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Spanair accident at Madrid

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Spanair accident at Madrid

Old 4th Sep 2008, 16:06
  #1461 (permalink)  
Rather old then bold
 
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LUALBA;
IF - I repeat IF - what the media has reported is true, I have the following remarks on your post:

To say that the TWAS failure is the primary cause of the accident is not true; if the pilots had selected the right flaps there wouldn't have been an accident - regardless of wether the TWAS was functioning or not. Please keep in mind that 99,99% (or there about) of all TO with the MD-80 are done without any TWAS warning and in most cases the pilots would not know if the system is working or not - because they've set the right configuration. I do agree that the absens of a TWAS warning might be a contributing factor in this becoming an accident.

Regarding GPWS and Stall they are designed so give warnings to the pilots in the air - not on ground (I don't know the MD-80 systems enough to know if the warnings are inhibited on ground or not).
The TWAS is configured to only give a warning when the plane is on ground, and thus a faulty ground/air switch in the nose gear (as has been suggested and explained in this thread elequantly) and the plane "belived" it was in the air the TWAS would be inhibited.

I would strongly recommend that you read through the thread - there is a bundle of accurate information from professionals to learn from.

Regards,

MjA
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Old 4th Sep 2008, 16:48
  #1462 (permalink)  
 
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In response to post 1475:

Your source:
A loud horn designed to alert the crew to equipment problems apparently did not sound, sources familiar with the investigation was quoted as saying.
The MD-82 has a speech system. The warning would be "CONFIG SLATS, CONFIG FLAPS", if they'd forgotten to set them at all.

If the slats were set but not the flaps, you get "CONFIG FLAPS" on it's own. This would be very apparent in the CVR, too.

Felipe Laorden of the Official College of Commercial Aviation Pilots (Copac) was commenting on a report in the US newspaper Wall Street Journal that the MD-82 did not have its wing flaps, which provide extra lift, fully extended.

Laorden said the plane's alert system may have had 'a mechanical or design error.' It had initially been suspected that the problem lie with the plane's reverse thrust, but Wall Street Journal said the engines appeared to have been working properly.
This looks like second-hand information. Here we have a guy unconnected to the investigation commenting on second-hand reports coming out of the WSJ? This isn't news!


ECAM Actions.
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Old 4th Sep 2008, 16:55
  #1463 (permalink)  
 
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xkoote,

Quote:
1. The ARt fire light and the slat takeoff light are clearly visible in daylight....when you are looking at them. They are not the glow in the corner of your eye type of light like the reverser unlocked lights for example. In a situation of distress you would not be able to answer the sim instructor's question if the ART fired or not if you were the pilot flying (come to think of it maybo you can as the sim is always dark )

It says here that the ART and slat lights are visible when looking directly at them, but not as bright as the TR unlock lights which are much brighter and (might I add) more than twice as big.
This goes to show how written text can be subject to interpretation. I honestly read "the glow in the corner of your eye . . ." to mean less brilliant than the ART fire light and the slat takeoff light as you explained they are clearly visible in daylight (when you are looking at them).

Thanks for clearing the issue, at least i have learned now that the TR unlock lights on the MD8x aircraft won't go unnoticed when they illuminate.


Regards,
Green-dot
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Old 4th Sep 2008, 17:17
  #1464 (permalink)  
 
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Hi,

I think it is important to realize that it doesn´t matter how long one is flying an aircraft type and how experienced one is - the checklist should always be used, even if you memorized it completely and do the procedures for years.

Bernie
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Old 4th Sep 2008, 17:31
  #1465 (permalink)  
 
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MAYOR ATTACH wrote:

"To say that the TWAS failure is the primary cause of the accident is not true; if the pilots had selected the right flaps there wouldn't have been an accident - regardless of wether the TWAS was functioning or not."


I'm completly agree, I never said "primary cause". If flaps/slats are not properly set for TO is under crew functions. So you have to addmit also that it's true that if the take off congifuration warning warns ( Terrain Awareness and Warning System ) then the crew will abbort TO.

Concerning the GPWS and stall warnings: According spanish media those warnings are audible ( from data from CVR ). IF ( I repeat IF ) tha take off configuration warning did not sound and the stall and GPWS did, maybe, just maybe, means that the system was "working" properly...

