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Spanair accident at Madrid

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Spanair accident at Madrid

Old 25th Oct 2008, 22:07
  #2301 (permalink)  
 
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Don't remember anyone asking the question, did this flight have to respect a CTOT ( slot time) on it's 2nd departure, as that for sure adds a degree of stress/urgency to the start-up & taxi phase. Of course, in MAD, taxy time is never short time wise, but people can sometimes become very wound up, concentrating only on reaching that R/W before expiry of the slot to the exclusion of everything else ( cabin secure/ de-ice hold over time etc) I have seen it too often, and that could provide an explanation ( but not an excuse) for the rushed / skipped / screwed-up checks.
With apologies to anyone who feels otherwise, the F/O may be the one who lowers flaps, but the guy with the 4 stripes is in charge and ultimately responsible for the safety of the aircraft. If they tried to take-off with no flaps I can't see how anyone else can carry the can. Sure McDonnell Douglas the Spanair engineers ( and by failing to find out about/implement the cx before each T/O the Chiefs of Spanair) made it easier to turn an omission into a tragedy, but finally the "blame" if as a society we absolutely have to identify the "culprit", lies firmly on two guys who have paid the ultimate price for their mistake.
This thread is going round and round in circles now, surely it is time to realise the simple facts. Pilots are human, they make mistakes, when they do lots of people can die, they are included in this toll so don't want to make mistakes.
Designers Regulators and Managers don't have this immediate exposure to death, but they too make mistakes. The Pilot is always the one left holding the Baby, sometimes it slips from his hands. Everyone says how did he drop it? less people ask why did you hand it to him covered in soap and wrapped in cellophene. This is the nature of the profession of Pilot, you can die, you can kill others. Some will villify you, a few will understand, a few will even try to defend you and find excuses for your mistakes.
Finally, [email protected] happens, and you are the last link in a very long chain so expect to be blamed whether you were good or bad and whether you survive or not.
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Old 25th Oct 2008, 23:10
  #2302 (permalink)  
 
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I agree.

But remember that, if you are handed out a soap-covered baby and you accept it, it is certainly to great extend your responsability to not drop him. If you don't want the responsabilty and want it to remain with the person handing you out the baby, don't babysit. Choose another profession.

But if the baby handed out to you only had a small band-aid in the forehead, and you dropped him with fatal consecuences, don't blame exclusively the person handing it out because he had a previous minor head injury.

Sure, "without the previous band-aid" the baby had more chances to survive the drop. But he probably would've perished even w/o it anyway if you dropped him like that, and he certainly would've survived just fine with the small band-aid if you didn't drop him.

There are times the responsability is 100% with the "handler" and 0% with the "parent" (i.e. the baby was in perfect condition and you just were overly careless). There are times when it's 80%-20%. There are times when it's 1%-99%. But there are very few times when it's 0%-100% (it would be irresponsible and liable to accept a baby you know is gonna fall w/o remedy -- you would only be excused if you had a gun pointing at you and forced to accept him).

I'm quitting now. This baby analogy is giving me the goosebumps.

Last edited by justme69; 26th Oct 2008 at 00:29.
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Old 26th Oct 2008, 12:25
  #2303 (permalink)  
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Originally Posted by ssr
if you TRUST everyone to do their job, including yourself, you will be dissapointed one day.
- sorry for the delay - been a bit busy.

I agree, I have been and no doubt will be again, and sadly a lot of folk were indeed 'dissapointed' that day. I insist, however, there has to be trust in the system - are you so certain of you and your crew's abilities that you don't think the pax should be checking your fuel loads or approach speeds (or flap settings, come to that) or are you exempt from this - you need to confirm the engineers' actions but the pax just have put up with you? It appears you benefitted from an unusually deep airline systems training regarding the RAT heater which I doubt is universal.

I would still maintain that before this incident there were not many MD drivers who knew the A/G gotchas we have discovered here, and that it is unreasonable to attach blame to them, or to the LAE who 'fixed' the defect if HIS/HER training (including the MEL) also turns out to be inadequate. Indeed I suspect this thread has been invaluable in that respect.

It still looks as if the a/c would have taken off safely if correctly configured despite the rectification actions. Whether or not a crew should be trained/able to recover a stall following mis-configured flaps, I prefer not to comment.
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Old 26th Oct 2008, 14:03
  #2304 (permalink)  
 
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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?

