Spanair accident at Madrid
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Thankfully, there is a public judiciary investigation going on and I'm sure the judge will request updates and evaluations from the QAR data, the flaps handles, and other important data within the next months. 10th October 2008 23:39
It would be best wait until the CIAIAC final report. Then, legal actions can be iniciated according to the results of the report.
What are we looking for ?? What are you looking for 69 ??
Looking for a guilty ? ... or for enhancing air safety through the recommendations given by the investigation team??.
If you put under doubt the proffesionalism of the pilots ( who died in the accident, may I remember ? ) because a phrase was not properly ended in that moment - who knows why -... then any investigation is needed, all is clear.
Please take into account that you are now comfortably seated in front of your computers. From this position, is very easy to question the actions taken by others in unknown cicunstances.
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Ferrobus, I think you are missing the point.
Remember that in Spain, the CIAIAC is working for the judge, there is judiciary investigation on going that will determine (if possible) the cause of the accident, and CIAIAC is very important in giving their point of view.
I don´t think that 69 is looking for a guilty, even though he as some kind of compromise with the case, I ignore which one, but I understand that he is trying to make things as clear as its possible at this very moment.
Remember that in Spain, the CIAIAC is working for the judge, there is judiciary investigation on going that will determine (if possible) the cause of the accident, and CIAIAC is very important in giving their point of view.
I don´t think that 69 is looking for a guilty, even though he as some kind of compromise with the case, I ignore which one, but I understand that he is trying to make things as clear as its possible at this very moment.
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Wileydog3
Sorry to hear about your shoulder, and I hope it is well on its way to recovery, but the point of modern accident analysis and investigation should not be focused on why you did not see the hole (or whole for that matter),
but why the hole was there in the first place,
Why the race organisers did not notify you about it
why the street maintenance people did not repair it before you fell in......
You get the picture..... all accidents have multiple causes and many can be avoided by simply by filling in the hole.
Cheers
Kent
Sorry to hear about your shoulder, and I hope it is well on its way to recovery, but the point of modern accident analysis and investigation should not be focused on why you did not see the hole (or whole for that matter),
but why the hole was there in the first place,
Why the race organisers did not notify you about it
why the street maintenance people did not repair it before you fell in......
You get the picture..... all accidents have multiple causes and many can be avoided by simply by filling in the hole.
Cheers
Kent
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Let me clarify.
I say that thankfully there is a judiciary investigation because it will, for the next 1.5 to 2 years (according to the CIAIAC), be the ONLY source of OFFICIAL information to find out more about this case, as the CIAIAC vocal had already said that that's the amount of time they estimate to conclude their investigation and they will not publicly speak of it until then (unless, of course, they conclusively find something majorly wrong earlier and for the sake of safety they must issue a statement).
If I was i.e. a relative of a passenger/crew in that plane, I would like to have as much news as possible on what happened there, not a short preliminary report 7 weeks later and then complete silence for more than a year.
That is the part of the process I object to. Not mentioning that one must blindly trust CIAIAC members to be doing their job right.
Incidentally, if someone (say Spanair, Boeing, the ground engineer, the pilots, a passenger, a terrorist, etc) did something knowingly majorly wrong to cause the accident, and I do NOT believe that ANYBODY did in this case, why wouldn't you want to know? Why do you want the CIAIAC to end an investigation 2 years from now so that only THEN, once they (i.e.) decide that there was some sabotage by someone, a judge can open another investigation that would take so many more months etc?
(Again, I don't think that anybody is guilty of knowingly wrongdoing or criminal neglicency)
From my point of view, the "more" investigations, the better. Even the "street investigations" by the press and "couch investigations" like on web forums are, from my point of view, better than no investigations at all or only one investigation or only two investigations.
If you want to sit and wait for CIAIAC report, please by all means do so. I will wait and see for more information from the judiciary investigation, that, since it has precedence in hierarchy over the CIAIAC, has access to all the information the CIAIAC has plus additional one if the judge so demands.
We are all seeking the truth and as much information as possible so that these accidents can be prevented, right?
About the pilots, nobody doubts they were professionals with proper licenses to fly this airplane, substantial experience and additional training. The point is not to find out if they said a sentence right or wrong, but why they (potentially) failed to set the flaps/slats and verify their indicators.
If we had more information (CVR, i.e.) that showed the crew was overly distracted (i.e. like the similar LAPA case that also tried to take off without flaps and slats YouTube - Audio de la caja negra del accidente de LAPA (completo) ), then the conclusion is different than if they just "skipped over" a single item by some mistake. In the first case, the checklist system may still be "working". In the second case, something should probably be done to improve it (i.e. it has been suggested here a "killer item" quick last moment check right before take off).
And my involment in this case comes, mostly, from having a close friend that was almost killed in the similar incident to an MD-83 from MAP in Lanzarote last year. I patienly waited for the CIAIAC report and, after 15+ months of COMPLETE SILENCE, I got tired of waiting (and remember, the plane was intact, the crew was available for investigators and the company that owned the plane, MAP, carried out their own intensive investigation that concluded about a year ago and told the CIAIAC).
