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Spanair accident at Madrid

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Spanair accident at Madrid

Old 24th Oct 2008, 14:03
  #2281 (permalink)  
 
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I do not want to exclude any posibility.
There is no video camera on the cockpit so we only have the CVR.

The oficial preliminary report states that the crew completed the checklist.
They say nothing about rushing items or missing items. Anyone that has flown in Barajas knows the long taxi to the runway so they should have not rushed any items anyway.

The report concludes the crew was performing the appropiate checklist.
No comments there, nothing was rushed, ommited or neglected, but still some people wonders if the pilots may have been doing some wrong

Seems that for some people here it is easier to assume that the crew was just reading a checklist but not doing their job rather to assume that a not uncommon flap/slat extension failure happened.

You must forgive me but without discarding any possibilities I prefer to think that if one pilot was challenged with the "Flaps and Slats" question and he positively answered "Flaps and Slats OK" he meant that.

If you want me to change my mind about that, demonstrate it otherwise.
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Old 24th Oct 2008, 14:36
  #2282 (permalink)  
 
Join Date: Aug 2008
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Well, I don't want to get in an argument here, but if indeed the response to the checklist item flaps/slats was "OK", then that's your first evidence that the crew wasn't doing their job properly.

They should've answered with the degrees setting and the setting, like "11/Takeoff", as trained and required by the SOP.

Also, it wouldn't be the first proven case in the history of aviation of a rotten response, but it would be the first one of a multiple system failure involving a very simple and reliable mechanism that developed into no less than 8 (4 for each wing) simultaneous failures (flaps actuators, flaps sensors, slats actuators, slats sensors), that resulted in a lighted indicator and an analog watch dial indications TAKEOFF for slats and 11 for each of the flaps when indeed both flaps were at 0 and the slats (likely) retracted.

If you choose to rather believe in someone saying "ok" rather than both needles of an ANALOG indicator gauge pointing "mysteriously" to 11 (while the flaps were at 0) and a lighted indicator receiving power from TWO switches (one on each wing) closed by "something" in the place of the slats while the slats weren't actually there ... well, that's your choice and indeed it's a possibility.

But realistically, we all know what is far more likely.

Also, it has been proven in the past that crews failed to deploy flaps and slats in at least 4 more cases (Detroit, Delta, LAPA, MAP). So it is not so "unusual".

And the CIAIAC CVR preliminary analisys doesn't say the pilots completed the checklist, only that there is evidency of SOME ITEMS of the checklists being performed. Exactly, what it says is:

"The conversations of the cockpit voice recorder (CVR) revealed CERTAIN EXPRESSIONS corresponding to the before engine start checklists .... the normal start list, the after start list and the taxi checklist ..."

It doesn't say anywhere that the pilots called flaps/slats and the response was "ok", which still would've been a wrong response, but at least it would show that they were trying and they probably thought they had set it.

And UNOFFICIALLY, sources close to the investigation say that you can perhaps, with foreinsic CVR analysis help, indicate that indeed the pilot called flaps/slats and the copilot answered ok. But that's unofficial and would still not prove that the actual flaps and slats were commanded to deploy and the indicators verified, only that they thought they had set them.

The alleged response of "OK" (instead of 11/Takeoff) could also mean that the copilot understood a different item to be checked instead of the flaps/slats and replied to that, while the pilot calling the item didn't verify or requested the proper response.

Last edited by justme69; 24th Oct 2008 at 16:03.
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Old 24th Oct 2008, 14:50
  #2283 (permalink)  
 
Join Date: Feb 2008
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Quest for continuous improvement

Hello !

justme69
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.

I fully agree and not only to learn more about the machine, but also about other very important aspects of his job. It is part of the required enthousiasm that is a character of good pilots. It is pure airmanship . If you are interested, I recommend Flying kow-How and Flying the weather by Robert N. Buck (Macmillan).

However, not all the pilots have the proper culture to progress by themselves in the several improvement paths. That is the reason every airline has a training department, even if they dont provide basic training or type rating. Instructors, chief instructors, head of operations should have - collegially - the required culture, experience, airmanschip and information (error reporting litterature) to design an appropriate continuous improvement program.