We did a no flap takeoff in the sim at SNA (5700 ft) to demo this using flap 11 V speeds. We lifted off late but even with the flaps up did not have any control problems. Of course we didn't over rotate knowing what that would do to controllability with no flaps. The Spanair pilots didn't have the luxury of knowing their flaps were up at rotation.
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Old 26th Oct 2008, 14:24
  #2305 (permalink)  
 
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Admitting pilot error

Hi Just You!

justme69
I think that, deep inside, we agree more than we disagree.
Not only inside ! It is just that I wanted to add a "plus" here and there to your most valuable posts ...

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.
Generally speaking, pilots are "without pity" against their colleagues ... except in public, and especially when those colleagues died due to their own mistakes.

Blaming dead pilots seems indecent ... In fact they already paid for their mistakes ...

And, it is not "fair" either ... Because pilots are human being, and as such, they do mistakes. Every day ... They will put the flaps to 11 instead or 15 ... or things like that. They will set up wrong frequencies, wrong heading bugs ... Not too serious, and almost every time, they will correct by themselves, or be saved by the other pilot, or by the check list, or by a "back up" safety device (TCAS ...) or by sheer luck .

Human failability is a part of the safety equation ...

When the mistake ends up in a fatal accident, it means that the pilots made an error, of course, but also that all the accident prevention program failed.

Since it is too late to improve the pilots, it's time to look at the system!

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.
Many pilots are not of that kind of reasonnable, wise, humble, persons ... If they do it their own way, they think they are doing a better job ... (sometimes, it could be true ... cfr those pilots silently reviewing killer items while lining up). Pilots are gods, you know ...

In big, safety conscious companies, it tooks a pilots generation to fully appreciate the benefits of a good CRM "spirit" ... God is no longer infaillible, a baby copilot can save the day!

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.
Ok, pilots are humans, they do mistakes. Every day ... They will put the flaps to 11 instead or 15 ... or things like that. They will set up wrong frequencies, wrong heading bugs ... Not too serious, and almost every time, they will correct by themselves, or be saved by the other pilot, or by the check list, or by a "back up" safety device (TCAS ...).

When an accident happens : "pilot error" - most of the times. Or : ATC error. Or : hardware failure (wing spar, rudder, fuel tank explosion ...).

Do you blame a cargo door for failing?

No, you want to investigate why that cargo door failed, and ultimately put the blame (and the responsibility) on the shoulder of those persons who ultimately approved the design, with the full knowledge it was flawed ... (Consider the infamous DC10 cargo door problem : the cargo door initial design system was flawed, the "design supervision people" caught the flaw and refused to approve the flawed design ... But the head of the FAA finaly approved it, after a minor correction ...

So when a crew proceed to take off without flaps and ends up into flames, the big questions are :

1. Understanding how such a mistake did happen ... and that is in fact looking at the system around the pilots, putting blame on some flaws of that "error prevention system".
2. How to improve things ...

Of course, recognizing the fact that the pilots made an error is crucial ... because it opens the question : how came they made that mistake?

But "blaming" the dead pilots ... is too indecent, unfair, useless.

I'm sure that, despite my poor english, we understand the nuance between "admitting the fact of a pilot error" and blaming a dead pilot for making an error ...

For myself, I admit many errors, and I blame myself for those errors. I also improved a lot as a pilot looking at my own errors, at other pilots errors, and - with very great interest - looking at students errors ...

When the day comes when we have acces to CVR transcript, I think that we all shall learn a lot about "how to make a big mistake" ...
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Old 26th Oct 2008, 18:18
  #2306 (permalink)  
 
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Courts Martial Are Real Courts

(Sorry, dont find a "Quote" button, so just highlighting it it manually):

Quote Rattler46:
Think of it a a court martial, keeping up the spirit while performing to the public, plenty of room still and nothing perjudicary stated with just the accusation. /EndQuote

Quote Similin_Ed: If I have misread the above quote, I apologize, but at least in the U.S., courts martial are real courts and they are deadly serious. Courts martial have been established by acts of congress under The Uniform Code of Military Justice. They are not show trials for the sake of public opinion. Convictions in courts martial are the same as convictions in any other federal court and the punishments awarded, including imprisonment and death, are very real./End_Quote

Sorry if that came along the wrong angle: By no means did I want to disqualify court martials in any way, I fully understand they are real courts (I am ex mil myself).

