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Spanair accident at Madrid

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Spanair accident at Madrid

Old 20th Oct 2008, 21:42
  #2221 (permalink)  
 
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el # and lomapaseo,

There are occasions where, me too, I briefly lift my leg against the fire hydrant of a particular subject to leave a trace, without having anything significant to say.

The reason is, that PPRuNe lacks the simple function (which exists in many other forums) to be able to subscribe (for email notification) to a thread without first having posted in it at least once.

There are threads I like to follow, without necessarily having anything to contribute myself. Having to post a brief pointless remark to subscribe annoys me, but it's the only way.

CJ
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Old 20th Oct 2008, 22:02
  #2222 (permalink)  
 
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Poor mechanics

Poor mechanics, it is probably the worst thing that could surpass one.

Will the mechanics be accused of having a responsibility for the defective TOWS.
And will the investigations find out that pilots did not use flaps, Then I could imagine that there are many mechanics who want to move to another branch.
Who will have such a responsibility on themselves, and be blamed for others' mistakes, and risk a penelty.
It is very exciting what the judge will concluded in this case.

Hopefully there will soon be a crucial track which can determine where the fault can be placed.
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Old 20th Oct 2008, 22:05
  #2223 (permalink)  
 
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There are threads I like to follow, without necessarily having anything to contribute myself.
Go to Thread Tools - and Subscribe.
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Old 20th Oct 2008, 23:16
  #2224 (permalink)  
 
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forget,
Gracias mucho!!
On most forums it's a small tag at the end of the topic, which is why I totally missed that one in the menu bar... which I normally have no reason to go to.
I mentioned it to a moderator, but he was not aware of the existence of that feature either. Issue closed for me, and thanks!

Christian
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Old 21st Oct 2008, 08:54
  #2225 (permalink)  
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I am not sure I understand what the mechanics are being currently subjected to :
First : Are they just "imputaded " to be heard by the judges to find out what they actually did to the aircraft prior the accident ( I could go along with that ) or is there an attempt to use them as (low rank) scapegoats for that accident ?

Secondly , in the SOPs, is the TOWS a safety net , or a tool ?

In my area of work , the failure of a safety net warning system in our (ATC) systems cannot be used to justify an incident/accident. It may contribute to it, but cannot be the cause.

The same in real life I would say : the failure ( or non-vailibility ) of the ABS on your car will not be the cause of the accident you may have .
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Old 21st Oct 2008, 09:59
  #2226 (permalink)  
 
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DISCLAIMER: this post is a theoretical rant.

Well, let's assume for a second (and I personally do not believe this is the case, it's just for the sake of conversation) that indeed the two engineers that did the "repairs" did their jobs carelessly and, as a result, they contributed to an accident that, should they have done their jobs as expected, the accident would've been likely avoided.

Again, just for the sake of this conversation.

Then, I wouldn't call the judge indicting them with criminal negligency "low rank scapegoating". After all, in that theoretical case, they would've done something punishable, right? I mean, the guys hold a degree in engineering, a vaild license for servicing these aircrafts and yet, the judge proves, they did their jobs without regards to the rules and neccesary diligence, resulting in loss of lives.

Also, the judge is indicting the head of maintenance for the whole Spanair, a "high ranking" position, in case he was pressing his subordinates into doing a bad job. A person that wasn't even aware at all that the repair took place, as he is only notified when the airplane is "out of service" and this one, technically, never was, as it was deemed to suffer a minor issue, a simple RAT probe heater that wasn't even needed for this flight in good weather "failing".

So no, *IF* they technicians did something wrong, I do not think the judge is acting wrongly. What's more, he is putting on the line just as well the highest ranked person in charge with supervising the maintenance operation for the whole Spanair.

Who else do you want him to charge? The head of human resources that hired them for not realizing they weren't "good" but careless technicians? The CEO of SAS airlines for not overseeing the acts of every single technician working (or subcontracted) by them? The college that educated the technicians for giving out a degree to somebody incapable of doing a good job? The CEO of Boeing for not releasing better educational materials that can be followed even by careless people?

