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Spanair accident at Madrid

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Spanair accident at Madrid

Old 5th Oct 2008, 09:28
  #2101 (permalink)  
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Forgive my laziness, but has anyone spotted (in the undergrowth) information on the actual MEL procedure that was applied? If that in itself was correctly followed but perhaps WRONG, albeit with 20/20 hindsight, then the emphasis shifts slightly, although I assume that the a/c should still have taken off safely with the correct flap/slat settings?
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Old 5th Oct 2008, 11:28
  #2102 (permalink)  
 
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James W. Hudspeth, American chief pilot with Austrian MAP, owners of the MD-83 OE-LMM at the time of the similar incident in Lanzarote last year, came out an spoke in an article for a Spanish newspaper.

On june 4th 2007, the day before the INCIDENT, the pilot of OE-LMM (an MD-83, similar to Spanair's MD-82) called out maintenance on a "faulty RAT sensor signaling higher temperature than should". The heater, of course, was erroneously on while on the ground. Technician's action: they pushed a popped circuit breaker (LEFT GROUND CONTROL RELAY).

On the MD-83, most systems that depend on front wheel ground/air logic, are duplicated on circuits from the "right wheel" and the "left wheel". But the RAT probe heater, strobe lights, take off configuration warning system (TOWS), and some ventilation/air conditioning systems are serviced exclusively from the left circuit.

The flight in Lanzarote (ACE), with destination Barcelona (BCN), making a service for Air Comet with 140 passengers on board and 6 crew, lined-up without flaps. "I saw the black boxes and there were no flaps or slats: the crew never deployed them, but the Take Off Warning System alarm didn't sound either", Hudspeth explained.

The same thing had happened 20 years before in Detroit on a similar plane operated by american Northwest. The CIAIAC report on the Spanair case mentions this prior accident, but fails to mention the Lanzarote case although they've had all the data on it being analyzed for well over a year.

The MD-83 is more "powerful" than the MD-82. That saved the plane. "Although the MD-83 was at max capacity for that runaway (ACE), around 65.000kg, that is not the maximum capacity it can carry", said Hudspeth. It was at 89% capacity, while Spanair's was operating at 96%. "Our crew was able to keep the airplane airborne, as they had a nice front-wind and more powerful engines (with the runaway being short, they also quickly retracted the landing gears). That allowed them to control the aircraft."

(Also, ACE runaway is at sea level and temperature was probably around 25, while MAD is elevated, temperature was 30, and w/ 6-8 knots of tail wind)

But barely. The aircraft almost touched the runaways barriers and buildings in front of it. It made (wing stall induced) uncommanded rolls of up to 55 (), much steeper than Madrid's case (where the steepest was 32). Tragedy was close.

(The pilots declared an emergency and turned around. They realized the flaps' handle was up, and they landed. Witnesses speak of the airplane clearing obstacles by "barely a couple of meters" and showing a very erratic flight behavior. Some people in the flight path threw themselves on the ground thinking the airplane was going to crash on them. The pilots are said to have exited the airplane in state of shock, even crying.)

Hudspeth, was chief pilot for Mapjet at the time (who rented out airplanes to other airliners) and he flew personally to Lanzarote to figure out what happened. "We found out that in the cockpit one circuit breaker was pulled, the one that would signal TOWS and RAT if they are on ground or air mode. Nobody tells you about that c/b, but it is very important and pilots should check it every time they board an MD."

In Detroit's case, it was never conclusively found out why the TOWS alarm didn't sound. The investigation could only conclude a generic "electrical failure". In Mapjet's, because the airplane was intact, it was found out what the cause was and why it had happened. "We took the airplane to be thoroughly checked in Stockholm, and they couldn't find anything wrong with it other than the circuit breaker was pulled out".

Hudspeth investigated why the c/b was out and found that "It was a very common procedure during maintenance. Mechanics, during daily checks, would pull it to check the strobe lights while on the ground. We couldn't find proof that it was left out by mistake, but it is within human nature to sometimes forget to put things back".

The c/b panel on the MD-83 is behind the pilot's back. Crew should check them over their shoulders when they enter the cockpit to verify they are all in correctly. In Lanzarote, "The white 'collar' around the cb in the panel that signals if the circuit breaker is pushed in or pulled out was dirty-black from so much usage, which made it hard to notice if it was out".

In Lanzarote's case, company investigation concluded that the austrian MAP's crew, veteran argentinean pilot Ricardo Simaro (ex president of a pilot's association) and copilot, venezuelan Rodolfo Ovelar, did not deployed the flaps/slats, didn't check the TOWS alarm system and didn't notice the pulled c/b that a technician had left improperly out that same day before the prior flight".