On AIB, TO Warnings:

CONFIG
. SLATS/FLAPS NOT IN T.O CONFIG: Aural warning ( CRC ), master light - MASTER WARNING

When?

A/C not in TO configuration when thrust levers are set at TO, or Flex TO, or when pressing TO CONFIG. pb.

Last edited by LUALBA; 4th Sep 2008 at 18:25.
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Old 4th Sep 2008, 17:34
  #1466 (permalink)  
 
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I think it is important to realize that it doesn´t matter how long one is flying an aircraft type and how experienced one is - the checklist should always be used, even if you memorized it completely and do the procedures for years.
True, but.....
That "works" in the perfect-pilot-world, and there is no.

All SLF want/expect to fly in a perfect maintained a/c. and normally they are well maintained! SLF have no clue about MEL-items and so on.
They, SLF, are the first to complain and sue BUT ALSO THE FIRST AND LAST TO SWITCH THEIR MOBILES ON AND OFF!

And yes, I have seen pilots operate without using their checklist........
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Old 4th Sep 2008, 17:57
  #1467 (permalink)  
 
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Predictably this thead is going to swing back over to a single cause/blame whether it be engines, reversers or now taking off with the wrong configuration.

The professionals on this forum recognize the concept of the layers of swiss cheese between a single cause and an accident. albeit some want to always argue the primary cause is the first layer and that's all she wrote.

Again, the purpose of accident investigation is prevention, so of course the most important thing in all this is what is going to be done now along those lines.

I learned a long time ago that all one can do is minimize, you really can't eliminate many causal factors. Crew error like configuration botches have been with us for a long time and will remain with us forever. The issue then is to look at the various layers of cheese to find out what assumption under the regulations were made in the statistical error rate (including latent or hidden failures) in any of these layers. My tendancy is to identify that layer that is furthest out of wack with the design/certification assumptions as the one that needs the most attention.

So I will sit back and read this thread to see if anybody has identified failure rates of all the parts of the system (including crew) in this accident.
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Old 4th Sep 2008, 22:29
  #1468 (permalink)  
 
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As usual, some of this report on the spanish press doesn't seem, well, all the accurate one would want. Whenever there is a comment on my side, I will write in in parenthesis. Otherwise, is a verbatim translation. When it doesn't quite make sense or it is ambigous, it's because it was also so in the original text.

"The commander checked the equipment with his copilot and expressly said: 'slats flaps, ok' That means that he did check the position on the sustaining devices on the wings was the correct one for take off. The investigating commision has paid much attention to this fragment of the conversation extracted from the black box to find out if the pilot correctly configured the airplane.(Can't they figure this out cathegorically from the FDR?) The degree of inclination on the flaps requires a specific speed to take-off. Assuming the pilots didn't forget something as essential, investigators are wondering if the flaps could've failed. The mechanism activates from a switch (lever), if it fails there is a 'watch' (gauge) that indicates its real possition. A redundant system fires an alamr sound if the configuration is wrong. It would've whistled even before take-off and the pilot would've aborted the operation.

¿Could then the alarm system have also failed? It would be rare because when the plane took off it did work; two sound alarms warned on the impact against the ground and the lack of sustenability. (That's what it says)

It was 15 terrible seconds (previously reported as 7 seconds) that the comission is trying to bring light to. So far, the only evident thing is that the airplane didn't have the neccesary speed for take-off.

One research team in checking the possibility that the flaps failed and another failure on the engine reverser (singular but ambigous) that could've activated taking away thrust from the engines."


(This last sentence doesn't make perfect grammatical sense in spanish, it was probably meant to be that two different teams are looking into each scenario, rather than one team looking into both "failures")

And that's it for the translation. Now, on my own words, I'm just wondering who exactly wrote that piece of news, since if they were so close to the investigation's commision they would've certainly know by now, through the FDR, if the reverser deployed or not, what speed/thrust settings they were using, how long rotation took, etc.

Edit: It seems the information comes from a news piece by news agency atlas/efe, possibly from insights from the official college of pilots of Spain.

Also, FWIW, some more reviewed "wild" estimates by the press on the airplane height before going down: 10m

Some more tidbits:

-The maintenance technician that did the probe's heater "repair" went back in front of the judge to answer questions about the reverser (indeed locked out of service) and "some other even smaller malfunctions" that the plane had, all of them compatible with the fit-to-fly status.

