Spanair accident at Madrid
Accident Investigation
but Ed, you appear to be missing the point of an accident investigation
You and I seem to agree that there certainly is ample evidence that the flaps and slats were not set properly but the accident investigators don't say that. They are weasel-wording the interim report for their own reasons, whatever they may be. Saying that they could not conclusively determine the position of the flaps and slats is pure hogwash. That's why I ask, "What more do they want?"
Last edited by Smilin_Ed; 29th Aug 2009 at 19:34. Reason: Clarity
Yes, yes, yes, firm adherence to SOPs and checklists, killer items especially, should preclude any such accident, but the fact remains that people screw up from time to time, even the highly trained and experienced.
The TOWS is a backstop to the crew. But what I see here is a vital backstop that can very easily be bypassed without knowing that that has happened.
Put me in the camp of those who agree that it should be checked on every flight, especially as we have seen how easy it is to inadvertently disable it.
But I still want to see it harder to disable this system -- or some obvious indication on the breaker that it supplies a flight critical system.
The TOWS is a backstop to the crew. But what I see here is a vital backstop that can very easily be bypassed without knowing that that has happened.
Put me in the camp of those who agree that it should be checked on every flight, especially as we have seen how easy it is to inadvertently disable it.
But I still want to see it harder to disable this system -- or some obvious indication on the breaker that it supplies a flight critical system.
Join Date: Sep 2007
Location: uk
Posts: 388
Likes: 0
Received 0 Likes
on
0 Posts
Accident Investigation
Smiling Ed
I stand corrected. I have perhaps read your "what more do they want" ? rather too literally, as in "they would appear to have information to finalise report now" as opposed to just flap position confirmation.
My apologies for mis-reading you.
SB
I stand corrected. I have perhaps read your "what more do they want" ? rather too literally, as in "they would appear to have information to finalise report now" as opposed to just flap position confirmation.
My apologies for mis-reading you.
SB
Join Date: Jul 2007
Location: UK
Posts: 140
Likes: 0
Received 0 Likes
on
0 Posts
Unfortunately smiling Ed if only those honorable principles of separating accidents from blame in the military could always be upheld. Mr. "Jonny Rotton", a Chinook helicopter and a Scottish mountain spring to mind.
Judicial vs. Administrative
SB, no problem. We just needed to get on the same frequency.
For windytoo:
I'm not familiar with the case you cited.
I've been on both sides of that wide green table. At least in the U.S., there can be no judicial action as the result of an administrative investigation. It is the purpose of the administrative investigations to further flight safety. What can, and does happen is that administrative action can, and does, result from non-judicial investigations. In my own case, my administrative superior sided with my side of the question and my flying career continued unimpeded. There was no separate judicial investigation.
For windytoo:
I'm not familiar with the case you cited.
I've been on both sides of that wide green table. At least in the U.S., there can be no judicial action as the result of an administrative investigation. It is the purpose of the administrative investigations to further flight safety. What can, and does happen is that administrative action can, and does, result from non-judicial investigations. In my own case, my administrative superior sided with my side of the question and my flying career continued unimpeded. There was no separate judicial investigation.
Join Date: Dec 1998
Location: UK
Posts: 289
Likes: 0
Received 0 Likes
on
0 Posts
Having just read the accident report, it would seem the likely but unproven cause of the accident was an intermittant failure of the R2-5 relay which determines the air/ground mode of certain systems, including the rat heat and T/O config warning. This was a recurrent fault but there was no clear maintenance procedure to follow and the engineer would have needed prior experience of this fault to know what it was. They dispatched legally in accordance with the MEL.
The captain interrupted the after take off checklist right at the point when they should have selected flaps to tell the F/O to call for taxi clearance. During the taxi checks, flaps were not mentioned. During the line-up checks the F/O applied 'lip service' to the checks and read what the flaps should be reading not what they were.
The T/O config warning failed to sound, probably because of the failure of the R2-5 relay. The aircraft stick shaker activated after rotate and was not recognised as real by either pilot, the co-pilot calling 'engine failure?' and the Captain asking how he could turn it off.
I don't quite understand why the right thrust lever was retarded as they rolled to the right?
I also am not familiar with the Spanair MD-80 checklist. Is the after take-off flaps check 'read and do' or 'do and read'? Also, is flaps a specific check in the taxi checks or is it only included in the 'take-off briefing' review? (Pages 44-45 refer but are not clear).