Sometimes a mistake is only the responsability of the person making it. I'm sure that there are doctors with the finest education in the finest institutions in the world that, once every 20 years, make a serious mistake that impacts the life of a patience significantly.

I'm sure just as well that there are highly experienced pilots, with the finest training available, in the best working conditions in the world, that also make mistakes every so many years.

And it's nobody else's responsability but their own. And no, it's not always that they are reckless and careless (although that's often the case). They are just human.

I'm not talking necessarily in this particular case with the Spanair accident. But I'm getting the feeling that some people in this board think that a pilot (or a techinician or an engineer working for Boeing designing airplanes) can NEVER make a mistake and that, when they do, it's the fault of some mega corporation for (pick your choice): hiring them, not training them, paying them too little, making them work too much, not investing more in safety, not getting their job reviewed 200 times by other professionals, not insisting on more laws and regulations passed, etc, etc.

I agree that, very often, that may be the case.

But we all must also agree that, sometimes, that is NOT the case and a single or a couple of individuals are the sole responsable for their actions and mistakes.

Again, not necessarily in this particular Spanair case, where a bunch of people made small mistakes that helped turn the big mistake made by the pilots into something worse than it needed to be.

(i.e. Boeing engineer's for designing a less than optimal TOWS, Spanair person in charge of SOPs for not insisting on more TOWS checks, Civil Aviation authorities in Spain and the rest of the world for approving these SOPs and these TOWS designs, CIAIAC investigators for not warning about MAP Lanzarote case on time, maintenance technicians for improperly MEL'ing a disconnected symptom instead of a fixing a problem, the person in Boeing in charge of writing the maintenance manuals for not making the connection more clear, etc, etc, etc.)

Last edited by justme69; 21st Oct 2008 at 10:10.
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Old 21st Oct 2008, 10:19
  #2227 (permalink)  
 
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"And it's nobody else's responsability but their own. And no, they are not "careless". They are just human."

Responsibility comes from conciously following procedures and otherwise doing the best job you can in the way you've been taught. As you say we're all human and make mistakes, but that's not necessarily through being irresponsible.

If a responsible person makes an honest mistake that causes a catastrophy, then it would be far more productive to investigate why the procedures in place didn't prevent the accident. Punishing the individual does nothing to help stop the same thing happening again.

The increasing culture of the blame game is extremely unproductive.
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Old 21st Oct 2008, 10:42
  #2228 (permalink)  
 
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Agree totally, nobody goes to work thinking, lets see if we can transform this ship into a pile of smoking debris.
A mistake is just that, a mistake. Living with the consequences of an oversight is probably punishment enough in a just society.
Will punishment bring the dead back ? . . . . obviously not, will it make the victims families feel any better ?I seriously doubt it. Most importantly, will it add yet more incentive to cover up future errors to avoid punitive measures? undoubtedly. As the other thread on justice vs safety discusses, these witch hunts serve only to keep solicitors and judges in employment. They have absolutely NO positive contribution to make to future air safety, and contribute nothing to the future welfare of any victim or family thereof.
Scandalous, simply scandalous short sighted eye for an eye knee jerk reaction ,which to me proves whether a nation should count itself as civilised or not, so that, I imagine, leaves a very short list that are.
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Old 21st Oct 2008, 10:57
  #2229 (permalink)  
 
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It is clear that there are countries where accident investigations become perverted and undermined by judiciary investigations interweaving themselves to the point where it becomes impossible to distinguish the two.

The message to anyone having the misfortune of becoming involved in future investigations is to keep your mouth shut.
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Old 21st Oct 2008, 11:58
  #2230 (permalink)  
 
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justme wrote
DISCLAIMER: this post is a theoretical rant.
..., the guys hold a degree in engineering, a vaild license for servicing these aircrafts and yet, the judge proves, they did their jobs without regards to the rules and neccesary diligence, resulting in loss of lives.
...
So no, *IF* they technicians did something wrong, I do not think the judge is acting wrongly. What's more, he is putting on the line just as well the highest ranked person in charge with supervising the maintenance operation for the whole Spanair.

