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Spanair accident at Madrid

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Spanair accident at Madrid

Old 14th Sep 2008, 20:21
  #1681 (permalink)  
 
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Unfortunately I don't speak spanish, and I don't pilot, but isn't there too much conversation going on to take any notice of what the airplane is telling them?
Having tested config warnings on the 737 hundreds of times I don't know how you could miss it. Wrong config and it sounds as soon as you advance the throttles just as in the video/audio.

Only possibility I can think of is noise cancelling headsets, and too much verbal masking the horn.
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Old 14th Sep 2008, 20:29
  #1682 (permalink)  
 
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Quote:
Much better: YouTube - Audio de la caja negra del accidente de LAPA (completo)
Unfortunately I don't speak spanish, and I don't pilot, but isn't there too much conversation going on to take any notice of what the airplane is telling them?
Having tested config warnings on the 737 hundreds of times I don't know how you could miss it. Wrong config and it sounds as soon as you advance the throttles just as in the video/audio.

Only possibility I can think of is noise cancelling headsets, and too much verbal masking the horn.
The pilots are talking nonsense with a CC woman, and you can hear that one of them says that everything is all right when the alarm sounds. The whole thing was about lack of maintenance of the planes and poor trainement of the pilots.
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Old 14th Sep 2008, 21:06
  #1683 (permalink)  
 
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Yeah. In that particular case, the pilots of LAPA heard the warning early enough (they reacted to it), one of them asked what the hell that was, the other replied he didn't know but everything looked fine, and basically it looks like they decided to ignore it and continue with the TO, although it can be guessed from the audio that they kept looking around to see if they found the cause (obviously, didn't look hard enough or couldn't figure the right cause, for whatever reason, which seems to have been the lack of flap deployment).

Seems the pilot had 6,500 hours of experience, but only 1,710 on 737. The copilot 4,085, but only 560 in the 737. During the CVR conversation the pilot comes across as a bit overcondident, perhaps, but this, of course, is subjective and can not be extrapolated in general but to the minutes before the accident.
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Old 14th Sep 2008, 21:14
  #1684 (permalink)  
 
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relevent interruption

Forgive my interruption.
I wonder if those participating in and following this thread might also be interested in another thread on an MD-82 incident on PPRuNe, the crash of OG269 in Thailand last September 16?

The similarities between the crashes are few, just that both were MD-80s, both were budget airlines, and both had significant horrible fatalities.

The most significant difference is the credibility of the crash investigators and the efforts of the airline and the government to determine the cause of the crash.
Since the crash of OG269, there has been significant untruths stated by the government and the airline management, and no change to aviation in Thailand.

I lost my brother in OG269. After the Thai government declared "No punishment will be imposed on any agency or personnel after completion of the investigation because the accident was beyond control.", I created a web petition asking the Thai government to properly investigate the crash.

The Thai government has most definitely not responded. Interestingly, the aviation community has. They have sent evidence, proof and information regarding maintenance fraud, checkride fraud, excessive work hours, corruption, falsification of documents to crash investigators and much more. Where possible for the safety of all involved and after careful verification, we have published that proof on the website.

If you are interested, the petition is at: www.InvestigateUdom.com. Follow the proof and evidence link to see that material.

We can use all the help we can get. Thank you.
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Old 14th Sep 2008, 21:17
  #1685 (permalink)  
 
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The similarities between the crashes are few, just that both were MD-80s, both were budget airlines, and both had significant horrible fatalities.
Ah ... I wouldn't call Spanair a budget airline by any strech. Belonging entirely to SAS, Scandinavian Airlines group, they are the second most important airline operating in Spain, with aprox. 20% of the market of the whole country.

This is not an airline that was unsafe or budget or overworked and underpaid or undertrained employees. Not at all. And their fleet is on the average at about half its service life.

This was Spanair first accident with deadly consecuencies in 20 years of operations, since it was founded. Likewise, it was the first accident with deadly victims in the airport of Madrid in almost 25 years. Not counting this accident, 40 people have died in aviation related accidents (planes and helicopters) within the whole Spain in the past 10 years.

It seems the pilot, 38 years old, with 9 years of service in Spanair, upgraded to commander in 2007, had over 9.000 hours of flying experience (not sure how many on the MD-82, but 3.000 of those were in the army, as pilot on an air rescue squad SAR until 1999, where he serviced for 10 years).

The copilot, 32, though, seems like only had 1.000 hours of flying experience (again, I don't know how many on the MD-82, but potentially less than 700). He was in the list of personnel that Spanair was planning to dismiss (he would've been offered another job inside the company if he wanted as "attendant").