I didn't want the same thing to happen in this Spanair case. I wanted everybody to know, as much as possible and to the best of the available information, the likely reasons and explanations of this accident so that each could draw their own PRELIMINARY conclusions and apply their own preventive actions, until the CIAIAC reaches theirs. Without the access to all the technical information that the CIAIAC has (and doesn't share) this is, of course, very difficult. But I think we must try anyway to the best of our abilities for the sake of safety and of those demanding an explanation for the accident.
If you read this thread, you'll find out that there are many out there that want everybody to NOT disclose any information, speculations or thoughts in this thread until an official investigation report is out. I have said many times before that that's ok and they have the right to think that way and express their feelings, of course.
Some of us, on the other side, disagree that that's the best course of action, and think that it's better for everybody to continue discussing silly speculations and stupid ideas around this unfortunate accident. It's our own way of dealing with the situation. It may not be the best one and we understand that some of you feel offended by it. My apologies in advance and may I suggest you do not read this forum so that you don't become more and more offended for another year or two until the CIAIAC report concludes.
Unless, of course, you have some information you would like to share or some experience that may help others understand the accident better.
I say that thankfully there is a judiciary investigation because it will, for the next 1.5 to 2 years (according to the CIAIAC), be the ONLY source of OFFICIAL information to find out more about this case, as the CIAIAC vocal had already said that that's the amount of time they estimate to conclude their investigation and they will not publicly speak of it until then (unless, of course, they conclusively find something majorly wrong earlier and for the sake of safety they must issue a statement).
If I was i.e. a relative of a passenger/crew in that plane, I would like to have as much news as possible on what happened there, not a short preliminary report 7 weeks later and then complete silence for more than a year.
That is the part of the process I object to. Not mentioning that one must blindly trust CIAIAC members to be doing their job right.
Incidentally, if someone (say Spanair, Boeing, the ground engineer, the pilots, a passenger, a terrorist, etc) did something knowingly majorly wrong to cause the accident, and I do NOT believe that ANYBODY did in this case, why wouldn't you want to know? Why do you want the CIAIAC to end an investigation 2 years from now so that only THEN, once they (i.e.) decide that there was some sabotage by someone, a judge can open another investigation that would take so many more months etc?
(Again, I don't think that anybody is guilty of knowingly wrongdoing or criminal neglicency)
From my point of view, the "more" investigations, the better. Even the "street investigations" by the press and "couch investigations" like on web forums are, from my point of view, better than no investigations at all or only one investigation or only two investigations.
If you want to sit and wait for CIAIAC report, please by all means do so. I will wait and see for more information from the judiciary investigation, that, since it has precedence in hierarchy over the CIAIAC, has access to all the information the CIAIAC has plus additional one if the judge so demands.
We are all seeking the truth and as much information as possible so that these accidents can be prevented, right?
About the pilots, nobody doubts they were professionals with proper licenses to fly this airplane, substantial experience and additional training. The point is not to find out if they said a sentence right or wrong, but why they (potentially) failed to set the flaps/slats and verify their indicators.
If we had more information (CVR, i.e.) that showed the crew was overly distracted (i.e. like the similar LAPA case that also tried to take off without flaps and slats YouTube - Audio de la caja negra del accidente de LAPA (completo) ), then the conclusion is different than if they just "skipped over" a single item by some mistake. In the first case, the checklist system may still be "working". In the second case, something should probably be done to improve it (i.e. it has been suggested here a "killer item" quick last moment check right before take off).
And my involment in this case comes, mostly, from having a close friend that was almost killed in the similar incident to an MD-83 from MAP in Lanzarote last year. I patienly waited for the CIAIAC report and, after 15+ months of COMPLETE SILENCE, I got tired of waiting (and remember, the plane was intact, the crew was available for investigators and the company that owned the plane, MAP, carried out their own intensive investigation that concluded about a year ago and told the CIAIAC).
I didn't want the same thing to happen in this Spanair case. I wanted everybody to know, as much as possible and to the best of the available information, the likely reasons and explanations of this accident so that each could draw their own PRELIMINARY conclusions and apply their own preventive actions, until the CIAIAC reaches theirs. Without the access to all the technical information that the CIAIAC has (and doesn't share) this is, of course, very difficult. But I think we must try anyway to the best of our abilities for the sake of safety and of those demanding an explanation for the accident.
If you read this thread, you'll find out that there are many out there that want everybody to NOT disclose any information, speculations or thoughts in this thread until an official investigation report is out. I have said many times before that that's ok and they have the right to think that way and express their feelings, of course.
Some of us, on the other side, disagree that that's the best course of action, and think that it's better for everybody to continue discussing silly speculations and stupid ideas around this unfortunate accident. It's our own way of dealing with the situation. It may not be the best one and we understand that some of you feel offended by it. My apologies in advance and may I suggest you do not read this forum so that you don't become more and more offended for another year or two until the CIAIAC report concludes.
