Spanair accident at Madrid
Plastic PPRuNer
"You donīt want to know how many people die without valid reason while on the operating table, "
Very few, based on 35 years of experience in many different surgical disciplines and operating theaters.
"....how many people get operated on the wrong part of their body...."
In tens of thousands of procedures witnessed and preformed professionally I can recall two
"....or based on a wrong diagnose."
Yes it happens, but not very often. Can't always get the diagnosis right. I'm good, but I'm not God.
"CRM in the operating room is still in a developing stage."
That at least is true - but we have pretty good CRM in my theaters.
If you're going to be alarmist at least base it on facts.
Mac
Very few, based on 35 years of experience in many different surgical disciplines and operating theaters.
"....how many people get operated on the wrong part of their body...."
In tens of thousands of procedures witnessed and preformed professionally I can recall two
"....or based on a wrong diagnose."
Yes it happens, but not very often. Can't always get the diagnosis right. I'm good, but I'm not God.
"CRM in the operating room is still in a developing stage."
That at least is true - but we have pretty good CRM in my theaters.
If you're going to be alarmist at least base it on facts.
Mac
Last edited by Mac the Knife; 9th Sep 2008 at 05:42.
I don't think asking CC to check flaps/slats is practical, each person chosen would have to be trained, especially if variable settings are used at different airports. This would complicate crew rostering and those with the responsibility would probably want more pay.
Better to ensure that pre-takeoff checks by the aircrew are more prominent before rolling. Human error cannot be entirely eliminated.
Better to ensure that pre-takeoff checks by the aircrew are more prominent before rolling. Human error cannot be entirely eliminated.
Last edited by Oldlae; 8th Sep 2008 at 16:58. Reason: Reworded
Mac;
Thanks for your comments, esp. on CRM in the OR.
Atul Gawande has written two books entitled, "Complications", and "Better" in which he discusses the use of aviation-based CRM techniques to help in avoiding human error. I've spoken with enough medical people to know that the communications and SOP techniques employed in aviation to make it safer still have a long way to go but the path is at least set and that is very positive.
Do you have any thoughts on this approach as to utility, realistic/practical implementation, resistance and training regimes? For us, "CRM" began around 1991 or so - quite late really, and has progressed through about 3 stages. "SMS", safety management systems, means collecting data rather than relying solely upon standard procedures and regulatory obedience - in other words, the approach to safety is reality-based rather than ideologically-based though there remains at some organizations and within some individuals, stiff resistance to such situational awareness.
Thanks,
PJ2
Thanks for your comments, esp. on CRM in the OR.
Atul Gawande has written two books entitled, "Complications", and "Better" in which he discusses the use of aviation-based CRM techniques to help in avoiding human error. I've spoken with enough medical people to know that the communications and SOP techniques employed in aviation to make it safer still have a long way to go but the path is at least set and that is very positive.
Do you have any thoughts on this approach as to utility, realistic/practical implementation, resistance and training regimes? For us, "CRM" began around 1991 or so - quite late really, and has progressed through about 3 stages. "SMS", safety management systems, means collecting data rather than relying solely upon standard procedures and regulatory obedience - in other words, the approach to safety is reality-based rather than ideologically-based though there remains at some organizations and within some individuals, stiff resistance to such situational awareness.
Thanks,
PJ2
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"....or based on a wrong diagnose."
Yes it happens, but not very often. Can't always get the diagnosis right. I'm good, but I'm not God..
Yes it happens, but not very often. Can't always get the diagnosis right. I'm good, but I'm not God..
like airliners - which probably complicates diagnosis alot.
Installing a FDR and voicerecorder at birth might be an idea..
M
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I strongly reccommend that this discussion on CC/SLF input be directed to another thread wholy discussing that topic. This thread is long enough without having to read through 4 pages of meandering thoughts on why CC should or should not speak up. Back to topic please, updated information on the SPANAIR crash.
Oh, and Rainboe, you are always extruing the fact that non informed people are making a mockery of threads that should be Pilot related only, yet you do the same thing in threads such as this. Lets keep the thread related to information on the SPAINAIR crash, any other discusssions can be in their own individual topics.
Oh, and Rainboe, you are always extruing the fact that non informed people are making a mockery of threads that should be Pilot related only, yet you do the same thing in threads such as this. Lets keep the thread related to information on the SPAINAIR crash, any other discusssions can be in their own individual topics.