The most shocking part of the investigation is that the company found out that at least another 6 times in the previous 3 months planes from their fleet had flown in that state (i.e. TOWS disabled, RAT heater connected on the ground, therefore, likely wrong outside air temperature readings).

Figuring out around 850 similar MD's flying around the world, makes it very likely that many are routinely taking off with the c/b not correctly set. He says the design should be improved, as well as maintenance instructions and pilot awareness.

During his investigation, he found out that during maintenance in Dublin, Warsaw or Madrid, pulling this c/b was something common. "A pilot told me that, in Dublin, the RAT heater was noticed turned on while on the ground, a technician came on board, immediately pushed the c/b like if he already knew what the problem was and it got fixed".

In Madrid, though, the technicians for Spanair didn't make the connection between the probe heater miss-behavior and faulty ground/air logic. The technician in Madrid didn't check the state of the Left Ground Control Relays c/b, situated in position K-33 of the c/b panel, he only concentrated on RAT probe itself, checking Z-29 in the lower right of the panel.

(Most likely scenario in Spanair's case is that this c/b was in the right pushed-in position and it was the R2-5 relay that malfunctioned, producing similar but even less conspicuous results).

Hudspeth informed of all of this January 24th to the CIAIAC, where, incidentally, he "met with the (female) investigator, another man, and a SPANAIR CAPTAIN that was acting as advisor in the investigation. My declaration was taped for over 2 hours and I told them all this, but they haven't done anything".

CIAIAC has declined to make comments about this, as they (oh gosh, how much I hate secrecy for the sake of secrecy) "Do not comment on ongoing investigations until they are final".

He also was puzzled as how the investigators kept questioning him on how it was possible that the pilots forgot to deploy the flaps/slats, and he found odd that they didn't concentrate much on why the TOWS didn't sound, as "if they already knew about the problem".

Also, it seems, the RAT probe heater in Madrid's case was also "acting-up" the day before. But it seems that it only reached 90. It wasn't until the hot mid-day Madrid that the probe went over 99 (105), and it is only then when an alarm goes off in the cockpit to indicate the condition on limited automatic gas intake for the engine (autothrust warning?). The taxing of the MD-82 form Madrid's T2 to the runaway on T4 was longer and in hotter weather than the conditions on the MD-82's previous flight of the day, early in the morning in colder Barcelona.

Although it wasn't conclusive, it took Detroit's crew two attempts to engage automatic gasses intake (autothrust?), pointing to a potential similar problem.

Last edited by justme69; 7th Oct 2008 at 11:16.
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Old 5th Oct 2008, 14:41
  #2103 (permalink)  
 
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PLEASE:

Prior to sitting down for the purpose of flight, check the circuit breakers thoroughly.

upon entering the cockpit, with electrical power on, move the throttles up and hear the warning.

know signs of plane THINKING it is in the air (rat epr gauge heated on ground, strobes on (you might even hear them in your radio), gear over ride button retracted.

check killer items on runway

AND IF THE PLANE DON'T FLY RIGHT< FIREWALL POWER< FLAPS 15.

bubbers is right of course about nose oleo strut

justme69 has some good things to say too.


and ALL MEL's are a load of crap...the plane should be right to start.

Another example of a bad MEL is : autopilot inop along with pressurization in manual mode. IT is hard to fly this plane with the ap out and the other pilot having to work the pressurization wheel manually.
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Old 5th Oct 2008, 14:47
  #2104 (permalink)  
 
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and yes, there should be a big frickn light that says:

AIR MODE

GROUND MODE

and all planes should have this, not just the MD80.

this ''fix'' should cost about 5 bucks, but will really cost about 50k
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Old 5th Oct 2008, 16:26
  #2105 (permalink)  
 
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It is fairly recently that we have been advised to not just look at this or that unserviceable item one can operate with but also the interaction of various unserviceablities. Used to be you just looked for an item in the MEL and if it was there you were good to go. Now you are supposed to stop and think about the implications of coupled unserviceabilities, with updated MELs showing you how to do that.
If true, there has been a collective or unconcious downgrading of training... isn't a 'What if?' thinking process, instilled at about day one?
.. and then reinforced at every step thereafter?
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Old 5th Oct 2008, 17:11
  #2106 (permalink)  
 
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If true, there has been a collective or unconcious downgrading of training... isn't a 'What if?' thinking process, instilled at about day one?
.. and then reinforced at every step thereafter?
it would hurt your head for a pilot to work out the correct measure of "what ifs" relative to an MEL.

