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Spanair accident at Madrid

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Old 22nd Aug 2009, 19:40
  #2541 (permalink)  
 
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Don't really get your point I am much better described as "computer illiterate" rather than "computer literate" (Oh & occasionally I suffer from not understanding spellcheck ) I therefore don't propose myself as a candidate to fly a computer governed aircraft (don't trust them anyhow )
Well if that makes me an @rse in your eyes tough titty on you I say.
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Old 23rd Aug 2009, 00:22
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Link Is Truncated

The problem is that the link is not complete. The "..." following the 9 indicates something left out. Apparently some of our computers truncate it. Don't know why.
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Old 23rd Aug 2009, 00:31
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In case someone is having difficulties, here is another attempt to the link:

http://www.fomento.es/NR/rdonlyres/9...INO_01_ENG.pdf

and here is the full link that you would have to type manually, preceeding it with www:

fomento.es/NR/rdonlyres/9AA08FE0-1151-41A0-9A57-9C5DF8BF6F8E/52772/2008_032_A_INTERINO_01_ENG.pdf

You would of course need Adobe (or someone else's) Acrobat Reader installed first to open it.

And it takes a few seconds/minutes to open, so you have to give it some time after clicking on it.

It's my understanding that, indeed, it was the copilot in charge of the take off maneuver and probably the carrier of most actions related to the moments of the accident.
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Old 23rd Aug 2009, 17:53
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Link still not working.

The critical path is surely that TOWS check was only recommended on this type before every flight instead of being compulsory. Now it is compulsory. Did all those people have to die just to discover the difference between a recommendation and a command?
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Old 23rd Aug 2009, 18:14
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link not working

It works OK in Firefox, but not in IE on my machine. Another argument for a modern browser.
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Old 23rd Aug 2009, 18:23
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English Interim Report

Looks to me that the document has been removed or renamed. I tried listing the directory but don't have the privilege.

Perhaps somebody got a copy and can host it.
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Old 23rd Aug 2009, 19:31
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report removed

Indeed the link that I posted in #2544 has been removed. The same happened on CIAIAC's own website, where the link on the bottom on the following page is not working anymore: 2008 - Investigación - CIAIAC - Órganos Colegiados - Ministerio de Fomento

I'll see tomorrow if I saved the doc on my HDD elsewhere and if so make that available to anyone interested to put that online.
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Old 23rd Aug 2009, 20:54
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Links to report

I have tried all the links which some of you cannot get to open, and for me, they all opened without hesitation. Strange.
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Old 24th Aug 2009, 02:10
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For those still having problems obtaining the english interim report, I uploaded it to mediafire. Click on the link below, wait a few seconds and click the "click here to start download" button that shows up:

2008_032_A_INTERINO_01_ENG.pdf
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Old 24th Aug 2009, 14:10
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justme69, as you always have been on this thread, very helpful indeed.
Thank you for taking the trouble on our behalf
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Old 25th Aug 2009, 11:58
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Finally got around to reading it this morning, from a CRM/Human error point of view it makes for fairly depressing reading.
Skipped /interrupted checklists are bad enough, but the crews reaction to the stall warning was. . . well, lets say not really appropriate or adequate.
"engine failure" ! ? WTF ? & then the Capt wanting to silence the warning had me thinking of the infamous Avianca CFIT ( also at Barajas) "Woop woop pull up ! !Shut up Gringo . . sound of impact"
Well, we shouldn't speak ill of the dead, but it strikes me that even at the very last moment, firewalling the thrust levers and selecting flaps just "might" have had a better outcome than deciding an engine had failed & then worrying about shutting up the warning.
People spent a lot of time slagging off the Turkish airlines crew, I don't believe there is much difference here in demonstrated ability / professionalism.
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Old 25th Aug 2009, 15:08
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it's back

The interim report is back online on the official site again. It's last modified on 17 August, the original publication date. So, from that point of view no changes to be expected.....

http://www.fomento.es/nr/rdonlyres/9...NO_01_ENG1.pdf
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Old 25th Aug 2009, 23:40
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What More Do They Want?????