Full report here:
http://www.fomento.es/NR/rdonlyres/9...NO_01_ENG1.pdf
The captain interrupted the after take off checklist right at the point when they should have selected flaps to tell the F/O to call for taxi clearance. During the taxi checks, flaps were not mentioned. During the line-up checks the F/O applied 'lip service' to the checks and read what the flaps should be reading not what they were.
The T/O config warning failed to sound, probably because of the failure of the R2-5 relay. The aircraft stick shaker activated after rotate and was not recognised as real by either pilot, the co-pilot calling 'engine failure?' and the Captain asking how he could turn it off.
I don't quite understand why the right thrust lever was retarded as they rolled to the right?
I also am not familiar with the Spanair MD-80 checklist. Is the after take-off flaps check 'read and do' or 'do and read'? Also, is flaps a specific check in the taxi checks or is it only included in the 'take-off briefing' review? (Pages 44-45 refer but are not clear).
Full report here:
http://www.fomento.es/NR/rdonlyres/9...NO_01_ENG1.pdf
Join Date: Jan 2008
Location: Herts, UK
Posts: 748
Likes: 0
Received 0 Likes
on
0 Posts
it would seem the likely but unproven cause of the accident was an intermittant failure of the R2-5 relay which determines the air/ground mode of certain systems, including the rat heat and T/O config warning.
The cause was taking off with the flaps & slats in the incorrect position
Join Date: Dec 1998
Location: UK
Posts: 289
Likes: 0
Received 0 Likes
on
0 Posts
Very true. But if the relay hadn't failed they wouldn't have returned to stand, so perhaps I should have said causes! As usual a chain of events casued all the holes in the cheese to line up unfortunately.
Join Date: Jun 2000
Location: last time I looked I was still here.
Posts: 4,507
Likes: 0
Received 0 Likes
on
0 Posts
Going back to handle the RAT problem is a complete red herring. Checklist discipline and airmanship. Plain & simple. When you know you have been caused to get out of sequence, or out of sync, you apply extra vigilence and sure as hell follow SOP's very carefully.
Join Date: Jun 2009
Location: US
Posts: 497
Likes: 0
Received 0 Likes
on
0 Posts
All of our different aircraft used the slide checklist which could only be blanked out when all required responses from both pilots confirmed configuration or action. At the end of their taxi that checklist item would still be open using the slide checklist. Starting over is fine too but it takes more time. How does starting over work with multiple interuptions from company changing weights, etc?
Join Date: Feb 2008
Location: Belgium
Posts: 58
Likes: 0
Received 0 Likes
on
0 Posts
Cheating with ATC?
A well trained crew is normally quite able to operate an airliner safely, without any written check list.
At least without any kind of "do list" (procedural type).
So the check list is a "back up", a procedure to help verify that no essential action was missed.
- verify that essential actions
- were properly performed
- were properly performed before calling for the check list.
The good time to call for a check list is when the crew is ready, I mean, fully ready, for the next step.
So call for the "before taxi" Check List should happen when the aircrafte is fully ready for taxi. Except for the taxi clearence and the parking brake release ...
I have seen to many crews requesting taxi clearence well in advance, when they are not ready at all ... this being done in the hope to "gain" some better ATC sequencing. I call this "cheating". And I remember certain Spanish crews being educated by their company to do so.
For the same reason : many "checks" (actions) being delayed to be actually performed during taxi, instead of being done as far sas possible before moving ...
With the adverse consequences of hurrying up in the "before taxi" and before take-off actions and checks, if the taxi clearence come fast and the take-off clearence as well ...
With fatal consequences last year in Madrid ...
Poor technicians and pilots training, poor supervision ...
At least without any kind of "do list" (procedural type).
So the check list is a "back up", a procedure to help verify that no essential action was missed.
- verify that essential actions
- were properly performed
- were properly performed before calling for the check list.
The good time to call for a check list is when the crew is ready, I mean, fully ready, for the next step.
So call for the "before taxi" Check List should happen when the aircrafte is fully ready for taxi. Except for the taxi clearence and the parking brake release ...
I have seen to many crews requesting taxi clearence well in advance, when they are not ready at all ... this being done in the hope to "gain" some better ATC sequencing. I call this "cheating". And I remember certain Spanish crews being educated by their company to do so.
For the same reason : many "checks" (actions) being delayed to be actually performed during taxi, instead of being done as far sas possible before moving ...
With the adverse consequences of hurrying up in the "before taxi" and before take-off actions and checks, if the taxi clearence come fast and the take-off clearence as well ...