What I wanted to express with my post was that the inquisitionary juridical system in Spain (I live here, just FdR) with an "instructional" judge heading the *criminal* (and none else) investigation has some similarities to court martials in as that you can get accused of just about anything fairly easily (and much easier than in traditional common law "civil" criminal procedures) as long there is just a hint of "reasonable suspicion" of a criminal responsability, more or less along the lines of "...better be on the safe side...".

AFAIK (at least in Germany, where I served 8 yrs), about 95% of the court martials, long before oral trial, terminate w/o accusation (i.e. no formal charges brought against the defendants), from what I understand this is the same in an instructed criminal investigation case in Spain, as said in the name, this is an investigation and nothin more, after all.

FWIW, Rattler
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Old 26th Oct 2008, 23:32
  #2307 (permalink)  
 
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justme69
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?
I don't agree at all! Do you really think management have the time to watch or listen to a tape of every departure to catch "bad apples"? A waste of their time and talent. So hire people specifically for the task - can you imagine how well they would do such a boring, repetitive job?
Good SOP's, training and self-discipline are part of the solution - but we are all human.
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Old 26th Oct 2008, 23:38
  #2308 (permalink)  
 
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Sorry, can't resist.
Do you really think management have the time to watch or listen to a tape of every departure to catch "bad apples"? A waste of their time and talent. So hire people specifically for the task - can you imagine how well they would do such a boring, repetitive job?
You mean like the airport security people?
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Old 27th Oct 2008, 09:06
  #2309 (permalink)  
 
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TyroPicard:
I wouldn´t do it in that way. I´d only record certain parameters of the flight just to introduce them in a program. It would gave me lots of useful information to evaluate the behaviour of the pilots. May be it´s already in use ....in this case forgive me for my appreciation.
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Old 27th Oct 2008, 09:45
  #2310 (permalink)  
 
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Well, if "blame" from the pilot's actions is consistenly going to be put in management, and I was one in an airliner, I would no doubt put a couple of "video ipods cameras" recording audio/video for several hours in cockpits and retrieve them "at night".

Then, I would hire someone to spend the whole day fast-forwading through to the important maneuvers (take-off, landing), going to normal motion when he suspected the crew was acting up.

And I would personally review a few of the "tapes" myself, at least one operation (i.e. takeoff) of each of my crews a month.

Just knowing that the cameras are there, would make a lot of pilots realize that "their system" is not better than the "checklist", i.e., or that looking at the flaps gauge is not optional.

The alternative is to have a system where the pilot is only nominally supervised (during training excercises, tests, QAR, inspectors) like we have now and, when he screws up for not following the training, it's probably only his "fault", not ONLY that of the ones that "didn't catch him not following trained procedures".

Last edited by justme69; 27th Oct 2008 at 10:07.
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Old 27th Oct 2008, 13:16
  #2311 (permalink)  
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agusaleale;
I wouldn´t do it in that way. I´d only record certain parameters of the flight just to introduce them in a program. It would gave me lots of useful information to evaluate the behaviour of the pilots. May be it´s already in use ....in this case forgive me for my appreciation.
That's what FOQA/FDA - Flight Data Analysis programs have been doing, in some cases (BA) for over fourty years, in other cases a few years.

A QAR - Quick Access Recorder records the same if not many more parameters than the crash recorder. It is analyzed by specialists, usually a small group of pilots designated for the task or an independant company, and the de-identified reports are provided to the airline's management.

Now, it is far, far more complex than this, so I might suggest you google, "FOQA" as a good place to start.

Data analysis is, as you suggest, proactive, and is looking for both trends and incidents/events. In many arrangements, calls to the crew are made not by management but by the pilots' own peers usually through an agreement with the airline. The program is extremely effective in discovering what the airplanes and crews are doing on a daily basis.

PJ2
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Old 27th Oct 2008, 14:15
  #2312 (permalink)  
 
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More witnesses declare -- Nothing new

A couple more witnesses declared in front of the judge in charge of the investigation today. Nothing really new. You can skip this post.

The worker in charge of fueling the airplane before the RTG declared how much he put in an hour before departure, etc. He also declared that his co-worker, who was the one to later add more fuel after the RTG (and who will declare later), told him about the anti-collision lights being on while on the ground.