Unless, of course, you have some information you would like to share or some experience that may help others understand the accident better.
Last edited by justme69; 13th Oct 2008 at 19:55.
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Justme,
as others did, I want to thank you for your valuable input throughout this discussion. Just keep it up, even when some might still not understand your position.
There is a difference between "blame someone guilty" and "looking for reasons" (and thus be able to prevent a re-ocurrence), which seems not too obvious to everybody...
as others did, I want to thank you for your valuable input throughout this discussion. Just keep it up, even when some might still not understand your position.
There is a difference between "blame someone guilty" and "looking for reasons" (and thus be able to prevent a re-ocurrence), which seems not too obvious to everybody...
the point of modern accident analysis and investigation should not be focused on why you did not see the hole (or whole for that matter),
but why the hole was there in the first place,
Why the race organisers did not notify you about it
why the street maintenance people did not repair it before you fell in......
You get the picture..... all accidents have multiple causes and many can be avoided by simply by filling in the hole.
Cheers
Kent
but why the hole was there in the first place,
Why the race organisers did not notify you about it
why the street maintenance people did not repair it before you fell in......
You get the picture..... all accidents have multiple causes and many can be avoided by simply by filling in the hole.
Cheers
Kent
The expression "but-for" to describe the existance of a hole that led to a causal chain ending in an accident is simplistic in finding fault but not in the prevention of accidents emanating from a causal chain.
In complex systems one must presume multiple sources of initial faults and therfore the need for multiple barriers. Thus the variance initiating faults is presumed to be dealt with by "in-spite of" barriers any one of which by itself prevents the accident. So then ask yourself which one is easiest to fix?
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Boeing
Has Boeing issued anything more?
I guess the issue here, however, is that:
I guess the issue here, however, is that:
- Pilot error would be a user problem not a manufacturer problem?
- The TOWS/Relay problem has ALREADY been communicated so there would be no need to re-report?
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Boeing has said that they would quickly and openly comply with whatever air regulation authorities, anywhere in the world, decides that they should change as a result of this accident.
A newspaper went so far as to openly said that Boeing is already studying a TOWS re-design modification. (Boeing evalúa un cambio en la alarma de los MD · ELPAÍS.com )
But Boeing, of course, needs to be careful right now. Because they have a civil law suit on going in the USA on behalf of some of the victim's families, they can not readily imply that a TOWS re-design is a good idea, as it may play against them in the eyes of a judge/jury.
TOWS, like any electrical systems, can fail at any time w/o much warning. Boeing is going to argue that putting an alarm to alert of a malfunction on an alarm is ... well, you get the point.
The main reason of the accident seems to have been an user error that prevented setting a mandatory item (flaps/slats). Therefore, other systems (i.e. a mandatory TOWS test) could just as well have been ignored by the pilots.
The airplane can fly just fine without the TOWS, of course, so there is no "absolute need" to make the system overly redundant or deploy yet another alarm when the TOWS alarms fails.
The TOWS is there for ADDED safety, not for primary safety reasons. The LAPA accident had the TOWS working and yet, the pilots still tried to take off w/o flaps.
So, in the event of user errors, I think that the plane can both: fly without TOWS (of course, as long as slats are out i.e.) or fall down with the TOWS working for, basically, the same issue (i.e. not making sure flaps are deployed, as in LAPA case).
When Boeing found out about this 20 years ago (Detroit accident), I guess they evaluated and concluded that the best, although not perfect solution, at the time, was to run a TOWS test right before each flight. Also the cheapest, mind you.
They decided against setting a lighted indicator of operationability in the instrument panel of the cockpit. I don't know why, but I guess that such a system was deemed unlikely to be consistenly checked by the pilots, plus it would give the false sense of security that the TOWS was working, while the truth is that it would've only signaled if the TOWS was receiving power (i.e. the TOWS could still fail from an electronic logic board malfunction, a blown loudspeaker, etc). The TOWS must positively be tested and the alarm HEARD by the pilots, or else, there is no guarantee that they are working even if some "light indicator" signals they are receiving power.
Checking the TOWS shortly before take off doesn't prevent the TOWS from failing between the time they were tested and the time they are actually needed, but reduces the chances significantly. And it would render a "lighted failure indicator" redundant and almost useless. The pilots are not going to consistenly stare at a lighted indicator to see if it's on as they push the handles for takeoff and hear "silence".
And as any pilot can atest (specially Airbus ones) ... electrical systems such as TOWS, and even more important ones, can fail absolutely at any time without much prior warning.
This time around, though, I have the feeling that Boeing could and should easily retrofit the TOWS with additional logic that would give a positive indication of the system being operative instead of silence when the take-off conditions are ok.
But if the CIAIAC suggests that they should change the TOWS design, besides not having authority to make it a regulation, Boeing is gonna be upset because lawyers are going to use it as proof that the TOWS, a +30 years old design that was deemed safe at the time by regulators, is actually "bad".