It is nowaday recognized that the initial type rating could not provide all the in-depth kowledge of an aircraft. You have to build that in-depth kowledge by adding layers of kwowledge above layers of training and operational experience. With proper supervision an progressive checking.

The fact is that there is litlle or no standard about that continuous improvement of competency and airmanship. Its rests upon the shoulders of the chief pilots and instructors.
So each time you hear Our airline is fully complying with the standards it means NOTHING.
Or , in fact, it means : we are satisfied with minimum standards L

justme69
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).
1. Obviously, MacDouglas and Boeing should have done better ...


2. Better human knowledge (of the aircraft systems and other safety related toppics) doest not come from more training, it comes from better training Better training is given by better instructors, using appropriate tools and a better syllabus. You don't need the latest multi-million simulator to train better pilots, what you need is :
- first class instructors (instructors with extra airmanship, instructors who think ) not the kind of repetitors that are so frequent among sim instructors
- selected pilots applicants selected and trained not for their parents wealth, but for their smartness and enthousiasm for flying.

When airlines used to train their future pilots ab-initio and for free , their first objective was to select the right stuff .

Only a very limited percentage (5% or so) of applicants made it to the right seat of an airliner.
Today, training is given by commercial subcontractor, and paying trainees are indeed customers . You wont reject customers
Selection is a joke. It is just a selection by the money So, only a very limited percentage of applicants are rejected in commercial FTOs and TROs.


3. Better technology can help to some extend. Airbus was supposed to provide that cutting edge technology improvement towards flight safety. You think they made it ?

Actually, the best improvement in flight safety came with the introduction of CRM and scenario based recurrent training. A real improvement from the previous macho philosophy. Still a long way to go (at least with Spannair) :
- A properly CRM trained crew member would "never ever ever" accept a sloppy challenge and response check list. (Just considering it as an insult ...)
- A properly scenario trained crew would know better about stress and distractions

justme69
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.

I do not agree with the "more frequent test" remedy.
The main business of a pilot is not to test again and again his parachute The main business of a pilot is to make sure not to have to use that last ressort safety net.
Before take off, there are much more important items to check, rechek and cross-chek The system tests should really be kept to the minimum (I agree with a test during the prestart scan ... as a normal pilot habit!)
But, once the aircraft starts moving, chek list should be restricted to the killer items, and to those items that were impossible to set/check while the aircraft was at the stand.

sevenstrokeroll
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.

I fully agree.
For the same reason that the maintenance manager has to report to justice, I think the chief pilot and a few other managers should be involved as well.

An airline his supposed to have a strong structure garanteeing safe operation :
- a trainging departement and a flight ops department working in close relationship. They are supposed to be headed by very competent and experimented responsible managers
- a quality manager, a quality system and a safety officer working in close relationship, and coordinating/supporting other managers efforts.
- scheduled quality management meeting, examining audit reports and propositions for improvement.

Let us not forget the triple mission of the quality system :
- make sure that mandatory standards are complied with. We know that lobbying by short sighted cost conscious airlines have reduced those standards to a level well below what was previously in force by first class airlines. Just a paper work challenge ...
- seek for continuous improvement above those bare minimums. It means of course see at it that the "responsible managers" really work in that direction ! A very exciting challenge indeed, provided that all the managers are willing to play and that they have the time and smartness to be honnest players.
- keep the top management "in the loop".


It is a fine structure ...
But that structure did fail ...well before the crew entered the airplane that day.
There was a latent defect somewhere ...
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Old 24th Oct 2008, 15:30
  #2284 (permalink)  
 
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BIS,

I agree with most of the points you raise. When we post here, we all obviously try to be brief and shortcut our explanations a bit.

So just to clarify, when I said "increased training" I meant "more, better training". I disagree that knowledge doesn't come from "more" training but only from "better" training. I think that it comes from both, but that's just semantics.

When I said "more frequent TOWS checks" I meant more than just once a day and whenever pilots changed or were away from the cockpit for a long time. In more practical and specific terms, I meant "once a day by maintenance and shortly before each takeoff by the crew". Obviously TOWS check is an important safety measure, as shown in this an other cases, second to killer items, of course, but not far behind, lacking a better solution (i.e. technologically super-reliable TOWS which gives a big and clear indication when it fails)

I fully agree with the "right culture" against the "macho" culture. I think there is a LOT of that in Spain at least (Iberia, Spanair, Air Europa, Binter, Air Comet, etc). I have no problems pointing fingers where I think they are due.