With fatal consequences last year in Madrid ...
Poor technicians and pilots training, poor supervision ...
Join Date: Aug 2008
Location: Canary Islands, Spain
Posts: 240
Likes: 0
Received 0 Likes
on
0 Posts
Mapjet MD83 incident report released
And finally, after years (and years), the CIAIAC just released the report on the incident of the MD83 operated by Mapjet in Lanzarote in 2007 which had some similar circunstances with the Spanair case.
Here it is in english
http://www.fomento.es/NR/rdonlyres/7...022_IN_ENG.pdf
The differences between both cases have been previously discussed in this thread, but nonetheless it could be of theoretical interest to those studying a take off in the MD-8x types with an improper wing configuration, which also happened in Spanair's case.
Here it is in english
http://www.fomento.es/NR/rdonlyres/7...022_IN_ENG.pdf
The differences between both cases have been previously discussed in this thread, but nonetheless it could be of theoretical interest to those studying a take off in the MD-8x types with an improper wing configuration, which also happened in Spanair's case.
Join Date: Jan 2008
Location: United Kingdom
Posts: 274
Likes: 0
Received 0 Likes
on
0 Posts
Is it not a little unfair to hold the mechanics responsible for the manslaughter of 154 people for trying to clear a faulty OAT gauge when the actual cause of the crash was the failure of the pilots to select any flap for takeoff?
Join Date: Oct 2006
Location: on the sunny side
Posts: 16
Likes: 0
Received 0 Likes
on
0 Posts
Looks more like the report states "lack of discipline" in following SOP:s by the flight crew as the cause... Where does it say that the maintenance staff were responsible?
Join Date: Jan 2008
Location: United Kingdom
Posts: 274
Likes: 0
Received 0 Likes
on
0 Posts
Zon3
The last 2 paragraphs of the article with todays date stated:
Investigators believe the faulty external temperature gauge may have been caused by a mechanical fault that also affected other parts of the aircraft.
Two Spanair maintenance technicians have been charged with the involuntary manslaughter of 154 people and 18 cases of bodily harm in a case currently under investigation by a Madrid magistrate.
Two Spanair maintenance technicians have been charged with the involuntary manslaughter of 154 people and 18 cases of bodily harm in a case currently under investigation by a Madrid magistrate.
Join Date: Jan 2005
Location: N. Spain
Age: 79
Posts: 1,311
Likes: 0
Received 0 Likes
on
0 Posts
This is the actual transcript from a local paper followed by my translation. Anyone caring to improve this translation, please feel free. The 3rd person mentioned is thought to be another pilot visiting the flight deck.
- Mecánico: Puedes traer una bolsa de hielo... o de cacahuetes.
- Sobrecargo: ¿Para vosotros?
- Mecánico: No ¡hombre!, es una broma, es para enfriar la sonda. La estamos vacilando.
- Comandante: Tengo que escribir todo esto porque es un retraso guapo. Íbamos en hora, macho.
Unos minutos después...
- Mecánico: Pues lo vamos a despachar así, con el heater inoperativo, ¿vale?
- Comandante: Es quitar el breaker, ¿no?
- Mecánico: Es que lo que estaba calentando... el sistema se queda inoperativo.
- Comandante: ¿Se quita el breaker o tú desconectas algo más?
- Mecánico: No, el breaker, pero está inoperativo. Yo lo voy a despachar de acuerdo al MEL (la lista del equipo mínimo con el que debe volar un avión), con el breaker fuera, inoperativo.
- Tercer ocupante de la cabina: ¿Qué es lo que era? ¿Han cambiado el relé?
- Copiloto: No, lo han quitado.
- Tercer ocupante: ¡Cómo van a quitar el relé! ¿Han puesto hielo al final?
- Copiloto: Pues de puta madre.
- Tercer ocupante: ¿Ha bajado mucho la temperatura?
- Copiloto: ¡Joder, del tirón!
- Tercer ocupante: ¿Para que se enfríe antes el sensor? Pero si el problema ha sido el sensor, volverá a subir. Es un parche lo que han hecho ahí.
- Copiloto: Se puede hacer así.
- Tercer ocupante: Pero poner hielo a un sensor para que esté dentro del límite...
- Copiloto: No, no, eso es para que se enfriara mucho antes.
El avión ya rueda por la pista.
- Comandante: De no haber tenido ninguna incidencia, voy a tener tres en una semana, tres vueltas al parking.
- Tercer ocupante: ¿Sí?