If Boeing voluntarily changes the design now, same thing: everybody is going to finger point them as guilty.
All this, assuming that the TOWS indeed "broke" (i.e. R2-5 failure) and not that it was working fine but was disconnected by mistake (i.e. LEFT GRND RLY c/b popped), like in the MAP case in Lanzarote.
But after all, it doesn't seem to be too bad of a design if, due to its potential malfunction, it only failed to prevent the Spanair accident in 30+ years (the Lanzarote incident was a case of the TOWS disconnected on purpose by pulling a c/b and the crew not checking for activation/operation and the Detroit one was for unknown reasons, so perhaps it was also deactivated on purpose on that case, we could assume, and the crew didn't test them either).
And yet, even the Spanair case, the crew also failed to check the TOWS (SOP didn't require it) while Boeing warned to make checks before each flight as the only valid means to verify its operation.
If a TOWS check wasn't even required on the Spanair SOP, what makes anybody think that a "check lighted indicator for TOWS active" item is gonna show up in the checklist, much less consistently followed?
I guess Boeing is gonna have to wait until people forget about this accident and then silently start offering an upgraded replacement TOWS kit to their clients, one that signals that it's working during take off with some sort of noise instead of with silence, hopefully.
Out of curiosity: is there any airplane that has a TOWS that, when the handles are set to takeoff while on the ground, auraly signals the "OK to takeoff" condition or do all remain silent unless there is a bad configuration problem (or they are broken
)?
A newspaper went so far as to openly said that Boeing is already studying a TOWS re-design modification. (Boeing evalúa un cambio en la alarma de los MD · ELPAÍS.com )
But Boeing, of course, needs to be careful right now. Because they have a civil law suit on going in the USA on behalf of some of the victim's families, they can not readily imply that a TOWS re-design is a good idea, as it may play against them in the eyes of a judge/jury.
TOWS, like any electrical systems, can fail at any time w/o much warning. Boeing is going to argue that putting an alarm to alert of a malfunction on an alarm is ... well, you get the point.
The main reason of the accident seems to have been an user error that prevented setting a mandatory item (flaps/slats). Therefore, other systems (i.e. a mandatory TOWS test) could just as well have been ignored by the pilots.
The airplane can fly just fine without the TOWS, of course, so there is no "absolute need" to make the system overly redundant or deploy yet another alarm when the TOWS alarms fails.
The TOWS is there for ADDED safety, not for primary safety reasons. The LAPA accident had the TOWS working and yet, the pilots still tried to take off w/o flaps.
So, in the event of user errors, I think that the plane can both: fly without TOWS (of course, as long as slats are out i.e.) or fall down with the TOWS working for, basically, the same issue (i.e. not making sure flaps are deployed, as in LAPA case).
When Boeing found out about this 20 years ago (Detroit accident), I guess they evaluated and concluded that the best, although not perfect solution, at the time, was to run a TOWS test right before each flight. Also the cheapest, mind you.
They decided against setting a lighted indicator of operationability in the instrument panel of the cockpit. I don't know why, but I guess that such a system was deemed unlikely to be consistenly checked by the pilots, plus it would give the false sense of security that the TOWS was working, while the truth is that it would've only signaled if the TOWS was receiving power (i.e. the TOWS could still fail from an electronic logic board malfunction, a blown loudspeaker, etc). The TOWS must positively be tested and the alarm HEARD by the pilots, or else, there is no guarantee that they are working even if some "light indicator" signals they are receiving power.
Checking the TOWS shortly before take off doesn't prevent the TOWS from failing between the time they were tested and the time they are actually needed, but reduces the chances significantly. And it would render a "lighted failure indicator" redundant and almost useless. The pilots are not going to consistenly stare at a lighted indicator to see if it's on as they push the handles for takeoff and hear "silence".
And as any pilot can atest (specially Airbus ones) ... electrical systems such as TOWS, and even more important ones, can fail absolutely at any time without much prior warning.
This time around, though, I have the feeling that Boeing could and should easily retrofit the TOWS with additional logic that would give a positive indication of the system being operative instead of silence when the take-off conditions are ok.
But if the CIAIAC suggests that they should change the TOWS design, besides not having authority to make it a regulation, Boeing is gonna be upset because lawyers are going to use it as proof that the TOWS, a +30 years old design that was deemed safe at the time by regulators, is actually "bad".
If Boeing voluntarily changes the design now, same thing: everybody is going to finger point them as guilty.
All this, assuming that the TOWS indeed "broke" (i.e. R2-5 failure) and not that it was working fine but was disconnected by mistake (i.e. LEFT GRND RLY c/b popped), like in the MAP case in Lanzarote.
But after all, it doesn't seem to be too bad of a design if, due to its potential malfunction, it only failed to prevent the Spanair accident in 30+ years (the Lanzarote incident was a case of the TOWS disconnected on purpose by pulling a c/b and the crew not checking for activation/operation and the Detroit one was for unknown reasons, so perhaps it was also deactivated on purpose on that case, we could assume, and the crew didn't test them either).