Who else do you want him to charge? ...

Sometimes a mistake is only the responsability of the person making it. I'm sure that there are doctors with the finest education in the finest institutions in the world that, once every 20 years, make a serious mistake that impacts the life of a patience significantly.
...
And it's nobody else's responsability but their own. And no, it's not always that they are reckless and careless (although that's often the case). They are just human.
...
But we all must also agree that, sometimes, that is NOT the case and a single or a couple of individuals are the sole responsable for their actions and mistakes.
...
Sorry justme, but I completely disagree with your opinion.

First of all, you seem to blame exclusively the mechanics. If you take into account that the main problems seems to be the slats/flaps not deployed by the pilots, then this last ones are the first one in being guilty.

Second, I think that the mechanics, even if the have a degree or a license in engineering, were hired and worked for Spanair, so the company is responsible for their actions, under the legal point of view and under the practice, as they should have been supervised by their actions in a better way.

For sure it is very possible that the mechanics did things wrong, I don´t know, and that the pilots did things wrong, just to be proved.

But the company will not be excused, even though you seem to do that in your arguments.

The only way for that would be that the accident were caused by something external, and it doesn´t seem to be this situation.
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Old 21st Oct 2008, 12:17
  #2231 (permalink)  
 
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Were the mechanics responsible for the aircraft taking off with no flaps?
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Old 21st Oct 2008, 15:17
  #2232 (permalink)  
 
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Were the mechanics responsible for the aircraft taking off with no flaps?
Well. If we IMAGINE a FICTICIOUS scenario where:
-A) The pilots were trained (and allowed by SOP/regulations) to blindly trust the TOWS would catch any configuration mistakes and
-B) The mechanics KNEW (or should've known if they were doing their jobs right) the TOWS were broken and yet didn't do the proper repairs ...

... then yes. They would be responsable. If they would've fixed the TOWS, the pilots wouldn't have taken off with no flaps.

But this is a FICTICIOUS scenario.

I guess for some people it wasn't clear that my position in the previous post was a THEORETICAL position.

I do NOT believe that the mechanics are responsable for the accident.

I do believe that they could've done a better job diagnosing the failure and perhaps that would've saved the day. But I don't know to what extend their actions or lack of REQUIRED ones actually contributed to the outcome.

So, again, if I must say, so that it becomes clear for everyone, I PERSONALLY believe that the contributing factors were the ones I'm listing below. If the CVR recording proves the pilots were more distracted than reasonable (i.e. the LAPA case), then that would shift my opinion even further. Same thing if they were following checklist in that "fast and furious" automatic way I have seen done many times in the past, where the pilots would answer non-standard things, put off some items to come back to them later from memory, etc, etc. That's not the way they were trained and encouraged to do it.

If you have NEVER seen a pilot carrying out a checklist way too fast like it was some kind of race, and you have ALWAYS seen them following the items carefully, writing checkmarks to each item, pointing to the instruments as they read the answers, etc ... then good for you. Please let me know the name of the airline so I can book safer flights for my family.

-The copilot: he was the one in charge of lowering the flaps/slats. He was also the one doing the takeoff maneuver. Although he had been working on the MD-82 for about 2 years and had some +1000h of experience on that aircraft, he can be considered somewhat of a rookie. W/o the exact CVR transcript and actually recording, I don't know how much of his mistake was the result of a "legit" oversight or of a "careless" attitude. Nonetheless, on him goes 50% of the "blame" at this point in MY opinion.

-The pilot: his +10 years of experience and +10000h of flytime should make him now better than trust a "rookie" copilot without double checking the important stuff. For me, he holds another 40% of the "blame".

-The other "highly contributing factor", the failure of the TOWS, from my point of view, COULD be considered an "act of God". Although in this particular case there were other circunstances, the TOWS could've theoretically have failed EXACTLY 1 minute before takeoff. TOWS is an electrical machine. There is NOTHING anybody can do to avoid failure 100.00% of the time. With that kind of design, whenever it fails is up to "God", no matter what maintenance or anybody does. If they allow that type of design to exist in an airplane, failure can occur at any time whatsoever w/o ANY warnings. I'm pretty sure the pilots kind-of-new that, but we all prefer to think it will never happen to us. We all know that, at any time, the brakes in our cars can fail. But we know it's so rare that this happens, that we trust them like if the were never going to fail. Until they do.