A team of experts should have already worked these out and had them validated by the regulator. That's not to say that they got them all right, as there is always something to be learned in the in-service data in combination with human error.

The pilot has the choice of not taking the plane, but keep your arguments simple.
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Old 5th Oct 2008, 17:25
  #2107 (permalink)  
 
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I always thought part of being a professional pilot was looking at mechanical problems from our perspective and when maintenance had done their work take a look at what they did and how it could affect your next flight. I would rather risk a headache thinking it through rather than severe head trauma from not.
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Old 5th Oct 2008, 17:42
  #2108 (permalink)  
 
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Another example of a bad MEL is : autopilot inop along with pressurization in manual mode. IT is hard to fly this plane with the ap out and the other pilot having to work the pressurization wheel manually.
SLF Here...

IMHO MELs exist just to justify the operation of an aircraft which does not satisfy the safety requirements.
How can a piece of equipment (i.e. a/c) can be operated for 10 days, and than grounded because is not safe?
Still in IMHO MELs were created to avoid to ground planes for minor issues, but now are used to keep the planes off the ground as long as possible. Today most of the operators are not looking at MELs as a way to minimize the cost of repair, but as a way to maximise profit.

Still a silly opinion of a SLF
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Old 5th Oct 2008, 19:45
  #2109 (permalink)  
 
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I always thought part of being a professional pilot was looking at mechanical problems from our perspective and when maintenance had done their work take a look at what they did and how it could affect your next flight. I would rather risk a headache thinking it through rather than severe head trauma from not.
Agree

on "your" next flight it is appropriate. That's what i meant by your option not to accept
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Old 5th Oct 2008, 20:00
  #2110 (permalink)  
 
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so, don't like the MEL...write your congressman, or whatever you have in your nation.

IT IS WRONG..the whole concept of MEL is MONEY driven.
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Old 5th Oct 2008, 20:39
  #2111 (permalink)  
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sevenstrokeroll;
..the whole concept of MEL is MONEY driven.
Absolutely correct.

With airlines keeping minimum inventories on parts and keeping maintenance staffing at mainline and offline stations, the MEL is being treated as a scheduling tool, not a maintenance tool.
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Old 5th Oct 2008, 21:59
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the MEL is being treated as a scheduling tool, not a maintenance tool
Those two concepts are not exclusive
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Old 5th Oct 2008, 22:53
  #2113 (permalink)  
 
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Originally Posted by HarryMann
Quote:
If true, there has been a collective or unconcious downgrading of training... isn't a 'What if?' thinking process, instilled at about day one?
.. and then reinforced at every step thereafter?
it would hurt your head for a pilot to work out the correct measure of "what ifs" relative to an MEL.
I actually meant fitters and technicians, not pilots...
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Old 6th Oct 2008, 01:24
  #2114 (permalink)  
 
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HarryMan, That is what I thought you meant. The maintenance people should make sure what they are MELing isn't associated with other systems that could cause problems. Also pilots should look at what was done and not let questionable fixes put them back in the air again.
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Old 6th Oct 2008, 03:46
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Originally Posted by sevenstrokeroll View Post

and yes, there should be a big frickn light that says:

AIR MODE

GROUND MODE

and all planes should have this, not just the MD80.

this ''fix'' should cost about 5 bucks, but will really cost about 50k
That sounds a really nice simple fix, but think logically about it and it will make the situation much, much worse.

As I understand the posts here, this plane has several sensors/circuits that take part in the ground/air mode decision. So which one do you choose to light up your big frickin light? Only part of the plane thought it was in air mode, the rest was still on the ground. Put in your light and choose the wrong circuit to drive it and you make the whole thing many times worse.

"Oh look,. RAT heater is on."
"That can mean the plane thinks it is in the air - remember Spanair at Madrid?"
"No, it can't be the same as that, the big frickin light says we are in ground mode....."
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Old 6th Oct 2008, 05:33
  #2116 (permalink)  
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lomapaseo;
Those two concepts are not exclusive
Yes, I'm fully aware of that but thank you for making the point clearer, even if only some pilot starting out in his/her commercial career reads this and learns one more fact about aviation that isn't taught as a licensing requirement...

The key requirement has been amply stated in the thread. However, hands up those who haven't either been fooled only to realize it later or probably more likely at least had maintenance try to fool you into taking the airplane "under the MEL" when you know damn well the airplane doesn't belong in the air?