I, nonetheless, disagree that training or "corporate culture" in those companies promote or condone this kind of behavior, but SOME pilots engage on it right away shortly after their license/rating is granted.

Firing someone with a powerful union behind is not easy or cheap in Spain. And with closed-door cockpit policies, other than consistently spying on your own pilots through CVRs and QARs I don't know how they can figure out the good apples from the bad.

I'm all in for planting videocameras in the cockpits and have one person in the airline reviewing everyday random flights and suspending pilots left and right. But I can see hell being raised by them and their unions, so it probably won't happen and the "machos" will continue to dominate the skies.

I have two relatives that are in the aviation industry. One is an ATC and the other is an airline captain for a major airline in Spain. The horror stories he tells me of while travelling around in jumpseats are not for the faint of heart.

DISCLAIMER: Obviously there are very fine, top of the line worldclass pilots in Spain. But we have ALL seen what some less stellar ones do around here. And not only here, of course. Look at the CVR from LAPA or Delta (etc, etc) in similar accidents for much much worse.

And on the good side of news today, all survivors have left the hospitals in Madrid, although one of them would still need local medical supervision for a while. All 17 PAX and 1 avan crew member that survived have been able to recover favorably.

Last edited by justme69; 24th Oct 2008 at 16:00.
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Old 24th Oct 2008, 15:44
  #2285 (permalink)  
 
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I encourage you to see a movie, Whisky Romeo Zulu, from Enrique Pieyro, former pilot of LAPA. The movie has its name as it was the LAPA plane, LV-WRZ
I dont know if there is any version of it in English, but those who know spanish will appreciate it.
The case of the LAPA plane was not only about pilots forgetting to put the flaps/slats and not giving attention to the TOWS (that in that case worked fine).
It infoms precisely the many layers of swiss cheese that were aligning in that company that lead to the disaster.

Besides all, we are forgetting the particular circumstances of that day, the copilot in charge of the take off knew that he would be fired or offered an administrative work; also a press comunicate from the sindicate pronouncing some facts about the risk in the operations in Spanair (that never saw the light as a consecuence of the accident)...

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Old 24th Oct 2008, 16:08
  #2286 (permalink)  
 
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I have seen the movie and considered it too biased. But what would you expect from a movie made by a pilot unionist.

Otherwise, except for a couple of times when I thought it was being overly one-sided, it raised many vaild issues to public awareness that basically shows the caos in Argentinean civil aviation industry.

And all of you are going to excuse me, but I still fail to see how management or training etc can have much to do with a basic, simple human mistake like not lowering flaps.

I would understand that undertraining and generally unsafe practices unsupervised could lead to pilots making mistakes during complex maneuvers or extreme situations.

But something as basic as lowering the flaps handle while taxiing on the ground for 20 minutes by a rested, non-overworked crew?

Isn't every single pilot in the (first) world taught to never ever skip the checklists, do them right, and never forget the flaps/trims/spoilers/landing gear/etc like a million times?

How come when they fail to do that is NEVER their fault but "the company" for not firing them/training them (even) better?

I guess I have a question to make.

When is a pilot's mistake ONLY his fault and nobody elses? Never?

In that case, congratulations to all of you who are pilots. You can never fail because when you do, it's not your fault, it's somebody elses that apparently is human, unlike you.

Last edited by justme69; 24th Oct 2008 at 17:03.
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Old 24th Oct 2008, 18:57
  #2287 (permalink)  
 
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the whole point is this:

if you are taught to use a checklist, but don't...it is vital that you be found out ...but if the management doesn't look for problems, they won't be found.

I would like to listen to the CVR and try to hear the movement of the flap handle into the detent. Or the actual movement of the slats...I've heard them at idle thrust when selected.

I would also like to know if the CVR picked up the stall warning horn.

I think the crash would have been more survivable if the use of the ''snatch'' rotation had been discouraged. Waiting for the plane to ''fly'' off might have given a better chance of surviving the crash. rolling off the end, right on centerline certainly would be better than slipping off the side into a ravine.