And yet, even the Spanair case, the crew also failed to check the TOWS (SOP didn't require it) while Boeing warned to make checks before each flight as the only valid means to verify its operation.
If a TOWS check wasn't even required on the Spanair SOP, what makes anybody think that a "check lighted indicator for TOWS active" item is gonna show up in the checklist, much less consistently followed?
I guess Boeing is gonna have to wait until people forget about this accident and then silently start offering an upgraded replacement TOWS kit to their clients, one that signals that it's working during take off with some sort of noise instead of with silence, hopefully.
Out of curiosity: is there any airplane that has a TOWS that, when the handles are set to takeoff while on the ground, auraly signals the "OK to takeoff" condition or do all remain silent unless there is a bad configuration problem (or they are broken
)?
Last edited by justme69; 14th Oct 2008 at 17:45.
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the CIAIAC would have recommended in the preliminary: "when a failure is reported, please investigate the cause. Do not "remove the problem" in order to return the aircraft in flight as soon as possible"
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How many MD80 or even DC9 series A/C are operational in the world? How many have been built and how many have had accidents? Are their more accidents /incidents on this type due to a wrong config´s. on T/O or indeed Lndg., than any other? I cannot imagine that the B737 series of which more have been built, has had more accidents for the same reason even though the TOWS system seems to work better. In this type of accident, I think you will find that, it all trickels down to crew´s faling to config. the A/C properly and not following SOP´s and checklists. I am not saying that this is what exactly happened here but, looking back at several accidents in the past lots of them can be attributed to crews oversight in following procedures. Design or even mechanical failures are well documented ( rudder problems on the B737, etc) Environmental related yes, CFIT and indeed not following procedures are examples of accident related causes in the past. This accident by the looks of the prelimanary report was due to a wrongly configured aircraft. Do you blame the A/C systems, a non selection of a take-off config. or, is it a slip up in reading and verifying a checklist? It´s going to interesting to see the outcome of the final accident report and hopefully we will learn a little more into what more can cause an accident!
Last edited by MPH; 14th Oct 2008 at 14:45.
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We discussed it before, and this accident pisses off the judge big time because it had 3 very simple ways to be (likely) avoided. Any single one of this 3 things would've probably prevented it from happening:
-If the crew would've made sure the flaps and slats were out. But, as humans, we are all entitled to make a mistake once every 10 years. This would be the "fault" of the pilots, as they were trained and required by the SOP to do it. But then again, all it takes is a second of distraction to "skip" or "missunderstand" or "screw up" setting one item in the checklist.
-If the SOP demanded a TOWS test (and/or the crew actually performed a TOWS test). This would be the "fault" of the airline for not "insisting" on the test to be made. Hopefully, the crew wouldn't have made the additional mistake of "forgetting" this other item as well as the flaps.
-If the TOWS would've been working. But, like anything electrical (specially 30 years old designs), if it's not overly critical (otherwise the airplane couldn't physically fly), it's entitled to fail at any time. Hopefully, it can be re-designed to be more reliable or to be more easily diagnosed. This would be the manufacturer's "fault". But the manufacturer had already advised that the only way to be (somewhat) sure the system is operative ... is to test it right before its use.
So everybody is "at fault" yet nobody is "at fault" for doing something majorly wrong knowingly. Spanair claims they were never told about the change in SOPs recomendations, Boeing claims they told everybody to never trust the TOWS 100% and constanly check them and the pilots thought they had followed the checklist and thought they had actually set the flaps/slats. If they are proven not to have been overly distracted and to have performed the TOWS check in the previous flight from Barcelona, then it's a case of a single, "reasonable", unlucky, mistake.
Everybody thought they were doing the right thing yet none of them did 100%.
Seems that this cheese was small in size but had plenty of really tiny small holes aligned ...
-If the crew would've made sure the flaps and slats were out. But, as humans, we are all entitled to make a mistake once every 10 years. This would be the "fault" of the pilots, as they were trained and required by the SOP to do it. But then again, all it takes is a second of distraction to "skip" or "missunderstand" or "screw up" setting one item in the checklist.
-If the SOP demanded a TOWS test (and/or the crew actually performed a TOWS test). This would be the "fault" of the airline for not "insisting" on the test to be made. Hopefully, the crew wouldn't have made the additional mistake of "forgetting" this other item as well as the flaps.
-If the TOWS would've been working. But, like anything electrical (specially 30 years old designs), if it's not overly critical (otherwise the airplane couldn't physically fly), it's entitled to fail at any time. Hopefully, it can be re-designed to be more reliable or to be more easily diagnosed. This would be the manufacturer's "fault". But the manufacturer had already advised that the only way to be (somewhat) sure the system is operative ... is to test it right before its use.