-In THIS particular accident, the other 10% of the blame is spread among all those that could've made the TOWS less likely to fail or the pilots less aware than optimal about the importance of correct takeoff configuration (i.e. a SOP requesting to triple check killer items, etc).

Say something like 6% of the "fault" would go to Boeing for not making a better TOWS design/better diagnosis/better maintenance manuals/better spreading the frequent TOWS test recomendations, a 1% to the person in Spanair responsable for failing to include the latest recomendations on the SOP or a SOP with a killer item double check right before takeoff, a 1% on the technicians for not taking a better look at the consecuences of their "repairs" and a 2% to the rest of the people/companies/regulatory bodies/CIAIAC/training systems/etc that allowed the plane to fly with pilots that overtrusted their TOWS (the pilots didn't even tested them prior to this flight, which wasn't even required in their SOP, indicating that they trusted them more than they should've. Somebody should've warned them better of the real danger.)

That's my PERSONAL opinion so that I'm not accused here of defending other positions I do not.

And, of course, I may be wrong and/or there maybe other contributing factors which I failed to mention or which contribution to this accident may be more relevant than I estimate. Again, this is a "rough" PERSONAL opinion, nothing more. I RESPECT that others may have the view of this matter were the "blame" is almost the opposite reverse to my OPINION, and they think that the pilots only have a small percentage of the "fault" and other factors (training, regulations, pressure, etc) are the main culprits. I don't agree, but I respect the view.

And finding "who/what is at fault" is the least important part. The "how can this situation be improved" is more important.

Personally, I think that, no matter how much training, how much experience, how much required procedures (i.e. double and triple checks on the checklists), human error can never been "ruled out" from the equation. Sure better SOPs and checklists can be developed to reduce the chances, though, and better training never hurts.

But I think that technology has a lot to say in cases like this. The TOWS can certainly be made much better nowadays w/o much trouble or expense, so why not start there?

I see no point on not making (all) TOWS nowadays something like this.
When takeoff thrust is applied on the ground or a CONFIG button is pressed as part of the checklist, the TOWS should run a quick self diagnosis, tap all positive sensors and reply:

-A distinctive "musical tone" with the words OK in "happy tone" by i.e. a female synthetic voice (i.e. LA-LA-LEE- "Configuration OK")

-A distinctive alarm tone with the name of the failing configuration in serious tone by a male synthetic voice (i.e. OOOORRGG - Slats - OOOORRGG - Flaps - etc)". This alarm tone would also be used in case of an autodiagnosis fail (i.e. "OOOORGGG - TOWS failure" when a stuck sensor or other condition is detected)

-When silence is "heard", the pilots should notice something familiar is missing and hopefully will conclude the TOWS didn't work for whatever reason (i.e. blown loudspeakers, sound amplifiers, logic board, lack of power, faulty "air mode" ground logic). They should consider aborting the takeoff if they can or be extra alert if they are past V1 when they notice, as they don't have a working electronic watchdog for any unnoticed configuration problems/mistakes there might have been.

I know this is not as simple as it may sound, specially in 30+ year old airplanes, and that too many alarm tones etc can also distract from ATC communications or other more important alarms (fire, etc), or even that the pilots could still try to take off without TOWS "approval" (i.e. LAPA) but I still think that technology can be one of the easy, cheap, effective ways of reducing the likehood for this type of accidents.

Last edited by justme69; 21st Oct 2008 at 16:51.
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Old 21st Oct 2008, 17:59
  #2233 (permalink)  
 
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justme69, you can have all the technologies you want with all the backups you hope but the most important for an airline is safety culture, resources, quality, training…
Remember the e-mails from the Spanish pilots' union SEPLA to Spanair management : "The lack of resources and their quality on the ground, the repeated AOGs in the fleet, the scarcity of crews and the system of movement of crew members, mean the general feeling is one of operational chaos that places the passengers at risk."

