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Spanair accident at Madrid

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Spanair accident at Madrid

Old 11th Nov 2008, 13:32
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MEL

Originally Posted by littlebulbs
If you are called to an aircraft that has returned to stand, you go to the MEL. If you cannot find a relevant section in the MEL for the defective item that you have, it means that it is either an non airworthiness item or it is a no dispatch.
As a pilot, I don't need to return to stand to put a heater off and check the MEL ... I would do that in less than 2 minutes at the holding point.

If I need a technician, it means I need its professionnal expertise :
- documentation ;
- tools ;
- manual skills ;
- experience ;
- analysis skills ;
- ...

Because one should not put an item on the defect list iaw the MEL and go flying, without :
- properly identifying the failure (here a relay failure)
- properly isolating the system
- analysing the consequences of the failure

The MEL objective was never to dispatch an aircraft in a hurry, without even "thinking". That is the reason the captain came back to the stand in the first place : investigation!

By the way, since the problem was not new, somedy (a supervisor?) would have got the time to think about it in the previous 24 hours. Normaly the maintenance office would collect, read and analyse the maintenance reports at least on a daily basis, and as close as possible as in "real time". This is not intended to be a boring paper work job! This is supposed to support the field technician ... in the confort of an office, with all the neat documentation on hand.

I know ... we don't live in an ideal world !
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Old 11th Nov 2008, 13:33
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the captain probably didn't notice the RAT heating...if he had checked the current draw at the gate, he wouldn't have started engines.

he probably noticed the gauge which gives the EPR setting for takeoff providing a very low power setting for takeoff

taking off with low engine power/thrust would/could cause a crash too.

after seeing the low power setting, he might have checked the RAT current...we really don't know.

awhile back I blamed the airline, I still do. DID the airline get all updates for operating the plane before the first revenue flight? Its their responsibility.

Did the airline train the pilots to understand the systems, checklist procedures, stall avoidance and recovery?


DID the boss of the airline get pay raises that would have paid for better training?


MONEY!
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Old 11th Nov 2008, 15:47
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Bis47, infrequentflyer789 and others, you re-exposed my point exactly.

If further discussion on that (as periodically happens) I will point to your posts!
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Old 11th Nov 2008, 16:21
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McDonnell Douglas recommended all MD-80 series operators conduct a check of the TOW system before engine start prior to every flight
Why "recommended"? Why is it not in the AFM? Would it be because including it would involve Boeing admitting liability in the 1987 accident? I hope not, because if true, now they've got two.
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Old 11th Nov 2008, 17:36
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When a trouble is reported, at the main base, one airline is intended to first try to repair the aircraft, taking time to do it. Then, after troubleshooting, if the delay is too long, the airline may use the MEL.
But, due to economic pressure (“punctuality first”) people now rush to the MEL without trying to repair the trouble in order to dispatch the aircraft as soon as possible.
Everybody find that practice acceptable. Can you accept that crews rush through their check-lists?
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Old 11th Nov 2008, 18:09
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Rob Bamber, good point (#2483).
Normally in aviation where a recommendation is made, it could be assumed that there is supporting documentation giving the reason for the check so an operator could choose an alternative, but equally safe course of action. Does anyone know if this was the case for the pre-flight TOCW check?
Did the investigations into previous accidents recommend a check or just cite a malfunction?
Did subsequent investigations refer to the first accident and any recommendations made? – I have mislaid the links to the accident reports – previously in this thread.
If there was no such recommendation(s), does anyone know who/where/why a check was selected in preference to a system change?
This is normally a certification activity (FAA), but implemented by the manufacturer. Unless there is regulatory support a mandate (AFM change), it may only be possible for the manufacturer to issue a recommendation.
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Old 11th Nov 2008, 18:22
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The most ambiguous statement in an MEL in my mind is "Reasonably Practicable". Define reasonable. My initial understanding of this is if you have a spare available to do this and the manpower available, then you fix the problem. However, there is an argument that has been used that time comes into this equation. If you have enough time, then fix it, if not, then dispatch IAW the MEL.
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Old 12th Nov 2008, 07:41
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Authority supervision

Originally Posted by sevenstrokeroll
awhile back I blamed the airline, I still do. DID the airline get all updates for operating the plane before the first revenue flight? Its their responsibility.
And what about the authority (which is supposed to be immune of "commercialism")?

The authority should make sure, before giving/maintaining the AOC that
- the airlines would operate iaw with current updated information ...
- that all the AD's concerning the aircraft and its equipment are complied with, that all the SB are analysed, and cw unless "optional" (or obviously marketing driven)
- and that other requirements (by the dozen) are met ...

