate the 'black hole' that is SC with SOME glimmer of information about what your connection is with this forum and industry?

"Sorry BOAC you need to look further back than just the day before the accident." - actually you need to understand I am primarily looking at the 10 minutes or less before the accident.

"You are obviously BA". - wrong! 0/10 there.

"You are also the classic type who treats symptoms but not causes." - did you mistype that?

"Plug this hole and wait for the next achieves nothing except changes the circumstances of the next hole in the ground." - wrong! You hopefully prevent another similar hole in the ground, so the wait is a long one - a worthy ideal, no?

"Cure the number one single cause, COMMERCIALISM and you are well on your way to a heavy reduction in incidents." - I wait with interest to see your background

Bis47

9th Nov 2008, 10:15

Before deregulation,
When airlines were "protected", or state owned ...
Money was never a problem.

Commercialism was not a factor!

But accidents were more frequent at that time.
Plein stupid accidents.
From human error, including pure neglect.

Commercialism is a factor, I fully agree ... it is not the factor, obviously.

glad rag

9th Nov 2008, 11:23

OK define "Bad Troubleshooting" :ugh::ugh::ugh::ugh:

They stopped the probe overheat problem, albeit not at the root cause, but enough to dispatch the aircraft.

Was the TOWS system snagged or would that have prevented dispatch (as well as initiating investigation););););)

Bis47

9th Nov 2008, 11:49

I think that TOWS was a no-go item.

Joetom

9th Nov 2008, 11:56

"Bad Trouble shooting"

Thread is very long, am I correct in saying that a pilot reported defect was sorted out buy a normal use of an MEL item ?

If the above is correct, we need to be clear on how we go on from here.

Do we remove the MEL or expect engineers and pilots to understand every problem that can exist on an aircraft and judge every MEL item with their limited information.

I understand that many many aircraft attempt to T/O with various items/controls in the wrong config, most often picked up by config warn systems, on some occasions config did not operate or crew took off anyways, some are lucky and maintain flight, some are not.

May be this age old problem can be sorted out the same way logic has now been applied to engine rev, think they call it 3 lines of defence, think a 767 rev in flt and loss of aircraft drove that change.

Sorry for drift, Joetoms.

forget

9th Nov 2008, 12:36

Do we remove the MEL or expect engineers and pilots to understand every problem that can exist on an aircraft and judge every MEL item with their limited information.

MELs are produced by factory engineers to allow aircraft to fly with certain bits inop.

When the MD-80 RAT Heat MEL was written up it allowed flight with no forecast icing conditions. Simple, and no problem so far. Pull the RAT Heater circuit breaker and off you go. Crucially, what wasn’t considered by the MEL writers was why the RAT might Heat on Ground. A failure of Relay R2-5 (Flight Mode) would do it – which would also disable the TOWS. So, pull the RAT Heat circuit breaker, RAT Heat problem fixed, TOWS is now inop with NO indication of failure. And I defy any line engineer, no matter how smart, to raise his hand and say “Hold on guys, RAT Heat on, I bet R2-5s failed and we can’t just pull the RAT breaker because the TOWS might also be inop”. That’s down to the MEL actions and, from what I’ve seen in this case, they ain’t up to the job.

This accident has been waiting to happen from the day the aircraft left Long Beach. Very poor TOWS/Flight/Ground logic design, and very poorly written MEL.

glad rag

9th Nov 2008, 12:49

"This accident has been waiting to happen from the day the aircraft left Long Beach. Very poor TOWS/Flight/Ground logic design, and very poorly written MEL. "

Yep, seems that way from the limited info on here, the final nail being the training of the operators, apparently less comprehensive than that envisaged when AC was designed..........

el #

9th Nov 2008, 13:56

forget, you write:
And I defy any line engineer, no matter how smart, to raise his hand and say “Hold on guys, RAT Heat on, I bet R2-5s failed and we can’t just pull the RAT breaker because the TOWS might also be inop”.

I have no experience in airplane maintenance, but I believe many good engineers would think exactly along these lines. Just like pilots develop a "pants seat" feeling over time, engineers do the same, actually their most important quality is not only to be able to repair, but to properly diagnose first.

Beside, in this case, there has been a major lack of proper analysis and logic thinking.
A failure in which and electrical device, be an heater, bulb or whatever else, remains ON all the time, it's obviously a failure of the circuit that energizes it, not a failure of the device itself.
The breaker there is really meant just to cut power in case a short circuit overdrawing current, or when there something else wrong with the heater itself.

I know many automotive mechanics that are really unable to deal with even the simplest electrical problem, while others are surprisingly good. I suppose the same happens with airplane engineers, not everyone has the same skills and is equally proficient in all areas. E.g. a local hydraulics guru said to "better not touch electrics", if you get what I mean.

I feel very bad for the engineer(s) that service the A/C that day, but it cannot be contended that they failed to properly diagnose a fault that was very well in their own domain.

Then we can discuss if we want engineers to be smart or not, if was poor design, if we need better diagnostic flowcharts, etc, but saying that the mechanics properly worked on the A/C in case, it's like saying the pilots properly executed the T/O checklist.

forget

9th Nov 2008, 14:16

I feel very bad for the engineer(s) that service the A/C that day, but it cannot be contended that they failed to properly diagnose a fault that was very well in their own domain. (Is this what you meant to say :confused::confused: - or the reverse?)

They followed the manufactures documents (MEL) relating to RAT Heat.

justme69

9th Nov 2008, 15:04

Well, Boeing (McDonell) was made aware of their TOWS limitations after Detroit accident. And as a result they DID take action: They tried to convey that the TOWS was not a 100% trustworthy device to be relied upon and that at least it should be checked as frequently as possible, specially shortly before each attempt to take off.

Tons of airplanes fly everyday with TOWS that do not produce overly noticeable signs of failure.

It has happened with similar results (accidents leading to deaths) to 737's and even 747's (Lufthansa 540), i.e. !!!!

A better TOWS is always desireable, but in its absence, crew/training/manteinance/regulation discipline on exercising frequent tests would usually save the day (it would've in Spanair case, in theory, of course, because the crew could've just as well neglected to carry out a pre-engine start TOWS test, i.e., or the failure occurred after testing).

So only (a small) part of the blame, from my point of view, lies on the TOWS designers. But no point on not having a re-design for 2009. Nowadays it should be a cheap and easy endeavour and no point on risking lifes for a stupid $100 microcontroller re-do.

Making an alarm to warn on a malfunction of an alarm is, as you can guess, a "catch-22". The "lighted iluminator" or "alarm failure warning" could've just as well have failed. Not to mention that a diagnosis system might imply the TOWS is fine only to find out that the loudspeakers to sound the "horn" have blown up right around that time. So we would need an alarm for an alarm for an alarm for an alarm failure.

Nothing is really better than an "actual test" to see if the thing works or not for sure.

Except the better solution of a design in which the TOWS announces both, a working and a bad config state. Then "silence" can only means it is not working right and hopefully crew will recognize silence as something is wrong.

I think that human error can not be eliminated. It has happened before and after "commercialism" and will continue to happen. "Stupid" human error happens to INCREDIBLY top of line PERFECTLY trained pilots (i.e. chief test pilot for airbus A330 case, etc), on INCREDIBLY safe "culture" airlines.

It happens even more to "bad pilots" on crappy airlines, and it also happens more to crappy designed or maintained planes, of course.

But it just can not be eliminated.

So, in my view, rather than "training" (which is consistently ignored by us humans after a few years of repetitive tasks), regulation, etc, I vote for technology to try to tack these problems. Technology will introduce their own set of problems, DIFFERENT from human errors, but those problems (hopefully) CAN be resolved and eventually be done with. Human error CAN NOT be ever "fixed" and done with. Unless humans are substituted by "robots". Thus my point.

Let's say that 10 accidents a year are PROVOKED by pilots doing something "stupid" to perfectly safe/working planes/conditions.

Let's say that another 10 accidents a year happen because mechanical/electrical/machine failures that humans on board are not capable of overcome (i.e. humans were "useless" against a wild cabin fire, multiple engine failure, catastrophic structural damage, etc).

Let's say 3 accidents a year, due to severe malfunctions, would've ended it total catastrophy if a robot/computer was piloting. But because it was a human, human inginuity saved the situation from a "certain death" against all odds. The human did something no machine would've ever "thought of".

As a result, that year, we had 20 accidents.

If humans "weren't involved" in the equation, we would've had 10+3=13 accidents. We would've saved the lifes involved in the other 7.

Most of those accidents left could probably be "fixed" through even better technology, learning from the errors causing the accidents. But the 10 cases due to human errors, it has been proven through history, are fairly consistent in spite of countries/cultures/training/regulation/comercialism/you name it.

Anyway: the industry is already moving in that direction with airbuses etc. For a while, NEW accidents due to "technological" malfunctions will replace those "saved" by the computers not-allowing pilots to make "stupid" actions.

But eventually those problems will be fixed and, unlike humans that can not be fixed, the rate of accidents will hopefully go down.

I vote for, technology permitting, gradually phase out humans from the equation. It never hurts to have a trained human supervising the whole thing in case something goes major hiwire and he can save the day.

But I'm afraid that if a (redundant, fail-safe) computer can't deal with the situation, the human certainly better be smart and trained (and lucky) to stand a chance.

As it stands today, well over 60% of aviations accidents are the result of "trained" humans making really bad choices on "perfectly fine" (to fly) airplanes under not-extreme conditions (some minor "issues" or "malfunctions" which confused the heck out of the pilot when he *should've* known better).

And, of course, there is a large fleet of airplanes made before technology (redundancy, independently developed multiple-software-agreeable systems) was up to the par on seriously taking over human functions.

It's probably unavoidable. It may take 100 years or 1000 years, but machines will eventually fly us from A to B w/o much fuzz and as few failures as "God" allows. So no point in trying to avoid working on it right now.

Do you wanna know if I'll ever trust my daughter to be transported by a computer? Just ask yourself which you rather send your children with: a "fairly good record computer" or an unknown (but you trust well trained) taxi driver.

PJ2

9th Nov 2008, 17:11

Philipat;
Your inputs are always informative, intellegent and pragmatic and I have nothing but respect. I will stand corrected as necessary. I think I actually made my point in the earlier referenced post, but to summarise, the issues I saw were as follows:

It is taking far too long to reach a sensible conclusion, balancing the consequences of being too quick or too slow.
Boeing should ensure that all operators of MD8X aircraft are compliant with TOCW check requirements ahead of EVERY TO in the light of this and several prior incidents. Has this been done and, if not, why not?
Boeing should ensure that the MMEL addresses the relay issues involving the RAT probe. Has this been done and, if not, why not?I understand that there are legal issues and that these these issues have already, largely, been communicated to lines. However, it still seems to me that the set of circumstances involved would justify repetition for the sake of clarity and the possible saving of lives in future.

Wise (Retired) pilots such as yourself have already concluded that, as good airmanship, a final check of the "Killer items" whilst lining up for TO, whilst not required as an official check, makes very good sense. If I were a pilot I would have learned from this thread that this can save your own life and those of passengers. Why is this not a formal final check? Many lines also now mandate that Flaps be deployed after push back and before taxi commences. Why nor ALL lines?