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I demand attention!
I must admit - I've done it! I DEMANDED a cabin crew member's attention on a LH A300 departing FRA for LHR. We were approaching 18 for departure and I could see that the Flaps were fully retracted.
I left my seat and walked back down the aisle to the CC jumpseat.
"SIT - SIT DOWN - SIT DOWN..NOW" she shouted at me.
"LISTEN TO ME," I said, "you must call the flight deck NOW and inform them that the flaps are not extended."
She did.
And the reply came back that at the operating weight, Zero Flap was OK. I have no Airbus experience - obviously!
I felt a bit of a Charlie, but I'd do the same again tomorrow if I thought something was amiss.
I left my seat and walked back down the aisle to the CC jumpseat.
"SIT - SIT DOWN - SIT DOWN..NOW" she shouted at me.
"LISTEN TO ME," I said, "you must call the flight deck NOW and inform them that the flaps are not extended."
She did.
And the reply came back that at the operating weight, Zero Flap was OK. I have no Airbus experience - obviously!
I felt a bit of a Charlie, but I'd do the same again tomorrow if I thought something was amiss.
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I would have too! Glad I read this.
Going in to work I saw an aircraft on taxi towards the runway with a pitot cover flag fluttering. Jumped into the first aircraft in the hangar and called the tower..........Bealine xxx thanks but he's just going for a wash!
Before anyone says this is off topic I think it's worth persuing the speak up part of this thread.
Going in to work I saw an aircraft on taxi towards the runway with a pitot cover flag fluttering. Jumped into the first aircraft in the hangar and called the tower..........Bealine xxx thanks but he's just going for a wash!
Before anyone says this is off topic I think it's worth persuing the speak up part of this thread.
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I think one of the main problems of CRM is that sometimes the degree of knowledge is very different between crew members. I tend to brief FAs that they are my eyes in the passenger cabin and that anything they consider unusual should be reported to us right away. Sometimes I regret having said that since calls from the back don't stop. You stop trusting their input quickly. Maybe better training on aircraft technical stuff could help.
rcl
rcl
Back to topic:
From www. extracrew.com
http://www.extracrew.com/verDebate.a...fault%2Easp%3F
Sorry, only in spanish
From www. extracrew.com
http://www.extracrew.com/verDebate.a...fault%2Easp%3F
Sorry, only in spanish
Plastic PPRuNer
"Installing a FDR and voicerecorder at birth might be an idea.."
Excellent idea! It would certainly simplify court procedures!
And PJ2, yes, due to my interest in aviation I have given considerable thought to expanding the existing ad hoc CRM that already exists in theatre.
The problem, as I see it, is that it is not so much that a procedure is badly performed as the appropriacy of the procedure performed. I have not often had reason to question the technical performance of a procedure but I have not infrequently had reason the question as to whether the procedure is appropriate for that particular patient in that particular situation.
And therein lies the rub.....
Mac
Excellent idea! It would certainly simplify court procedures!
And PJ2, yes, due to my interest in aviation I have given considerable thought to expanding the existing ad hoc CRM that already exists in theatre.
The problem, as I see it, is that it is not so much that a procedure is badly performed as the appropriacy of the procedure performed. I have not often had reason to question the technical performance of a procedure but I have not infrequently had reason the question as to whether the procedure is appropriate for that particular patient in that particular situation.
And therein lies the rub.....
Mac
Last edited by Mac the Knife; 9th Sep 2008 at 05:44.
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testpanel/mac/pj2
CRM or its variant in the OR is something I have delved somewhat deeply into. I dont want to creep the thread off the Madrid incident but just want to point out a few things. testpanel... I for one am listening and its one of my main reasons for visiting this site as Ive learnt a lot from aviation safety and investigation in my professional capacity. In a very direct way I would like to challenge the comments of some who seem to feel that as some of us who post here are not pilots then we cannot add anything valuable to a discussion. Although I can just about work out which way is forward on an aircraft I am a professional at incident investigation and I feel that some of my views may be valid.
Should as nurse intervene during surgery? The short answer is that if an OR nurse has a responsibility for an action, such as a swab or needle count, if it is incorrect then the nurse is obligated to intervene. This may mean halting the surgery or preventing closure of the wound. (If its a nurse interrupting an operation to give her opinion on surgical technique, its different as the nurse isnt trained in surgery.) I cannot think of any parallels within aircrew where a FA can practically order a flight crew to take a particular action, but if you can enlighten me I would be grateful.
