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Spanair accident at Madrid

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Spanair accident at Madrid

Old 16th Oct 2008, 08:23
  #2181 (permalink)  
PJ2
 
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Flight safety should not be based on having a real smart engineer.
Absolutely true.
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Old 16th Oct 2008, 09:20
  #2182 (permalink)  
 
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Smart engineers

Flight safety should not be based on having a real smart engineer.
Flight safety should be based on employing smart people, using smart procedures written by smart people, trained by smart instructors, being themselves checked by smart officials.

In this accident, I don't see any smart people, all the way up to the top of the scale ...

Problem? Smart = Expensive.

For some years now, the official position (authorithies and operators) is that you can dispense with smart people, provide you meet the official standards ... which, by the way, were not written by very smart people ... (IMHO - based on facts I'm very familiar with)
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Old 16th Oct 2008, 10:14
  #2183 (permalink)  
 
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I tend to agree with the need for "smart people".

If Boeing would've been "really smart" instead of "by the bare minimun of the book", they would've:

-Designed (or retrofitted) a TOWS that was easier to diagnose. One that, i.e., when it failed, gave a nice warning instead of the same sign as a "configuration ok for takeoff" (silence).

-Made absolutely sure all airlines in the world, in the absence of a better, more reliable, easier to diagnose TOWS, at least knew about it and was following the recommendation of making tests every flight.

-In the absence of all the above, they would've at least have made better maintenance instructions available on how to deal with a probe RAT heater that turns on while on the ground, so that less "smart" engineers can not confuse the instructions of "faulty"-heater=MEL is just fine.

If Spanair would've been really smart, they would've hired a smart chief pilot that, eventually, after studying TOWS for so many years (Spanair's been flying for 20y), would've realised that a TOWS check each flight was good safety operation to follow and needed to be included in the SOP.

If the pilots would've been really smart, they would've realised after so many years the same thing with the TOWS and run tests, required or not by the SOP, prior to each flight.

If the ground engineers would've been really smart, they would've realised the heat probe problem was actually the symptom of a larger problem, not the problem itself.

But, with the exception of the pilots that were (theoretically) the only ones to make a flat-out mistake (who knew they had to lower the flaps, who had been well trained to lower the flaps and yet, they didn't), everybody simply "followed the book to the bare minimun" and that was enough to avoid the prevention of this accident.

It's arguable that the ground engineers followed or not the instructions "by the book", but as others have written here, "the book", if not very clearly written and covering all posibilities down to the "T", allows for some interpretation that can be "less smart" than it was intended to. It's not the first case of a pilot, a copilot and two engineers agreeing that an item was OK to MEL when it actually wasn't (strictly or as performed).

So much for the safety of "stupidly" following a book that can be miss-interpreted as valid for 3-4 (smart or not so smart?) people ...

Here is part of the judge's reasonings in his proceedings:

-He believes there is strong evidence that the airplane could've fall at the flying conditions from a stall induced by the flaps and slats not being deployed.

-He believes there is strong evidence that the TOWS alarm didn't warn the crew of the configuration error.

-He can read from the maintenance manual that it shows that the RAT heater and the TOWS receive power (on a reverse logic) from the same relay R2-5.

-That there is a possibility that the RAT heater problem was a manifestation of a multi-system malfunction affecting the TOWS, and that such condition was not found by the maintenance technicians.

-He estimates that those actions could constitute criminal neglicency with the result of 154 charges of involuntary manslaughter and 18 of involuntary negligent lesions.

-He requests the two technicians and Spanair's chief of maintenance to report to court to declare as accused parties.
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Old 16th Oct 2008, 10:47
  #2184 (permalink)  
 
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Lurking around the thread since its start and reading the later posts, I'm a bit surprised that the consensus opinion appears to equate the ommission to set the flaps and the inop TOWS as equal contributing causes to the accident.

IF (and clearly this is still the subject of the investigation) the crew indeed forgot to set the slats/flaps, then this is the prime and only direct cause of the accident. Setting flaps is a part of basic airmanship, no doubt the investigation will heavily focus on the particular and systemic causes for the crew to have made such a gross error.

The TOWS is a secondary system that while legally required to operate, technically is not essential to fly the aircraft. Had the accident not occurred, possibly the fact that it was inop would never have been revealed. That it did not work can only be considered a contributing cause, certainly not on par with the primary cause.