So everybody is "at fault" yet nobody is "at fault" for doing something majorly wrong knowingly. Spanair claims they were never told about the change in SOPs recomendations, Boeing claims they told everybody to never trust the TOWS 100% and constanly check them and the pilots thought they had followed the checklist and thought they had actually set the flaps/slats. If they are proven not to have been overly distracted and to have performed the TOWS check in the previous flight from Barcelona, then it's a case of a single, "reasonable", unlucky, mistake.
Everybody thought they were doing the right thing yet none of them did 100%.
Seems that this cheese was small in size but had plenty of really tiny small holes aligned ...
Last edited by justme69; 14th Oct 2008 at 15:45.
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Justme69
On the Embraer 145, when you push the 'config' button, she says:
"Take off- OK" or,
"Take off- Flaps" or whatever you forgot.
All configs should be like this. On my current type, we press it every sector, and if configured correctly- silence- like on the Spanair.
So how do we know if the config sys has failed?
Simple- we don't.
On the Embraer 145, when you push the 'config' button, she says:
"Take off- OK" or,
"Take off- Flaps" or whatever you forgot.
All configs should be like this. On my current type, we press it every sector, and if configured correctly- silence- like on the Spanair.
So how do we know if the config sys has failed?
Simple- we don't.
So everybody is "at fault" yet nobody is "at fault" for doing something majorly wrong knowingly. Spanair claims they were never told about the change in SOPs recomendations, Boeing claims they told everybody to never trust the TOWS 100% and constanly check them and the pilots thought they had followed the checklist and thought they had actually set the flaps/slats. If they are proven not to have been overly distracted and to have performed the TOWS check in the previous flight from Barcelona, then it's a case of a single, "reasonable", unlucky, mistake.
Everybody thought they were doing the right thing yet none of them did 100%.
Seems that this cheese was small in size but had plenty of really tiny small holes aligned ...
Everybody thought they were doing the right thing yet none of them did 100%.
Seems that this cheese was small in size but had plenty of really tiny small holes aligned ...
I say you need some historical data
Examine the failure rate for the individual faults, if the actual fleet failure rates in combination predict the accident with a greater than 60% probability than look at the manufacturer for preventive action. If the failure rates in combination are much less than this than look at the operator for preventive action
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I like this summation so what should/can be done?
I say you need some historical data
Examine the failure rate for the individual faults, if the actual fleet failure rates in combination predict the accident with a greater than 60% probability than look at the manufacturer for preventive action. If the failure rates in combination are much less than this than look at the operator for preventive action
I say you need some historical data
Examine the failure rate for the individual faults, if the actual fleet failure rates in combination predict the accident with a greater than 60% probability than look at the manufacturer for preventive action. If the failure rates in combination are much less than this than look at the operator for preventive action
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As a matter of gratuitous curiosity, is this thread some sort of record for PPRuNe at 110 pages ( not counting the many deleted threads at the beginning) or have we done other subjects even more to death.
BTW, I don't include the good info such as that by justme69 in the " done to death" tag, I think you have done a sterling job, and even if it is not your field, you have grasped the subject matter of this far better than some who would believe themselves in some way "knowledgable".
BTW, I don't include the good info such as that by justme69 in the " done to death" tag, I think you have done a sterling job, and even if it is not your field, you have grasped the subject matter of this far better than some who would believe themselves in some way "knowledgable".
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CIAIAC will probably keep everything secret until most people have forgotten about this accident. At least this thread has made us participating to be a little more aware that the TOWS will not save you 100% of the time. Knowing your systems, not accepting sign offs of maintenance items blindly and going through the killer items before each take off might prevent another disaster like this one from happening again. At least not with us. Most pilots don't read this forum so will not have this benefit.
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I no longer fly Boeings but when I did there was a philosophy mostly ignored by operators that only critical (killer) items were included on the checklist. For example the Boeing takeoff checklist for the B744 was "Flaps ... Set". Everything else (Call the cabin, set the transponder etc) were procedures and did not show on the checklist. This made the checklist effective and more relevant and would, if this philosophy was to be adopted, more likely to be used and to be used correctly.
When the carriers pad the checklists with all the procedural items it is more likely that single items will be missed, and that item could well be the killer item that the checklist was originally intended to protect.
So one of the causes of this accident must be that the crew did not check the flap, or if they did, they did not do it in accordance with the checklist ("Set" would be defined as lever position, indications and lights). Why did they not do so? Were they distracted? Were they used to only paying lip service to the checklist? Had the checklist been padded with extraneous items so that it was really a mini-operations manual?
When the carriers pad the checklists with all the procedural items it is more likely that single items will be missed, and that item could well be the killer item that the checklist was originally intended to protect.
So one of the causes of this accident must be that the crew did not check the flap, or if they did, they did not do it in accordance with the checklist ("Set" would be defined as lever position, indications and lights). Why did they not do so? Were they distracted? Were they used to only paying lip service to the checklist? Had the checklist been padded with extraneous items so that it was really a mini-operations manual?