I wish that spanish judge would chat with me.
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Old 24th Oct 2008, 19:27
  #2288 (permalink)  
 
Join Date: Feb 2008
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justme69
When I said "more frequent TOWS checks" I meant more than just once a day and whenever pilots changed or were away from the cockpit for a long time. In more practical and specific terms, I meant "once a day by maintenance and shortly before each takeoff by the crew"

Im not type rated on the MDs
As far as I know, the actual procedure for testing the TOWS is to advance thrust levers while the flaps are up or the airbrakes are out.
Nobody wants to do that while taxying, and nobody wants to be in an abnormal condition shortly before take off just to test the warning system !
But this is so easy to perform (at least partially) before start, that I dont see any reason not to perform it before each start up. (Let it be a partial check : the airbrakes out condition would not be checked )
First flight of the day checks are a pity A test is either important and then it is wise to make an habit of checking those systems before each flight or that test is not really so important, and then let us forget about it and concentrate on more important items directly affecting safe operation.
Then, giving a look at the RAT indication before departure would give a clue about air/ground mode if the reading is abnormaly high. And there are other good reasons to observe that instrument shortly before departure ...
There are other ways to improve proper take-off configuration set-up :
- do it as soon as practicable, as a priority action. Say - typically - just after push back
- keep the taxi checks to a strict minimum
- ask for before take-off check list before calling ready for departure and keep that check list short ! By the way, a captain should silently review the killer items just for himself before asking for the check list (IMHO and that is my personal private safety net, my pride not to be saved be the check list).

Justme69
I, nonetheless, disagree that training or "corporate culture" in those companies promote or condone this kind of behavior [macho culture], but SOME pilots engage on it right away shortly after their license/rating is granted.

Firing someone with a powerful union behind is not easy or cheap in Spain. And with closed-door cockpit policies, other than consistently spying on your own pilots through CVRs and QARs I don't know how they can figure out the good apples from the bad.

I'm all in for planting videocameras in the cockpits and have one person in the airline reviewing everyday random flights and suspending pilots left and right. But I can see hell being raised by them and their unions, so it probably won't happen and the "machos" will continue to dominate the skies.
It is part of the chief pilots responsibilities to see at it that a macho culture does not survive in the company. Many tricks are available during sim checks to have macho's regain some humility ...
Yes, spying crew as much as practicable is a chief pilot duty and a common practice by top companies. Crews are aware that recorders are going to be checked, either by their chief pilot or by state inspectors
Firing an undisciplined pilot is difficult, or expensive ? Try an accident !
In any way, that will hold true for the first firing, less so for the second one and then, there will no longer be any need to fire somebody ...

Justme69
And all of you are going to excuse me, but I still fail to see how management or training etc can have much to do with a basic, simple human mistake like not lowering flaps.

I do excuse you You cannot realise the accident prevention intricaties and subtilities if you are not in charge in the real world
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Old 24th Oct 2008, 20:21
  #2289 (permalink)  
 
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Thank you, Bis

Just for the record, I do understand some of the "subtleties" involved, like checking the RAT reading and RAT air intake anti-ice heater having more to do than simply showing potential air/ground logic faults. The autothrottle computers would appreciate having the correct temperature readings for the calculations.

I do not know if the MD80 have alarms for when the heater fails while on the air, but I know some similar (but more vital) devices like the pitot do.

Again, for short, I guess I didn't specify that by testing TOWS shortly before takeoff, I meant right before the engines are started is close enough if that's the most convinient time to have the flaps up and move the throttle to switch activate position w/o bothering/endangering anyone.

"Overnight" daily checks done by maintenance are, from my point of view, a good thing as it provides with a less stressful and rushed enviroment in which an engineer expert rather than a pilot can test systems more deeply. Some times, I understand other systems are better tested while flying and/or performed by the crew.

And I do understand that a better managed, very supervising company, where knowledge is spread and advanced during time, etc, etc, can strongly contribute to a safer operation where a "simple", "silly" mistake like forgetting to lower the flaps is LESS LIKELY to happen.

I guess I didn't make myself clear. My problem is with "inmediately" blaming the company/management with something that COULD be the sole fault of the pilot. Granted it's not always the case. Perhaps even not the most common, I concur.

