Spanair accident at Madrid
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Of course the crew is at fault. Maintenance set them up by disabling the take off warning system, but if they had done their checklist everything would have been fine. We all need to think about how easy it would be for this happening to us if we don't stay disciplined. Don't ever rely on your checklist to do what needs to be done. Have a final scan of flaps, gear, trim and spoilers on every take off or landing, it only takes a second. Do it on short final or cleared onto the runway. I did it once at 200 ft once landing and noticed we didn't have the autospoilers armed then noticed we hadn't done any of the landing checklist. We had it all done in the last few seconds. It was basically all done except for arming the speedbrakes but checking the basics to back up everything can be good some days when you are snoozing.
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Perfect example of the swiss cheese model, as someone pointed out already!
Which makes me think about the role of the lasf of that slice of cheese which is usually located at the end of the line: the pilots.
We are the ones who have a chance to stop the chain of events that has filtered through several other cheese slices.
The more the talent we have, the better the education we have had, the better the training we have had, the better the selection process in airlines is, the more experienced we are... the fewer holes that cheese slice has.
quality, good training, experience and good selection will result in good airmanship and hence more safety.
Recommendations in this direction should be made in any "swiss cheese" accident.
Which makes me think about the role of the lasf of that slice of cheese which is usually located at the end of the line: the pilots.
We are the ones who have a chance to stop the chain of events that has filtered through several other cheese slices.
The more the talent we have, the better the education we have had, the better the training we have had, the better the selection process in airlines is, the more experienced we are... the fewer holes that cheese slice has.
quality, good training, experience and good selection will result in good airmanship and hence more safety.
Recommendations in this direction should be made in any "swiss cheese" accident.
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Report on Spanair Crash
From The Reader Daily news and information in English for Spain
Three directors of Spanair airlines have been indicted on 154 counts of homicide after the 2008 crash at Barajas airport in Madrid.
Judge Javier Perez, investigating the Spanair plane crash occurred on August 20, 2008, has indicted the three heads of area for reckless homicide and reckless injury resulting in 18 crimes and 154 homicides.
Antonio V., in charge of the Spanair Base in Madrid at the time of the accident, David T., responsible for Line Maintenance, and S. Alexander, director of quality control at the time of the accident, have all been charged by the judge. They have been ordered to appear before the Judge on 20, 21 and 22 June, along with Jesus T., the Spanair maintenance supervisor who was already charged in the case. (My emphasis).
The charges are produced following the conclusions of the expert report carried out by eight experts appointed by the judge and the expert report by a French expert in aircraft accidents.
Shortly before the crash, the aircraft had to return to the hangar after a first takeoff attempt after it detected a fault in the heater temperature sensor (RAT). One of the mechanics of the company consulted the minimum equipment manual (MEL) from Boeing and deactivated the RAT sensor heater. Since the beginning of the investigation, the instructor believes that "the failure of the RAT on August 20 was a consequence or manifestation of a multifunctional failure which also affect TOWS (that warn of an improperly configured for takeoff), fueled by same relay, which resulted in the crash".
(Note: The Reader is an online Spanish daily newspaper produced in English for expats)
Three directors of Spanair airlines have been indicted on 154 counts of homicide after the 2008 crash at Barajas airport in Madrid.
Judge Javier Perez, investigating the Spanair plane crash occurred on August 20, 2008, has indicted the three heads of area for reckless homicide and reckless injury resulting in 18 crimes and 154 homicides.
Antonio V., in charge of the Spanair Base in Madrid at the time of the accident, David T., responsible for Line Maintenance, and S. Alexander, director of quality control at the time of the accident, have all been charged by the judge. They have been ordered to appear before the Judge on 20, 21 and 22 June, along with Jesus T., the Spanair maintenance supervisor who was already charged in the case. (My emphasis).
The charges are produced following the conclusions of the expert report carried out by eight experts appointed by the judge and the expert report by a French expert in aircraft accidents.
Shortly before the crash, the aircraft had to return to the hangar after a first takeoff attempt after it detected a fault in the heater temperature sensor (RAT). One of the mechanics of the company consulted the minimum equipment manual (MEL) from Boeing and deactivated the RAT sensor heater. Since the beginning of the investigation, the instructor believes that "the failure of the RAT on August 20 was a consequence or manifestation of a multifunctional failure which also affect TOWS (that warn of an improperly configured for takeoff), fueled by same relay, which resulted in the crash".
(Note: The Reader is an online Spanish daily newspaper produced in English for expats)
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Antonio V., in charge of the Spanair Base in Madrid at the time of the accident, David T., responsible for Line Maintenance, and S. Alexander, director of quality control at the time of the accident, have all been charged by the judge. They have been ordered to appear before the Judge on 20, 21 and 22 June, along with Jesus T., the Spanair maintenance supervisor who was already charged in the case. (My emphasis).
Spanair seemed to be renowned for having a general high level problem of complacency regarding safety and overall poor management procedures so if there was to be any sense in bringing criminal charges against anyone it ought to be the Chief Executive and any other main board director(s) directly responsible for Operations or Safety of the airline as a whole.