And "making sure" doesn't mean "thrusting" an old chap ... it means checking, really checking!

I understand quite well the judge position, not to thrust the CIAAC ...
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Old 12th Nov 2008, 19:01
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Well, the maintenance technicians declared today for several hours in front of the judge.

Doesn't look very good.

It seems that Boeing's repair manual that Spanair gave the judge detailed the RAT heater and related issues. That would be the manual used for training.

The technicians declared that they didn't consult the manual, only the MEL. They also declared that they didn't perform a TOWS test, as that would've been the pilot's job. They also re-assured that the c/b they disconnected only affected the RAT heater and nothing else.

I have the feeling the judge thinks that wasn't enough and their jobs required a bit more foresight.

They continue being indicted.

The judge has called another set of technicians in Barcelona who previously dealt with reported RAT heater issues the day before.

He has also requested declarations from the technicians dealing with the pilot's report of autoslat warning light several days before (this last thing, not related to the accident in all likehood, but the judge has to follow every concievable lead, I guess, as well as try to stablish if there could've been any relation or not. Any technician can tell him that it is not technically possible that any sort of autoslat failure could have prevented the slats to be mid-seal deployed with a just the "green" takeoff light and the flaps retracted while the analog watch indicator measuring 11ş for both wings).

Last edited by justme69; 12th Nov 2008 at 22:16.
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Old 13th Nov 2008, 07:56
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Surely, he didn't think that the mechanic who pulled the CB on the day should have known?
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Old 13th Nov 2008, 09:59
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Well, it looks like the only interesting previously unknown information from the declaration is that a technician mentioned that the pilot told him that, before calling them in for maintenance assistant, the pilot tried to "fix the RAT heater problem" by pulling an c/b himself, but that didn't work. We don't know which circuit breaker or if he reset it, but probably so and probably not of consecuence for the accident.

Nothing overly important, but it goes to show that if the pilots would've figured out the "correct" c/b to pull to turn the heater off, maybe they wouldn't even have returned to gate and called maintenance at all.

Who, BTW, weren't of much help trying to avoid the accident either.

The repair manual details the tests to perform and systems that could be affected. This was followed by the technicians in Barcelona the night before. But it seems the problem didn't manifest during the night test.

The MEL, of course, pretty much only states that the airplane can fly with an inop RAT probe heater if the conditions don't have any risk of ice formation.

Maintenance standard procedure when the airplane is "in service": look the MEL, figure if the airplane can fly with the defect. It's not "written in a book", I don't think, but it's the "understood" procedure to follow.

I personally think that's not the "right" way. To me, this job would imply to spend 5 minutes trying to troubleshoot it and, once it's clear it needs more time but the defect is "isolated" and quite understood, then you can look up the MEL to make sure the airplane can fly with the problem until there is time for a proper repair. You could still have missed something important, but at least you gave it a shot.

But to give a problem ZERO thought, not to even bother to look it up in the manual to give it a quick glance and spend 3 or 4 minutes with it, but to blindly go straight to MEL while "liberally" interpreting it ... well, it had to happen some day.

We all understand the "pressure" of commericalism, but I'm sure nobody minds any 5 min delays that are there for true safety reasons. Spending 5 minutes of brain power to figure out possible ramifications of a quite clear problem is better than taking the risk of spending 15 years in prison, like it may well happen to those two poor guys.

I don't think the third person indicted, the chief of technical maintenance for Spanair, will be finally prosecuted at the end (or at least, sentenced), as his participation was pretty much nil and each repair action that is not consulted is the sole responsability of the licensed technician involve.

Both technicians directly involved in the action consulted with each other and they both understood what was being done and they both agreed their actions were the correct ones. This was also explained to the pilot who agreed as well that the airplane could fly.