Nobody has strictly said what lights they were talking about, but the prior mention of this situation to the police was that he noticed the lights "on top and underneath the airplane", leading to believe that he didn't mean the wing's strobes.

It was said here by those familiar with the MD80 that those lights, as oppossed to the strobes, turn on and off only through a manual switch in the cockpit.

Having them on during the refueling while they were parked and right after the "repairs", probably only means that they never turned them off when they stopped the airplane to have it serviced.

The press, of course, is already jumping to the conclusion that the airplane was in "air mode" and that provoked the accident.

The witness also declared that he co-worker did talk to one of the pilots, who stepped outside of the airplane to give him instructions on the amount of fuel, etc.

Not related, but some may be interested in this article:
Airliner Repair, 24/7 | Flight Today | Air & Space Magazine

Last edited by justme69; 27th Oct 2008 at 22:14.
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Old 27th Oct 2008, 23:57
  #2313 (permalink)  
 
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Maybe I'm wrong, but I get the impression that justme69 feels that the aviation industry has been asleep at the helm in scientific analysis of aviation safety.

As PJ2 says.
Data analysis is, as you suggest, proactive, and is looking for both trends and incidents/events. In many arrangements, calls to the crew are made not by management but by the pilots' own peers usually through an agreement with the airline. The program is extremely effective in discovering what the airplanes and crews are doing on a daily basis.
TEM, FOQA, etc, have been in use for more than a decade, along with several other equally important programs.
The Flight Safety Foundation is a good source of links to what has been, and is, going on.
Here is link to one (of many) TEM articles:
http://www.flightsafety.org/pdf/tem/...pt_12-6-06.pdf
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Old 28th Oct 2008, 08:32
  #2314 (permalink)  
 
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Management Involvement in SOP

Some time ago (1 year?) the Ryanair boss made it public that he would fire any crew that would be caught as not being stabilized on final below 1.000 ft. (?)

I guess he meant it.

A pilot has to be bold ...
An airline manager too.
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Old 28th Oct 2008, 09:10
  #2315 (permalink)  
 
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They need lots of that in Iberia.

Aviation Video: Airbus A340-300 - Iberia

Anyway, I indeed do not know much about FOQA and similar programs, but got up to speed and read a couple of articles, like Avionics Magazine :: FOQA: Training Tool, And More

Looks like it's slowly (not as fast as some people here seem to think) catching up with airliners and starting to become effective, specially with newer aircrafts where extensive computer use makes it easier to monitor many parameters.

I doubt it has made much in-roads in ATR's or MD-80's of small airliners, but maybe it'll get there.

Putting miniature solid state "mini-QARs" that in many cases even upload the information wirelessly (or manually on memory/PCMCIA cards) is a good idea and provide quite a bit of monitoring over flight performance to be then analysed by software and supervisors.

Still, crew "attitude" in their work place (closed cockpit) monitoring could still get a helping hand from similar solid state recording that shows the audio/video of the performance.

As I said, I'm not "all in" for spying on the pilots, but I'm also not "all in" for blaming the managers for "letting them do" unsafe practices they have not been encouraged to do during training.

This FOQA thing seems to be another great tool for increasing safety and a step in the right direction, but one that is quite recent, not as widely used yet, not 100% effective (but pretty good) and not too expensive.

So I'm all for a lot more of it.

Do you think that if such a program was being used on this MD-82 over at Spanair it would've prevented the accident?

Obviously, not necessarily, unless it was able to indicate that this particular crew was often not following all the checklists items like they should, which is likely not the case. They obviously (I'd like to think), never before neglected to lower the flaps or set any other important item from the checklist. But a video showing them rushing through items or not checking them properly would've raised a red flag.

FOQA can probably not detect, i.e., that a crew is hardly ever visually checking flaps/slats indicators when they activate the handles. A video showing how they lower the handles w/o hardly even looking at the handle itself and quickly moving to another item is a clear indication, though.

Last edited by justme69; 28th Oct 2008 at 12:28.
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Old 28th Oct 2008, 10:40
  #2316 (permalink)  
 
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They need lots of that in Iberia.

Aviation Video: Airbus A340-300 - Iberia
This is one of the worst airports to land, you may already know, and Iberia lost a big bird there.
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Old 28th Oct 2008, 14:28
  #2317 (permalink)  
 
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Never been to Ecuador, but indeed I hear Quito is usually an airport with challenging landing conditions.