Those are my only issues and, as I said, I am learning from this and stand ready to be corrected.
I think we're on the same page here - I did read your earlier post as well and agree with, "fix it" - in my view (as with many), this thread is, with a number of rabbit trails, some worth it many not, about how to fix it. I think the thread is emminently worthwhile reading through and learning from. I disagree with bubbers44 who states that the thread is a long winded recital and that the accident is "as simple as that", and have said so asking for a clarifying response. I'm not so sure we're on different pages but have merely misconnected.

BOAC:
PJ2 - "If that's all there was to this accident, the thread could have finished on page 1" - I strongly disagree!
No problem - disagreement is more productive than agreement of course, but help me out a bit - why and how do you disagree?

Just to be clear, I was referring to statements made which conclude that the crew screwed up and that's all there is to this long-winded narrative. I strongly disagree with such a statement, as my posts on these matters (safety systems, SMS, data collection and human factors) clearly indicate. I know some posters here eschew such approaches because they consider their operation perfect and do it right every time so they don't need these programs, assorted rexalls and prophylactics against accidents but many others either cannot or do not meet that herculian standard in aviation. So not sure if we've got a disconnect here or what.

The whole point of 2400 posts goes to the heart of human error, system and SOP/MEL design. The entreaty that we just need to ramp up professionalism, expectations and so on is hollow because nobody sets out to be unprofessional let alone have an accident, (obvious and trite). The key in the long-windedness of this remarkable thread is the acknowledgement that while human error can never be eradicated, a sustaining safety culture where high standards of professionalism are expected (and enforced where needed), can help reduce such and that focussing just on the crew or the maintenance people will not prevent the next accident of this type.

A culture which recognizes human error as real encourages "error-checking" behaviours which are essentially "recursive" - not in the sense of second-guessing one's every action or decision, but constantly reviewing what was just done with a view to catching mistakes, is a culture that has embraced the notion that it is possible to be wrong. While there are obvious signs of lack of cockpit discipline here (and in other accidents), why does such continue to occur?

Why do these kinds of accidents happen in the rail industry, medicine and the nuclear industry? People screw up is the reason but such a conclusion, (there is no analysis) is tautological and not informative.

As the point has been made many times here the latest of which is justme69's post above, the TOCWS is a secondary warning system at best - it isn't a "mission-critical part where failure of same will cause loss of the vehicle and crew", so to speak. In fact, if all crews did their job with absolute strict adherence to the SOPs, a TOCWS wouldn't be required, (and that point has been discussed).

Many posts make comments regarding safety cultures, commercial priorities, absence of informed leadership from the CEO and his/her executive team and from my own quarter, lack of belief in or use of safety data and the total absence of CEO comprehension, support or even interest. Sorry, have we misconnected here or have I misunderstood these statements as dismissing these broader notions as trying to convey something else, because it seems to me that the thing to do is go far, far beyond stating that the crew messed up into discovering why -that is what SMS is truly about, (even though it has yet to be done properly in my view).

BOAC

9th Nov 2008, 17:43

PJ - I've no doubt you know my 'simple' pilot's view of this - that the probable cause was pilot error; thus, because we have all learned so much about the MD systems, I say it would have been fruitless to 'end on page 1' (figuratively speaking, of course). I sincerely hope that many pilots and probably line engineers - and hopefully, of course, DDM writers, have learned much from all these pages. Whether there are managerial lessons to be learned - we have to hope the 'enquiry' will reach properly and deeply to establish.

el #

9th Nov 2008, 18:07

They followed the manufactures documents (MEL) relating to RAT Heat.

They followed proper procedure only partially. Yes, dispatch with disconnected RAT heater is OK per MEL. But, they failed to diagnose an air/ground related failure.

PJ2

9th Nov 2008, 18:07

BOAC - thanks - I hope that in my writings I never, ever convey disrespect for "simple" pilots as I was one myself before a forced retirement at 60 who happens to have a passion for a particular area. Like any and all profession airman who hang around cockpits long enough, where "pilot error begins", many times I have been in less-than-ideal circumstances which, but for the interventions of crew members and others factors (pucker covers a lot of sin), could have turned out differently and I have been in circumstances where as captain when being pushed by all and sundry, a line was drawn in the sand over which I, my crew and airplane would not be crossing without a change in fuel/MEL/destination etc etc etc...it is "the way" and happens thousands of times every day without comment or visible, spectacular result. Thanks for your response - I know we, pilots through to non-airline contributors are all aiming at one seemingly elusive goal within a system which must always, in the end, pay for itself to survive.

Litebulbs

9th Nov 2008, 18:15

el,

If more actions other than dispatching IAW the MEL are required, then the MEL should have stated that. You are not fault finding using the MEL, you are dispatching the aircraft with an inop system. That is what it is there for.

el #

9th Nov 2008, 18:57

Litebus, the MEL as the name suggest, is a List only. It doesn't contain the diagnostic procedures, that are specified in other manuals and are part of an Engineer's experience and trade. To restate in other words, the MEL is not a bible to which adhere when mantaining an A/C. and mere observance of it does not gurantee that one have done a good job.

At the end of the day, they dispatched A/C with all the systems depending on R2-5 in ground mode, inoperable.
When I troubleshoot electrical in my car (it's a bit old so sometime it needs that), I use a schematic and try to understand all the reasons and ramifications. I know it's a oversimplifying comparison, but when they did started work on the the A/C, either did not used a schematic, or failed to interpret it properly.

I'm convinced that you can ask any certified engineer on the MD-80, and he will tell you that the expected professional standard would have been either diagnose the real fault, or not release the plane for flight. Remember, an alternate machine was avaialble and it had been considered already.

Litebulbs

9th Nov 2008, 19:17

The MEL is not just a list. They can contain reference to maintenance and operational procedures to be carried out when dispatching an aircraft with an inop system.

el #

9th Nov 2008, 19:20

To support what you say, can you show us an example for the MD-80, Litebus. My point is that it doesn't contain diagnostic procedures while it can perfectly list maintenance and operational procedures that are immaterial to the consequences of a misdiagnosis.

If I had access to MD-80 diagnostic flowcharts, I would post the section related o symptom "RAT heater ON while on ground". My reasonable expectation is that it would instruct be to test R2-5 at some point.

I rest my case that proper work an A/C cannot be completed using the MEL only, under both legal and practical aspects.

Rightbase

9th Nov 2008, 20:29

A bold generalisation - if there were no accidents - ever - then safety provisions would lose credibility. It is the recurrence of accidents that maintains safety awareness. To keep the recurrence rate low, we need long memories.

We can artificially enhance safety awareness by adding 'near misses' to the accident pool. With credible extrapolation they can be as effective as accidents, but much less painful.

We can increase the value of each accident to safety awareness by publishing it widely discuss it at length and looking at what caused it. We get even more safety awareness by looking at what else might have caused the accident. In this way a safety hazard that might have but didn't cause the accident can surface without the need for it to cause an accident. So speculation magnifies the value of each accident to the safety awareness objective.

We get best value out of near misses and the speculation accidents that didn't happen. The killer accidents such as the one that prompted this thread are the expensive ones.

I suspect that the incidence of TOWS episodes has dropped recently, and awareness of the killer items is high at the moment. Paradoxically, over time, awareness will drop, TOWS episodes will begin to save the day again, and at some time in the future, another accident will remind us of these or other killer items.

Every time the TOWS goes off, it means that if a tiny transistor, a small sounder, one of a dozen connections, or a relay had failed to work, hundreds of lives could have been lost. It is a warning to the crew that (probably) a human procedure AND a human check have both failed, and only the last line of defence saved the day. It is a warning that for some reason the human systems are under performing, and that today is one of those days - a day to be extra careful...

The TOWS saves lives. Its contribution to safety awareness depends on whether the crew's response to it is simply to put the configuration right, or to register the TOWS event as a near miss, and add it to the safety awareness pool. Registering it mentally adds it to your own awareness pool. Registering it publically adds it to everybodys.

The TOWS saves lives. If pulling a breaker disables this or any other major warning system, it must be a major factor for the crew who would heed that warning. It cannot be difficult to produce and present to the crew a list of warnings any breaker disables. Knowing that they have no last line of defence against a killer mistake could make a useful difference, especially when today is one of those days...

lomapaseo

9th Nov 2008, 20:56

However the TOWS originally should have been checked prior to each flight. But of course due to that balance between safety and commercial viability it was soon to interpreted to mean prior to the first flight of the day.

safety and commercial viability balances are nice sounding words after the accident in suggesting blame to some mysterious financial organization group but worthless in communicating strategies for preventing accidents .

I see some productive pointers in today's discussions but past tense commercial viability is not one of them.

forget

9th Nov 2008, 21:05

Safety Concerns (?) Here we go again. Lets get the facts right

NO CB WAS PULLED WHICH AFFECTED THE TOWS

Please point out where this has ever been said :confused:

PS. Most people here can read small print.

Litebulbs

9th Nov 2008, 21:23

el,

You are not using the MEL to work the aircraft. You are deferring a problem in accordance with the MEL. If you are pulling a C.B. for the RAT heater, you are carrying out a maintenance action to deactivate a system. The reason you are deferring fixing an item can be for many reasons and the most common are time and spares availability.

As has been discussed before, the aircraft appears not to have been in the air mode on the ground, but has had a relay with contacts in the incorrect sense . Relays fail in many ways, so the TOWS may have been working, but just the RAT probe heater contacts of R2-5 failed. This appears to be a reoccurring problem, so maybe it should have been found on previous TOWS tests, but it was not.

NigelOnDraft

9th Nov 2008, 21:32

Please point out where this has ever been said AFAIK only 1 CB got pulled - the one for the RAT Heater, and the RAT Heater alone... so I for one believe it has been said repeatedly.

The query seems to me whether the reason the RAT Heater was heating was examined i.e. investigate the cause of the problem, or whether just the symptom was addressed i.e. not work out why the RAT Heater was incorrectly heating, just stop it doing so.

Whilst I am sure some Spanish judge will state the Engineer should have "thought more deeply", and the 20:20 hindsight pPrune judges as well, my personal opinion is that "curing the symptom" is what 90% of engineers would have done, especially given the time pressure. That is how MELs are used today - you might not like, and I don't :{

The immediate solution is to amend the MEL for the RAT Heater (and other systems) to prevent pulling those CBs without specific other fault finding.

But longer term, I think MEL philosophy needs to be addressed. These are supposed to concern "faulty / defective" items i.e. not working. Items working correctly but at the wrong time, or intermittently, can cause additional problems, or mask the real problem, and the MEL IMHO should not be the first port of call :ugh:

NoD

Litebulbs

9th Nov 2008, 21:36

NoD,

Exactly! :) :)

NigelOnDraft

9th Nov 2008, 21:41

Would this accident have occured with a fully functioning TOWS but RAT heater CB pulled?

The answer is NO it wouldn't.Disagree :ooh: Posts above show occasions where TOWS have been ignored.

2 systems seem to have "failed". One was deployment of Flaps. One was TOWS. One is critical, one is supplementary...

If the Flaps don't get deployed, we have a major system / SOP failure. TOWS is a supplementary system designed to "trap" the first failure, and usually would do. However, we cannot rely on it doing so, nor blame the TOWS for the accident. Even if the TOWS had been tested, it might have had a failure mode that allowed it to say it passed, and/or failed later on.

The recommendations of the inquiry, need IMHO, to 90%+ concentrate on stopping an aircraft getting to a takeoff roll without Flaps deployed. If an aircraft starts rolling, then aborts due no Flaps + TOWS - that is not the safety system working "correctly". It just a **** lucky near accident :=

NoD

forget

9th Nov 2008, 21:44

Here we go again. Lets get the facts right. NO CB WAS PULLED WHICH AFFECTED THE TOWS

Please point out where this has ever been said that a CB was pulled which affected the TOWS.