Comments ?
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Old 16th Oct 2008, 11:52
  #2185 (permalink)  
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Here is a scenario. Early flight first leg everything is ok. Then the second leg:
1) RAT fault on taxi out or just before T/O.
2) Returned to ramp, problem fixed, book is signed off and was acccepted by the flight crew.
3) Needed more fuel and decided everything was ok, taxied out.
4) Tired and in a rush, ran through a checklist and checked everything ok.
4) Lined up for T/O applied T/O power and then at VR the bird does not fly!!
Many conclusions from this forum, up to the investigative panel, judge, the company and indeed all of us. Blame everybody except...... Hmmm this swiss cheese or manchego, cheese lined up in a very subtle manner and everyone involved failed to see it? I would like to see how much of this report/ investigation is influenced by the liabilty and responsability involved ( ie Spanair).
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Old 16th Oct 2008, 12:49
  #2186 (permalink)  
 
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Technicians face manslaughter charges for Spanair disaster

Here's a new twist . . .

Technicians face manslaughter charges for Spanair disaster
From ABC Australia

The judge investigating the Spanair jet crash in August that killed 154 people is pursuing the technicians who checked the plane before it took off for manslaughter, a judicial official said.

Judge Juan Javier Perez has launched legal action against the head of Spanair's maintenance and two mechanics for "manslaughter and injuries caused by carelessness," the official said.

They have been summoned to attend a first hearing on November 3, the source said.

A report released last week into the August 20 crash that killed 154 people in Madrid said the wing flaps were not properly extended on take-off and an alarm failed to alert the pilots to the problem.

The MD-82, on a flight to the Canary Islands, crashed moments after lifting off from Madrid airport.

Only 18 of the 172 people aboard the aircraft survived Spain's deadliest air accident in 25 years.
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Old 16th Oct 2008, 12:51
  #2187 (permalink)  
 
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Here is a scenario. Early flight first leg everything is ok. Then the second leg:
1) RAT fault on taxi out or just before T/O.
2) Returned to ramp, problem fixed, book is signed off and was acccepted by the flight crew.
3) Needed more fuel and decided everything was ok, taxied out.
4) Tired and in a rush, ran through a checklist and checked everything ok.
4) Lined up for T/O applied T/O power and then at VR the bird does not fly!!
Many conclusions from this forum, up to the investigative panel, judge, the company and indeed all of us. Blame everybody except...... Hmmm this swiss cheese or manchego, cheese lined up in a very subtle manner and everyone involved failed to see it? I would like to see how much of this report/ investigation is influenced by the liabilty and responsability involved ( ie Spanair).
I agree with everything except the "tired" and, to a reasonable extend, "in a rush" part.

The pilots had worked less than 40 hours a month. Consistently for the past 2 years. They had significant vacation periods as well.

They had only been working since 8 that morning, and had a 2 hours resting period right before this flight, and it was only "noon" on a flight that was going to take only 2:30h (3:30h if we account the delay). All in good weather and within the same timezone.

The whole issue with the RAT probe produced exactly a 1 hour delay from start to finish, hardly too much to induce an excesive need to rush.

Also, I do not believe that anybody was (particularly) "rushing" the pilots. Spain, for those few that perhaps don't know, is a country known worldwide for our relaxed pace.

Regardless, the pilots need to know that, no matter how much PAX or other factors may induce some (or a lot) need to "rush", they still need to follow the procedures adecuatly.

But indeed, from the point of view of the pilots, sans the "tired and rush" part, that is also what I think happened.

Once the CVR transcript is made public, perhaps we'll be able to see if they were carrying their job adequately and it was just a reasonable mistake (seems that way so far) or if they actually were engaged in too-lax, perhaps unaceptable behavior or if indeed they were overly tired or "rushed" for whatever unknown reason.

The responsability of Spanair (SAS, actually, they are wholly owned and managed) is also being investigated, but their SOPs seem to be according to worldwide regulations and manufacturer's original recommendations, their training and hiring programs on par or exceeding world standards, their safety record in 20 years impeccable, their safety culture on par with similar operators, their compliance with work conditions fully within western european regulations, ...

I fail to see how, other than not knowing the SOP was recommended (not required) to be changed to include more frequent TOWS tests on the MD-82, SAS could have any responsability for a licensed and experienced pilot's error (or errors), aided by a coincidental system malfunction that had been "serviced" by licensed technicians with significant experience.

CIAIAC's investigation may lean towards keeping happy manufacturer's or operators, but certainly I don't think anybody can (or should) suggest that the parallel judiciary investigation is biased and will not press charges against anybody or any company suspected liable for any voluntary wrongdoing.