The data from the investigation indicate that the takeoff maneuver took place with the flaps and slats retracted, which constituted an improper configuration that did not ensure safety. The inspections of the slat components recovered from the accident site showed evidence consistent with a slat retracted condition. In addition, though an inspection of the flap components did not yield a definitive conclusion regarding their position at the time of the accident, the values recorded on the digital flight data recorder (DFDR) indicate that the flaps remained retracted for the length of the taxi phase to the runway, the takeoff run and throughout the entire accident sequence until the recorder ceased operating following the impact. Furthermore, the laboratory tests conducted on the flap actuating lever recovered from the wreckage revealed the existence of impact marks located in the position corresponding to the flaps/slats retracted (UP/RET), possibly caused by the lever itself.
What more do they want?
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Old 26th Aug 2009, 10:02
  #2554 (permalink)  
 
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Well, the problem with determining the flaps/slats possition is that the CVR *DOES* show the crew announcing the flaps/slats as 11º/deployed, so now it becomes a matter of refuting their "word" against the machine's indications.

A different story would've been if the crew never mentioned the wing configuration as being "ok". Then, there is not such a large need to proof the telemetry recording as right, since nobody is challenging it.

So from the judiciary point of view, it has to become as clear as possible why the pilots (seemed to) believed that the flaps/slats were out. Thus the painstaking research into establishing their position beyond "reasonable doubt", if possible, determining stuff such as whether the lever was actuated at all or not, or if there is any possibility that the indicators could show the wrong possition, etc, to challenge the crew's "final words" that the wings were set to go as recorded in the CVR.

Otherwise, anyone in the know understands there is just no way the wings could've been set or any indications pointing to that matter being shown to the pilots and that the crew simply forgot to set them as it happens every-so-often in the world and that they answered the challenge call without really looking at the indicators, as I'm sure is not the first time it happens either.

But this has to be "proven", which is always hard to do with 100% certainty and thus, the benefit of the doubt is always given.
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Old 26th Aug 2009, 12:03
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To quote from the report taken from CVR

14:12:08 After start list was initiated.
Before reading the last item , flaps/slats the Capt told the co-pilot to request taxi.
Before the list was read there was no record on the CVR of the Capt mentioning flaps
14:15:56 They read the taxi checklist, when they reached the last point (take off briefing ) the co-pilot read it but no reply was heard from the Capt on the CVR
14:22:06 The co-pilot did the final items on the list saying" final items we have, sorry eight eleven stowed eleven stowed". He immediately started talking about the possibility of engaging the autopilot as soon as they took off.

From all of this, while I agree that legally speaking the crew have to be given the benefit of the doubt, it seems clear that the Capt does not appear to have been asked by the Copilot ,or indeed to have volunteered the fact ,that it was clear outside so the flaps could be lowered. The Capt interrupted the copilot from reading this item to ask for taxy clearance (bull in a china shop ? ) and the copilot either didn't think, or didn't feel able to bring up the issue but just did as he was told. The Capt then became agitated and two mins later asked ATC how long would be the delay.
The copilot did not appear to receive a reply to his challenge "take off briefing", so he was at this stage operating single crew with no crosscheck/participation from the Capt, who seems to have become fixated on getting airborne to the exclusion of everything else.
The copilot appears to have been drawn into this rush rush rush mentality as he wanted to shorten the checklist correct response to "final items we have" then corrected himself by saying "sorry 8, 11 stowed (I guess he meant 8 flap rather than the 11flap they planned) 11 stowed". This to me sounds like paying lip service to it in an effort to rush and appease the Capt ,rather than physically checking the position of the handle and the amount of flap displayed on the indicator. It appears also that the crew were slightly fixated on the need to manually set thrust, and the copilot preoccupied with engaging the autopilot, to the exclusion of normal checklist completion.

Finally :

Robust SOP's can help you to do the job.

Actually doing/checking the items you have verbalised on the checklist will also be better.

A functioning TOWS may help as a last line of defence.

If you adopt (as many suggested hundreds of pages ago ) a personal "killer items" checklist it may save your ass even if all the foregoing didn't.

If you still screw up and you react to a synthesised voice telling you "stall" by taking stall recovery action, rather than musing over engine failure and how to shut the warning up, maybe, just maybe you could still retreive the situation.