AFAIK only 1 CB got pulled - the one for the RAT Heater, and the RAT Heater alone... so I for one believe it has been said repeatedly.

The two statements do not tally. Pulling the RAT Heater CB did not, does not, and cannot, affect the TOWS in any way.

justme69

9th Nov 2008, 23:28

Just for clarification, there have been several accidents of this type where slightly different reasons have led to similar consecuences.

-There have been cases where a perfectly serviceable TOWS was disconnected by a "human" pulling a c/b (MAP case in Lanzarote).

-There have been cases where a (electrically) "working" TOWS has not been activated due to a bad switch in the thrust handles (727's like in Delta Dallas accident or 737 in DCA incident). In those cases, a theoretical "lighted indicator" that would've signaled the TOWS was powered on the ground would've given the false sense of security that the TOWS was working, when it actually wasn't for practical purposes.

Even worse, in Dallas case, the switch was determined to work "some times", perhaps once every 2 or 3 actuations, so checking the TOWS would've only LIKELY, but not for sure, have detected the malfunction. Neither an "operating" lighted TOWS indicator nor a test are 100% effective measures to know the TOWS won't fail when it's needed. The most effective measure given current designs is the test shortly before each takeoff, though, as it would most likely catch an inop TOWS on time. The pilots are not going to be staring at a lighted TOWS indicator to see if it's on while they take off. And having it "on" doesn't mean the TOWS will work if the switch in the handle is broken or if the loudspeaker is blown, i.e. Only chance of catching it is to test it and pray it doesn't fail from that time until the time it's needed.

(Incidently, in Dallas Delta accident, i.e., the crew answered the checklist FLAPS/SLATS as the correct "15/15/Green light" while the FDR and the CVR showed no indications that they ever moved the handle nor did they really had appropiate time to have done it as they moved to the next item in a like less than a second. So paying "lip service" to checklists is a long known fact.)

-There have been cases where the TOWS failed for undetermined reasons (Northwest in Detroit).

-There have been cases where (probably) the TOWS failed due to part of the ground/air logic circuit failure (Spanair).

-There have been cases where the TOWS worked just fine but the crew failed to take appropiate action (LAPA).

-There have been cases of accidents with victims where it wasn't clearly reported why or if the TOWS failed (Lufthansa in Nairobi or India Air in Hyderabad).

But the short story is: quite a few airplanes have tried to take off with incorrect configurations, when procedures, training and aircraft indicators (flaps/slats panel indicators) should've made it clear that this wasn't a good idea. Most of them have been "saved" by the TOWS. Of the rest, most have crashed and some have saved the day one way or another (quick command of flaps, reducing angle of attack and flying ground effect, aerodynamics conditions allowing for clean takeoff with little performance penalties, etc).

But we come back to quite common even nowadays scenarios of landings with gear retracted (forgotten, usually on small private planes, but even recently in small and even some large airliners), spoilers in the wrong setting, or similar events. They range from simple oversights to configuration alarms being turned off by the crew while dealing with another malfunction that made them distracted.

A 100% reliable TOWS is not "impossible", but it's probably not "worth the time and effort". Such a design and expense is probably better use on other, more vital systems. But a much better design is certainly possible, one that is close to 100% effective and today's technology should make it more than cheap enough to be considered. So why not?

But the main reason for these accidents, crew failure to perform vital actions for which they were trained and under not overly-stressful circunstances (well rested, before a takeoff, plenty of time to double check on 20 minutes long taxiing... some of you would simplify it as "pilots simply screwed up"), will not really be solved, only "masked" by the more effective TOWS.

lomapaseo

10th Nov 2008, 00:14

It was determined by the regulators that the system should be checked prior to each flight. However that gets in the way of making a profit so some operators drop it down to first flight of the day only.

Are you sure that there are facts supporting this hypothesis?

Do you have anything other than supposition to support this?

grumpyoldgeek

10th Nov 2008, 01:02

It's time to wake up. Commercialism and its supporters will kill this industry.

I thought they (and a healthy dose of government subsidy) built the industry.

bubbers44

10th Nov 2008, 01:11

The TOWS check takes 10 seconds. Usually during push back. It would not slow down operations at all. Yes, the TOWS would not be required if pilots did their checklsts properly. I always thought if I really did the checklist nothing should be a problem. Just responding to the checklist is another matter that is easy to fall in to. We get bored and keep repeating the same checklists and sometimes just say the words. That is where the problem lies. Saying the response then looking at the actual position. Usually you realise the mistake but the checklist reader may assume what you said was true if he did not verify. Humans are prone to get complacent when doing the same thing over and over.

el #

10th Nov 2008, 07:04

2 systems seem to have "failed". One was deployment of Flaps. One was TOWS. One is critical, one is supplementary...

Sorry NOD, but if you use words as above, that is the same ambiguity present in the preliminary report and various press pieces.

1) The flap system has NOT FAILED. evidence so far suggests that pilots have NOT set flaps.

2) The TOWS system HAS FAILED. Due to R2-5 malfunction,

3) Maintenance has FAILED to detect and address (2).

Regarding the comment about 90% of engineers would have done (3) same as in Madrid. I have a problem in believing so, but if it's true that makes me happy that I'm not a Pilot and I don't fly that often after all.

All the rest I agree with you.

NigelOnDraft

10th Nov 2008, 08:17

el #

1) The flap system has NOT FAILED. evidence so far suggests that pilots have NOT set flaps.Agreed, but I did clarify it with:
If the Flaps don't get deployed, we have a major system / SOP failure.

Re the Engineers, I am afraid that is my observation, with quite a few years of Airline Ops, a good number as Capt - and increasingly so. Defect in book (e.g. an ECAM Message), ECAM Message in MEL cross refers to MEL procedure, MEL actioned PDQ, or if "No Maint Actions required" then Flt Crew expected to accept it under ACF.

It is the MEL sections, under the above scenario, that are supposed to "trap" insidious deeper problems...

I am not saying that the Spanish / Spanair / MD-80 philosophy is the same since I work under a different authority / airline / type(s). But I am saying that from my experience, the apparent chain of events as far as the RAT Heater / Engineering actions went, is much as I would expect, and certainly not enough as far as those individuals were concerned to have been e.g. negligent enough to carry any responsibility in law.

NoD

FlyGooseFly!

10th Nov 2008, 10:57

Blubbers44 posted :-
Just responding to the checklist is another matter that is easy to fall in to. We get bored and keep repeating the same checklists and sometimes just say the words. That is where the problem lies. Saying the response then looking at the actual position. Usually you realise the mistake but the checklist reader may assume what you said was true if he did not verify. Humans are prone to get complacent when doing the same thing over and over.

Once upon a time I thought I had engaged and involved four other people in a calculation - fortunately one with a non-fatal outcome - when it turned out to be incorrect I remonstrated at length only to be told - "Oh, we heard what you said but we didn't bother to actually work it out because we thought YOU knew what you were doing!"

GXER

10th Nov 2008, 11:03

forget said:

When the MD-80 RAT Heat MEL was written up it allowed flight with no forecast icing conditions. Simple, and no problem so far. Pull the RAT Heater circuit breaker and off you go. Crucially, what wasn’t considered by the MEL writers was why the RAT might Heat on Ground. A failure of Relay R2-5 (Flight Mode) would do it – which would also disable the TOWS. So, pull the RAT Heat circuit breaker, RAT Heat problem fixed, TOWS is now inop with NO indication of failure. And I defy any line engineer, no matter how smart, to raise his hand and say “Hold on guys, RAT Heat on, I bet R2-5s failed and we can’t just pull the RAT breaker because the TOWS might also be inop”. That’s down to the MEL actions and, from what I’ve seen in this case, they ain’t up to the job.

This accident has been waiting to happen from the day the aircraft left Long Beach. Very poor TOWS/Flight/Ground logic design, and very poorly written MEL.

Purely from logic perspective - the conclusions (a) that MEL writers did not consider why RAT might heat on ground and (b) that the MEL was poorly written is not justified by your argument you present, unless the MEL actually contemplates the scenario of the RAT heat operating when air/ground logic dictates that it should NOT be operating. If the MEL merely states that flight is permitted with RAT heat inoperative (for whatever reason) in certain circumstances (no icing forecast), then the MEL did the job it was designed to do. Of course it is possible to argue that it should do more - but that's another issue.

sevenstrokeroll

10th Nov 2008, 13:18

communication on the internet forum is imprecise...

yikes

we are pilots talking to pilots...sometimes we are cryptic, it is our way.

we use one word that covers many in radio work.

we chat on this forum as if we were in the ''ready room'' talking things over with our fellows.

I don't always agree with Nigel, but I wouldn't point at his posts as imprecise.

when we don't understand, we should ask questions...say again

Someone indicated that when the airlines were regulated we had more plane crashes...true. But we have more safety gadgets now, more experience and we shouldn't be repeating accidents from 20 years ago.

30 years ago the US airline industry was deregulated. IF it had remained regulated, adding new safety gadgets to the cost of a ticket, things might even have been safer.

cryptically yours

sevenstrokeroll

sevenstrokeroll

10th Nov 2008, 13:33

imagine if another plane had been right behind the doomed flight? imagine if one of the pilots behind the doomed plane noticed that the flaps/slats were not extended.

imagine if that pilot didn't radio a warning prior to taking the runway?

imagine if that pilot DID radio a warning?

WE are our brother's keeper. Keep your eyes open for the problems of others...and after you check their plane out for problems...CHECK YOUR OWN PLANE ONE MORE TIME. (or like count basie, ''april in paris'' one more once)

TyroPicard

10th Nov 2008, 13:33

MEL precision...
You may fly with RAT probe heat INOP.
The RAT heat is on on the ground, when it should be off.
The fault is not in the RAT heat, it is in the system that auto-controls it, so a different MEL item may apply. But the RAT heat is not INOP.
Simple, innit.

Joetom

10th Nov 2008, 14:55

Defect. "One nav light inop on left wing tip"

Action. "Crew will not accept MEL, so new bulb fitted, still inop"

Aircraft N/stopped and crew and passengers to hotels.

Working party on route to troubleshoot and fix inop nav light.

This appears to be the way some see things going.

One point has crossed my mind, this MEL item may of been used many many times in the past for the same said pilot reported defect, when defect was fixed by changing a relay, did no alarm bells get sounded !

BOAC

10th Nov 2008, 15:48

It is indeed a sobering thought, NoD, that if the crew HAD tested the TOWS as per the apparent manufacturer's rec., before the return to stand, things could well have been different.

lomapaseo

10th Nov 2008, 16:50

It is indeed a sobering thought, ..., that if the crew HAD tested the TOWS as per the apparent manufacturer's rec., before the return to stand, things could well have been different.

It's going to be interesting in the timing of this kind of test. Just how often and when?

Should it be in the takeoff checklist right before the crew call out green green for the flaps/slats. If not is there a chance that someday a crew does the check on taxi out then aborts the takeoff for any reason goes back to the stand and some maintainence function mistakenly disables the TOWS.