Spanair's financial situation, though, had deteriorated greatly in the past year or two and SAS was trying to downsize it, reduce personnel, cancel routes and even put up for sale the Spanair branch. Still, I don't think one can compare Scandinavian Airline's SAS management of Spanair to, i.e., that of argentinean LAPA a few years back.

Civil Aviation safety in Spain is not worse or better than in other european countries. According to the ECC study of safety statistics
(EUR-Lex - 52001DC0390 - EN ):

* Airlines from Africa, Asia and South/Central America have accident rates at least twice as high as the world average, (in 1998 four times higher in the case of Africa and six times higher in China).
* North America has a rate much better than the world average.
* Western European countries, together with Australia, have the lowest accident rates.
* Eastern European countries including the CIS states, have a very high accident rate, nearly 50 times higher than in western Europe, and higher than in any other world region

Generally speaking, Spain, a typical tourist destination, is a country with relatively high air traffic, visited by airlines from many countries. In the year 2004, it was the second most visited country by tourists in the world (according to the UN France and Spain remain world’s top tourist destinations – UN agency= ), with about 60 million visitors annually (about same in 2006/7 http://www.unwto.org/facts/eng/pdf/b...en_excerpt.pdf )

Like the accident in Tenerife in 1977, which involved an american PanAm airplane and a dutch KLM one (YouTube - Mayday:Catastrofe en Tenerife(5/5)Catastrofes Aereas ), deadly accidents can happen anywhere beyond the control of just about anyone, and often are a result of a number of actions in which important human errors are statistically the main cause in aprox. >60% of the cases (<30% mechanical, aprox. 10% weather/other).

In the case of Tenerife, i.e., bad weather and some radio interference made the dutch pilot take the very bad deccission to start TO without ground permission. Other signs and transmissions that would've clearly hinted he wasn't in a possition to TO seems like they were ignored by this pilot, according to CVR analysis. Other factors contributed to the accident (the PanAm pilot missed his turn and the KLM decided to "over" refuel so it wouldn't have to later, which made it too heavy to TO on time). Technology has since (1977) greatly lowered the chance of interference due to transmissions simultaneously initiated.

It is my PERSONAL opinion, though, as a frequent flyer in Spain, that generally speaking, spanish pilots are from a slightly more "macho" culture than some of their european partners and I have witnessed first hand my share (many dozens) of high speed, steep attitude, last-minute-full-30-flaps landings, TO accelerations while still turning on the the runaway, and other "aggressive" piloting behaviour that seemed rooted in the industry for a long time. This has greatly eased in the past years, probably due to more automated planes like the airbusses that mostly inhibits that type of flying behaviour, but some of that remains. I don't consider the behaviour generally in the country "careless or rushed" AT ALL during pre-flight, etc, just unnecessarily aggressive once on the controls, which is not good at all when some unexpected problem develops ...

Of course this is not true of ALL (or even most) of the pilots/airlines, just my SUBJECTIVE opinion when comparing statistically BY ME flights within Spain with flights from other airlines in western countries. In central and south american countries it feels just as bad or worse. Not much experience with asian, african or eastern european airlines.

Last edited by justme69; 15th Sep 2008 at 10:37.
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Old 14th Sep 2008, 21:59
  #1686 (permalink)  
 
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Forgive me if I was unclear. My point was to say that similarities appear to be mostly superficial while the crash and its surrounding factors might be of interest to those participating in and following this thread as the aircraft is similar. (I might add that OG269 also was filled is vacationers. In this case, young people honeymooning and celebrating college graduation.)

We know the Spanair will be properly investigated. Clearly, the only investigation OG269 will ever receive is the investigation conducted by the PPRuNe participants and the efforts of the families. We families can use every bit of help we can get.

Thank you for your interest.
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Old 15th Sep 2008, 02:50
  #1687 (permalink)  
 
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Big lessons

I think some posters are missing the point.

What we need to learn from this accident and others, is not who (or what) to assign blame, but how to improve the entire aviation system to prevent future accidents.

Don't be distracted by mechanical minutia and miss the larger lesson. If the flaps and slats were not extended and the crew announces that they are set (by rote memorization of the checklist) the problem is not with the individual crew, but with an aviation system that distracts and pressures the crew to hurry and make bad decisions.

Most pilots have been there. Delay, delay, delay. Then suddenly hurry to make the assigned takeoff slot and woe to those who taxi too slow or run the checklist as slowly and deliberately as they normally do.

I truly hope that both pilots are exonerated of all wrongdoing, but if the investigation shows they made a mistake, I understand completely having endured the crucible of five airline bankruptcies in twelve years.