CRM in the OR is in its infancy but with aircrew its easy to recognise yourself as part of a cohesive team. This isnt necessarily so in the OR. The nursing staff may have more recognition of a team structure between themselves and not with the surgeon. Additionally within the same room and working on the same patient there is another medical and nursing team with diffierent practices, that is the Anaesthesiology team. Whilst in the main the different teams work towards a common end, the successful completion of surgery, there are often conficts, sometimes of a severe nature.
SOPs however are not well developed within the OR and there is much work to be done on that. It would go a long way to prevent wrong side/organ surgery, which as mac pointed out, is extremely rare anyway, but there are other examples where a checklist and a challenge/response system would be most useful. In my experience, the cultural/professional/training issues with clinical staff tend to make adoption of such a procedure difficult. Oddly enough within some well functioning teams in OR the challenge/response system seems to develop itself.
Valid reasons for a patient dying on the table? there may be many but it may be splitting hairs to say that a valid reason for a death may not mean that any procedure or professional competence is to blame. Although I accept that there are many variables with avaiation there are many with surgery. The surgery itself may be diagnostic and it is not uncommon for the diagnosis to be catastrophic. Some surgery is inherently very very risky... I'm thinking particularly about repairing ruptured aortic anerurysms which have 100% mortaility without surgery and about 90% with surgery. I cannot imagine a pilot attempting a takeoff with a 90% chance he will fail. I'm not being derogatory but pointing out that the decision making priorities may be different.
CRM or its variant in the OR is something I have delved somewhat deeply into. I dont want to creep the thread off the Madrid incident but just want to point out a few things. testpanel... I for one am listening and its one of my main reasons for visiting this site as Ive learnt a lot from aviation safety and investigation in my professional capacity. In a very direct way I would like to challenge the comments of some who seem to feel that as some of us who post here are not pilots then we cannot add anything valuable to a discussion. Although I can just about work out which way is forward on an aircraft I am a professional at incident investigation and I feel that some of my views may be valid.
Should as nurse intervene during surgery? The short answer is that if an OR nurse has a responsibility for an action, such as a swab or needle count, if it is incorrect then the nurse is obligated to intervene. This may mean halting the surgery or preventing closure of the wound. (If its a nurse interrupting an operation to give her opinion on surgical technique, its different as the nurse isnt trained in surgery.) I cannot think of any parallels within aircrew where a FA can practically order a flight crew to take a particular action, but if you can enlighten me I would be grateful.
CRM in the OR is in its infancy but with aircrew its easy to recognise yourself as part of a cohesive team. This isnt necessarily so in the OR. The nursing staff may have more recognition of a team structure between themselves and not with the surgeon. Additionally within the same room and working on the same patient there is another medical and nursing team with diffierent practices, that is the Anaesthesiology team. Whilst in the main the different teams work towards a common end, the successful completion of surgery, there are often conficts, sometimes of a severe nature.
SOPs however are not well developed within the OR and there is much work to be done on that. It would go a long way to prevent wrong side/organ surgery, which as mac pointed out, is extremely rare anyway, but there are other examples where a checklist and a challenge/response system would be most useful. In my experience, the cultural/professional/training issues with clinical staff tend to make adoption of such a procedure difficult. Oddly enough within some well functioning teams in OR the challenge/response system seems to develop itself.
Valid reasons for a patient dying on the table? there may be many but it may be splitting hairs to say that a valid reason for a death may not mean that any procedure or professional competence is to blame. Although I accept that there are many variables with avaiation there are many with surgery. The surgery itself may be diagnostic and it is not uncommon for the diagnosis to be catastrophic. Some surgery is inherently very very risky... I'm thinking particularly about repairing ruptured aortic anerurysms which have 100% mortaility without surgery and about 90% with surgery. I cannot imagine a pilot attempting a takeoff with a 90% chance he will fail. I'm not being derogatory but pointing out that the decision making priorities may be different.
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The link referred by testpanel a few posts back seems to come from a Spanair maintenance technician (possibly the one that disconnected the RAT probe heater?) and basically it just says what we all know. In my own words, but inspired from his article, his main points are:
-That airplanes are very well maintained by licensed and qualified personnel.
-That a ton of inspections are carried out daily, weekly, monthly ...
-That just about all planes from all airlines have (minor, not affecting flight capability) maintenance issues which repairs are routinely delayed a bit to avoid late flights.