It's not easy to pick out the best solution without data and analysis of the Pro and Cons

sevenstrokeroll

10th Nov 2008, 19:18

whenever mx does work in the cockpit, we have to do an ''originating' checklist...meaning first flight of the day.

whenever I got into the cockpit, I checked that the engines were not running and then I moved the throttles, got the warning and pulled them back.

it takes less time than it takes to type.

atceng

10th Nov 2008, 19:22

The information came from a block diag and from post #2003, mermoz92,although they refer to the possibility that breakers feeding the RAT heater breaker may have been switched of as per maint man to ensure isolation.If these were not reset other functions would be unpowered including tows.
I must try to read your Graph thoroughly after assembling the tiles,to see if it is possible to establish if RL2-5 was faulty or if alternatively there is any evidence that the sensor logic feeding the relay was erroneously causing it to be de-energized.
Apologies to the winged fraternity for boring technicalities.:bored:

justme69

10th Nov 2008, 20:00

For that and other reasons I do not believe at all it was for "commercial reasons" that some airlines (not only Spanair) "stuck" to the original McDonell recommendation of checking TOWS in the first flight of the day and then whenever pilots entered a "new" cockpit or where absent from an "old" one for a long time.

They know TOWS don't fail that often nor are they too hard or expensive to fix (relatively quite a simple system).

They know it SAVES them money. They know it only takes 2 seconds to test them.

But somewhere, the person translating/writing the SOPs for Spanair (and other airliners) never heard of Boeing LATER recommendations to change that to "check the TOWS before each and every takeoff-period".

Nor did the FAA or EASA or any other regulatory body in the world make such a recommendation mandatory.

I'm pretty sure should there have been better communication between Boeing and Spanair (or the other operators which SOPs still didn't include the updated procedure), I'm pretty sure it would've been adopted.

In fact, Spanair adopted it a few days after the accident, before any recommendations or directives were out.

I do not know what communication channel failed there. I don't know if it is each individual airline job to constantly bombard Boeing with:
-"Have you changed anything from our SOP"?
-"Have you changed anything from our SOP"?
-"Have you changed anything from our SOP"?

Or if it is Boeing's job to query each operator flying their airplanes:
-"Have you included recommendation update YYY-XXX?"
-"Have you included recommendation update XXX-YYZ?"
-"Have you included recommendation update AAA-BBB?"

Or if all Boeing has to do is fax EASA/FAA/each country's authority and say:
"Remember procedure XXX-XXX? Well, it was wrong. We found a better one. Please tell everybody to use YYY-ZZZZ instead. This is the only communication we will send out."

And then pass the ball to each country regulatory body to oversee the update and compliance.

Spanair claims they were never told about the update in procedure and therefore never included it. Their SOPs were the ones they thought were recommended by the manufacturer and approved by Spanish and European regulatory agencies and of course would've passed FAA ones too. Other airliners flying at the time in Europe used the same standard procedure.

So who do we "blame"? Obviously all of them have some "fault" in the subject, but who is the main culprit? The way it is now, it seems they all thought they were doing the right thing. Except, maybe, Aviación Civil or perhaps FAA/EASA?

justme69

10th Nov 2008, 20:53

Oh, no, I understand the recommendation.

I also know the first one was made AFTER the accident in Detroit, and it was not the original, approved procedure.

I also know that many operators claim they NEVER WERE NOTIFIED of the recommendation. Plenty of them flying around up until very recently. As you very well say, for over 20 years since it was made.

I know Boeing CLAIMS they notified it to all operators that AT THAT TIME were using MD-80's. I also know that Spanair (and others) didn't exist at that time and started their operations AFTER the recommendation was sent out.

I'm also curious if Boeing recommended individual types, or better yet, ALL their planes, not only those with a generic "similar TOWS design" referring to the MD-80 series (other types have suffered similar accidents/incidents).

I wanted to know how it was possible that Spanair "inherited" an approved SOP that didn't include it and, apparently, nobody told them.

And why this recommendation wasn't "approved" and mandated by the FAA or ANY similar international bodies at all.

Until a week ago.

Oldlae

10th Nov 2008, 22:17

Please bear with me, I do know anything about the aircraft and it's systems, what I do know has been gleaned from this thread. It is not clear how the engineers disabled the RAT heater, from the diagrams posted earlier if it was disabled from the ccb this should have have not affected the other services from the relay R2-5. Much has been made of the aircraft being "in flying mode" causing the heater to be on, surely if the sensors thought that the aircraft was flying the TOWS was redundant as it was already "in the air".
If the procedure to check the TOWS before each TO was considered to be essential this should have been in the Flight Manual, if not, it cannot be considered to be mandatory.
Having been involved in the compilation of MEL's, they are considered to be a guide to acceptable deferred defects (ADD's) where for instance if an engine oil pressure guage is u/s:- as long as there is an alternative indication of low oil pressure, such as a low pressure warning light, it is acceptable to fly until a replacement guage can be installed, the reasons for the fatal flight appeared to be acceptable as icing was not to be expected during the flight.

el #

10th Nov 2008, 23:52

Oldlae, it has been said many times already: R2-5 failed stuck in air position causing rat heater to go on, and disabling TOWS.

Maintenance did not diagnose that, only remedy was to cut heater via CCB as MEL allows.

Litebulbs

11th Nov 2008, 00:09

el,

Without wanting to sound like a stuck record, the aircraft was dispatched in accordance with the MEL. If you are dispatching an aircraft in accordance with the MEL, you are not carrying out any troubleshooting. You are deferring that action to a time that is more reasonably practicable. If the MEL says go, then go. If there is any ambiguity, then write a better MEL.

But on the counter to that, this appears to be an intermittent defect. If it s an intermittent defect, then the TOWS would have failed numerous times as well. Why was this not spotted by the various flight crews before when carrying out a TOWS check?

bubbers44

11th Nov 2008, 00:37

Intermitent means it comes and goes. They had several intermitent failures in the days prior to the accident involving the rat overtemp. Since the R2-5 relay controlled both rat heater and TOWS the TOWS would have failed too if checked at that time. It was the only relay of the eight or so that failed, controlled by the L nose gear oleo switch. The other relays on the same oleo circuit worked fine. The only way the rat heater can get power is through the R2-5 relay. Many mechanics must have missed the connection that the only way that could happen is if the relay was in de-energized air mode. The MEL they used was for an inop RAT heater. Obviously the heater was working fine but shouldn't have been powered on the ground. MEL's have to be read very carefully to make sure what you are doing is the intent of the MEL.

Litebulbs

11th Nov 2008, 00:49

The MEL should not be a crossword and should not need any careful reading. However, in practice they do and that is wrong. The conclusions from this investigation will hopefully lead to some changes, but that might be too late for the engineers being investigated and definitely for those crew and passengers who lost their lives.

el #

11th Nov 2008, 00:51

If you are dispatching an aircraft in accordance with the MEL, you are not carrying out any troubleshooting.

I'm fine with that.
My point is that when maintenance is called for any reason, cannot simply act robotically for the purpose on complying with a MEL, as the human brain is supposed to be engaged all the time - except perhaps when tragic errors are made like in this case.

Any engineer or technician knows that when a device supposed to be OFF automatically, remains ON instead , the problem CANNOT be in the device itself, instead SURELY is in the switch or logic powering such device.

If you think anyway that maintenance actions have been 100% correct (no case to respond), then consequenly these cannot even be a concurrent cause.
I just happen to think otherwise.

MUC089

11th Nov 2008, 06:43

"Any engineer or technician knows that when a device supposed to be OFF automatically, remains ON instead , the problem CANNOT be in the device itself, instead SURELY is in the switch or logic powering such device."

Yes, and after a few minutes this engineer decides to solve the problem by disabling the heater.

After more than 2 months and nearly 2500 posts it is very easy to say "the engineer should have known that the TOWS could be affected too" - but could he really?

Bis47

11th Nov 2008, 08:56

Hello,

I also know that many operators claim they NEVER WERE NOTIFIED of the recommendation. Plenty of them flying around up until very recently. As you very well say, for over 20 years since it was made.

I know Boeing CLAIMS they notified it to all operators that AT THAT TIME were using MD-80's. I also know that Spanair (and others) didn't exist at that time and started their operations AFTER the recommendation was sent out.

A fax or a telex by Boeing about about a critical operational item was an emergency action ... that required "follow-up".

And the normal way to make sure that everybody, present and future, will be provided with the correct information was to include that recommandation either in the Aircraft Flight Manual (FAA approved) or in the FOM (Boeing advisory stuff). Or to make it a service bulletin (Boeing responsibility) or an AD (FAA responsibility).

AD and AFM revision if it is considered as a modification required for the continuous airworthiness of the aircraft.

SB and FOM if it is considered just as a Boeing recommandation.

If Boeing did not proceed like that, they are at fault for not disseminating a critical information along the standard channels. Then neither the national authorithies, nor the company would be kept accountable for not taking into account a 20 years old sheet of paper that doesn't fit in the standard information package that comes with an aircraft, and that is meant to be updated as often necessary.

By the way, it was reported somewhere that Spannair had recently undergone an audit by Boeing, with honors.

So ?

el #

11th Nov 2008, 09:09

MUC089, note I never said (and I don't think neither) that "the engineer should have known that the TOWS could be affected too".

I think that just taking on the problem with an "electrical mindset" would have guaranteed focus to be about the power circuit and not the RAT heater itself, even without knowing or remembering about the relation with TOWS, it would have been enough.

Note I say that having the most respect toward Engineers category (I'm one, but in a different industry) and with the most compassion for specific individual involved.

From the preliminary report I see that he may have been present at the A/C for 15 minutes the most, perhaps less. That can not be enough time to correctly address (even just identify) "strange" or intermittent problems. I think it was also reasonable for the Cap.n to accept the actions taken without questioning on the rationale (to each own his job) and just go for second T/O.

Bis47

11th Nov 2008, 09:13

I have heard an old timer reporting to the dispatch :
"There are 42 open items in the Hold Items List (old termninology). I cannot cope with so many defects. I do not accept that aircraft."
And the aircraft was towed back to the hangar ...

There is a provision in the MEL's : final responsibility to accept flying with the defects lies in the captain judgement.

This means that the captain has to carefully analyse each reported defect, and the possible cumulative effects of multiple defects.

Yes, the captain is supposed to know the aircraft systems in depth ... and to have good judgement.

Bis47

11th Nov 2008, 09:38

Eight years ago, nearing the end of my flying career, I was finaly thaught how to study a "system" in an aircraft ...

1. Look at the main "power" part of the system : where is the power coming from, what are the normal and abnormal flowspaths of power (power could be electrical, hydraulic, pneumatic ... or even "manual")

2. Look at the controlling circuit(s) : how is the power activated, regulated, diverted, cancelled ...

3. Look at the indictors circuit(s)

4. Look at interaction with other systems ...

This is a very usefull way to simplify system diagrams! Just use 3 colors to "mark" the diagrams line and components ...

A good way do diagnose troubles ...

So quick in the Spannair RAT cause!

a) we have power ... so the power circuit is ok (there are no dedicated indicators, but we can feel the heat, use the aircraft ammeters, or a technician ammeter/voltmeter/ohmmeter standard tool).

b) So the problem must lies within the controlling circuit. What is the controlling circuit made off? That infamous relay!
Bingo!

c) How can we make sure ? See what other system are controlled by this relay ... So easy to test the TOWS ... Double Bingo!

Litebulbs

11th Nov 2008, 11:01

Bis47,

I do not believe anybody is calling into question the engineers troubleshooting skills, because in all probability no troubleshooting was carried out. You are trained to dispatch an aircraft in a safe and timely manner. If it is on the deck for a number of hours, you would start troubleshooting, If you are called to an aircraft that has returned to stand, you go to the MEL. If you cannot find a relevant section in the MEL for the defective item that you have, it means that it is either an non airworthiness item or it is a no dispatch.