Last edited by justme69; 16th Oct 2008 at 14:12.
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Old 16th Oct 2008, 13:35
  #2188 (permalink)  
 
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2) Returned to ramp, problem fixed, book is signed off and was acccepted by the flight crew
I donīt agree the "problem fixed"-thing, thats what most of the discussions here is all about!
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Old 16th Oct 2008, 14:06
  #2189 (permalink)  
 
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I donīt agree the "problem fixed"-thing, thats what most of the discussions here is all about!
Well, I think that what MPH means is that, from the point of view of the pilots, they (and the engineers) thought the problem had been "fixed", at least well enough to sign the airplane fit to fly that flight.

Obviously they were both wrong. But they both were unaware that the TOWS was also inoperative on that flight, as nobody thought of giving the airplane a more complete test and the SOP didn't mandate a TOWS test for the conditions of that particular flight, nor did the maintenance manual suggested a TOWS test after a RAT probe heater problem.

So, from the point of view of the pilots, the plane was "fixed" (which it wasn't), they followed the checklist (which they didn't) and the aircraft refused to fly properly after VR for reasons that weren't obvious to them.

All this, of course, speculating that indeed what happened is that the crew forgot to deploy flaps/slats and the TOWS alarm had become inoperative due to an electronic malfunction since the last time it was tested in the previous flight.
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Old 16th Oct 2008, 14:14
  #2190 (permalink)  
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Perhaps nobody was rushing the pilots, but I know from experience - as do all LAEs past and present - that everybody was rushing the engineers. The big curse of the industry is the accursed "Delay Meeting" driven by senior management and with BIG fingers pointing at the man on the front line with the screwdriver. There's not many that can resist the pressure.

Delays are inevitable when it comes to complex machinery; the greater the complexity, the greater the unreliability and its time we learned to live with it. Not many aeroplanes depart on flights today that don't have at least one page of ADDs lurking in the back pages of the tech log, simply because engineering are denied the time to investigate and rectify them before departure. An MD once said in my presence "You engineers are far too concerned with airworthiness items, instead of concentrating on the important things. That's what the M.E.L is for!" By important things he was referring to cabin trim, seat recline and on-time departure.
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Old 16th Oct 2008, 14:20
  #2191 (permalink)  
 
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Justme69,
Can you be relax when your Flight Duty Time is just below your day limit?
In Madrid Barajas airport you cannot be relaxed while taxi out time is not less than 20 min, ground times are really shorts, particulary, when the airplane is full of pax and finally, your rotation is very tight. Actual flight time might be longer than calculated in the OFP mainly for south configuration.
MAD, BCN are not airports to be relaxed at all.

REGARDS
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Old 16th Oct 2008, 16:25
  #2192 (permalink)  
 
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Well, I think that what MPH means is that, from the point of view of the pilots, they (and the engineers) thought the problem had been "fixed", at least well enough to sign the airplane fit to fly that flight.
Gracias como siempre -69, yes that could be a "human kind of thinking/trusting".

I think most of us has been there; experienced on the type, many years in the company, knowing the maintenance guys and girls etc etc.
I have flown in spain as well and still working here, and enjoying it, BUT I have been in situations e.g I had to tell the Maintenance-guy/girl not to reset the computer but to read-out the code what triggered the malfunction....
This was on a turbo-prop, which is/can be much more foregiving. But this should not be a difference!
One day a (maintenance)-person told me; I rather work on a jet (not getting my hands dirty) then on a "prop-thing", (working in the engine, prop, oil etc etc)

In Madrid Barajas airport you cannot be relaxed while taxi out time is not less than 20 min, ground times are really shorts, particulary, when the airplane is full of pax and finally, your rotation is very tight.
Also true, its not funny to get your airway and startup clearance sometimes, blocked frequencies, long taxi routings etc etc.
And than Your company is asking you your delays??
You kind of feel pushed, its up to us to determine what is safe and what is not (how many of our spanish collegues are out of a job, as we speak?)

IF (and clearly this is still the subject of the investigation) the crew indeed forgot to set the slats/flaps, then this is the prime and only direct cause of the accident. Setting flaps is a part of basic airmanship, no doubt the investigation will heavily focus on the particular and systemic causes for the crew to have made such a gross error.
Fully agree, all what happened before MAY have been a contributing factor, but if investigated and they "forgot" the flaps..........

I remember 2 accidents in BCN last year, i think.
1. A contracted (no spanish registration) turbo-prop landed nose-gear-up in bcn.
2. Whithin 24 hours a "little"-jet (spanish registration) landed completely gear-up in bcn

In case of nr.1 a fully initial report is available (in no time) via the spanish DGAC.
In case of nr.2 some initial fact are known, while most of the spanish aviation-community knows that, "due to circumstances", they simply forgot to lower the gear.

