Spanair accident at Madrid

[BOAC]

I'm with you, justme.

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

[sevenstrokeroll]

BOAC

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

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

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

The pilots should have recognized it also.

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

AND KILLER ITEMS crossing the threshold are still vital.

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


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

[justme69]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[ZQA297/30]

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

The "reasonable performance" spoken of is in fact a legal requirement set by the authorities, and checked aggressively several times a year, not just at licence issue.
Things may have changed since I was flying, but if you flew a full roster-especially long haul, you barely had time to get over jet lag, much less attend kids functions, mow the grass, get the car serviced, and all the other things that eat up your time. You had 2 sim checks a year (requiring some level of preparation no matter how good you are), one route check, and a host of short courses in dangerous goods, firefighting, ditching, emergency equipment, security, etc, etc, etc.
Where on earth do you find the time (and money) to make yourself a "better pilot"? And who is willing to pay for this superior knowledge?

[justme69]

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

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

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

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

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

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

And who is willing to pay for this superior knowledge?

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

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

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

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

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

[sevenstrokeroll]

justme69

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

I learned to fly

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

My airline flew the DC9/MD80.

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

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

MY airline's mechanics were taught this too.

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

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

SIMPLE IS BETTER.

[justme69]

Seven,

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

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

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

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

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

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

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

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

[Smilin_Ed]

Amen!

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

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

[sevenstrokeroll]

justme69

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

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

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

I believe in being simple.

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


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

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

PM me if you like

[justme69]

Thanks for the reply, seven.

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

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

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

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

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

Thanks again.

[sevenstrokeroll]

justme69

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

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

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

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

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

[bubbers44]

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

[justme69]

Thanks again seven for clearing things up.

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

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

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

But I thought we were already doing that.

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

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

The chief of operations for Spanair, Javier Muelas, claimed on TV that they established in their SOPS checks for the flaps 3 times before each take off (i.e. google translated short extract Versión traducida de http://www.salabriefing.es/nuke/modules.php?name=News&file=article&sid=1975 )

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

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

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

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

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

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

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

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

or

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

[SPA83]

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

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

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

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

[Furia]

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

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

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

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

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


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

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

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

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

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

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

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

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

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

[captplaystation]

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

[justme69]

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

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

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

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

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

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

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

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

[lomapaseo]

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

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

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

Human error stubborn snag in airline safety - USATODAY.com

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

[captplaystation]

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

[sevenstrokeroll]

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

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

it is a very remote possibility, very remote.

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