It appears that the fault was diagnosed as a heater problem and action was taken just for that and the RAT heater CB was tripped. As I have said before, if any changes are made to any procedure after the investigation has finished, then the problem does not lie with the engineers. If all the procedures remain the same, then the judge will be stating that the level of knowledge and training of the engineers involved should have been enough for them to understand that the problem was that a relay was in the wrong sense, so causing the RAT heater to be on when it should be off and that the use and understanding of the MEL was incorrect.

SPA83

11th Nov 2008, 11:32

Just opening the electrical circuit breaker connecting the heating element is not a good troubleshooting. This is just a meaning to dispatch the MD as soon as possible

Litebulbs

11th Nov 2008, 11:43

Yes, that is exactly it. No troubleshooting, not bad troubleshooting. You could stop this ever happening again and take MEL's off of the aircraft.

If the Captain had not noticed the RAT heater was heating on the ground, would the aircraft still have crashed?

FlexibleResponse

11th Nov 2008, 12:02

If the Captain had not noticed the RAT heater was heating on the ground, would the aircraft still have crashed?

I think you should be very careful with that comment.

Litebulbs

11th Nov 2008, 12:21

Why?

The Captain noticed a fault with the RAT heater. The aircraft crashed. It is all the what ifs that went of in between these two events that we are speculating on.

infrequentflyer789

11th Nov 2008, 13:31

Bis47,
If you are called to an aircraft that has returned to stand, you go to the MEL. If you cannot find a relevant section in the MEL for the defective item that you have, it means that it is either an non airworthiness item or it is a no dispatch.

It appears that the fault was diagnosed as a heater problem ...

That diagnosis is what may be questionable. The heater is pretty simple, and appears to have been working (and obviously so - that was the reported problem). Therefore what was the "heater problem" ? And if the heater wasn't the "defective item"... then what was MELed ?

I wonder, did they test the heater, and did it pass ?

Should it be a reasonable expectation for engineer to realise that if a heating element heats up when it isn't supposed to, then the heater is not broken (which is what the MEL deals with), something else is broken ?

We don't need to get as far as whether we can expect the engineer (at the stand) to realise this is a air-ground sensing fault (although some might, if they've seen it before), just to get as far as realising that something other than the heater is broken.

Bis47

11th Nov 2008, 13:32

If you are called to an aircraft that has returned to stand, you go to the MEL. If you cannot find a relevant section in the MEL for the defective item that you have, it means that it is either an non airworthiness item or it is a no dispatch.

As a pilot, I don't need to return to stand to put a heater off and check the MEL ... I would do that in less than 2 minutes at the holding point.

If I need a technician, it means I need its professionnal expertise :
- documentation ;
- tools ;
- manual skills ;
- experience ;
- analysis skills ;
- ...

Because one should not put an item on the defect list iaw the MEL and go flying, without :
- properly identifying the failure (here a relay failure)
- properly isolating the system
- analysing the consequences of the failure

The MEL objective was never to dispatch an aircraft in a hurry, without even "thinking". That is the reason the captain came back to the stand in the first place : investigation!

By the way, since the problem was not new, somedy (a supervisor?) would have got the time to think about it in the previous 24 hours. Normaly the maintenance office would collect, read and analyse the maintenance reports at least on a daily basis, and as close as possible as in "real time". This is not intended to be a boring paper work job! This is supposed to support the field technician ... in the confort of an office, with all the neat documentation on hand.

I know ... we don't live in an ideal world !

sevenstrokeroll

11th Nov 2008, 13:33

the captain probably didn't notice the RAT heating...if he had checked the current draw at the gate, he wouldn't have started engines.

he probably noticed the gauge which gives the EPR setting for takeoff providing a very low power setting for takeoff

taking off with low engine power/thrust would/could cause a crash too.

after seeing the low power setting, he might have checked the RAT current...we really don't know.

awhile back I blamed the airline, I still do. DID the airline get all updates for operating the plane before the first revenue flight? Its their responsibility.

Did the airline train the pilots to understand the systems, checklist procedures, stall avoidance and recovery?

DID the boss of the airline get pay raises that would have paid for better training?

MONEY!

el #

11th Nov 2008, 15:47

Bis47, infrequentflyer789 and others, you re-exposed my point exactly.

If further discussion on that (as periodically happens) I will point to your posts!

Rob Bamber

11th Nov 2008, 16:21

McDonnell Douglas recommended all MD-80 series operators conduct a check of the TOW system before engine start prior to every flight
Why "recommended"? Why is it not in the AFM? Would it be because including it would involve Boeing admitting liability in the 1987 accident? I hope not, because if true, now they've got two.

SPA83

11th Nov 2008, 17:36

When a trouble is reported, at the main base, one airline is intended to first try to repair the aircraft, taking time to do it. Then, after troubleshooting, if the delay is too long, the airline may use the MEL.
But, due to economic pressure (“punctuality first”) people now rush to the MEL without trying to repair the trouble in order to dispatch the aircraft as soon as possible.
Everybody find that practice acceptable. Can you accept that crews rush through their check-lists?

PEI_3721

11th Nov 2008, 18:09

Rob Bamber, good point (#2483).
Normally in aviation where a recommendation is made, it could be assumed that there is supporting documentation giving the reason for the check so an operator could choose an alternative, but equally safe course of action. Does anyone know if this was the case for the pre-flight TOCW check?
Did the investigations into previous accidents recommend a check or just cite a malfunction?
Did subsequent investigations refer to the first accident and any recommendations made? – I have mislaid the links to the accident reports – previously in this thread.
If there was no such recommendation(s), does anyone know who/where/why a check was selected in preference to a system change?
This is normally a certification activity (FAA), but implemented by the manufacturer. Unless there is regulatory support a mandate (AFM change), it may only be possible for the manufacturer to issue a recommendation.

Litebulbs

11th Nov 2008, 18:22

The most ambiguous statement in an MEL in my mind is "Reasonably Practicable". Define reasonable. My initial understanding of this is if you have a spare available to do this and the manpower available, then you fix the problem. However, there is an argument that has been used that time comes into this equation. If you have enough time, then fix it, if not, then dispatch IAW the MEL.

Bis47

12th Nov 2008, 07:41

awhile back I blamed the airline, I still do. DID the airline get all updates for operating the plane before the first revenue flight? Its their responsibility.

And what about the authority (which is supposed to be immune of "commercialism")?

The authority should make sure, before giving/maintaining the AOC that
- the airlines would operate iaw with current updated information ...
- that all the AD's concerning the aircraft and its equipment are complied with, that all the SB are analysed, and cw unless "optional" (or obviously marketing driven)
- and that other requirements (by the dozen) are met ...

And "making sure" doesn't mean "thrusting" an old chap ... it means checking, really checking!

I understand quite well the judge position, not to thrust the CIAAC ...

justme69

12th Nov 2008, 19:01

Well, the maintenance technicians declared today for several hours in front of the judge.

Doesn't look very good.

It seems that Boeing's repair manual that Spanair gave the judge detailed the RAT heater and related issues. That would be the manual used for training.

The technicians declared that they didn't consult the manual, only the MEL. They also declared that they didn't perform a TOWS test, as that would've been the pilot's job. They also re-assured that the c/b they disconnected only affected the RAT heater and nothing else.

I have the feeling the judge thinks that wasn't enough and their jobs required a bit more foresight.

They continue being indicted.

The judge has called another set of technicians in Barcelona who previously dealt with reported RAT heater issues the day before.

He has also requested declarations from the technicians dealing with the pilot's report of autoslat warning light several days before (this last thing, not related to the accident in all likehood, but the judge has to follow every concievable lead, I guess, as well as try to stablish if there could've been any relation or not. Any technician can tell him that it is not technically possible that any sort of autoslat failure could have prevented the slats to be mid-seal deployed with a just the "green" takeoff light and the flaps retracted while the analog watch indicator measuring 11º for both wings).

airsnoop

13th Nov 2008, 07:56

Surely, he didn't think that the mechanic who pulled the CB on the day should have known?

justme69

13th Nov 2008, 09:59

Well, it looks like the only interesting previously unknown information from the declaration is that a technician mentioned that the pilot told him that, before calling them in for maintenance assistant, the pilot tried to "fix the RAT heater problem" by pulling an c/b himself, but that didn't work. We don't know which circuit breaker or if he reset it, but probably so and probably not of consecuence for the accident.

Nothing overly important, but it goes to show that if the pilots would've figured out the "correct" c/b to pull to turn the heater off, maybe they wouldn't even have returned to gate and called maintenance at all.

Who, BTW, weren't of much help trying to avoid the accident either.

The repair manual details the tests to perform and systems that could be affected. This was followed by the technicians in Barcelona the night before. But it seems the problem didn't manifest during the night test.

The MEL, of course, pretty much only states that the airplane can fly with an inop RAT probe heater if the conditions don't have any risk of ice formation.

Maintenance standard procedure when the airplane is "in service": look the MEL, figure if the airplane can fly with the defect. It's not "written in a book", I don't think, but it's the "understood" procedure to follow.

I personally think that's not the "right" way. To me, this job would imply to spend 5 minutes trying to troubleshoot it and, once it's clear it needs more time but the defect is "isolated" and quite understood, then you can look up the MEL to make sure the airplane can fly with the problem until there is time for a proper repair. You could still have missed something important, but at least you gave it a shot.

But to give a problem ZERO thought, not to even bother to look it up in the manual to give it a quick glance and spend 3 or 4 minutes with it, but to blindly go straight to MEL while "liberally" interpreting it ... well, it had to happen some day.

We all understand the "pressure" of commericalism, but I'm sure nobody minds any 5 min delays that are there for true safety reasons. Spending 5 minutes of brain power to figure out possible ramifications of a quite clear problem is better than taking the risk of spending 15 years in prison, like it may well happen to those two poor guys.

I don't think the third person indicted, the chief of technical maintenance for Spanair, will be finally prosecuted at the end (or at least, sentenced), as his participation was pretty much nil and each repair action that is not consulted is the sole responsability of the licensed technician involve.

Both technicians directly involved in the action consulted with each other and they both understood what was being done and they both agreed their actions were the correct ones. This was also explained to the pilot who agreed as well that the airplane could fly.

Accusation lawyers are bitching about how the same problem had two different responses from the Barcelona and the Madrid technicians. The answer: the first ones were trying to fix it and followed the manual. The seconds were just trying to avoid it and didn't even look at the manual.

airsnoop

13th Nov 2008, 10:14

Still, it makes a mockery of the Flight Safety Foundation "Joint Resolution regarding the Criminalisation of Aviation Accidents" doesn't it. Judicial authorities should be discouraged from taking such action before the proper national authority has had time to do an investigation under ICAO Annex 13.
I only wish someone in FSF, ISASI, ICAO or similar organisations would stand up and be counted but :ugh: dream on.

sevenstrokeroll

13th Nov 2008, 10:37

there is always the possibility that the wiring of the plane was somehow incorrect, connecting one system to the wrong circuit breaker

I doubt this, but have to throw it out there.

again, the plane seems to have crashed because the slats/flaps were not set properly for takeoff.

not because the warning system didn't work, though that might have saved them.

there are few things a pilot has to do before takeoff..and flaps is right up there with the most important of things.

airsnoop

13th Nov 2008, 10:38

The problem is that courts are invariably not into the reality, and it is much easier to prosecute the mechanic who burred the nut because he used the wrong spanner than the manager who put him on the night shift and didn't make sure he had the right spanner and knew how to use it. If you see what I mean?
Maybe, after 48 years in the business I should retire before I burr the nut.

justme69

13th Nov 2008, 10:42

Just another note: the main technician in charge had 11 years of experience in Viva Air (owned by Iberia and Lufthansa) and another 9.5 years in Spanair (lately owned by SAS). I don't know the experience of his assistant in this case.