Lessons (to be) learned
The main contributors to this accident appear to be a human element (resulting in error) - the lack of flap/slat; and a system failure - the configuration warning. This does not exclude the other combinations in the 2x2 matrix, e.g. mechanical flap failure or human error preventing the config warning, but as currently reported the first option is the most likely scenario.
The accident was the result of the combination of these ‘rare’ events, which can represented by the Swiss cheese model. The failure of the warning system was a latent factor and the human element the ‘unsafe act’.
Safety would be improved by either preventing the contributors (close the holes), or in the event of one or both being present, preventing their confluence – another slice of cheese – a new defensive barrier.
Improving the weaknesses in the human element is difficult. The industry accepts that errors will occur (1 to 3 errors/hour); only a few (5%) are undetected, of which only half might have any consequence.
However, the required standard of safety means that HF, CRM, TEM training, etc are still required to avoid, detect, or deal with the consequence of error in order to minimize the risk of a major accident, but this does not prevent the human element being a contributor to accidents.
The latent factor appears easier to deal with; in this instance, the reliability of the warning system could have been better. Previous accidents had identified a weakness (and as indicated by this thread, a continuing weakness), which in airworthiness terms could have warranted a system redesign, but it was judged that an additional check would be adequate. Note that this course of action has several paths where the human element might also be a safety factor. First, the human judgment that the additional check vs a system redesign would be enough, second that the check involves a human, and third, that the need for the check is both communicated and implemented as envisaged; all have opportunity for error.
In some instances, the certification process does allow ‘grandfather rights’, i.e. no need to meet a later standard of certification due to an earlier design/certification, MD-80 evolved from DC-9. This could have been an issue in the decision to use a check.
Thus, with humans involved in the system’s aspect too, it is not wholly possible to eliminate the system contributing to an accident.
The other option of preventing the combination might require identification that either of the contributors was present – use another crew member to monitor or a config-warning system failure detection.
In hindsight, and with concerns about human reliability, an improvement in the aircraft design by addiding config-warning system failure detection might be the better solution. The certification requirements (#2104), states that some aircraft already have ‘config warn inop’ or similar alerting. However, even this option is not totally error proof.
The EBR example in #2201 might have a weakness in that ‘Takeoff’ is announced by someone (thing) other than ATC – (Tenerife?). In other installations, the failure condition might be given during the test, which could be embedded in crew’s memory enabling a real event to be misinterpreted or ignored (Helios?).
There may not be a single safety solution – if there is, it might only prevent ‘this’ accident from happening again. In order to avoid similar, generic accidents, then a broad base of activities is probably required. The industry needs continued effort on HF training (CRM/TEM) and with management (certification) awareness of HF, but equally improvements in the certification and continued airworthiness processes would be required, and in a time scale matching those of operational training.
Ref: 1 to 3 errors/hour – Amalberti. ‘The paradoxes of almost totally safe transportation systems’. Also, see Helmreich et al. LOSA reports.
FAA Certification process study.
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Good and bad news in the case.
On the bad side, the judge has decided to charge the two maintenance technicians that did the probe heater "repair" and the chief of maintenance for Spanair with involuntary homicide and criminal neglicency.
He is pissed nodoby took proper care of the heater problem in a period of over 24h spread in two days (albeit in different cities). Also, nowhere did it say in the manuals that the working air intake heater could just be disconected, only that a faulty heater could be delayed for maintenance if the flight conditions didn't pose risk of ice formation (good weather).
The judge took this decision late today as a result of the declaration of the first round of witnesses that he was interviewing.
Also, the judge decided NOT TO TRUST THE CIAIAC to carry out the "official" investigation and has ordered a new technical investigation to take place parallel to the CIAIAC's.
He ordered to recruit two pilots, two maintenance engineers and two aeronautics engineers to investigate for him. He ordered the official professional pilot's association to send the court a list of 30 suitable professional pilots with over 15 years of experience. Same thing with the association of aeronautical engineers. There isn't an official association of professional maintenance technicians in Spain, so he requested from the Ministry of Development (Fomento) a list of 30 wide-experience, certified mechanics that specialize in MD-82.
The first round of witnesses included some members from the rescue squads.
Next Friday he will call another 6 witnesses, including some workers of ground services for Spanair's subcontractor Newco. Another 4 witnesses on oct. 27th and more on the 31st.
My personal position is that, although there is no doubt the technicians could've done a much better job, it's understandeable that they felt the problem was minor and could've been easily isolated temporarily and taken care of later. If the pilots wouldn't have forgotten the flaps/slats until the airplane arrived at another location with Spanair's ground engineers, it would've gotten fixed and everything would've been ok (sort-of).
Also, it was the pilot's decission to fly the aircraft and not use the other one that was fully ready, with a gate assigned and personnel present, with the busses to move the PAX already in place waiting by the aircraft. Even more, the crew could've made another "start of the day" check (i.e. TOWS check) if they weren't sure the airplane was in perfect shape.