I was told, case nr 1 was handled professional, pax informed, atc informed etc etc.
This was not the case in the nr.2

I donīt know, but I feel a little "protecting our own market"-thing in spain.
No, I didnīt use the words "cover-up".
But, its just an observation, which I hope will not happen in the spanair-case; "let the true but nothing than the true" come out.
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Old 16th Oct 2008, 17:22
  #2193 (permalink)  
 
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wood versus trees

I am not a professional pilot - how do those of you who are - deal with the issue of distinguishing the wood from the trees in all this check, check, checking ?

I work in a safetly critical job (medicine) and have an ocean of SOP's to get through many times a day. Every time i take resonsibility for a patient and having gone through industry and company policies/SOP's - i then have my "own" checklist of killer items/gross checks to stop me doing something really stupid as i line up on the centreline. I also have training responsibilities and (quietly) try to impart some of this "supplementary" behaviour/paranoia to my younger colleagues.

Sometimes the biggest mistakes are the easiest to make (in an environment full of background noise, invented by A.N Other) like taking off and heading 020 instead of 200 - because no one told you to make sure the big yellow sun thing was in front of you rather than behind you (northern hemisphere !!).

Properly conducted 200 item checklists should work fine - but it's common for homo sapiens to see what they expect/want to see.

How do you stop extensive checking missing gross errors ? Nobody expects the spanish inquisition - but Cleese and Palin still turn up.


"aux vaches"

"correct patient, correct operation, oxygen flowing, ventilator on, chest moving, anaesthetic delivered and vital signs ok " (7 steps to avoid quadruple jeopardy !)
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Old 16th Oct 2008, 18:02
  #2194 (permalink)  
 
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Spot on post Blacksheep.

However it isn't just maint managers that apply the pressure.
Airline station managers with maybe just one or two flights a day can really get their bonus' cut if the engineers/crew etc delay "their" aeroplane.

There for the grace of....etc.
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Old 16th Oct 2008, 18:15
  #2195 (permalink)  
 
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"aux vaches"
A couple of pages back, boofhead in post #2206 made much the same point.
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Old 16th Oct 2008, 21:27
  #2196 (permalink)  
 
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Sometimes the biggest mistakes are the easiest to make (in an environment full of background noise, invented by A.N Other)
aux vaches, how I agree! There are so many edicts and procedures coming from who knows where these days. So many acronyms to remember (is flying an a/c safely really that complicated?).

We often need to take a step back from what we are doing to see metaphorically where "the ship is heading" or, as my dad taught me, "hurry slowly".
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Old 16th Oct 2008, 23:57
  #2197 (permalink)  
 
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To be correct, it is involuntary manslaughter thruogh negligence (sounds different ?), if convicted they will be getting off on a fine.

Also, but on the same line, accusation is *NOT* an automatic conviction here in Spain no matter what uninformed sources might tell ya.

From the judgeīs point of view, all he needs is indication for a crime (felony) to take action, and he has made it clear that he figures there are plenty of them (personally, I agree, but do not think it will lead to conviction as the main cause seems stll to be the misconfiguration in first instance).

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.

The judge charging them with a homicide seems a bit extreme.
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Old 17th Oct 2008, 00:12
  #2198 (permalink)  
 
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I have thought about this all day long, after seeing that the Engineers are to be called to answer and may be punished for their actions.

Whose shoes would you rather be in? The flight deck, who, God bless, are no longer with us, or the Engineers, who are living this every day?
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Old 17th Oct 2008, 00:51
  #2199 (permalink)  
 
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The link below to the BMJ states that 70% of aviation accidents have human error at the root.
But what is remarkable is:
The US Institute of Medicine estimates that each year between 44 000 and 98 000 people die as a result of medical errors. When error is suspected, litigation and new regulations are threats in both medicine and aviation.
A rush to institute legal proceedings is therefore entirely predictable. Sigh.



On error management: lessons from aviation -- Helmreich 320 (7237): 781 -- BMJ
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Old 17th Oct 2008, 08:58
  #2200 (permalink)  
 
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Whose shoes would you rather be in? The flight deck, who, God bless, are no longer with us, or the Engineers, who are living this every day?
Seeing as you asked.......I'd rather be in the engineers shoes, I'd rather be alive, able to still see my wife and kids and them still able to see me.
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