Both, of course, fully licensed for the type.

One of them was carrying test actions from the outside and the other one inside the cockpit. The one outside also briefly came in to label heater/cb as MEL'ed. They both communicated (by radio, I'm assuming) and decided on how to tackle the problem and agreed that it had been properly "fixed".

The pilot was aware of their actions.

lomapaseo

13th Nov 2008, 13:33

agusaleale

13th Nov 2008, 14:25

justme I do not appreciate your approach. It shows signs of being journalistic. Bark up another tree

I don't see a problem. he cites rumors and news as sources and expresses an opinion. He doesn't appear to create news. If he's journalistic he at least understands aviation

I agree, but I think his own source is what is being told in the trial. If so, you have to strongly believe in his words, under the legal point of view in Spain.

airsnoop, bang on. However if we all took a step back and looked at the industry you would soon realise that all too often money is paramount, not safety.

But, hey lets persecute the weakest link and pretend everything is still rosy
I agree with you, when things happen this way, the only reason for that is that it is not an isolated problem, I think It happened all time, not only with the RAT but with many other things.
When you arrive to such a situation, you don´t stop and try to find out the causes, you only try to repair the effects to go ahead to the next one.
If you have enough time you try to find the origins, but when all time this kind of things happen, and they are not appropiately arranged, then finish this way. Is like trying to fix everything with wires.

DingerX

14th Nov 2008, 14:55

Sure, in an ideal world, the technicians would have analyzed the issue, and figured out exactly the problem instead of fixing it to the MEL.

But if you want to make a system truly safe, you reduce the amount of analysis at each step of the way in favor of SOPs. Every time you require someone to think about a safety-critical element, you incur a significant risk that that person will come to the wrong conclusion. That's why the MEL are checklists are there in the first place.

Look, there's no need for any of this to have a reason, beyond the fact that whenever people are in a hurry, they make mistakes (and hence the proper response to pressure to speed things up is to slow everything down). But if you have to find some sort of technical or procedural reason to crusade vainly for, why not pick on something basic? If every major system on board is affected by whether the aircraft thinks it's on the ground or in flight, shouldn't that state be indicated somewhere obvious and not need to be inferred through looking out the window at the strobes or listening for the faint sounds of fans? I understand some flight crew have even gone so far as to diagnose certain warning horns as a result of the aircraft thinking it was on the ground.

See, now that's a dumb idea too, but not as dumb as prosecuting mechanics.

bizdev

14th Nov 2008, 16:42

MD11Engineer

14th Nov 2008, 17:33

I know of instances where an engineer has been disciplined for causing a delay to an aircraft - because he tried to fix a reported defect - when the aircraft could have dispatched on time IAW the MEL!

bizdev

Smack on!

Usually the part of fixing a snag which takes most time is the troubleshooting process.
E.g. in this case troubleshooting could have taken easily several hours, while actually replacing the relay would be a matter of minutes.

And, on the other hand, the troubleshooting process reveals that there is no serious fault in the background and that it was all about an easily deferred problem, the engineer will be disciplined for unnecessarily grounding the aircraft.

bonatti

14th Nov 2008, 20:53

Whilst i find it difficult to attribute some of the blame on the engineers involved that day, ( the biggest mistake, but not the only, was the pilots failure to follow their checklist) there is one thing i feel uneasy about.

The MEL stated the RAT heater,IF INOPERATIVE, may be isolated and deferred. The RAT heater WAS NOT inoperative , and, as an engineer that would have had me asking questions !

The MEL is a straigt forward document that , unfortunately , is open to abuse should you choose to mis-interperate it.
It is down to the engineers and crews personnel integrity not to abuse the MEL, regardless of commercial pressure. Management and operations can be easily baffled by some technical garb to buy you some time to go and look at the schematics. A further 15 minutes delay isnt going to change anyones day.

SPA83

16th Nov 2008, 05:41

The « punctuality first » logic :

- “Hi ground engineer! I have the engine n°2 fire warning light illuminated!”
- “No problem captain, I’m going to remove the lightbulb!”
- “Thank you very much”

Joetom

16th Nov 2008, 06:44

MEL examples.

Nbr 2 tank fwd boost pump will not switch off ?

Capt wiper will not switch off ?

Left taxi lamp will not switch off ?

F/O seat moves on elects with no request ?

Storm light will not switch off ?

Nbr 1 Rev stuck in deploy ?

Nbr 3 eng oil ind shows full(flt deck), but oil level is half full on glass ?

Nbr 2 pack on when switched off ?

TAT probe inop ?

These are normal defects that the MEL allows for.

A question I have asked before but still no answer on here, I would suspect that the MEL item in question has been used before and again would of expected TOWS to be found INOP before MEL item was fixed, and so would of expected some form of feedback that may have changed the conditions for this item inside the MEL ?

Or may be, this was the first time this event was found ?

Can anybody answer my question ? Tks in adv.

NigelOnDraft

16th Nov 2008, 07:38

A question I have asked before but still no answer on here, I would suspect that the MEL item in question has been used before and again would of expected TOWS to be found INOP before MEL item was fixed, and so would of expected some form of feedback that may have changed the conditions for this item inside the MEL ? :ugh: It would seem the use of the MEL/CB had nothing to do with the non-functioning of the TOWS. If the theories quoted here are correct, then pulling the RAT Heater CB leaves the TOWS functioning. The question is whether the RAT Heater "on" at an inappropriate time should have led to futher trouble shooting, and not quick use of the MEL, as per:

The MEL stated the RAT heater,IF INOPERATIVE, may be isolated and deferred. The RAT heater WAS NOT inoperative , and, as an engineer that would have had me asking questions ! Now bonatti says he would have been asking further questions. Good on him, and his company, if that is encouraged / permitted etc.

Regrettably, I would say most companies in practice would have done what was done in the Spanair accident. Can we make the MEL fit? If so, then do it... It does not matter if the "component" is stuck On, Off, Intermittant etc. Often (would not be appropriate here) no CB is pulled - you are just left with an intermittant system and repeated failure messages. On other occasions the CB is pulled - and whether or not the system was strictly "inoperative" before, it is now, and so the MEL can be used.

I'm not saying I like it - just that is in practice what happens :ooh:

NoD

Joetom

16th Nov 2008, 15:05

Before this accident.

Has a RAT ever been made inop as per the MEL, then found the TOWS also inop because relay R2-5 was problem, then found R2-5 relay change also fixed the RAT ? (or never understood until this accident)

My thinking is if the above has previous, did any form of feedback not change the conditions on the MEL for the RAT item ?

bubbers44

16th Nov 2008, 15:43

Since R2-5 is energized any time the ac is on the ground with electrical power they must have a regular failure rate over 10 or 20 years of operation so this must have happened dozens or 100's of times prior to this time.

Phalconphixer

17th Nov 2008, 00:39

Re-Killer Checks;

I was directed to this video by someone on another quite unrelated forum and it would appear that despite comments made elsewhere in this thread about a flap / slat check being a required item on three of the departure check lists it is not necessarily complied with.
Here is one example…At least the very last minute Killer check worked or maybe it was advancing the throttles to get him around the corner onto the runway kicked off the TOWS?
Aviation Video: McDonnell Douglas MD-83 - Spanair (http://www.flightlevel350.com/Aircraft_McDonnell_Douglas_MD-83-Airline_Spanair_Aviation_Video-10619.html)

One thing I cannot get my head around however; reading the report of the MD-82 Detroit accident. As I understand it V1, Vr and V2 are calculated for a given set of conditions associated with weight, temperature, and wing condition ie recommended flaps and slats settings. In the case of the Detroit accident a clean wing would have given a stall speed of 170KIAS and I assume that the Spanair aircraft would have had a roughly similar calculated stall speed given the same loading.

According to the NTSB Accident Report, extending the slats to their normal take off setting would have reduced the stall speed to around 130KIAS and the flap extension would have reduced it to around 122KIAS. Now assuming VR=1.25xVs we get 152kts.

The Spanair aircraft rotated at 154KIAS ie., the nose wheel was lifted at 154 but this was still well below the likely actual stall speed of around 170KIAS because the aircraft was clean wing; the stick shaker operated 4 seconds after the nose wheel was lifted and the stall warning sounded, so in short the aircraft was effectively stalled from the moment it left the ground until it fell out of the sky some 15 seconds later.

Firewalling the throttles and selecting flaps and slats at this time would have done no good at all, since with the best will in the world the crews reaction times coupled with the responding actions and deployment of the systems would have been too late.

If I am talking a load of rowlocks here someone please put me right.(But gently please!)

I am a retired Avionics Engineer with a lifetime of experience behind me but I have never been faced with the kind of pressure that the mechanics were faced with. The last fifteen years of my life were spent with the worlds largest operator of the Dassault Falcon 20 and whilst many will say that there is a world of a difference in the systems employed in this aircraft, I would disagree; for a small biz jet it is actually a mini airliner and has exactly the same dual redundancy systems fitted as many a 737 or MD-80 series aircraft and the operating procedures are the same.

But I never had Flight Ops breathing down my neck to get an unserviceable aircraft full of hot and sweaty Spanish passengers fixed. I never had to suffer the chief pilots wrath because one of our aircraft was five minutes late on task. I worked with many ex-airline staff who had however and it comes as no surprise that things get overlooked in the haste to get the aircraft back in service.

The economic problems being faced by Spanair must have played a large part in the outcome; The co-pilot who handled the second engine start was under redundancy notice and the threat of redundancy was very heavy all round. I have worked under these conditions; its not nice and mistakes do get made as a result of trying not to make a mistake.

I personally would have had second thoughts about WHY the RAT probe was working on the ground, but that is something I can say now with the benefit of hindsight and when I’m away from it all. The action taken by the Spanair mechanics to fix the reported problem was right but right for the wrong reason! Pulling the C/B achieved nothing but to isolate a serviceable probe and protect the associated wiring.

Another question evolves from the accident concerning the TOWS. Why didn’t the crew pick up on the fact that when they taxied out for the second time, presumably clean wing, the TOWS alarm didn’t sound when they opened the throttles?

I have been wracking my brain to see if there could be any other reason for the non deployment of flaps/slats on this aircraft. One report here in Spain states that this aircraft had two instances of flap/slat defects in the ten days leading up to the accident.
I am not privy to the nature of the defects, but the engineer in charge at Spanair Barajas has been questioned about them and the authorities it seems are none to happy with the answers.

The very sad thing is that someone could go to jail for this and it looks like it could be the engineers. In this litigious society we have to have someone to blame, someone to jail, someone to sue. This is so wrong. No-one wanted these poor people to die, no-one profited from their deaths; there was no crime. It was an accident; an accident not caused by a single episode but a whole series of events, which as is so often the case in our business had the inevitable result.

sevenstrokeroll

17th Nov 2008, 07:54

phalconphixer

why do you say the extension of slats/flaps and firewall power wouldn't have helped?