All that the bringing of these criminal charges will do is to make a few sacrificial heads roll whilst allowing the powerful individuals who earn the really big bucks from Spanair and who allowed this culture of corporate safety complacency to prevail to walk away totally scot free.
Unfortunately this Latin predilection for bringing criminal charges over airline crashes will only encourage people to cover up what has really happened rather than be open about it in future incidents so that the root causes can be established and addressed. Criminal charges are in my opinion only effective against the board directors of the company who are usually responsible for things like cutting corners budgetarily on providing enough money for maintenance. To make the guys further down the line responsible for the inevitable consequences of the corner cutting actually initiated by the main board directors is in my opinion quite ridiculous and grossly unjust.
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All that the bringing of these criminal charges will do is to make a few sacrificial heads roll whilst allowing the powerful individuals who earn the really big bucks from Spanair and who allowed this culture of corporate safety complacency to prevail to walk away totally scot free.
What a joke. The systems theory approach is more about class snobbery than it is about safety. The only people who are safe in such a system are not the passengers but the corporate heads.
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Hi,
To read
El accidente del JK5022 podra haberse evitado
Unfortunately this Latin predilection for bringing criminal charges over airline crashes will only encourage people to cover up what has really happened
El accidente del JK5022 podra haberse evitado
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This thread is an amazing example of fault tree analysis from aviation professionals and non-professionals alike (Justme69!), and should be retained in the annals of the PPRUNE archive for posterity . How very perceptive it was of the individual (#318) who identified from the first images from the crash scene that the flaps were in a retracted position. Lessons learned here have clearly come with a high human cost and it is for the industry to recognise that highly coupled events do not become safer by increasing complexity. Chief amongst this review should be the manner in which the FMS acknowledges inputs made to the critical control checklist items, in relation to a configuration calculated for take-off. The lack-of redundancy for supporting subsystems is also an issue here, notwithstanding the ultimate responsibility for ensuring that the basic safety principles are adhered to, which sadly fall on the human element in this tragic instance.
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Yes. The Europeans like to triumphant to the skies how their "systems theory" approach is so much better than the empirical approach of the Americans. See, as a perfect example, the quote from Safety Concerns above of this page about TEAM work.
What a joke. The systems theory approach is more about class snobbery than it is about safety. The only people who are safe in such a system are not the passengers but the corporate heads.
What a joke. The systems theory approach is more about class snobbery than it is about safety. The only people who are safe in such a system are not the passengers but the corporate heads.
, least of all anyone who questions axiomatic thinking.
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Hi,
http://lasmentirasdebarajas.********...liot-ness.html
******** = b l o g s p o t (no spaces)
Debates en AviacionDigital.com - Noticias de Aviacin
http://lasmentirasdebarajas.********...liot-ness.html
******** = b l o g s p o t (no spaces)
Debates en AviacionDigital.com - Noticias de Aviacin
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Spanair accident final report
What a whitewash, passing all the blame onto the crew and never mind the failures in maintenance procedures, the question as to why the operating manual wasn't up-to-date, and all the other holes in this swiss cheese accident. Disgusting. Good, isn't it - crew dead so we can blame it all on them. And let's sneak the report out at the start of the summer when a lot of Spanish are on holiday - oh, and only in Spanish.
I really do hope the relatives of the deceased take this further.
I really do hope the relatives of the deceased take this further.
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I posted on my experience here over a year ago of a similar MD80 R2-5 relay being put in the airborne mode by a nose gear ground/air sensor sensing air mode because of an over inflated nose gear strut. Taxiing out at night the strobes were flashing, the idle was at approach idle and obviously my takeoff warning systems was inop but at the time I didn't know it. Knowing the strobes turned on with nose strut extention I used aggressive braking to compress the nose gear strut. Strobe lights went out and idle went to ground idle. Also even at the time I didn't know it I got back the take off warning system.
Sounds like the same thing happened to them but during daytime the strobes wouldn't be noticed and they might have missed the higher than normal idle. It would be easy to check though with the FDR. I don't think the crew was totally at fault. As in all accidents, if they are dead, they are the easiest and cheapest way out.
Madrid has a long taxi for takeoff, I had a short taxi at midnight in California so never got a probe overheat.
Sounds like the same thing happened to them but during daytime the strobes wouldn't be noticed and they might have missed the higher than normal idle. It would be easy to check though with the FDR. I don't think the crew was totally at fault. As in all accidents, if they are dead, they are the easiest and cheapest way out.
Madrid has a long taxi for takeoff, I had a short taxi at midnight in California so never got a probe overheat.
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Sounds like the same thing happened to them but during daytime the strobes wouldn't be noticed and they might have missed the higher than normal idle. It would be easy to check though with the FDR. I don't think the crew was totally at fault. As in all accidents, if they are dead, they are the easiest and cheapest way out.
The ONLY relays that was malfunctioning was the R2-5....
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I never said the crew wasn't at faullt and, as far as I can recall, nor did anyone else. The point I was making was that it wasn't only the fault of the crew. The whole point - forgive me for teaching grandmothers to suck eggs - of safety systems is that they come into play when the human element fails. Pilots are human and they fail, so safety systems ensure that there is a second line of safety. TOWS should have been working - that's what it was there for.
