Spanair accident at Madrid

[411A]

The last item on our before takeoff checklist, to be completed when the aircraft is lined up on the runway...

Configuration check

Flaps/slats.....set
Speedbrake lever...forward
Stab trim.....takeoff range
Compasses.... compared (and agree with the desired runway)

Do this, and an attempted takeoff without having the aircraft properly configured, is highly unlikely.

So far as I know, there was only one airline that incorporated a configuration check as the last item...PanAmerican.

Tristar (That was a lovely airplane)

It still is...

[HotDog]

One of the items of the preflight checks on the 747, which the Flight Engineer carried out; was checking all cockpit circuit brakers set. He also checked all aural warnings including the T/O warning which was activated by the No.3 thrust lever. Further check sequences verified flap, slat and stab positions amongst other things prior to take off.

[fdr]

function test

B777300ER:

that check is a reasonable check of system functionality, but the problem becomes a disruption to procedure following an exceptional event in the normal flow of a flight; the crew have returned to blocks for a defect, and in the clearance action for the defect, the aircraft function is unknowingly interrupted.

If the crew redo a check like the thrust level advance prior to start, then they would identify a new defect, but as they would normally do the check on the initial preflight setup, they would have to repeat the check. Humans being adept at finding work arounds and time saving behavioral patterns, tend to short circuit such activities.

On a related point:

The Reason model of causality probably fits to some extent to this event, however, the event also may serve to indicate that the behavior of aviation safety systems are in fact dynamically non linear and also have unbounded chaotic behavior, which results in stochastic or non deterministic system behavior. Accidents can happen.

About the only thing that is simply indicated is that sometimes things don't work out as desired, on spite of reasonable efforts by various parts of the system and reasonable rules and procedures.

regards

[Right Way Up]

MadDogDriver,

Those strobes maybe annoying when someone is lining up but they may just save a runway collision. We used to leave them in auto position to switch on when airborne. After a few very close calls (BA nearly landing on a BMI at LHR) our Sop changed on the BUS to put them on entering the runway. It seems a shame that not all MDs have been modified, because it sounds like this accident may not have happened if that was the case.

[lugarri]

to wings1011

I,ve been a groung engineer for 3 years, a f/e 10 years and now a f/o (9 years)in a well known airline in Spain, and sadly i do agree very much with you. In my opinion this could be happen as you´ve said, word by word. A chain of mistakes is not as unlikely as it seems.
Congratulations for your commentaries.
Just one question. The Captain notes on the runway, when first attemp for takeoff that the Rat was very hight and then go back to the ramp. Why on the takeoff? it´s easier to note that on taxi, unless..Have the before takeoff checklist any item especifycal for that?
Regards

[PENKO]

So as a passenger in the back - if we're taxing to the runway and the flaps aren't extended - do I notify the F/A?

There's that bit of hesitation that everything is normal and you're just a passenger - so what do you know?

But after spending a lot of time on planes and usually sitting in the exit row, if not upfront, I tend to make a note of the flap/slat extension after-start and provide an extra verification before my flight takes off

Would you like to crosscheck the weight and balance too? Just kiddin'.
There may be reasons the aircraft taxies to the rwy without flaps. For instance, if there is snow or slush on the taxiway some SOP's say leave the flaps in till at the runway. Or maybe the aircraft will be de-iced at a remote station.

Having said that, you have a point. I don't think there is a pilot here in the room that will not have a strong urge to shout something when they see the flaps are not set at all approaching the runway. Maybe the will then shrug it of thinking 'there goes the config warning'...

I have twice told the crew about something I thougt was wrong, both times I was wrong, but better safe than sorry. The other way around we've had a passenger telling us AFTER the flight that one of our speedbrake panels was fluttering. Of course we shrugged it off, but called for an engineer anyway just to be sure, who subsequently found a major rupture in the panel's hydraulic actuator, grounding the plane for the rest of the day. NOW I wish that pax had spoken up in flight! Of course you understand that it is a delicate balance. There would be a problem if passengers loose trust in the crew and start taking ACTION, like opening emergency exits the moment they think something is wrong (countless times on every flight). It might occasionally save one aircraft, but it would endanger thousands of other flights. But sure, if you think something is really wrong, think about it for a second and then speak up.

[stilton]

I always turn on the strobes when taking the runway, all other lights come on when cleared for take off.

If you don't like to look at the strobes then...don't

[idle bystander]

The Reason model of causality probably fits to some extent to this event, however, the event also may serve to indicate that the behavior of aviation safety systems are in fact dynamically non linear and also have unbounded chaotic behavior, which results in stochastic or non deterministic system behavior.

Gosh! someone has invented a way of expressing Murphy's Law in a pseudo-scientific way. I think I prefer the original: "If it can go wrong it will go wrong."

Sod's corollary to Murphy's Law (with acknowledgments to Perry): "When it goes wrong it will be at the worst possible moment."

[sevenstrokeroll]

to PASSENGER in BACK

I was deadheading on a 737...short taxi, we were on the runway and the flaps were not set.

I knew that if I heard the takeoff warning, the pilots would catch it. BUT IF IT DIDN"T GO OFF, I was prepared to run to the cockpit door and bang on it like HELL.

OF course I was in my pilot uniform and that would have helped matters. The horn went off, the flaps came down and I yelled at the pilots at the destination. IDIOTS!

I know of one case in which the spoilers deployed on landing of a 737 and when the handle was moved to retract them, the cable broke...so the handle moved to the correct spot, the light that said the spoilers were extended went out BUT THE SPOILERS WERE STILL EXTENDED. It was missed onthe walk around...but some guys in back on the next flight, deadheading noticed and stopped the takeoff in time...THERE WOULD HAVE BEEN NO WARNING.