I've trained for that in the sim...it takes more time to write this than to do the above.

REMEMBER that a HUGE SIGN SAYING STALL and a VERY LOUD warning sound would get your attention.

NigelOnDraft

17th Nov 2008, 08:25

7sr...

There is a chance, on some types, that a rapid selection of full power and Flaps/Slats might rescue the situation.

However, it is, IMHO, the "wrong" way to analyse this accident. Firstly we need to deal with an "average crew" on a "bad day" under "pressure" and "distractions". We need to assure the Pax / Safety System we can operate safely... Requiring an instant, unco-ordinated non-SOP response I don't think matches that?

Put it another way, you are asking for a very high standard of flying, analysis, SA and reaction time from a crew who, up to that point, have (for whatever reason) exhibited none of those traits in getting an aircraft to that point without Flaps/Slats.

The "Superior Pilot... avoids use of Superior Skill..." saying springs to mind ;)

PP
You raise some good points. You are possibly slightly incorrect abouit it being stalled from the moment it left the ground... if it had, it would never have lifted off (nor Detroit). In practice, ground effect came into play, allowing both aircraft to reach a low altitude, where the loss of ground effect, and the high drag, took over. Also, swept wings do not always stall in the classic sense - both here and Detroit the "wing rock" at high AoA become significant.

As you conclude, accident are rarely a single cause. Prosecutions help nobody, except in clear cases of malicous intent. All it achieves is make some politicians think they are doing something :ugh: Errors were made, some by people alive, some probably by people not alive... As you say, the fact that the P2 was basically informed of redundancy that morning is unforgiveable, and IMHO will be a possible or contributory cause...

NoD

sevenstrokeroll

17th Nov 2008, 13:32

NIGEL

one thing that has not been determined is whether or not spanair teaches takeoff stall recovery as I have mentioned.

you speak of superior skills and that...this would also speak to the idea that spanair didn't allocate the resources in their training and evaluation department to create superior pilots.

I recall a TWA L1011 that crashed on takeoff when a stall warning was activated and the copilot gave up flying the plane and the captain put it back on the runway...hard.

at least that one was survivable. imagine if spanair had cut throttles and crashed upon the runway.

oh well, I hope future pilots will remember spanair and detroit in the same breath.

Phalconphixer

17th Nov 2008, 13:44

7SR;
The reason I suggest this is because of the timeline.
From Vr to impact took 15seconds.
From Vr to stick shaker took 6 seconds.
From the initial stick shaker action to impact took 9 seconds.

By my reckoning given that during that 9 seconds the aircraft was rolling left and right and the necessary actions were being taken by the crew to respond to these undemanded rolls, and the fact that the EPR was recording 1.95 anyway (pretty well firewalled anyway, I assume for this sort of reading) I would guess that the crew just ran out of options.

REMEMBER that a HUGE SIGN SAYING STALL and a VERY LOUD warning sound would get your attention.

9 seconds to convert what has effectively become a 130 ton brick back into a flying machine…

9 seconds to diagnose the problem, realise that the slats were not deployed, operate the flap handle, wait for the flap/slat mechanisms to respond and deploy, and become active; they just ran out of time.

The whole point being that in the Sim it doesn’t matter; you have laboratory conditions and no-one is going to get hurt. You can always go back and do it again and the only damage is to your ego…In real life there would be the realisation that this is for real and even the coolest crew would be subject to an element of panic as the need for self preservation kicked in.

So sorry, I’m sticking to that line.

NoD:
Thanks for that explanation about ground effect; that’s the bit I couldn’t get my head around!

agusaleale

17th Nov 2008, 22:06

http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo (http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo)
A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.

Subject: Importance of Standard Operating Procedures (SOP) as Evidenced by a Take-off Configuration Hazard in Boeing DC-9 series, MD-80 series, MD-90, and B-717 Airplanes.
Purpose: To emphasize the overall importance of SOP and specifically the need for SOP to ensure proper operation of the Take-off Warning System (TOWS) for DC-9 series, MD-80 series, MD-90 and B-717 airplanes.

Background: A recent loss of an MD-82 aircraft during takeoff and a subsequent Airworthiness Directive (AD) by the European Aviation Safety Agency (EASA) serve to underline the criticality of correct take-off configuration. The investigation of this accident is still ongoing and the probable causes have not yet been identified, however, preliminary information released by the investigating authority indicates the airplane’s flaps and slats were not configured for take-off.
A review of accidents and incidents involving civil transport category aircraft shows that, worldwide, take-off configuration errors have figured in 49 accidents and incidents since 1968. These events have resulted in 392 fatalities. It should be noted that the FAA has already taken actions in response to these accidents and incidents such as revising airworthiness standards and issuing ADs. The hazard of mis-configuration of the flaps and slats at take-off can be mitigated in two distinct ways:

1) warning systems, and
2) standard operating procedures.

The recent MD-82 loss underlines the need for the industry to consider its SOP, as well as warning systems when mitigating take-off configuration hazards.

Discussion: DC-9 series, MD-80 series, MD-90 and B-717 airplanes are specifically equipped with a TOWS intended to prevent mis-configuration during take-off. Likewise Original Equipment Manufacturer (OEM) -recommended and air carrier-approved SOP have been designed to prevent a mis-configuration take-off. A warning system and SOP can only be effective mitigations if the system is properly maintained and the SOP is properly designed and followed.
The AD issued by EASA addresses SOP for DC-9 series, MD-80 series, MD-90 and B-717 airplanes. This AD revises Airplane Flight Manual SOP to require the crew to check the TOWS before engine start prior to every flight. This was previously recommended by McDonnell Douglas following a 1987 accident. In the AD, EASA states concern that “some operator’s procedures no longer reflect the initial intent of the [McDonnell Douglas] recommendation…as the check is performed less frequently.” Readers may review the entire AD at the following website: http://ad.easa.europa.eu/ad/2008-0197 (http://ad.easa.europa.eu/ad/2008-0197)
SOP are universally recognized as basic to safe aviation operations, as evidenced by the MD-82 example. In 2003, the FAA issued an advisory circular (AC) on SOP, AC 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers”. In that AC, the FAA noted the following key features of SOP:

“KEY FEATURES OF EFFECTIVE SOP.

a. Many experts agree that implementation of any procedure as an SOP is most effective if:

(1) The procedure is appropriate to the situation.
(2) The procedure is practical to use.
(3) Crewmembers understand the reasons for the procedure.
(4) Pilot Flying (PF), Pilot Not Flying (PNF) / Pilot Monitoring (PM), and Flight Engineer duties are clearly delineated.
(5) Effective training is conducted.
(6) The attitudes shown by instructors, check airmen, and managers all reinforce the need for the procedure.”

In order to be most effective, operators should review OEM recommended procedures, define SOP, explain the reason behind the SOP, and effectively train SOP. Each operator should avoid a “double standard” between SOP as trained and as operated in routine practice. To do otherwise is to eliminate one of the most simple and effective hazard mitigations in flight operations. Readers may review the entire AC at the following website:
http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/b173ba8a295764f086256cde006a44ad/ (http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/b173ba8a295764f086256cde006a44ad/)$FILE/AC120-71A.pdf

Recommended Action: Directors of Operations, Directors of Maintenance, Directors of Safety and Directors of Training should review their procedures to ensure that maintenance procedures and flight crew SOP are effective for ensuring proper operation of a TOWS. Operators of DC-9 series, MD-80 series, MD-90, and B-717 operators may refer to the OEM-recommended procedures for the TOWS. Operators of other airplanes should review their maintenance and flight crew SOP to determine if the procedures achieve a similar assurance of configuration warnings.
Directors of Operations, Directors of Maintenance, Directors of Safety and Directors of Training should ensure that their operations and maintenance personnel are effectively trained in and follow approved standard procedures for their aircraft.

sevenstrokeroll

18th Nov 2008, 00:42

phalconpixer

have you flown the dc9 or md80?

I have. a well trained pilot could have recovered...if spanair doesn't take the time to train well, that's part of the problem.

I was able to speak: firewall power flaps 15...5 times in 9 seconds.

there is no diagnosis, it is a pavlovian bell/response if properly trained.

you think what you want...but if someone had to tell you about ground effect, you need alot more training to figure any of this out.

bubbers44

18th Nov 2008, 01:06

7SR.

Pilots who rotate to normal deck angles and don't get normal lift off performance should not just pull back more to get airborn. Something is wrong and if you have a long runway there is time to make a quick check of what is wrong. Why waste the last few thousand feet that would fix a flap setting error by over rotating? Hopefully grabbing the flap handle and setting them would get you off ok or even if that was too late the extra few thousand feet would get you off clean. Thinking outside the box if you do everything else wrong might save the day.

justme69

18th Nov 2008, 12:48

The judge has decided to cancel the status of indicted to one of the technicians that participated in the maintenance action (RAT heater disabling) done to the aircraft soon before the accident.

The judge estimates his participation as assistant to the other technician, carrying out actions not directly related from the outside of the aircraft and only briefly coming inside to label the heater as inoperative is not enough to warrant his responsability in any potential wrongdoing.

The main technician in charge of the repair and the chief of maintenance for Spanair (who also didn't participate directly nor was informed at the time of any actions on the aircraft) remain indicted.

justme69

2nd Dec 2008, 15:43

Not much new.

The judiciary investigation continues. 4 survivors declared today in front of the judge for a couple of hours. 2 more will video-conference tomorrow. Also, the technician that looked into the RAT probe heater the night before the accident in Barcelona will tell the judge what he did about it a week from now.

The survivors, some of them declaring for the first time after being hospitalized (one even in induced coma) for a long time, all agreed that there was no "explosions" or "weird noises" or any "unusual events" other than the airplane feeling like it "lacked power" to elevate, rolled steeply side to side and fell.

The new technical commision that will work for the judge, independent of the CIAIAC one, has been formed today. The judge randomly selected 2 pilots with over 15 years of experience from a list of 30 qualified propossed by the official pilots school (federation). Similarly, 2 aviation engineers and 2 maintenance technicians were selected. All 6 members will be ordered by the judge to carry their own technical investigation and inform him of the findings.

The judge still considers indicted the main technician in charge of taking care of the fault discovered by the pilot soon before the accident (RAT probe heater turned on while on the ground) and the chief of maintenance for Spanair. The judge has decided not to consider the actions of the other technician acting as assistant in the "repair" as enough to warrant an indictment, and therefore he has been classified again as a witness.

justme69

16th Dec 2008, 12:15

Well, and there we have it.

It seems that the investigation pretty much points to the pilots forgetting to deploy the flaps and slats and no related mechanical malfunction other than the TOWS (as it was obvious already to anyone familiar with the situation).

It seems that right when the time to set the flaps/slats on the after start checklist came, the pilot can be heard on the CVR tell the copilot (running the actions) something like: "Take this chance now" meaning to take advantage of a gap in the tower radio busy communications to ask for taxiing clearance, so the checklist was interrupted at that point and permission asked over the radio.

It can be inferred that they later forgot this item and to properly deploy and check the wing configuration and that they only paid lip service (or nothing at all) to any posterior verifications (in the taxi checklist under briefing and in the inminent takeoff under Final Items).

The maintenance technician that checked the aircraft in Barcelona the night before the accident to attend to the problem of "excessive RAT temperature indications" reported by a pilot the day before, declared to have run the whole set of tests as indicated in the repair manual and found all systems working, indicating that perhaps the relay suspected to be faulty had actually an intermitent electrical problem (dirty/stuck contacts, loose or fractured cable connections or whatever).