My problem is with those that do not believe that the pilots EVER can do anything wrong because, if they do, it's only because other humans working in the airline, regulatory bodies, or at Boeing, or at a maintenance subcontractor made them.

My problem is with those that think that fogetting to set of the flaps at least 55 times in the USA in the past 7-8 years (voluntarily reported), means automatically that in all cases tons of airlines must have crappy training, bad safety culture and poor supervisory skills, and they should all be put in jail for that. Except the pilots, who simply "followed along" blinded from the dangers of not lowering flaps.

We are all humans and we all make mistakes. As long as pilots only forget to lower flaps once in their career, I'm ok with that. I can not, in good faith, demand for much better. Hopefully, when they do, the TOWS won't be inoperative. I can, though, reasonably demand for a better TOWS than the one involved in this case.

Last edited by justme69; 24th Oct 2008 at 20:48.
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Old 24th Oct 2008, 20:30
  #2290 (permalink)  
 
Join Date: Jun 2003
Location: Madrid
Posts: 146
Furia,
According your hyphotesis:

1 After start checklist was properly performed. Therefore:
i) Flap/slats were selected according TO performance calculation
ii) Slat secuence was checked as: disgree/TO/disagree-auto/disagree/TO
iii) Flap position indicator was checked to agree with selected flaps (both)
iv) Slats T/O light was checked to be ON and all other slat advisory lights
to be OFF.
v) Auto slat fail caution light on annunciator panel was checked as off.

2) Take off briefing during taxi was performed and flapp setting was checked.

3) Take off inminent C/L was properly performed and so:
Flap/slat position was verify( needles + light) during final/killer items check


Even though procedures comply 100% with SOPs, in FACT flap/slats were not deployed.
This scenario being true, I guess no MD pilot all over the world might trust this machine and the MD fleet should be grounded inmediately.
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Old 24th Oct 2008, 21:22
  #2291 (permalink)  
 
Join Date: Aug 2008
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Now, to be honest, I'm appalled at the aviation industry for a couple of things that were permissable 30 years ago but I no longer think they should be today.

Granted I haven't seen the operations inside a cockpit on large airliners (some small commuter planes don't even have cockpit doors) for a while, but last I saw say only 9 years ago or so (Spanair, Aviaco, Alitalia, Usairways I remember specifically), and they still were holding a crappy piece of folded paper as their checklist, going through the items from my point of view faster than neccessary.

I know that checklists are computerized in some airplanes, specially new ones, and I understand that older types like the MD80 don't have that luxury.

But would it be too much to ask to print out some decent (instead of crumbled) checklists and asks the pilots to put checkmarks on the items or use a little lighted electronic board to check them off as descibed before in this thread?

Also, while I was reviewing old Spanair checklists I noticed how the most important item was in the first position in larger type. Well, because of this, I did miss the Flaps/Slats in the inminent takeoff checklist on the first look, subconsciously thinking it was a header rather than an item. I'm not a pilot, though, so I guess I'm excused.

Frankly, I thought the whole checklist system was far below anything needed since the invention of the inkjet/laser printer. The typeface, colors, etc. It can all be done so much better by a 12 yo (I'm exaggerating, of course).

Also, from the checklists I have seen carried out, most of the time it looks like one pilot is simply reading and the other setting/verifying, with the first one taking whatever the second one says for granted while he concentrates mostly in taxing rather than double checking (except for crosschecks, usually).

And last, very few times I have seen a pilot actually truly checking the flaps indicator while lowering the handles. The one flying during landing would call "flaps 20" and the other would lower the handle and inmediately answer "set" w/o ever looking at the indicator. This always caught my attention. Sometimes the one lowering the handle wasn't even looking at the position it was (actually looking out the window), just trusting it was the right detent by the "feel".

Not to mention the "macho" pilots who would go down fast and high and straight to flaps 30 after a 180 at 70 roll... (or who knows what angle, I'm bad at estimating these things, but at least 45), but that's another story and the exception rather than the rule.