- Copiloto: Toco madera, tío. Nosotros vamos a pedir no volar juntos.
- Comandante: A ver, tampoco ha sido tanto.
- Copiloto: Cada vez que he volado contigo hemos hecho algo, dos veces hemos acabado en un guiso (...)
- Comandante: ¿Tuyo? (Cede los mandos a su compañero)
- Copiloto: Cagüen la puta.
- Tercer ocupante: Vamos que nos vamos.
Despegue y ruidos
- Copiloto: ¿Fallo de motor?
La voz de alarma suena cuatro veces.
-Comandante: ¿Cómo coño se quita la voz?
-Comandante: ¡Vuela el avión! ¡Me cagüen la mar! ¡Vuélalo! ¡Vuélalo!
Se escucha el primer golpe.
-Comandante: Mierda.
Se escucha el segundo golpe. El copiloto grita. Silencio.
Mechanic:Can you bring a bag of ice... or peanuts
Senior CC member: For you?
Mechanic: No mate, it’s a joke, we’re kidding
Captain (to mechanic) I have to write all this down because now it’s a delay. We were on time.
Some minutes later...
Mechanic: We’re going to despatch as it is, with the heater inoperative, ok?
Captain: Remove the breaker?
Mechanic: It’s that that’s overheating, the system will be inoperative.
Captain: Are you removing the breaker or disconnecting something else?
Mechanic: No, the breaker, but it’s inoperative. I’m going to despatch in accordance with the MEL (list of minimum equipment), with the breaker out, inoperative.
3rd Flt Deck occupant: What was it? Have they changed the relay?
Copilot: No, they’ve removed it.
3rd Person: How/why are they going to remove the relay (surprised??). Did they put on the ice in the end?
Copilot: Pues de puta madre (like “oh bloody great” in English, can mean good or bad depending on the tone used)
3rd Person: Has the temperature dropped much?
Copilot: Like a stone.
3rd Person: Why cool the sensor earlier? If the problem was the sensor it’ll overheat again. All they’ve done is patch it up.
Copilot: It can be done like that (it’s permissible).
3rd Person: But putting ice on a sensor just to get it within limits...(questioning?)
Copilot: No, no, this is just to cool it down faster.
The aircraft then heads for the runway.
Captain: From never having an incident I’m going to have three in one week, three returns to stand.
3rd Person: Yeah?
Copilot: Touch wood, mate. We should request not to fly together.
Captain: Come on, it hasn’t been that bad.
Copilot: Every time I’ve flown with you we’ve done something, twice we’ve ended up in a stew (...)
Captain: Yours? (passing control to the FO)
Copilot: Oh ****.
3rd Person: Come on, let’s go.
Take-off and Noises
Copilot: Engine failure?
The alarm sounds four times.
Captain: How the hell do stop the alarm?
Captain: Fly the aircraft!! Fly it! Fly it!
Sound of the first impact.
Captain: ****.
Sound of second impact. Copilot shouts. Silence.
- Mecánico: Puedes traer una bolsa de hielo... o de cacahuetes.
- Sobrecargo: ¿Para vosotros?
- Mecánico: No ¡hombre!, es una broma, es para enfriar la sonda. La estamos vacilando.
- Comandante: Tengo que escribir todo esto porque es un retraso guapo. Íbamos en hora, macho.
Unos minutos después...
- Mecánico: Pues lo vamos a despachar así, con el heater inoperativo, ¿vale?
- Comandante: Es quitar el breaker, ¿no?
- Mecánico: Es que lo que estaba calentando... el sistema se queda inoperativo.
- Comandante: ¿Se quita el breaker o tú desconectas algo más?
- Mecánico: No, el breaker, pero está inoperativo. Yo lo voy a despachar de acuerdo al MEL (la lista del equipo mínimo con el que debe volar un avión), con el breaker fuera, inoperativo.
- Tercer ocupante de la cabina: ¿Qué es lo que era? ¿Han cambiado el relé?
- Copiloto: No, lo han quitado.
- Tercer ocupante: ¡Cómo van a quitar el relé! ¿Han puesto hielo al final?
- Copiloto: Pues de puta madre.
- Tercer ocupante: ¿Ha bajado mucho la temperatura?
- Copiloto: ¡Joder, del tirón!
- Tercer ocupante: ¿Para que se enfríe antes el sensor? Pero si el problema ha sido el sensor, volverá a subir. Es un parche lo que han hecho ahí.
- Copiloto: Se puede hacer así.