Last edited by SPA83; 21st Oct 2008 at 18:10.
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Old 21st Oct 2008, 18:18
  #2234 (permalink)  
 
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justme69,

I concur with your post.

But.... maybe there never should have been a TOWS?

There are a few 'killer' items, and wrong flaps-and-slats settings are one of them. Should those items have become 'routine', because the pilots (maybe subconsciously) 'trusted' the TOWS to alert them to any mistakes and omissions?

Or should the TOWS never have been invented, the "killer items" marked in red in the check-list, and the pilots have it hammered into them, that the red-line items can kill, and have killed before, and if they ignore them, nobody and nothing is looking over their shoulder, and they may be the next on the KIA list....

Does the TOWS give somehow, somewhere a false sense of safety?

CJ
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Old 21st Oct 2008, 18:33
  #2235 (permalink)  
 
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So, to summarise:



1. No configuration warning check was conducted prior to the start of the take-off roll.

2. The aircraft commenced its take-off ground roll in an incorrect configuration.

3. No configuration warning was generated during the take-off ground roll.

4. After unstick, the aircraft departed from controlled flight, resulting in a fatal accident.

5. No clear cause of the incorrect take-off configuration has been positively determined.

Is that it?
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Old 21st Oct 2008, 18:51
  #2236 (permalink)  
 
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69: No offense, but I can not agree with your last post. All correctly analysed and probably what happened, but throwing percentage numbers onto the crew I found somewhat disturbing. Why 60 % and not 69 % or 49 % or 33.3 %. You give yourself a disclaimer at the end, basically saying that you dont mind the opinion others since its just your personel opinion. But accusing the crew to have 90 % (why not 88.7%?) responsiblility shows a lack of fligth safety related knowledge. Lets just quote James Reason, classification of errors:

• Intentional Noncompliance
• Procedural
• Communication
• Proficiency
• Operational Decision

One of which led to the catastrophic outcome of the accident. But what about the firewalls which are in place to avoid those errors.



The holes in the defences arise for two reasons: Active failures and latent conditions. Nearly all adverse events involve a combination of these two sets of factors. So latent conditions being a part of the error chain or rather the error prevention and recognition program. We find tons of latent conditions and neither one prevented things from happening in Madrid. CRM, SOP, Maintenance, Opertional supervision, Training and so on. It correct, at the end it was the SIC who made the mistake. You might as well blame his hand who didnt move the lever.

The US NAvy developed a system called HFACS (Human Factors Analysis and Classification System) a tool developed to investigate conditions which are leading to errors based on the Swiss Cheese model.

You might know all this, but allow me to jeapordise your blame post.
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Old 21st Oct 2008, 19:29
  #2237 (permalink)  
 
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Sorry it didn't come across more clear that those "percentages" were only a wild indication of my feelings, not an actual analysis of the situation. To quote myself:

Again, this is a "rough" PERSONAL opinion, nothing more.
So indeed, the percentages can be freely changed to just about anything you want as long as the order of importance and relative amount is similar. I.e. the copilot 40%, the pilot 30% and 30% for the rest of the factors.

It's just a way of expressing my view, not an actual study of the issues involved, and with the information we have in hand right now. And yes, I do not have hardly any knowledge at all about the aviation safety industry.

But I do believe that this particular case is one where relatively few factors were the real culprits. I believe that work conditions, operations, training, safety culture, etc, had little to do and it was more the case of a single, human mistake that coupled with an unfortunate, untimely technical fault.

I don't think that either, the mistake or the technical malfunction, as it has been on-going in MD-82's for a long time, could've been really avoided (in this particular case, more TOWS tests should've been required, but again, the TOWS could've failed just as well between the time they were tested and the time they were needed). And there is no way to AVOID (not reduce, AVOID) human mistakes. They will always keep happening.