This same relay, as we know, would've caused the erratic function of two devices: the RAT probe heater, which turned itself on while on the ground right before the accident, and the Take Off Configuration Warning System, which didn't sound in this accident in spite of the investigation pointing to a configuration error (flaps and slats not deployed).

At this time, the investigation officially hints to what we know: crew error due to "rushed" and not 100% "professional" operation of the checklists and procedures coupled with a recent hard-to-diagnose malfunction that wasn't properly noticed or corrected on time and made the configuration alarm inoperative for the takeoff.

The other circunstances surrounding the flight (heavy weight, tail wind, low air density, unfortunate random stall behaviour that deviated the aircraft from the runaway), completed the picture of the accident.

The judge is still trying to determine if the actions of the maintenance technician that disabled the RAT heater minutes before the accident constituted an act of neglicency.

And I guess this about wraps it up until the whole CVR transcript is made public and the official investigation ends a couple of years from now.

The judge is planning on closing the judiciary investigation much sooner, probably in six months or less.

May all the ones that lost their lifes in this unfortunate accident rest in peace. From everyone in pprune, our condolences to their families and friends and we sincerely hope steps can be taken to make as sure as humanly possible that it doesn't happen again.

Alanwsg

16th Dec 2008, 17:42

I've been following this thread with interest from the start and I'd just like to add my thanks to Justme69 for providing an unbiased and pretty comprehensive English commentary throughout.

Thanks.

hetfield

16th Dec 2008, 17:55

I fully agree.

justme69 did a very precise and accurate job here

Thx justme69

vanHorck

16th Dec 2008, 20:11

Justme69 should apply as moderator! Job well done!

bubbers44

16th Dec 2008, 20:34

Justme69 about sums up this long thread. Now we can let it RIP.

paulg

17th Dec 2008, 04:22

I will add my thanks to Justme69 and to all who have contributed to this sad but interesting thread which I too have followed from the beginning. One thing I have taken from this discussion is a greater awareness of the fallibility of humans and their machines. Human factors are ever present in aviation.:)
Paul.

Bis47

17th Dec 2008, 07:33

Hello!

Thanks for that update, and the new bit of information from the CVR

It seems that right when the time to set the flaps/slats on the after start checklist came, the pilot can be heard on the CVR tell the copilot (running the actions) something like: "Take this chance now" meaning to take advantage of a gap in the tower radio busy communications to ask for taxiing clearance, so the checklist was interrupted at that point and permission asked over the radio.

As stated, the after start check list looks like a "read and do" check list. :confused:

Not the best practice for standard routine actions, IMHO.

Who needs reading a book to accomplish simple actions such as setting the flaps? The check list should be called upon when the job is done by the crew member in charge, to check it was done! And this check is a two persons job ...

Southernboy

17th Dec 2008, 14:27

Sorry can't make the quote work. Justme69 said.

"At this time, the investigation officially hints to what we know: crew error due to "rushed" and not 100% "professional" operation of the checklists and procedures coupled with a recent hard-to-diagnose malfunction that wasn't properly noticed or corrected on time and made the configuration alarm inoperative for the takeoff."

So rushed departure created the problem & the failed system didn't warn them. If that's the case then it is easy enough to point at the people who initiated it but I'm still interested in why.

We all know about pressure put on engineers & we all know that pilots must put professionalism before being rushed for departure. I'm not talking about simple mistakes but cutting corners. How many here would say that the culture in their company would ensure this didn't happen? How many would say it could happen easily?

I've flown for both dodgy & highly professional outfits - all under the same regulator - and known damned well the company culture affects professionalism. Will the judge look any further or is this going to be another case of finding the obvious without asking why?

alf5071h

17th Dec 2008, 18:47

“Will the judge look any further or is this going to be another case of finding the obvious without asking why?”
A necessary and very sensible question.

“Now we can let it RIP.” #2521
So now knowing what happened, do we leave industry/public to allocate blame by default without considering why. No, not good enough!
We are members of a professional, well respected industry, which has an exceptional safety record. In part, this success is due to asking ‘why’ in previous accidents.

One aspect in this accident appears to be that lessons from similar accidents were not learnt – actions not implemented. Failure to ask why or implement the answers yet again might contribute to further events.

Even if the legal responsibilities are met by establishing what happened or by allocation of blame, it is not, nor can it be the way in which our industry is to progress.

In the absence of a formal report as to ‘why’, then everyone in the industry should consider what this accident might mean to them.
There is plenty of evidence in this thread and in ASW Dec 08 (www.flightsafety.org/asw/dec08/asw_dec08_p10-16.pdf) that the form of human error in this accident has and will continue to occur. Also, there is evidence that a TOCWS will detect error and benefit safety.
Thus for me a lesson learnt is to ensure that the TOCWS is serviceable for every takeoff; either by checking or by use of a robust monitoring / warning system.

We may not be able to eliminate human error, but every effort must be taken to reduce the occurrence of these errors.
The industry should look closely at the surrounding factors which contribute to rush, distraction, complacency, or violation of procedures. Perhaps it is time to re-evaluate the befit and risk of initiatives such as slot times, or the ever increasing commercial pressures on the ‘sharp end’.

We are told that error is more likely in times of change, but in the aftermath of this accident, unless we change, error will prevail.

ATC Watcher

17th Dec 2008, 20:03

I have also been following this thread since the beginning and I join my thanks to Justme69 for very informative and correct information posted here.

The failure ( or more correctly unavailibility) of any warning system is not a problem per se. But fact is we all start to rely on them and reduce our alertness. Same for ATC with Short Term Conflict Alert (STCA). Everybody is supoposed to be able to work without one, but if you get used to it over many years, and suddenly ( and/or unknown to you) it is disabled, errors can turn into accidents. Ueberlingen comes to my mind of course.

Check and re-check and never asume .

safetypee

18th Dec 2008, 00:00

ATC Watcher, you appear to overlook a key human factors point that no human can be expected to have ‘perfect’ alertness. There will always be errors; the safety objective is to reduce the frequency of error occurrence, or the severity of their effect if not detected.
Error detection, even with dual crews cannot be relied on, thus there is a need for ‘systems’.
I agreed that the operating human must not rely on these ‘error detectors’, and when they fail there must be a clear indication of their unavailability, e.g EGPWS.

I don’t think that the human aspects can be discussed in isolation. Safety defences involving human behaviour can only complement a range of other ‘error’ defences.
Also, it is not necessarily the number of defences that there are (defend in depth), as the quality of the existing defences. Many posts have identified many excellent defences in existing operations.

The current range of defences involves systems, management aspects such as procedures and safety culture, and at high level, input from the regulators.
In the latter instance the regulators could research contributing factors in this accident, as above (#2525), or mandate a new warning system. An earlier post identified AMC 25.703 Takeoff Configuration Warning Systems (Page 368) (www.easa.eu.int/ws_prod/g/doc/Agency_Mesures/Certification_Spec/CS-25%20Amdt%205.pdf) which discussed the philosophy of TOCWS including the latest ‘high reliability’ systems already - voluntarily, in some aircraft; a simple retrospective mandate would improve this aspect.

rafacub

14th Jan 2009, 11:16

Boeing no avisó a Spanair sobre el sistema de alerta · ELPAÍS.com (http://www.elpais.com/articulo/espana/Boeing/aviso/Spanair/sistema/alerta/elpepuesp/20090112elpepinac_12/Tes)

justme69

14th Jan 2009, 18:21

For those not willing to google it, basically the article says that Boeing has officially answered the question the judge made about whether Boeing ever informed Spanair of the need to check TOWS before each take off.

Boeing's answer: No.

Boeing's says Spanair's SOP is a slight deviation from their current one. But they also admit such tests weren't part of their original operating procedures, but a modification after Detroit's accident.

Boeing didn't inform Korean Airlines either, from whom Spanair purchased the aircraft. Boeing says there is no system in place to inform each subsequent owner of individual airplanes for which some safety recommendation has been issued.

Spanair sustains their SOPs are safe (safer than the originals, they say) and include 3 check points for wing configurations before each take off. TOWS checks by the crew are also mandatory on first flights of the day or after pilots enter a cockpit they have been away from for a long time. They argue their SOPs had been approved by Spanish air regulation authorities and that they had no knowledge of safety warnings asking for additional TOWS checks previous to each take off. Such changes in procedures for additonal TOWS checks were never mandatory by any civil air authority in the world before the accident, and remained a safety *recomendation* only.

Regardless, Spanair made mandatory as per SOP for crew to check TOWS before each individual take off nine days after the accident.

Boeing was also asked by the judge if the procedure employed by the technician (engineer) in charge of the "repair" shortly before the accident was correct according to their repair procedures. The pilot had reported excessive RAT temperature readings due to the RAT probe air intake heater being turned on while on the ground. The technician pulled out a fuse to disable the heater and dispatched the aircraft by MEL. AFAIK, Boeing hasn't answered yet.

Spanair has a solid insurance policy to cover individual accidents for up to 1.500 million €uros (almost $2billion). It is estimated that if the main cause of the accident was crew error, the indemnization to the families of the 153 victims would be in the order of 150.000€ each only (about $200k). It would be much greater if an important part of the fault was laid on either Boeing or Spanair.

Scandinavia's SAS, owners of Spanair, was thinking of putting the financially troubled branch for sale right around the time the accident occurred. It seems to be finally closing on a deal to sell it to a Spanish investment group based in Catalonia.

Spanair transported 8,9 million passengers on 2008, down about 10% due to weaker global travel and probably some impact from the accident. It operated at about 68% occupancy. The company had downsized recently, laying off about 800 employees and reducing their fleet and routes.

crisb

14th Jan 2009, 21:26

For the translation :)

rafacub

15th Jan 2009, 21:17

Justme69, thanks a lot for your professional transalation.

Un saludo.

HarryMann

16th Jan 2009, 02:03

Thanks JustMe, kept us well informed all along

A small point on Ground Effect:
In practice, ground effect came into play, allowing both aircraft to reach a low altitude, where the loss of ground effect, and the high drag, took over.Say 'Ground effect' to an aerodynamicist and the the first thing he thinks of is 'reduced induced drag', not increased Clmax.... because Clmax doesn't 'necessarily' improve, in fact can go either way, even reduce if circulation is reduced with some wing/ground configurations.

The intuitive effect that I imagine pilots feel, sense, and commentators are meaning, is 'dynamic stall' - that is the momentary Clmax increase due to 'rate of rotation' - an effect that birds and especially insects (operating in a thick air medium with thin wings) utilise to get instantaneous Cl's (up to 2) way over steady state ones.

So 'yanking it off' the ground at a significant rate of rotation, could, even can, give a false impression.. and get the aircarft airborne below steady-state stall speeds. As the starting vortex sheds and flow settles down, the true situation then asserts itself.. which is not necessarily because you are 40 or 50 foot up!

I happen to agree with those that are suggesting more instinctive flying responses might have reduced the casaulties in this awful accident... nose down, firewall the throttles and keep it straight - what an horrendous airfield to lose directional control on - yet something else to be factored in to the 'blame game'!

And failing the production of a clear systems flowchart for those awkwad relay failure symptons, that indicates a clear course of action, the engineer on the spot should be treated with a bit more respect by the investigating judge?
Quite why straightforward failure flowcharts for critically linked MEL/non-MEL system items aren't always to hand is beyond me - :ugh:

A very, very sad and sorry story.