Nonetheless, the number of accidents in the airport doesn't seem greater than some others in equal or even "worse conditions" and, behold, Iberia is right there on the recent A340-600 landing accident in Quito, that prompted Ecuador goverment to suspend operations of Iberia (and only Iberia) in that airport for a while, until Iberia could "guarantee" that their operations there wouldn't endanger anyone.

Ecuador's Dirección de Aviación Civil required from Iberia a security plan that included a commitment from the company to guarantee the "professionalism and permanent training of the pilots in that company". All they had to do is watch the (leaked) airport security camera video and figure it out, as it was later confirmed in the preliminary report by the investigators (landed high and fast ... the rest, the landing gear damage, lack of reverser deployment, etc, as contributory factors).

We won't talk about the evacuation fiasco in that case, or the previous blown tires a few months before in August on the same runaway by another Iberia A340.

Easy or hard airport, it wasn't my intention to finger point a particular airline or a particular airport. It was just an example. Many airlines could benefit from less risky pilot's behavior.

And Iberia or Spanair are not exceptions.

I hope the usual disclaimer is not needed on how Iberia/Spanair has many world class pilots and that a few rotten apples exist in any airliner in the world. And that accidents happen to good pilots as well. And that I'm not implying the pilots in the Quito accident didn't do everything they could but it just didn't work well for them. This was Spanair first accident with victims in 20 years and Iberia has moved 500 million passengers in 40 years with only 4 accidents with victims.

Last edited by justme69; 29th Oct 2008 at 04:52.
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Old 28th Oct 2008, 20:33
  #2318 (permalink)  
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justme69:
Do you think that if such a program was being used on this MD-82 over at Spanair it would've prevented the accident?
From the moment the airplane departed for the second time after it's return to the gate? - No.

But that is not what FOQA programs do. I believe you now have a better comprehension of FOQA. It's a good start but there is much, much more to such a program than can be gleaned by reading a few articles - the subtleties are enormous, the variations on how to do FOQA well are wide and the protections for crews also vary widely. Some (the Asians, typically, but now, apparently, others in Europe) use a pilot's data to punish rather than learn. Such a stupid approach to safety has it's own long-term reward and is universally discouraged under a Just Culture approach to flight safety but some owners/managers want instant solutions and remain largely ignorant that they are in the business of aviation.

What FOQA does is to identify trends and highlight incidents. In this, the program is extremely successful. Association pilots may call crews to learn more about the event because the program does not use the CVR data, does not record ATC transmissions, does not know what the weather was, does not know if the cockpit was sterile, (the TAM accident A320 cockpit was not - there was a female scream just as the aircraft went over the edge of the airport boundary and into the buildings across the street), and does not know what transpires between maintenance people and the cockpit crew on the ground.

The program uses exactly the same data as the crash recorder does. It is from the exact same sources - primarily the ARINC 429 and 717 - designated standard aircraft data busses although other ARINC standards are employed especially on the 787.

This is a crucial fact mainly because I have seen an airline dismiss some very serious "FOQA data" because, they said, it "wasn't from the DFDR and so they couldn't act on it". Using this as an excuse to continue operations when a different action was indicated is a grave misapprehension of what FOQA is, what the data sources are and how such actions may place the organization legally in harm's way. "Knowing and not acting" is the same as acting with intentional negligence.

What FOQA also does is put the lie to those management people who harbour and broadcast their illusions that their operation is completely safe, does not make mistakes and that their standard is second to none. Such is simply ignorant wishful thinking but is popular at safety board meetings where the tough issues don't have to be dealt with and no senior manager gets "branded" or otherwise thought that his/her department isn't the safest possible. That "safety is first" is simply another illusion. It is not. Cost is first and it is extremely difficult to change that world-view. The usual "intervention" is an accident, a pattern which repeats itself so often that safety people can always be found doing thus:

I continue to hear reactions such as astonishment when I describe what we are seeing in the data - raised eyebrows and "not our pilots!!" are typical of the reactions, followed by dismissal of the data in some very serious incidents in which most of the details may go unreported to the regulator but not unobserved by FOQA and, by reports, to management.

All these facts stated, the program itself is one of the most significant improvements in safety analysis in the last fourty years. British has been doing this kind of work since the late fifties and many enlightened airline managements brought in FOQA programs as computerization made such possible and cheaper.