This crew has done none of this, and have allowed themselves to become fixated on getting airborne, to the exclusion of everything else, including their primary role of assuring a safe operation.
They are not the first, nor will they be the last, it still happens in companies (particularly those whose modus operandi is "rush rush rush" ) and I personally know of a few times where disaster has been avoided in the last 2 years only by the timely intervention of the TOWS ( & amazingly the Crew sometimes chose to continue the T/O and configure on the roll even though the most junior crew member didn't wish to).
This happened even after the manufacture changed the checklist to stipulate putting the flaps down before taxying, giving several opportunities to catch it, IF the checklist was ACTIONED not just READ, and yet, resourceful humans that we are ,we still find ways to screw it up

Last edited by captplaystation; 26th Aug 2009 at 12:17.
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Old 26th Aug 2009, 14:32
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Indeed CPS

Captain 50%
CoPilot 25%
Poor TOWS design 10%
SOP list design10%
Ground Crew 5%

I can't quite understand though, why it was considered important to pull flaps up to taxi in, yet taxiing out is OK... is this just to cut the chance they're damaged by 50% or flaps down at the stand is a no-no?
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Old 26th Aug 2009, 22:07
  #2557 (permalink)  
 
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Co Pilot Deserves More Than 25%

The Co Pilot deserves more than 25%. After all, he's the one who hauled back on the yoke and ignored the fact that the plane wasn't flying.
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Old 27th Aug 2009, 12:32
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...presumably...

Rattler
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Old 29th Aug 2009, 08:44
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I generally agree with the assesements. Copilot was pbbly the PHYSICAL "prime responsable" of both, the most important actions that made them get into the situation and the most important actions that ended up not allowing them to get out of it.

In that sense, the copilot perhaps has a larger percentage of the "blame". But, as we all know, copilots can be a bit "rookie" and the captain is the final responsible for just about anything going on in the cockpit, and thus, the final culprit, and in this case he helped very (very) little, so he pbbly deserves to get many of those "guilt" points back.

Personally, I give the maintance crew (in Madrid as well as in Barcelona the day before), a slightly (say a couple of percentage points) more "shame" than 5%, but who am I to say? It's just a personal opinion.

The Lanzarote case, further disccussed previously in this thread, like here in page 107 http://www.pprune.org/rumours-news/3...ml#post4440133 , is also due its CIAIAC investigation report soon. The draft is already made and will be finalised anytime between now and the next 5 months or so.

In it, it becomes clear how the most important part in these types of situations is the crew. By extension, also their training, selection and cockpit management and safety culture.

The crew in Austrian Mapjet case of Lanzarote flight to Barcelona, had a 60 years old experienced captain (21000 hours, 7700 in the type) paired with a 31 yo copilot (2180, 2000 in the type) from different nacionalities and training backgrounds (Argentinian and Venezuelan), both rested and holding appropiate training courses and certifications, in the cabin. They had been flying together for about 2 weeks. Mapjet selection and additional training etc wasn't up to par around the time, though, as wasn't their crew subcontractor.

The procedures in the Mapjet case, DID call for TOWS verification check before each engine start, unlike Spanair's obsolete recommended procedure of "once a day" or whenever pilots entered a new cockpit for the first time or had been away from it for "too long". This check was not carried out by Mapjet's crew none of the two times the airplane flew that day (in the flight of the incident and the previous flight of the day from Madrid to Lanzarote), in spite of being required to do so by the SOP both times.

The TOWS in Mapjet case were proven in full working order, except that they had been rendered effectively inoperative by a maintenance technician pulling the circuit breaker K33 in the panel behind the pilot's seat during a routine strobe lights check the night before and forgetting to push it back. This rendered the whole Left Ground Control circuit (part of the air/ground sensor circuit) to effectively remain in the fixed "air mode" logic state, which included the TOWS. In Spanair's case, the TOWS lack of action seems it was most likely caused by an intermittent electrical fault, most likely caused by a malfunctioning single relay (R2-5).