WHILE it takes bravery to speak up to avoid a disaster (capt. smith, don't you think these icebergs could pose a problem?), you must be brave and speak up if you :

1. know something about planes

2. see something wrong.

A passenger noted something wrong with our flaps on landing...we extended them at the gate and wow, was there something wrong!!! grounded!

There are some planes that don't use flaps for takeoff...so please know your stuff.

[MadDog Driver]

Right way up and Stilton.

Point taken w rgds to the strobes "on" on the runway!
I do though, fail to see how you think that this accident could've been prevented by having had the strobes modified

It seems a shame that not all MDs have been modified, because it sounds like this accident may not have happened if that was the case.

Rgds MDD

[justme69]

I think he may be assuming that the CB was tripped by a technician to use it as a "not in ground mode test" (i.e. to check for the strobes to come on properly) and then he forgot to set it back. If there would've been a "test" or "bypass" switch to make the lights turn on while on the ground, he would've used that instead.

And there would be our first hole on the cheese ... leading to the temperature probe "overheating" ... leading to going back to parking ... leading to forgetting to re-deploy flaps on second TO ... leading to the GRD mode CB being still off so the alarm didn't sound ...

It's more likely the CB tripped for other reasons, as the plane had already landed from another flight (from Barcelona, I think it was). At midday, it had not been their first flight of the day.

Hopefully the investigation will find out when (and "why") the ground mode (theoretically) was in the "off" mode. Anything from a true malfunction with the WOW sensor, to other problems with the front landing gear, to actual electrical malfunction, to simply just forgetting to reset a circuit breaker after voluntarily (or inadvertendly) tripping it (either by the crew or technicians) etc etc are all "equally" possible at this point.

Of course, it is not unreasonable to think that there was no actual malfunctions and someone tripped it and forgot to re-set it again, and the crew neither checked it nor checked the TO alarms prior to trying to take off with improper wing configuration. *IF* they also missed setting the flaps/slats (rather than any sort of malfunction), well, that would certainly be a very bad combination, as no last minute warning would've possibly allowed them to correct the situation on time.

[Oakape]

Taking off in a B737-800 a few years ago, we didn't get the chimes from the cabin to say that they were ready. I was listening on the flight interphone, so I knew that they were pushing the button. I assumed that there was a failure with the interphone system, confirmed verbally with the purser that they were ready & decided to investigate further once on the way.

At top of climb we didn't get the chimes with the secal check & it dawned on me that we had a 'aural warnings' problem. A quick check revealed that the aural warnings C/B was out. We had just taken off without a working Take-off Config warning! Fortunately the swiss cheese didn't line up that day & everything else had been done right.

The aircraft was fresh out of the hangar & the engineers had pulled the C/B & not reset it. Evidently it is common practice to pull the C/B to prevent annoying warnings while certain items are being worked on.

I filed a report, but the company didn't seem to be that interested & the information wasn't disseminated to the other pilots at the airline.

I don't know if the other guy checked the C/B's, but I found that my C/B preflight check was inadequate. The said C/B is behind the F/O, right beside the fire extingusher. If you don't move your head right over so you can look vertically down beside the fire extingusher, you can't see the first column of breakers, where it can be found.

Complacency can set in with time, particularly when "nothing is ever out of place". I have sat in a cockpit & heard a crew respond to a checklist with "down - 3 greens" when the nose gear light wasn't illuminated.

It taught me a good lesson & now I 'watch' myself more than I watch anyone else, particularly if I am tired or distracted.

[PENKO]

I think the last page or two are full of lessons to a lot of us.

[Desk Jockey]

CBs after maint.

Unfortunately after maint, when you have tidied up the aircraft you drag the aircraft out to run the engines and as you advance the throttles, beep beep beep. No excuses but you reach back and pop the breaker.
Run finished and paperwork to do with everyone waiting. Last thing check round for loose articles and CB check.....but I guess we missed it too.
Why on earth isn't there a reset button that is out of reach of the crew seats?

[Ancient Observer]

"Belgrano's data unit"

Good question. I was only giving an e.g. of how Aviation's memory is preserved. The "Belgrano" is the offices of the UK's Safety Regulator, the CAA. Rather too well known to UK pilots, engineers, ATCOs and so on.
The data unit within it keeps all sorts of records of Aviation "incidents" around the world. As the UK operates a crude "freedom of information" regime, the info. held can be made available to Brit.s. The "Belgrano" tag comes from its looks - a hulk of a battleship-grey office block near LGW.

[Tjosan]

There may be reasons the aircraft taxies to the rwy without flaps. For instance, if there is snow or slush on the taxiway some SOP's say leave the flaps in till at the runway. Or maybe the aircraft will be de-iced at a remote station.

Not necessarily on the MD8x series, since leaving the flaps in flaps 11 will prevent ice and slush and other stuff from entering the engines. After landing moving flaps to flaps 11 will save you from lots of problems.

[XPMorten]

Do modern EICAS systems in any way warn you if a CB has been pulled?
Or do you still have to look over your shoulders to find out?

XPM

[Rananim]

Question to Mad Dog pilots

Has there ever been a MD SB detailing this relay c/b,its function,and the implications if it is left tripped?Does your airline safety program monitor all type-related incidents/accidents and disseminate that info to you asap?
Accident investigation is supposed to eliminate the possibility of ascenario being repeated.Only way to do that is through data dissemination via AD's/SB's and company safety programs.

[A37575]

The Reason model of causality probably fits to some extent to this event, however, the event also may serve to indicate that the behavior of aviation safety systems are in fact dynamically non linear and also have unbounded chaotic behavior, which results in stochastic or non deterministic system behavior. Accidents can happen

I see it all now..

[philipat]

English Translation

A37575:

I see it all now..

In plain English: **** happens (AKA Murphey's Law)