Accusation lawyers are bitching about how the same problem had two different responses from the Barcelona and the Madrid technicians. The answer: the first ones were trying to fix it and followed the manual. The seconds were just trying to avoid it and didn't even look at the manual.
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Old 13th Nov 2008, 10:14
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Still, it makes a mockery of the Flight Safety Foundation "Joint Resolution regarding the Criminalisation of Aviation Accidents" doesn't it. Judicial authorities should be discouraged from taking such action before the proper national authority has had time to do an investigation under ICAO Annex 13.
I only wish someone in FSF, ISASI, ICAO or similar organisations would stand up and be counted but dream on.
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Old 13th Nov 2008, 10:37
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there is always the possibility that the wiring of the plane was somehow incorrect, connecting one system to the wrong circuit breaker

I doubt this, but have to throw it out there.

again, the plane seems to have crashed because the slats/flaps were not set properly for takeoff.

not because the warning system didn't work, though that might have saved them.

there are few things a pilot has to do before takeoff..and flaps is right up there with the most important of things.
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Old 13th Nov 2008, 10:38
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The problem is that courts are invariably not into the reality, and it is much easier to prosecute the mechanic who burred the nut because he used the wrong spanner than the manager who put him on the night shift and didn't make sure he had the right spanner and knew how to use it. If you see what I mean?
Maybe, after 48 years in the business I should retire before I burr the nut.
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Old 13th Nov 2008, 10:42
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Just another note: the main technician in charge had 11 years of experience in Viva Air (owned by Iberia and Lufthansa) and another 9.5 years in Spanair (lately owned by SAS). I don't know the experience of his assistant in this case.

Both, of course, fully licensed for the type.

One of them was carrying test actions from the outside and the other one inside the cockpit. The one outside also briefly came in to label heater/cb as MEL'ed. They both communicated (by radio, I'm assuming) and decided on how to tackle the problem and agreed that it had been properly "fixed".

The pilot was aware of their actions.

Last edited by justme69; 13th Nov 2008 at 17:53.
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Old 13th Nov 2008, 13:33
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justme I do not appreciate your approach. It shows signs of being journalistic. Bark up another tree
I don't see a problem. he cites rumors and news as sources and expresses an opinion. He doesn't appear to create news. If he's journalistic he at least understands aviation.
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Old 13th Nov 2008, 14:25
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justme I do not appreciate your approach. It shows signs of being journalistic. Bark up another tree
I don't see a problem. he cites rumors and news as sources and expresses an opinion. He doesn't appear to create news. If he's journalistic he at least understands aviation
I agree, but I think his own source is what is being told in the trial. If so, you have to strongly believe in his words, under the legal point of view in Spain.

airsnoop, bang on. However if we all took a step back and looked at the industry you would soon realise that all too often money is paramount, not safety.

But, hey lets persecute the weakest link and pretend everything is still rosy
I agree with you, when things happen this way, the only reason for that is that it is not an isolated problem, I think It happened all time, not only with the RAT but with many other things.
When you arrive to such a situation, you don´t stop and try to find out the causes, you only try to repair the effects to go ahead to the next one.
If you have enough time you try to find the origins, but when all time this kind of things happen, and they are not appropiately arranged, then finish this way. Is like trying to fix everything with wires.
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Old 14th Nov 2008, 14:55
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Sure, in an ideal world, the technicians would have analyzed the issue, and figured out exactly the problem instead of fixing it to the MEL.

But if you want to make a system truly safe, you reduce the amount of analysis at each step of the way in favor of SOPs. Every time you require someone to think about a safety-critical element, you incur a significant risk that that person will come to the wrong conclusion. That's why the MEL are checklists are there in the first place.

Look, there's no need for any of this to have a reason, beyond the fact that whenever people are in a hurry, they make mistakes (and hence the proper response to pressure to speed things up is to slow everything down). But if you have to find some sort of technical or procedural reason to crusade vainly for, why not pick on something basic? If every major system on board is affected by whether the aircraft thinks it's on the ground or in flight, shouldn't that state be indicated somewhere obvious and not need to be inferred through looking out the window at the strobes or listening for the faint sounds of fans? I understand some flight crew have even gone so far as to diagnose certain warning horns as a result of the aircraft thinking it was on the ground.

See, now that's a dumb idea too, but not as dumb as prosecuting mechanics.
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Old 14th Nov 2008, 16:42
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MEL

I know of instances where an engineer has been disciplined for causing a delay to an aircraft - because he tried to fix a reported defect - when the aircraft could have dispatched on time IAW the MEL!

bizdev
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Old 14th Nov 2008, 17:33
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I know of instances where an engineer has been disciplined for causing a delay to an aircraft - because he tried to fix a reported defect - when the aircraft could have dispatched on time IAW the MEL!

bizdev
Smack on!

Usually the part of fixing a snag which takes most time is the troubleshooting process.
E.g. in this case troubleshooting could have taken easily several hours, while actually replacing the relay would be a matter of minutes.

And, on the other hand, the troubleshooting process reveals that there is no serious fault in the background and that it was all about an easily deferred problem, the engineer will be disciplined for unnecessarily grounding the aircraft.
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