Imagine the PERFECT scenario. The pilots are 100% well trained. The work conditions and operations are OPTIMAL. The airplane is in perfect shape. All tests were done and it all was fine.

The pilot forgets to set the flap. He just forgets. His mind tells him the flaps are set but they are not. It can happen, right? If you don't agree it can happen, then indeed there is no need for TOWS.

So, in spite of everything "perfect", the pilots manage to just miss the setting of Flaps the 2 or 3 times they are required by the SOP i.e.

And just 1 minute before take off, the TOWS in the MD-82 fails.

So now, where does the "blame" fall? Even more training? We established that it was optimal. Even better SOPs/checklists? We established they are the best they can be. Even more maintenance? We established the airplane was in perfect condition and recently tested. Better management? Why, we said conditions and operations were perfect.

It's ENOUGH of a condition for the pilots to miss this single item and, in the case of the MD-82, the alarm failing to operate for this accident to be, likely, unavoidable. Sure better training could perhaps allow them to recover the airplane on time and not enter the full stall condition, but we all know that it is hard to trust that an aircraft fully loaded with tail wind, close to the ground and speed way too slow to properly climb after ground effect can be necessarily recovered after running out of runaway space.

There is only one of two conditions for this accident to not EVER (in practical terms) occur:

-The pilots can NEVER make a configuration mistake.
... or
-The TOWS can NEVER fail right before the takeoff.

But the pilots are humans, and therefore, the first one can not be put in practice. And the TOWS are an electrical machine and, therefore, the second one can't be implemented either.

When they both align, no other factor is NEEDED (it may exist, but it is not needed) for these accidents to happen. In some "perfect" circunstances (which are not quite the case in Madrid, BTW), this cheese would have ONLY two holes. If you want more holes, you need i.e. to make sure there is some way to detect "FOR SURE" that the TOWS didn't fail right before the takeoff. Then you'll have a third hole, which may also be missed by the pilots etc, of course, but at least it's there. Right now, there are only two in a perfect scenario.

But, of course, in Madrid's case, the scenario wasn't perfect. The TOWS had only (theoretically) been tested by the pilots some 5 hours before, not inmediately before take off. If tested, it would've likely be found defective and the airplane AOG.

Also, maintenance was called on a "smaller problem" that was actually related, but they failed to figure it out.

And the flight's conditions weren't "perfect" because of the delay for the "rat probe heater failure", so everybody was somewhat rushed and distracted (but not enough to justify making extra, basic, mistakes, but making them more likely nonetheless).

Etc, etc.

Last edited by justme69; 22nd Oct 2008 at 01:19.
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Old 21st Oct 2008, 19:53
  #2238 (permalink)  
 
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I don't think that either, the mistake or the technical malfunction, as it has been on-going in MD-82's for a long time, could've been really avoided (in this particular case, more TOWS tests should've been required, but again, the TOWS could've failed just as well between the time they were tested and the time they were needed).
IMHO the poor design of the TOWS is a major contributory cause to this accident. But as many pointed out the money factor was predominant.
The TOWS is a simple ON/OFF system where no models are involved, just make sure that some conditions are satisfied. Is an ON/OFF logic, which could have been developed fool proof.
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Old 21st Oct 2008, 20:19
  #2239 (permalink)  
 
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The TOWS is a simple ON/OFF system where no models are involved, just make sure that some conditions are satisfied. Is an ON/OFF logic, which could have been developed fool proof.
Nothing is fool proof. Somewhere along the line it requires human intervention or lack thereof and humans make mistakes. The more foolproof you think that you make it the more the human relies on complacency to just get by with the least amount of work.

I'll wait and see what the investigators analysis of the TOWs finds relative to its performance with average pilots, average mechanics and a combination of worst conditions in operation.
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Old 21st Oct 2008, 20:48
  #2240 (permalink)  
 
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Originally Posted by BEagle
1. No configuration warning check was conducted prior to the start of the take-off roll.
(My emphasis).

Aren't you forgetting something...?

0. The correct take-off configuration was not set and not checked properly prior to the start of the take-off roll.

Why? We will never know.

CJ
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