-That he is very wary of the press for putting out so much missinformation.
-That airplanes are very well maintained by licensed and qualified personnel.
-That a ton of inspections are carried out daily, weekly, monthly ...
-That just about all planes from all airlines have (minor, not affecting flight capability) maintenance issues which repairs are routinely delayed a bit to avoid late flights.
-That he is very wary of the press for putting out so much missinformation.
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From accounts to the press from the ground airport personnel coordinator that assisted the MD82 for the aprox. 30 minutes they were on parking area 11 after the first aborted TO:
-During the conversation it was obvious that the pilot thought they were going to have to change planes. He asked for 2 busses to move the PAX. Busses arrived only to leave (empty) 10 minutes later.
-It was hot inside the cabin as PAX complained about no air conditioning.
-The pilot call to the Spanair coordinator: "Tell maintenance that the RAT heater is on while on ground" (unmistakenly, from the spanish: "Dile a Mantenimiento que el RAT se calefacta en tierra")
-Two maintenance technicians were waiting for the plane upon arrival to parking area.
-Another plane was requested and available for the change, if necessary. After the initial 5 minutes of the maintenance personnel looking at the problem, a plane change still seemed like was going to happen.
-By the time the busses arrived, the pilot told the coordinator to hold on a bit, cause maybe they were going to be able to fly with that plane after all.
-About 15 minutes later the couple of maintenance technicians left the plane. The ground coordinator steps up and asks the pilot: "so what are you finally going to do?". He answered to call for re-fuelling some 2.000 pounds of fuel and that they would take-off on the same plane.
-The pilot, in person, stepped down, talked to the fueling worker, and closed the fuel intake in person before going back into the plane. Two flight attendants were on top of the upstairs. Waived good bye and the plane moved backwards from the area.
The ground worker visually followed (from a large distance) the plane all the way to take-off. It all seemed normal to him until, after shortly on the air, it rolled side-by-side and he lost view of it. A bit later, as he was already heading to the closest building to call for help, he saw the smoke.
11 survivors remain hospitalized in Madrid. One is still in very serious condition in intensive care.
Also, some of the accounts of other rescue workers have appeared. They don't really shed light on the cause of the accident but do make a point as how even the shallow creek, which very likely helped some to survive (by keeping the fire away and dampening the fall), may have also contributed to the potential death of others.
Also of interest is once more the briefing to the police by the flight attendant on that landing flight from ecuador that witnessed the accident. She heard the pilot say: "He was eating the runaway" (reaching the very end of it). "14 seconds later the left engine 'sparked' and the plane fell like a leaf". (at this point, it's my *personal* understanding that the plane may have had all parts of it off the ground for ~7 seconds only, until the tail touched the ground again).
That piece of news say that only 1 survivor was travelling on the "back seats" (i.e. away from the area near the front were most survivors were sitting). Many survivors were awaken by the running water under their bodies. They had landed on the creek.
-During the conversation it was obvious that the pilot thought they were going to have to change planes. He asked for 2 busses to move the PAX. Busses arrived only to leave (empty) 10 minutes later.
-It was hot inside the cabin as PAX complained about no air conditioning.
-The pilot call to the Spanair coordinator: "Tell maintenance that the RAT heater is on while on ground" (unmistakenly, from the spanish: "Dile a Mantenimiento que el RAT se calefacta en tierra")
-Two maintenance technicians were waiting for the plane upon arrival to parking area.
-Another plane was requested and available for the change, if necessary. After the initial 5 minutes of the maintenance personnel looking at the problem, a plane change still seemed like was going to happen.
-By the time the busses arrived, the pilot told the coordinator to hold on a bit, cause maybe they were going to be able to fly with that plane after all.
-About 15 minutes later the couple of maintenance technicians left the plane. The ground coordinator steps up and asks the pilot: "so what are you finally going to do?". He answered to call for re-fuelling some 2.000 pounds of fuel and that they would take-off on the same plane.
-The pilot, in person, stepped down, talked to the fueling worker, and closed the fuel intake in person before going back into the plane. Two flight attendants were on top of the upstairs. Waived good bye and the plane moved backwards from the area.
The ground worker visually followed (from a large distance) the plane all the way to take-off. It all seemed normal to him until, after shortly on the air, it rolled side-by-side and he lost view of it. A bit later, as he was already heading to the closest building to call for help, he saw the smoke.