- Tercer ocupante: Pero poner hielo a un sensor para que esté dentro del límite...
- Copiloto: No, no, eso es para que se enfriara mucho antes.
El avión ya rueda por la pista.
- Comandante: De no haber tenido ninguna incidencia, voy a tener tres en una semana, tres vueltas al parking.
- Tercer ocupante: ¿Sí?
- Copiloto: Toco madera, tío. Nosotros vamos a pedir no volar juntos.
- Comandante: A ver, tampoco ha sido tanto.
- Copiloto: Cada vez que he volado contigo hemos hecho algo, dos veces hemos acabado en un guiso (...)
- Comandante: ¿Tuyo? (Cede los mandos a su compañero)
- Copiloto: Cagüen la puta.
- Tercer ocupante: Vamos que nos vamos.
Despegue y ruidos
- Copiloto: ¿Fallo de motor?
La voz de alarma suena cuatro veces.
-Comandante: ¿Cómo coño se quita la voz?
-Comandante: ¡Vuela el avión! ¡Me cagüen la mar! ¡Vuélalo! ¡Vuélalo!
Se escucha el primer golpe.
-Comandante: Mierda.
Se escucha el segundo golpe. El copiloto grita. Silencio.
Mechanic:Can you bring a bag of ice... or peanuts
Senior CC member: For you?
Mechanic: No mate, it’s a joke, we’re kidding
Captain (to mechanic) I have to write all this down because now it’s a delay. We were on time.
Some minutes later...
Mechanic: We’re going to despatch as it is, with the heater inoperative, ok?
Captain: Remove the breaker?
Mechanic: It’s that that’s overheating, the system will be inoperative.
Captain: Are you removing the breaker or disconnecting something else?
Mechanic: No, the breaker, but it’s inoperative. I’m going to despatch in accordance with the MEL (list of minimum equipment), with the breaker out, inoperative.
3rd Flt Deck occupant: What was it? Have they changed the relay?
Copilot: No, they’ve removed it.
3rd Person: How/why are they going to remove the relay (surprised??). Did they put on the ice in the end?
Copilot: Pues de puta madre (like “oh bloody great” in English, can mean good or bad depending on the tone used)
3rd Person: Has the temperature dropped much?
Copilot: Like a stone.
3rd Person: Why cool the sensor earlier? If the problem was the sensor it’ll overheat again. All they’ve done is patch it up.
Copilot: It can be done like that (it’s permissible).
3rd Person: But putting ice on a sensor just to get it within limits...(questioning?)
Copilot: No, no, this is just to cool it down faster.
The aircraft then heads for the runway.
Captain: From never having an incident I’m going to have three in one week, three returns to stand.
3rd Person: Yeah?
Copilot: Touch wood, mate. We should request not to fly together.
Captain: Come on, it hasn’t been that bad.
Copilot: Every time I’ve flown with you we’ve done something, twice we’ve ended up in a stew (...)
Captain: Yours? (passing control to the FO)
Copilot: Oh ****.
3rd Person: Come on, let’s go.
Take-off and Noises
Copilot: Engine failure?
The alarm sounds four times.
Captain: How the hell do stop the alarm?
Captain: Fly the aircraft!! Fly it! Fly it!
Sound of the first impact.
Captain: ****.
Sound of second impact. Copilot shouts. Silence.
Last edited by Shack37; 11th May 2010 at 21:22.
Join Date: Apr 2009
Location: Toowoomba Australia
Age: 76
Posts: 22
Likes: 0
Received 0 Likes
on
0 Posts
Routines check lists
We all take short cuts or get blase or distracted and we don't need sociology or psychology majors to do a study to tell us how and what pattern this is embraced. We already know this but need to ensure procedures minimise this human trait.
IF aircraft computers can talk to each terminal an automatic check list can be carried by on ground terminal computer BEFORE being given clearance to leave gate. Even so glitches will arise but it will reduce human oversight.
The cost? Ask the passengers or shareholders if $50 extra is worth it. It's executives trying to get bigger bonuses with too severe "savings" aided by accountants. All businesses should be run by experienced industry professionals and not transient ambitious execs.
IF aircraft computers can talk to each terminal an automatic check list can be carried by on ground terminal computer BEFORE being given clearance to leave gate. Even so glitches will arise but it will reduce human oversight.
The cost? Ask the passengers or shareholders if $50 extra is worth it. It's executives trying to get bigger bonuses with too severe "savings" aided by accountants. All businesses should be run by experienced industry professionals and not transient ambitious execs.