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humans
I am sure that the most proficient and expert over 20,000 hours experience pilots can recall at least one mistake that could have had very bad consecuences hadn't it been for a take off configuration alarm or a first officer, or similar, that warned them about their mistake.
Less experienced pilots maybe not, because it hasn't happened yet to them.
humans make mistakes. Even gifted ones. I've seen it happen.
Even Messi can shoot a penalty and send the ball to the 60th row.
The swiss cheese was there: maintenance, pressure, FO with low experience, bad company SOPs that didn't adopt manufacturer recommendations about an item in line with the maintenance cheese loaf and a mistake in line with the maintenance cheese loaf.
all together are to blame
Less experienced pilots maybe not, because it hasn't happened yet to them.
humans make mistakes. Even gifted ones. I've seen it happen.
Even Messi can shoot a penalty and send the ball to the 60th row.
The swiss cheese was there: maintenance, pressure, FO with low experience, bad company SOPs that didn't adopt manufacturer recommendations about an item in line with the maintenance cheese loaf and a mistake in line with the maintenance cheese loaf.
all together are to blame
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Article in SEPLA criticising Investigation
In the ongoing court case the Director of Quality face 600 years in jail
RTVC.es - Radiotelevisión Canaria - Noticias
The Errors in the System and Latent Errors not addressed enough in the report, apparently.
This accident needed and warranted a full blown Dryden style to change things and culture.
Time Pressure on Mechanics and pilots was a factor and still exists, this needs to be addressed. The hurry up syndrome.
So that maintenance guys are not pressured .
Human factor was huge in as by not hearing the Warning the crew felt they were safe.
Definitely DGAC and AESA had committed errors in their supervision that contributed to the accident.
What are the Spanish authorities doing to fix this now ?
Final Report in Spanish
http://www.fomento.gob.es/NR/rdonlyr...2008_032_A.pdf
One thing that is coming out is that there was complacency in Deferring Defects in general.
Extension of Deferred Defects in the MEL will not be given out so easily in Spain. Dont know if Extension of Deferred Defects will be affected in
RTVC.es - Radiotelevisión Canaria - Noticias
The Errors in the System and Latent Errors not addressed enough in the report, apparently.
This accident needed and warranted a full blown Dryden style to change things and culture.
Time Pressure on Mechanics and pilots was a factor and still exists, this needs to be addressed. The hurry up syndrome.
So that maintenance guys are not pressured .
Human factor was huge in as by not hearing the Warning the crew felt they were safe.
Definitely DGAC and AESA had committed errors in their supervision that contributed to the accident.
What are the Spanish authorities doing to fix this now ?
Final Report in Spanish
http://www.fomento.gob.es/NR/rdonlyr...2008_032_A.pdf
One thing that is coming out is that there was complacency in Deferring Defects in general.
Extension of Deferred Defects in the MEL will not be given out so easily in Spain. Dont know if Extension of Deferred Defects will be affected in
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EC-HFP. McDonnell Douglas MD-82. Aeropuerto de Barajas (Madrid) - 2008 - Investigación - CIAIAC - Órganos Colegiados - Ministerio de Fomento:
Originally Posted by CIAIAC
The original Spanish version of the final report, as approved by CIAIAC Board, is already available for free download. However, the translation into English is still ongoing. The English version will be posted on CIAIAC website, as soon as this translation be completed.
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Hi ALL,
Do not forget that there have been no final decision of the Judge.
Spanish Authorities ... Who?
Ministry: DGAC and AESA? They will not do anything from the standpoint of Civil or Criminal. Only a Judge can say whether civil servants and other individuals working for the Spanish Authorities, ie the Ministry (DGAC, AESA) are responsible for the accident, among other accused.
Unfortunately, it is much easier and faster blaming the dead pilots.
From my point of view, there is no doubt that there are responsibilities on the staff of DGAC and AESA. If they had been monitoring the matter as it should be, the accident could have been avoided. Unfortunately, there is much carelessness or complacency among the staff of DGAC and AESA as well as fellow drivers who did not check Slats and Flaps divices.
When operating with multiple inoperative items, what would you do?
Well, It must be subjet of pilot judgment:
-The inter-relation between those items
-The effect on aircraft operation and
-The crew workload.
Do not forget that there have been no final decision of the Judge.
Spanish Authorities ... Who?
Ministry: DGAC and AESA? They will not do anything from the standpoint of Civil or Criminal. Only a Judge can say whether civil servants and other individuals working for the Spanish Authorities, ie the Ministry (DGAC, AESA) are responsible for the accident, among other accused.
Unfortunately, it is much easier and faster blaming the dead pilots.
From my point of view, there is no doubt that there are responsibilities on the staff of DGAC and AESA. If they had been monitoring the matter as it should be, the accident could have been avoided. Unfortunately, there is much carelessness or complacency among the staff of DGAC and AESA as well as fellow drivers who did not check Slats and Flaps divices.
When operating with multiple inoperative items, what would you do?
Well, It must be subjet of pilot judgment:
-The inter-relation between those items
-The effect on aircraft operation and
-The crew workload.