11 survivors remain hospitalized in Madrid. One is still in very serious condition in intensive care.
Also, some of the accounts of other rescue workers have appeared. They don't really shed light on the cause of the accident but do make a point as how even the shallow creek, which very likely helped some to survive (by keeping the fire away and dampening the fall), may have also contributed to the potential death of others.
Also of interest is once more the briefing to the police by the flight attendant on that landing flight from ecuador that witnessed the accident. She heard the pilot say: "He was eating the runaway" (reaching the very end of it). "14 seconds later the left engine 'sparked' and the plane fell like a leaf". (at this point, it's my *personal* understanding that the plane may have had all parts of it off the ground for ~7 seconds only, until the tail touched the ground again).
That piece of news say that only 1 survivor was travelling on the "back seats" (i.e. away from the area near the front were most survivors were sitting). Many survivors were awaken by the running water under their bodies. They had landed on the creek.
Last edited by justme69; 8th Sep 2008 at 21:54.
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they were on parking area 11 after the first aborted TO
As opposed to a taxi out that then develops a technical problem, some maintenance is performed, and then a full takeoff is performed, up to and including rotation, and thereafter something unknown occurs which results in an accident
(which in my book = no "Aborted Takeoffs")NoD
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Yeah, well. As you know, the press basically talks about an aborted Takeoff. In spanish, that would be the common way of calling it.
Regardless, what has been reported about the first time through, the plane had already received take-off permission, taxied to the beggining of the runaway, got there, but then decided not to proceed and requested to taxi back. They were instructed to go to that parking area.
As far as I know, they didn't initiate acceleration the first time through, although they were already "aligned at the head of the runaway and ready to go".
Some 45m later, after the RAT heater "repair", they were once again granted permission to TO and taxied back to the runaway etc.
I understand that, technically, maybe it wasn't an aborted TO. But for short, everybody is referring to it as such. Also, the "second take off", also poses a bit of a problem to describe.
Technically, and from what we know (which, of course, is speculative at this point), the airplane did have all wheels off the ground. Albeit for only a matter of seconds. But they were definetly past (estimated) VR. So do we call it a "failed attempt to take-off" or a "failed attempt to land"? Makes it evey more uncertain if the pilots did try to stop earlier on (i.e. deployed the working reverser) or tried to gain altitude (i.e. commanded max. thrust and deployed flaps and lowered the nose).
Regardless, at the very end, they probably tried to stop anyway, of course, once it was obvious they couldn't possibly safely take-off ("again").
Regardless, what has been reported about the first time through, the plane had already received take-off permission, taxied to the beggining of the runaway, got there, but then decided not to proceed and requested to taxi back. They were instructed to go to that parking area.
As far as I know, they didn't initiate acceleration the first time through, although they were already "aligned at the head of the runaway and ready to go".
Some 45m later, after the RAT heater "repair", they were once again granted permission to TO and taxied back to the runaway etc.
I understand that, technically, maybe it wasn't an aborted TO. But for short, everybody is referring to it as such. Also, the "second take off", also poses a bit of a problem to describe.
Technically, and from what we know (which, of course, is speculative at this point), the airplane did have all wheels off the ground. Albeit for only a matter of seconds. But they were definetly past (estimated) VR. So do we call it a "failed attempt to take-off" or a "failed attempt to land"? Makes it evey more uncertain if the pilots did try to stop earlier on (i.e. deployed the working reverser) or tried to gain altitude (i.e. commanded max. thrust and deployed flaps and lowered the nose).
Regardless, at the very end, they probably tried to stop anyway, of course, once it was obvious they couldn't possibly safely take-off ("again").
Last edited by justme69; 9th Sep 2008 at 08:44.
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This is a "Professional Piloit's Forum"... apparently 
OK - so are we agreed that there was not an "Aborted Takeoff" first time around, just (at most) a routine line up and vacate?
An Aborted Takeoff is a fairly significant event/incident, and if it preceded the accident, almost certainly significant, if only in Human Factor terms. Please can we stick to the correct terms here, and leave Press terms to the ignorant Press?
NoD
As you know, the press basically talks about an aborted Takeoff. In spanish, that would be the common way of calling it.
An Aborted Takeoff is a fairly significant event/incident, and if it preceded the accident, almost certainly significant, if only in Human Factor terms. Please can we stick to the correct terms here, and leave Press terms to the ignorant Press?
NoD