I guess the circunstances leading to the crew forgetting to deploy the slats/flaps are pretty universal. Very lax procedures and checklists operation and radio distractions (in this case, asking ATC for some clarification of nearby traffic priority). They also had your usual conversations about manual/flex/auto/etc takeoffs decissions. They also had the additional workload of trying to deal with the "alarms and warnings" that resulted from the "faulty" ground/air logic.

Some different lessons learned in Mapjet case, prompted changes to the maintance procedures, with Boeing recently issuing new Check Cards for maintenance to clear up the difference between daily/every 3 days checks of external lights being different from checks of strobe lights, which were prompting maintenance facilities all around the world to routinely pull the K33 circuit breaker every 3 days, or daily in many cases, causing a non-intended overuse. Also, the recommendation of placing flags and collars on breakers was added to check cards whenever a breaker is pulled to reduce the chances of them being inadvertently left open.

In this case, i.e, the crew DID carry a check of the breaker panel, but because the K33 white collar was dirty from so much use, the visual inspection wasn't enough to make its (wrong) possition noticed by the crew.

And, of course, there is a reminding for crews to not forget to carefully check for open breakers as part of their checks when they enter a cabin, as required by procedures for the type in all operators.

The pulling of the K33 c/b, which practically left ~a dozen systems in air mode logic while still on the ground, gave the Mapjet crew an additional 5 o 6 alarms and warning lights which, in Mapjet's case, were also mostly ignored (they were each attempted to be "reset" by the crew and that was pretty much it). In Spanair's case, the fault resulted in very minor symptoms for maintenance or pilots to figure it out: the TOWS wouldn't work, which is not obvious unless a TOWS check is carried, and the RAT probe heater is activated in the ground, which was detected in that case, but unfortunately the maintenance actions didn't solve the matter, effectively just bypassing the problem rather than fixing it. Pretty much no other tell-tale signs.

The breaking of the Left Ground logic circuit in the type, on the other hand, can cause many signs such as:

3 AHRS lights on in Basic mode
No Flight Director FD, left or right
STALL IND FAILURE light ON
EPR LIMIT/TARGET flag
Amber NO AUTOLAND light in both Flight Mode Annunciators
RAT probe heater turns on, indicating excessive External Air temperature readings
TOWS would fail an operative test
AUTO SPOILER FAIL light goes Amber in the overhead pane
Cooling fan off (equipment ventilation, like radio, etc)

On the other side, the crew handling of the actual stall situation was better in Mapjet's case, where the engines were quickly firewalled, the attitude maintained low, the wing drops controlled (as per FDR, 63º right, 60º left) and the plane controlled until it reached ~200kt and started flying normally once again. Needless to say, flaps/slats retracted is NOT an approved configuration for take off in the MD-8x series and they were lucky they didn't find tall obstacles in their way.

Meterological circunstances were also better in Lanzarote than Madrid's, with ~15kt of front wind (instead of Spanair's ~7kt of tail wind). Temperature was 23º, sea level, and Mapjet's MD83 was carrying less weight (140.000lbs, 64ton) than Madrid, which was at ~97% of its capacity. The MD83 was also equipped with more powerful engines than Madrid's MD82.

The crew did retract the landing gear before full "normal" flying conditions were reached which, it seems, may not have been the best course of action as it temporarily offers worse aerodynamic performance while the gear's doors are being closed at a critical time, and perhaps the preferred method of action for the type is to leave the gear's configuration "as is" until sufficient lift is achived to get out of the stall warning entirely while being able to climb at the needed rate. I'm not sure about this, so please check with someone who knows how it would be best to proceed in your type with the gears in case you ever get caught in a similar situation (stall with landing gears down and no possibility of landing on that terrain, like while flying over a city, i.e.).

Last edited by justme69; 30th Aug 2009 at 22:23.
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Old 29th Aug 2009, 10:42
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Smilin_Ed

What More Do They Want?????
Yes, it appears that the accident happened because the aeroplane stalled because there were no flaps or slats deployed but Ed, you appear to be missing the point of an accident investigation (certainly a civilian one). It is not simply to prove what caused an accident or even whom to blame.

It is to understand every aspect of that accident and everything which led to it occurring, to better understand with a view to preventing such an accident ever happeing again.

Doesn't always work as history has proved but that is the intent.
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