Like I say, these are traps for young players and I'll bet you more than one crew has taken an airplane that shouldn't have gone.

As someone here said, "It's all about the money" and absolutely nothing else. Management never sets the park brake; that is up to us.
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Old 6th Oct 2008, 05:41
  #2117 (permalink)  
 
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That sounds a really nice simple fix, but think logically about it and it will make the situation much, much worse.

As I understand the posts here, this plane has several sensors/circuits that take part in the ground/air mode decision. So which one do you choose to light up your big frickin light? Only part of the plane thought it was in air mode, the rest was still on the ground. Put in your light and choose the wrong circuit to drive it and you make the whole thing many times worse.
Yeah,

At the very least, the light needs to tap on all sensors and indicate:
-Ground
-Air
-Disagree
-Off (light broken)

Unfortunately, if i.e. the Madrid case turns out to be a case of a malfunctioning single relay (R2-5), even if you make this more sophisticated logic, as you just mentioned, it will still confuse the heck out of the pilots ...

They will see an indicator lighted:
-Ground

Then, if they notice at all, they'll see a RAT probe indicating way too high temperature. Maybe they'll notice/figure the heater is on.

Maintenance will see the logic is "correct", so it must be a case of the heater "mysteriously" malfunctioning. Cut it out, MEL the thing, and out we go.

And we still get Madrid's likely inop TOWS takeoff condition ...

Boeing's recommendation of testing TOWS shortly before each take off is the best (and cheapest, mind you) solution. The alarm could still fail from the time it was tested til the time it was actually needed, but usually that would be some short period of taxiing time, so the risk is small.

Testing with a POSITIVE test, where you actually hear the alarm, not a test where you are suppossed to NOT hear the alarms, which is "worthless" in case of a "broken" TOWS.

The real "best solution" is a TOWS re-design where the alarm indicates both, possitive and negative results. Nowadays, with digital technology, I'm sure the change wouldn't cost all that much (at all). You push the handles and the TOWS will announce out-loud:

-Configuration OK (you are good to go)
or
-Beep - slats -- beep -- flaps (you are not yourself today -- drink more coffee and stop chatting on your cellphone with that cute flight attendant you are about to meet)
or
-Silence (TOWS is inop ... you are NOGO)

Last edited by justme69; 6th Oct 2008 at 07:12.
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Old 6th Oct 2008, 08:25
  #2118 (permalink)  
 
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There is a definite disconnect between pilot and engineer in todays world.Didnt used to be.Engineers were once flt engineers but then they took the third seat out.Pilots used to have work the engineers panel before sitting in the right.Pilots used to get shown the ropes in the hangar during C check..now they learn by rote and do the 6 month answer A,B or C monkey check.Some today have never seen an EEC or PACK..if you see it you'll catch on..a picture tells a thousand words etc.CP's in the old days were tough SOB's who'd wouldnt give a damn for this modern BS(Captain isnt a pilot but a flight manager)..they would have been on that Lanzarote incident like flies on dogsh*t and making sure data was disseminated to their guys..I know the powers that be will throw more SOP's at this as part of their answer..irony is you need less and a little more airmanship.Even if Madrid turns out to be the relay itself and not the cb,the lesson was check the TOWS every time..the full check at the gate during pre-flight.And if the SOP says the other guy checks this or that,doesnt matter,check it again..know the condition of your plane before you go flying.
Justme69,
Thank you for post 2133
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Old 6th Oct 2008, 08:41
  #2119 (permalink)  
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FORUM WARNNG! This post implies no judgement/implication/hint/rumour on the cause of this accident.

100% with Ranamin. However, and not wishing to be 'trite', all these 'devices' - TOWS, EGPWS etc are 'backstops', and surely the important lesson is to get it right in the first place. If you need flaps/slats xxx for departure - make sure you have them. If there is high ground (or even just 'ground') around, make sure you know where it is and you are etc etc. It does not matter how you do it, and if your company does not try to ensure there is such thinking in place, develop it yourself. SOPS are not the answer to avoiding accidents, merely part of the building blocks. Sitting in front of these SOPs are pilots with brains and hopefully some sort of survival instinct.
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Old 6th Oct 2008, 13:18
  #2120 (permalink)  
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All the warnings TOWS, AIR/GRND shift mechanism etc, still does not exempt any crew from visually checking the positions of the slats/flaps( including the postion of the flap selector) or,if applicable LE devices. Confusing that the A/C systems might not have worked, yes. But, to blame it on this alone, Hmm
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