-The only "direct" witness of the whole accident, a ground worker (those "follow me" car drivers) declares the usual "airplane taking a long time to take off", "briefly airborne rolling steeply left and right", "falling to the ground nearby losing its course", "dissapearing from his sight" (into terrain levels). He doesn't mention any "flashes" or "fires" or excessive yaw, etc on this news piece. But previously, he is quoted as saying (to the police, rather than to the judge) "I was next to Terminal 4S and saw the white MD rolling steeply, first to the right. The left engine caught in fire, spitting out some flashes. Then the airplane did some yaw, nose went up and fell down. Then some dust and finally an explosion."

This last piece of news goes on saying that the newspaper (La Razón) consulted specialist sources that wanted to say that those "flames" or "flashes" that the worker claims to have seen can be considered normal in this type of airplane during take-off with the engines working at high throttle.

-Police also wants to interview a truck driver that possibly witnessed the fall as well (he is outside of Spain for the time being).

Last edited by justme69; 4th Sep 2008 at 23:10.
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Old 4th Sep 2008, 22:32
  #1469 (permalink)  
 
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Question

el # wrote:
QUOTE
How on earth can anyone know? These things are usually decided after lengthy trials in court, do you realize that? Or you was just so curious and bored at the same time that went to the extreme of reading 1500 posts and register just for asking that ?
UNQUOTE
I hope you may read more carefully other kind of papers...
Although I have never posted any comments I joined the forum half a year before yourself.
What is really awkward is to place a non-based opinion as a fact, trying to teach everyone and at the same time to belittle someone´s comment on a main issue
I wonder if you are so well-informed and familiar to insurance procedures as to briefly justify what you say about compensations, just for the sake of illuminating all of us, poor ignorants...
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Old 5th Sep 2008, 04:41
  #1470 (permalink)  
 
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possible scenario of accident

Hi

I just wrote a long story of something that could be interesting but it disappeared somehow. Just to make it shorter, Our company did have an simailar incident last year at Lanzarote canary island while taking off with an MD83. After rotation experienced stall and 50 deg bank left and then recovering and then right 50 deg. This whent on for a few times back and fwd and somehow manage to get the aircraft stable with selecting gear up and just continue towards the slow hill at about 100 ft of altitude. Crew then found out flap handle in up position. How was that possibe ?? This is an officilal NTSB report and they found c/b -L/H GND CTRL RLY OUT when landed safely. What did cause that ??
Due to engineer performing their daily check and pulling this c/b to be able to check the strobe lights working on GND. A Std procedure since decades on the type among engineers worldwide.
This C/B does a few things it does:Put the aircraft partly artificially in FLT mode and does put the RAT sensor heating on and turn the avionic FAN off and the cabin recirculation fan off. This is normally easliy spotted is inside cockpit when turning systems off but potentially could be missed if systems already off ( i.e c/b already pulled when entering cockpit).
Going back to the accident aircraft they reported to have had problems with RAT probe heating and came back first time. And the engineer on duty just HIL the item without understaning why it actually had broken. Its by no coincident that just that probe is broken, thats the only one controlled by WOW (weight on wheels) and heating is turned on when a/c is airborne or the famous L/H GND CTL RLY c/b is pulled. The probe will soon go to ovht then fail. At the end of the day it could have been on for hours depending on when the last daily were performed prior flight.
Second thing they reported thrust rating problems, that is also no coincidence since the RAT probe is sensning current OAT and is controlling thrust setting in FLEX and other modes and if probe heat is on it will soon go to a 100 deg celcius and the the thrust management system will think all is crazy since it it sensing a 100 deg outside and the TRP will for sure go to "NO MODE" without anybody understanding why.
The famous C/B L/H GND CTRL RLY also does controll the take off warnig system of the MD80 aircraft that ofcourse means if it is pulled the take off warning system will NOT work. Then It is ofcourse possible to takeoff without flap and slap extended and NO warning will be coming on. I hope you do understabd my plaussable scenariao.
Just one of those flights when all went terrible wrong crashing with a almost perfectly working aircraft in almost perfect weather.Very sad !
What saved our aircraft compared to the Spanair one is the the MD83 is smoking the JT8D-219 and not the -217 mounted on most of the 82s and with less weight of the day and some slope ahead keeping the GND effect for a few moments and everybody alive.
Fellow guys-reading checklist properly and always and less complacancy with proper system knowlege saves LOTS of life.