It is easy to get distracted.

doodahdave
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Old 15th Sep 2008, 06:16
  #1688 (permalink)  
 
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Yes, doohdave, it's easy to get distracted, or to forget this or the other thing. And that's obviously true for any activity... Pilots are human, after all, and not perfect, godly beings.

The world is imperfect, and risk does exist everywhere. Many people wish to live in a fully riskless environment, but that's basically impossible...

Perhaps only very few modifications are needed, if any. After all, and in spite of some tragic and spectacular accidents, the global safety record of civil aviation is very good.

XXXavier
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Old 15th Sep 2008, 09:00
  #1689 (permalink)  
 
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Training

the problem is not with the individual crew, but with an aviation system that distracts and pressures the crew to hurry and make bad decisions.
Since first hearing about the "leak" in CVR :
"Slats, Flaps OK" at that time
and nowaday : "Slats, Flaps set"
I saw poor phraseology, or poor check list, or poor training ...

Mangement policy, not "aviation system" is in cause. Because the aviation system as produced at least the best training and the best sop's available as a result of 60 years of worlwide shared experience.

Better practice : tell the numbers .. say e.g. : "Flaps set 15" and point to the flaps indicator.

CRM basics : the person reading the check list crosschecks as far as possible the response given by the other crew member. Looking at the flaps indicator as well, and to any slats indicator or warning light.

Modern sim recurrent training : put pressure and distractions on the pilots and see if something is to be learned, if the procedures are as fail safe as practicable. Had the captain be properly trained, "Sat & Flaps set" type answer would be out of question.

More CRM basics : teach the young co-pilot to watch and to correct captain mistakes. Suffice to brief the captain conficentialy to make a few mistakes during a sim cession ...

Captain training basics - technical : learn the consequences of any breaker poping out, of any breaker being left out. Know the criticalities, think about multiple failures ...

My own sop : check controls, set and check configuration at the very beginning of taxi, when not yet in a hurry, when not yet distracted ...

And so on ...

From the little information we have at hand, modern training was not really "top quality" within Spannair.

And that is a management error.

Don't put too much confidence in "SAS" quality label ... More often than not, subsidiaries are set up so as not to inherit mother company costly philosophy ... We have seen that in Belgium with the couple "Sabena - Sobelair". Sabena was very conservative, Sobelair was less. A few of their captains ended up before courts for cheating with recorded flight times, and that was a rewarded practice within Sobelair ...
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Old 15th Sep 2008, 09:25
  #1690 (permalink)  
 
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Couldn't agree more!
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Old 15th Sep 2008, 10:50
  #1691 (permalink)  
 
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Since first hearing about the "leak" in CVR :
"Slats, Flaps OK" at that time
and nowaday : "Slats, Flaps set"
I saw poor phraseology, or poor check list, or poor training ...
It is highly likely that one of the pilots didn't reply "Slats/Flaps OK" in the CVR. But to me, it wouldn't be surprising if he did.

I'm 100% sure, though, that training in Spanair didn't teach them to do it that way.

I also have no trouble (at all) believing that, pilots trained anywhere in the world with TOP CLASS facilities and methods, like I believe the ones employed in Spain are, eventually develop ways to "relax" those procedures or even skip parts of them altogether.

I do believe that in some countries, due to cultural issues having to do with "I know better than everybody else" attitude, some of those "rules" are eventually relaxed more than others AFTER TRAINING.

Without having any knowledge on how far that can go in the piloting community in Spain, considering how people drive around with little regard to rules in a country where it takes on the average 3 months of theoretical training +40 hours of paid professional driving training to obtain a driver's license, again, I wouldn't be surprised if the pilots actually just casually said "flaps/slats ok" without even looking (not saying that it happened, just that it would not surprise me personally if it did).

Shhhsss ... there is people that still refuse to drive with safety belts on or that forget to wear them quite often.

Many here have admited being properly trained but eventually skipping parts of check lists, answering challenges w/o really looking, etc. It's not common, but it happens. Everywhere. Just yesterday, as you know, a pilot with over 30 years of experience in Canada tried to land w/o doing the check list and with the landing gears retracted ... I don't think he was taught to do it that way in Canada or that his checklist procedure was defective. Just that he didn't do it properly or at all.

Training and management I PERSONALLY don't think were part of the Spanair accident at all. Scandinavian Airlines is a serious company that takes those issues seriously. Spanair has not had accidents with victims in its 20 years of heavy operations.