These are the words of Spanair's chief of operation, Javier Muela, extracted from an interview and translated by me:

In relation to procedures for checking the takeoff devices he said: "from the time the engines are started until take off, the takeoff configuration is tested up to three times, specially the flaps and its indicators, to make sure it's the correct one" .... "This triple check is even more effective than a TOWS check recommended by the manufacturer, which nonetheless is made during the first flight of the day or, in consecutive flights, if the crew changes or if they have left the aircraft".

He said that the first (TOWS) check was done (should've been done by the pilots) in the previous flight from Barcelona and again in the next one, Madrid-LPA, where the airplane remained for over 2 hours in the stopover, as the crew had left the cockpit for a long time, so "the crew made (should've made) another (TOWS) check upon entering the cockpit".

They weren't required to check the TOWS again for takeoff after the Return to Gate due to the RAT "problem", as they had not left the airplane and (theoretically) had tested them already for that flight (about 1 hour before, if the SOP was followed). This does not follow Boeing's recommendation of testing them before each (attempt to) takeoff. Spanair has since changed the SOP and now requires a TOWS check for the MD's before each takeoff, not just upon both pilots entering a cockpit.

Because the CVR only records the 32 minutes prior to the accident, and the airplane suffered the "RAT heater problem" delay and long taxi times in excess of 15 minutes each way, a lot of the data for analyzing previous crew actions can not be properly known.

Last edited by justme69; 25th Oct 2008 at 07:27.
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Old 25th Oct 2008, 01:02
  #2292 (permalink)  
 
Join Date: Oct 2006
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Justme
These are the words of Spanair's chief of operation, Javier Muela, extracted from an interview and translated by me:

In relation to procedures for checking the takeoff devices he said: "from the time the engines are started until take off, the takeoff configuration is tested up to three times, specially the flaps and its indicators, to make sure it's the correct one" .... "This triple check is even more effective than a TOWS check recommended by the manufacturer, which nonetheless is made during the first flight of the day or, in consecutive flights, if the crew changes or if they have left the aircraft".
If this statement is true, then we have a clue. It is very possible that the TO configuration was checked only once.
If so, we can presume that the pilots were used to do this only one time, not three times, so the procedures were not followed, and in this case we can talk of poor management and training, as nobody noticed what they were doing.
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Old 25th Oct 2008, 04:06
  #2293 (permalink)  
 
Join Date: Aug 2008
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While I personally think that it's not easy at all to "catch" pilot's bad behavior, specially if it is only sporadic, I'm all for forcing airlines to install voice/image recording devices in the cockpits that last longer than the 32 minutes of the CVR which, best case scenario, would only allow to evaluate pilot's behavior for the landing part of the last flight.

That way airline supervisors can figure out what goes on behind the locked doors of the cockpit and catch bad apples before their actions becames a danger. Don't we all agree that this would be an easy, cheap and really effective way to monitor progress and compliance of crews with training?

After all, the last 8 large accidents with victims in the US have all been due to human error. This was Spain's worst accident in a long time, the first one with victims in Madrid in 25 years and the first one for Spanair in 20. Over 65% of aviation accidents are due to human error as the primary cause.

In that case, those within the company in charge of supervising could also be held responsables for repeated risky conducts of the pilots under their supervision/training.

It looks a bit like "who watches the watchman" to me, though.

So a pilot (consistenly, lets make this easy) fails to do his job as trained and the person that hired/trained him is to blame. Therefore, they failed too and all "four" go to jail. And it's OK to end it there. We don't need to hire someone to supervise that the supervisor is actually supervising the pilot, or that the trainer is actually properly training the pilots.

And if we establish such a position in an airline, then when a pilot fails, we send to jail also the supervisor for failing to catch him and the supervisor of the supervisor for failing to notice that the supervisor that failed to catch the pilot wasn't doing his job correctly.

I'm all for that too.

But why stop there? I would put a smiley face if the matter wasn't serious.

While I would totally understand the chief pilot/chief of operations/training of Spanair being charged by a judge if he never allowed the pilots to know how to properly deploy the flaps and how to follow the checklist, or if he had knowledge that they weren't routinely following the proper procedures, I don't see how he can be responsable if he never found an indication of that being the case and the training included more than sufficient information on the importance and proper procedures of flaps deployment.