My story anyway and I do think the MD 80 is an absolutely fantastic aircraft-most people killed in it did not for some reason follow the rules. By NO means saying that the Spanair guys didnt since no officilal report is made. This is just my own conclution and a possible scenario based on 17 years of experience on type and hopefully just some good analyzing

Ps. for you guys in the left seat of the MD80 pls have a closer look just behind your left shoulder if that famous C/B is pushed in, it could potentially have the different of coming down in one pice or in millions...
and you cold bet you sweet ass on that this particular C/B is pulled every single day on every MD 80 operator aound the globe so just make sure its IN before ju start !!!

Fly high


L1011

Last edited by wings1011; 5th Sep 2008 at 06:19. Reason: continuing
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Old 5th Sep 2008, 08:21
  #1471 (permalink)  
 
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Due to engineers performing their daily checks and pulling this circuit breaker to be able to check the strobe lights working on GND. A Standard procedure since decades on the type among engineers worldwide.
Using Circuit Breakers as Switches. HERE.

“One thing I note continuously throughout Apollo is the way they cycled circuit breakers, often as a matter of routine operations. In my experience with aircraft systems, circuit breakers are considered as protective devices that should not be used as a switch to turn systems on and off. While it may be acceptable for maintainers to open breakers to make a system safe for maintenance, it is not standard practice for pilots to cycle breakers. We would only put it into a checklist reluctantly, and only if no other way exists to turn off a system. Since the circuit breaker plunger is held in mechanically, repeatedly cycling it can wear it out. For a system or component that is required to be turned on and off, a Power switch should be used, with a circuit breaker also in the circuit for protection".

Also - From SR111 Canadian Report. HERE.

1.18.5.4 Circuit Breakers Used as Switches

The use of CBs as switches, either by design, or as a consequence of the system's in-service performance, is not recommended. The FAA guidance on this issue is contained in AC 43.13-1B and states "Circuit breakers...are not recommended for use as switches. Use of the circuit breaker as a switch will decrease the life of the circuit breaker."

Last edited by forget; 5th Sep 2008 at 09:03.
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Old 5th Sep 2008, 10:43
  #1472 (permalink)  
 
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Report late

05-06-2007. OE-LMM. McDonnell-Douglas MD83. Aeropuerto de Lanzarote (Las Palmas) - CIAIAC - Ministerio de Fomento

wings1011 - thx for the insight on OE-LMM. Had the final official report been out every MD driver would have been much more alert about the critical relevance of the CB and the necessity to check it's pushed. This comes back to critical deficiency and human factor training derived from incidents/accidents. The report not being out by now gives only few hope that the investigation on Spanair will be fast.

Btw and OT - anybody ever heard back from Kenya 737-800 in Douala?
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Old 5th Sep 2008, 11:21
  #1473 (permalink)  
 
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@wings1011


Good research! Sounds very logical....
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Old 5th Sep 2008, 11:59
  #1474 (permalink)  
 
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When I flew the MD83 one of our setup procedures was to advance the thrust levers prior to engine start and test the CAWS (Central Aural Warning System). If it worked properly, we would hear a "BEEP BEEP FLAPS, BEEP BEEP SLATS, etc". At the time, I thought of it as a rather rudimentary test procedure but I can't help but think it may have broken the chain here.
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Old 5th Sep 2008, 12:07
  #1475 (permalink)  
 
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Danger WSJ

I am making no comment as to causes probable or otherwise. But in relation to the WSJ I can state that one is dealing with a completely different kind of newspaper from any of the papers in either Spain or the UK. The WSJ even now it is owned by the Dirty Digger is a very serious operation.

If the Journal writes a story with this degree of certainty it is true. They will have talked to someone connected with the investigation, the fact checkers will have confirmed that the individual concerned was in a position to know and was not some wannabe. The conversation will either have been taped or contemporaneously noted.