Also, the issue with the probe heater turning on while on the ground, seemed to be an intermitent problem, so perhaps it didn't show on the times the technicians checked it the prior day, as they declared in the maintenance log that all tests with the probe went normal. And, theoretically, the crew run a TOWS test in the previous flight from Barcelona, as required by the SOP.
But a real smart engineer would've questioned how it was possible the heater was switched on while on the ground, and quickly realized that the only way was if there was an inop relay or faulty ground/logic system. Tracing it back, would've questioned the ability of the airplane to safely fly until many more sub-systems were checked, specially the TOWS.
If the heater had really malfunctioned, then there is no doubt in my book that the technicians wouldn't have done anything wrong by isolating it and signing off the a/c. But in this case, the heater was working just fine, except it did when it wasn't suppossed to. In my book, that deserves a little bit more attention and there is a (small) part of responsability in the results of those actions. I wouldn't go as far as to classify it as criminal neglicency, as a significant number of ground engineers would've done the same action given the situation. But not all of them, of course. Boeing also needed to make the maintenance information for that case more clear, I think.
On the good side, only 5 survivors remain hospitalized. The condition of one of them is not made public by desire of her family. The other four are getting better, but two still remain in serious condition, one of which is still in intensive care.
On the bad side, the judge has decided to charge the two maintenance technicians that did the probe heater "repair" and the chief of maintenance for Spanair with involuntary homicide and criminal neglicency.
He is pissed nodoby took proper care of the heater problem in a period of over 24h spread in two days (albeit in different cities). Also, nowhere did it say in the manuals that the working air intake heater could just be disconected, only that a faulty heater could be delayed for maintenance if the flight conditions didn't pose risk of ice formation (good weather).
The judge took this decision late today as a result of the declaration of the first round of witnesses that he was interviewing.
Also, the judge decided NOT TO TRUST THE CIAIAC to carry out the "official" investigation and has ordered a new technical investigation to take place parallel to the CIAIAC's.
He ordered to recruit two pilots, two maintenance engineers and two aeronautics engineers to investigate for him. He ordered the official professional pilot's association to send the court a list of 30 suitable professional pilots with over 15 years of experience. Same thing with the association of aeronautical engineers. There isn't an official association of professional maintenance technicians in Spain, so he requested from the Ministry of Development (Fomento) a list of 30 wide-experience, certified mechanics that specialize in MD-82.
The first round of witnesses included some members from the rescue squads.
Next Friday he will call another 6 witnesses, including some workers of ground services for Spanair's subcontractor Newco. Another 4 witnesses on oct. 27th and more on the 31st.
My personal position is that, although there is no doubt the technicians could've done a much better job, it's understandeable that they felt the problem was minor and could've been easily isolated temporarily and taken care of later. If the pilots wouldn't have forgotten the flaps/slats until the airplane arrived at another location with Spanair's ground engineers, it would've gotten fixed and everything would've been ok (sort-of).
Also, it was the pilot's decission to fly the aircraft and not use the other one that was fully ready, with a gate assigned and personnel present, with the busses to move the PAX already in place waiting by the aircraft. Even more, the crew could've made another "start of the day" check (i.e. TOWS check) if they weren't sure the airplane was in perfect shape.
Also, the issue with the probe heater turning on while on the ground, seemed to be an intermitent problem, so perhaps it didn't show on the times the technicians checked it the prior day, as they declared in the maintenance log that all tests with the probe went normal. And, theoretically, the crew run a TOWS test in the previous flight from Barcelona, as required by the SOP.
But a real smart engineer would've questioned how it was possible the heater was switched on while on the ground, and quickly realized that the only way was if there was an inop relay or faulty ground/logic system. Tracing it back, would've questioned the ability of the airplane to safely fly until many more sub-systems were checked, specially the TOWS.
If the heater had really malfunctioned, then there is no doubt in my book that the technicians wouldn't have done anything wrong by isolating it and signing off the a/c. But in this case, the heater was working just fine, except it did when it wasn't suppossed to. In my book, that deserves a little bit more attention and there is a (small) part of responsability in the results of those actions. I wouldn't go as far as to classify it as criminal neglicency, as a significant number of ground engineers would've done the same action given the situation. But not all of them, of course. Boeing also needed to make the maintenance information for that case more clear, I think.
On the good side, only 5 survivors remain hospitalized. The condition of one of them is not made public by desire of her family. The other four are getting better, but two still remain in serious condition, one of which is still in intensive care.
Last edited by justme69; 16th Oct 2008 at 08:52.
justme69
Flight safety should not be based on having a real smart engineer.
I would prefer to put my trust in an average engineer who follows the book. I'll let the investigators decide if the book was adequate in ths regard.
But a real smart engineer one would've questioned how it was possible the heater was switched on while on the ground, and quickly realized that the only way was if there was an inop relay or faulty ground/logic system. Tracing it back, would've questioned the ability of the airplane to safely fly until many more sub-systems were checked, specially the TOWS.
I would prefer to put my trust in an average engineer who follows the book. I'll let the investigators decide if the book was adequate in ths regard.