Last edited by justme69; 25th Oct 2008 at 04:51.
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Old 25th Oct 2008, 04:42
  #2294 (permalink)  
 
Join Date: Jul 2005
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Originally Posted by bubbers44
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.
You would only have noticed that something is wrong as soon as you had left the ground effect. Until then you would have used the same Vr and therefore required almost the same amount of runway to get the wheels off. Bouncing back to the runway is certainly not an option once the iron lady tells you stall especially when the plane starts rolling unexpectedly. What makes you sure, you would have saved the day?
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Old 25th Oct 2008, 07:11
  #2295 (permalink)  
 
Join Date: Feb 2008
Location: Belgium
Posts: 58
Crappy airlines by the tons? Yes

Hello!

Justme69
My problem is with those that think that fogetting to set of the flaps at least 55 times in the USA in the past 7-8 years (voluntarily reported), means automatically that in all cases tons of airlines must have crappy training, bad safety culture and poor supervisory skills,
I'm among those that think that [...]
Yes sir, that is the real world.
Tons of lifetime examples ...
Demonstration?
Let it be given by a sharp occasional observer :
Frankly, I thought the whole checklist system was far below anything needed since the invention of the inkjet/laser printer. The typeface, colors, etc. It can all be done so much better by a 12 yo (I'm exaggerating, of course).

Also, from the checklists I have seen carried out, most of the time it looks like one pilot is simply reading and the other setting/verifying, with the first one taking whatever the second one says for granted while he concentrates mostly in taxing rather than double checking (except for crosschecks, usually).
Now, to be honnest, taxying is not the best time for Challenge and Response check list ... So the necessity to restrict it to very essential items.

In short, there is a real need to improve the useability of check list, as well as to promote a good "tempo" for calling "Check list!".

- subtilities/intricaties of accident prevention
- need for smart people ...

Please, don't take me wrong, I do appreciate "strong" safety devices ... but I hate seeing them used as an argument to dispense with "strong" crews, witch is the modern tendency ...
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Old 25th Oct 2008, 07:53
  #2296 (permalink)  
 
Join Date: Aug 2008
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Hi Bis,

I think that, deep inside, we agree more than we disagree.

What I was trying to say is that I object to those that state, in cases similar to this, that they do NOT blame the pilots but the airlines for these accidents.

A pilot is a grown adult and knows very well that he is not doing his job right when he doesn't follow checklists as trained. The fact that nobody has caught him acting that way, doesn't mean that he is not responsable and, like a child, is not liable for his own actions.

Other people in the system may have also failed in their responsability (to catch and fire him), but you can't say: "I don't blame the pilots, I blame those who trained him", when those who trained him DID teach him correcly how to follow checklists and how to lower flaps and how important it was to do it right.

I'm ok with "I blame the pilots and I ALSO blame those who trained him". In most cases.

But to pretend a pilot is always "blame free" because, if he does something wrong knowingly and against his training, it's still some supervisor working at the airline's fault for not catching him ... hmmm.

No matter what he does, he is never responsable.

If he doesn't lower the flaps because he was never taught how to do it right, it's because he wasn't trained better.

If he was very well trained on how to lower the flaps and all its safety implications but he still didn't comply/made a mistake, it's because he was hired/never caught/not fired on time.

I'm obviously missing something in that line of thought.

But anyway, as I've said before, "whose fault" is not the most important part but "what can be done to fix it".

At this point, I vote for a (much) better TOWS design, a (slighty) improved checklist system, a (?) better maintenance manuals/MEL/etc and to plant AV cameras on the cockpits with 8h recording time digital DVRs (total cost $200) that are reviewed often by the airline to make sure pilots make good use of the training.

Improved training, as I've said before, can never hurt either.

Last edited by justme69; 25th Oct 2008 at 12:11.
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Old 25th Oct 2008, 09:50
  #2297 (permalink)  
 
Join Date: Oct 2006
Location: Spain
Posts: 82
Justme wrote
While I personally think that it's not easy at all to "catch" pilot's bad behavior, specially if it is only sporadic, I'm all for forcing airlines to install voice/image recording devices in the cockpits that last longer than the 32 minutes of the CVR which, best case scenario, would only allow to evaluate pilot's behavior for the landing part of the last flight.