At a rough thought I would guess the source is in the US part of the team but purely hypothesis on my part
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Old 5th Sep 2008, 12:33
  #1476 (permalink)  
 
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Thank you wings1011. That clears up a lot of questions I had related to my post:

http://www.pprune.org/4370893-post1443.html

Again, warning everyone that this is just "rumors" I'm talking about here and that I have NO specific knowledge on the aviation industry, it seems that another sign of these types of WOW sensor related malfunctions is, as described, automated flight control systems ("computers") may "act weird" when they receive grossly (over the limit) temperature readings from the outside air temperature sensor (due, i.e., to the heater being on while on ground for a long time on a hot day).

The first reports that I heard is that the pilots "felt" like the engines were "accelerating and deccelerating" erratically-quickly during take off (a real bad time for this to happen). At first, it was thought it could've been some malfunction with the autothrottler, it was rumored.

Wings1011 explanations makes it all look much clearer now. Is there a way to check what the probe's reading is in the cabin? If so, a sanity check could also be a good idea?

Obvioulsy the Spanair pilots noticed either the "impossible" temperature reading or some other sign that made them know there was something wrong with the "heat probe".

In other, more automated airplanes, like I think some airbusses may be, what would happen if an automation-assisted take off is attempted and an air temperature probe gives, due to a malfunction, a temperature reading of say 8º when the actual temperature is 28º?
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Old 5th Sep 2008, 14:34
  #1477 (permalink)  
 
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Wings1011

Due to engineer performing their daily check and pulling this c/b to be able to check the strobe lights working on GND. A Std procedure since decades on the type among engineers worldwide.
I find this very strange, since we never pulled that breaker out during daily checks on our fleet. I worked with MD-80s and DC-9s for nearly ten years and never pulled the mentioned CB, ever. As I recall, on our fleet anyway, you could turn the strobes on turning a switch on the right hand side of the glareshield (it is possible I remember wrong, it's been a couple of years since I've been inside an MD).

Second thing is, you said they had reported thrust rating problems. Have I missed something? It is possible that I have missed such a piece after reading this thread through.
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Old 5th Sep 2008, 16:14
  #1478 (permalink)  
 
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Wings 1011,
Thank you for your invaluable insight.
The famous C/B L/H GND CTRL RLY also does controll the take off warnig system of the MD80 aircraft that ofcourse means if it is pulled the take off warning system will NOT work.
The inference here is that a successful TOCW check was never performed during pre-flight.I am guessing that the FIRST OFFICER performs the cockpit set-up but both pilots must check everything before taking to the skies.If they dont and only work according to SOP Areas of responsibility,they are like lambs to the slaughter.A skipper must advance his thrust levers and check that warning.He must check his consummables.He must know that the fire bottles are working .The FIRST OFFICER may be highly competent but you never abrogate responsibility.Areas of responsibility are not mutually exclusive.I can stray into his and he can stray into mine.I have no problem whatsoever with a FIRST OFFICER checking me.In fact if he doesnt,it worries me.One pilot can miss a pulled c/b or a system check,but two?Never ever let a SOP hamstring you.When you're on fire off the end of the runway,its no use saying "I was following SOP's.He was supposed to check it"

Last edited by Rananim; 5th Sep 2008 at 22:44.
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Old 5th Sep 2008, 18:04
  #1479 (permalink)  
 
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Newcomers to the thread should take the time to read all of it. This scenario was proposed as early as thread 507 by sevenstrokeroll and elaborated on by others, myself included, shortly afterwards. A disabled T/O config warning plus poor checklist discipline, leading to a takeoff without slat/flap, is unfortunately the most likely scenario for this sad accident
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Old 5th Sep 2008, 19:02
  #1480 (permalink)  
 
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strobe light check

Regarding check of exteriour lights (strobe lights) by pulling the mentioned cirquitbraker is more or less the only easy way to verify if they are working depending of aircraft setup-Some of the aircrafts have modified the system so by just selecting the strobe switch on F/O glareshield lighting pnl it does come on. But basicly all of them I have seen during the years aircraft must be in FLT mode to get the strobe to come on, thereby engineers pulling it. Just for info our company have just the last 6 months filed no less than 6 official complains to two different maintenance providers operating in Spain for forgetting to reset C/B after carried out work on aircraft. That is then probably only a fractional of the actual ammount it has been forgotten by maintenance.
Normally it is just resettet and not mentioned to anyone but since the incident and the knowlegde of the magnitude it potentially could have it have been started to be reported when found C/B in out position when entering the aircraft.

Regards L1011
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