Often, FOQA is only taken seriously after an accident. That is the case at QANTAS after Bangkok, Air Transat after their Azores diversion, US Airways etc. Other carriers "get it" right away and do FOQA properly. Most are somewhere in between. The program is accepted worldwide, more or less, by almost all pilots because the intention is not "big brother" - the intention is to remain as informed as possible about what the fleet is doing and how the fleet is being flown. As such, it is a proactive approach to flight safety.

Now - to respond directly to your question, justme69, a FOQA program can tell both the pilots' association (if there is one) and management (if the deidentified data is shared with them, and it must be for due diligence requirements), depending upon how long the data is kept and who examines it on a daily basis, it can tell you if any of the fleet taxiied out with the slats/flaps retracted and it can, depending on the programming of the LFL, (Logical Frame Layout - a "map" of parameters and their values), tell you whether the takeoff warning horn sounded.

It can tell you how many times it happened, where and what the rate per nnn number of flights is, etc - once the data is available, it can be analyzed using graphing and statistical techniques.

It cannot "predict" an incident or accident but no one can. What it can do is point to heightened risk or the need to discuss an unreported incident with a crew, (using the pilots' peers, NOT management!).

In fact, many FOQA programs record over a thousand parameters, many more than the the aircraft's DFDR or FDIMU. So a very detailed picture (and, with suitable software, an animation) may be built of each flight the aircraft takes.

It takes a very experienced person who is also an active pilot with the airline to interpret the data successfully. Such a job cannot be handed over to the cheapest intern available because mistakes in interpretation will most assuredly be made. If the airline actually takes the data seriously and acts upon it, correct interpretation is fundamental.

I hope this helps - truly, a book could be written on doing FOQA properly and well.
PJ2
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Old 29th Oct 2008, 02:35
  #2319 (permalink)  
 
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PJ2:
Thanks for your information, it´s a great instrument the system itself. It is very helpful.

Do you know in the case of Spanair, if there was such a thing?
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Old 29th Oct 2008, 05:42
  #2320 (permalink)  
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No, I don't know if Spanair has or ever had a FOQA program. However, information regarding the existence of such a program usually finds it's way into these threads long before now, (loooooooooooonnnngggg before now) so it appears to me that they don't have such a program. I believe Iberia does but am not sure.

Given the nature of such programs and their importance to SMS, [Safety Management Systems] approach to flight safety, perhaps some airline managements would find it easier and "safer", (for the corporation) NOT to know what their fleet is doing.

In comparison with the return on investment, (safety, maintenance, airframe loads, fuel efficiencies), such programs, employed intelligently and thoroughly, are relatively cheap. One may conclude these days that the airline which has no such program in place is either ignorant of it's business and responsibilities, doesn't have a safety culture worth the name or the executive has made the [quiet] decisions that it does not want to know what it's fleet is doing. Those that have the program but don't use (or believe) the data and seem to have it "on the books as a box tick" fall into the same category. An airline which employs flight data in a manner discussed here recently regarding a firing does not have a safety culture, it has a culture of blame and punishment which discourages safety reporting and learning.

Such an approach works for a while but building systems based upon knowledge as opposed to being based upon punishment yields better, and more targeted results. Human factors are by far the largest single cause of an aircraft accident and learning about them through data analysis then finding ways to reduce/prevent them seems a more effective way to handle this most difficult of causes to fix. At least fifty-five takeoffs without slats/flaps were attempted/reported. How many more are hidden in the data? Airlines that don't have a FOQA Program and the appropriate events for such incidents will never know until the day an accident occurs.

Kicking tin only prevents the second accident. Not all incidents are reported, especially in a blame-and-punish culture. FOQA, used as intended, can tell an airline, more specifically it's pilots, about the first "accident" that, but for one layer of cheese almost happened. That way everyone quietly learns and headlines, lawsuits that put airlines out of business don't happen and most important of all, crews and passengers live.

Same goes for FOQA - it is almost like a free ride - a get-out-of-jail program. It can tell an airline where, when, and how the near-accident happened so it can do something before the next time. FOQA can tell an airline's management where it's soft underbelly is and equally important, it can tell an airline and it's pilots where it's strengths in training and SOPs are. But it must be used with complete integrity, honesty, knowledgeable support from the CEO on down and cannot be used to punish pilots for mistakes. That's what training and standards are for.

Last edited by PJ2; 29th Oct 2008 at 06:09.
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