That way airline supervisors can figure out what goes on behind the locked doors of the cockpit and catch bad apples before their actions becames a danger. Don't we all agree that this would be an easy, cheap and really effective way to monitor progress and compliance of crews with training?
...In that case, those within the company in charge of supervising could also be held responsables for repeated risky conducts of the pilots under their supervision/training.

...
So a pilot (consistenly, lets make this easy) fails to do his job as trained and the person that hired/trained him is to blame. Therefore, they failed too and all "four" go to jail. And it's OK to end it there. We don't need to hire someone to supervise that the supervisor is actually supervising the pilot, or that the trainer is actually properly training the pilots.

...
I am certainly suprised if airlines dont do this.
I work in a non critical job(such as pilots do) and I am strictly supervised daily.
I fully agree with you !!
agusaleale is offline  
Old 25th Oct 2008, 12:19
  #2298 (permalink)  
 
Join Date: Aug 2008
Location: Canary Islands, Spain
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I am certainly suprised if airlines dont do this.
I work in a non critical job(such as pilots do) and I am strictly supervised daily.
I fully agree with you !!
Well, if pilots don't want to be responsable for their mistakes, and the responsability must be found on those who train/supervise/hire them, then they must allow those people to closely monitor them at all times, obviously, and be willing to cheerfuly accept all corrective measures for any and every mistakes noticed.

Personally I don't think it's that great of an idea, as it would be like if I had someone constanly looking over my shoulder while I work. But then again, I do accept responsability for my own mistakes and don't blame my college professors when I fail to do correctly what they have taught me.
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Old 25th Oct 2008, 12:55
  #2299 (permalink)  
 
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Justme69, don't forget the camera in the airline management's desk...
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Old 25th Oct 2008, 14:06
  #2300 (permalink)  
 
Join Date: Aug 2008
Location: Canary Islands, Spain
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Justme69, don't forget the camera in the airline management's desk...
I'm all for that too. But who watches that camera?

Because the person that is watching the manager's camera, probably needs another one too to be monitored. And somebody to watch the person watching it.

Or perhaps, each adult professional should be reasonably left alone and be held responsable for his own mistakes.

When management/training makes a mistake, they should be held responsable. When a pilot doesn't lower the flaps as instructed, I do not believe that this would be the case (generally, in airlines that teach safety to good standards). Training obviously encouraged him to follow the checklist properly. That he didn't do it it's not due to management (under reasonable circunstances).

A different story is when a complex or caotic situation arises that is indeed due to bad training or bad management.

But a simple one like not following checklists correctly by a rested crew that is not "incredibly pressed" (and even if they are, a pilot needs to know that no matter what, for his own life, he can not stop to try to follow the checklists to the best of his abilities) and has been trained on how to do it properly, I still fail to see how it can be directly related to irresponsable management/training.

Somewhat related, maybe. *Necessarily* directly related, no.

And even if it is directly related, unless the pilots were actually trained and encouraged to not follow checklists (and they complied? Isn't that accomplicement?), that doesn't exempt pilots from the error's responsability.

It merely extends the responsability to include both, the pilot and the management/training.

That's my objection. In a case like this, of a reasonably good airline with reasonably good safety and resonably good training and reasonably good working conditions, a sentence like this can not be said: "I do not blame the pilots, I blame the training/management departments in the airline".

I have no objections with: "I blame the pilots and I also blame the airline", until more information can be had to see to what extend training on correctly following checklists or really bad work conditions were factors.

I think a scenario for this accident where the pilots had no responsability at all for their actions and it was all the fault of other workers (be Boeing engineers, SAS management or Spanair's training subcontractors), is very unlikely.

I have already stated, that besides the pilots, in this accident, in my opinion, there are many other factors and the people that produced them, that SHARE some (small) responsability (maintenance, Spanair's SOPs, CIAIAC, civil aviation authorities, MEL, Boeing, etc). And I have already said that, depending on more information from the CVR to see to what extend they were careless, I do not blame the pilots for what it looks could just have been an "honest" oversight.

All this, of course, assuming the pilots neglected to lower the flaps under the known conditions and the TOWS didn't work due to a recent unnoticed failure.

Last edited by justme69; 25th Oct 2008 at 21:36.
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