My PERSONAL and UNFOUNDED opinion is that it was probably an error on the side of the less experienced copilot, coupled with somewhat rushed and distracted operation (mostly due to the RAT heater previous issue), and the coincidence of having the config alarm disconnected due also to someone's oversight (i.e. CB tripped) or actual electrical failure not properly detected (i.e. intermitent fault with the front wheels ground sensor). Flights conditions (heat, weight, wind) and plain bad luck (plane deviated to unfavourable terrain/direction), PERHAPS completed the tragedy. To add insult to injury, one of the reversers maintenance, which could've been of use in this case (albeit pbbly not much), had been delayed for 3 days ...

Last edited by justme69; 15th Sep 2008 at 11:42.
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Old 15th Sep 2008, 12:17
  #1692 (permalink)  
 
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And more "official" details on the investigation, although again, most of them were already "unofficially" known.

-57yo Iberia pilot landing from Ecuador at 14:25, around the same time as the MD had the accident, informed of winds change, from 10 kt 200º to 5kt 50º. At 800 feet, ground control gave him a 220º 10kt wind reading. At 200' they were given 170º 10kt. But when it landed, plane instruments read east 50º winds and 5kt (somewhat sudden change in 1 minute).

-He also witnessed a large bird to the left and a smaller one to the right of the MD. He also witnessed the MD's roll to the left followed by "an abnormal and sudden roll to the right" of the plane before it started to fall. During the fall it yawed to the right. He also says he saw some flash on the left side of the plane (i.e. around the left engine/tail area).

-More survivors recently debriefed also agree on temperature inside the cabin higher than normal (i.e. air condinitioning not on or not properly working while the plane was attending the RAT issue and perhaps during TO shortly thereafter). They also confirmed that someone inside the airplaned shouted that the wing was going to touch the ground.

-I'll spare details, but once again more rescue workers briefed by the investigators confirm that the fire and smoke caused all sort of problems and damage.

10 survivors remain hospitalized, only 5 with significant medical issues. One remains in intensive care, but doing significantly better.

Last edited by justme69; 15th Sep 2008 at 12:43.
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Old 15th Sep 2008, 13:06
  #1693 (permalink)  
 
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I also have no trouble (at all) believing that, pilots trained anywhere in the world with TOP CLASS facilities and methods, like I believe the ones employed in Spain are, eventually develop ways to "relax" those procedures or even skip parts of them altogether.

I do believe that in some countries, due to cultural issues having to do with "I know better than everybody else" attitude, some of those "rules" are eventually relaxed more than others AFTER TRAINING.

Without having any knowledge on how far that can go in the piloting community in Spain, considering how people drive around with little regard to rules in a country where it takes on the average 3 months of theoretical training +40 hours of paid professional driving training to obtain a driver's license, again, I wouldn't be surprised if the pilots actually just casually said "flaps/slats ok" without even looking (not saying that it happened, just that it would not surprise me personally if it did).

Shhhsss ... there is people that still refuse to drive with safety belts on or that forget to wear them quite often.

Many here have admited being properly trained but eventually skipping parts of check lists, answering challenges w/o really looking, etc. It's not common, but it happens. Everywhere. Just yesterday, as you know, a pilot with over 30 years of experience in Canada tried to land w/o doing the check list and with the landing gears retracted ... I don't think he was taught to do it that way in Canada or that his checklist procedure was defective. Just that he didn't do it properly or at all.

Training and management I PERSONALLY don't think were part of the Spanair accident at all. Scandinavian Airlines is a serious company that takes those issues seriously. Spanair has not had accidents with victims in its 20 years of heavy operations
Justme69:
Your hypothesis is a complete "fallacy". Sorry, but I can´t accept it....
You seem to have reliable information about the failure of the pilots, I can accept that; but gettin´ suspicious of misconduct of every pilot in Spain because the driving license system is not too good !!
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Old 15th Sep 2008, 13:44
  #1694 (permalink)  
 
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If the flaps and slats were not extended and the crew announces that they are set (by rote memorization of the checklist) the problem is not with the individual crew,
Strongly disagree. You might as well say a drunken driver crashing his car and killing people is not really his fault but the fault of his parents for not teaching him as a child how to drink in moderation...
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Old 15th Sep 2008, 14:07
  #1695 (permalink)  
 
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I make no comment or inference on this accident since the investigation is still proceeding.

But on the issue of correct configuration for take off and confirmation of same I would like to suggest that this starts at the ab initio stage. Most light trainers include "Flaps" on the Before Take Off Checks - the correct response to this should be the the actual desired setting (Up or "x" as appropriate) AND a visual check on the wing that the flaps are correctly set for take off and/or observation of the flap gauge. Obviously a visual check is rarely viable or applicable on the big jets but tactile confirmation of where the flap lever is positioned and the correct settings on the flap gauge/indicator is necessary.

The point I am making is that this discipline starts at the basic stage which, I would suggest, avoids the "reply by rote" without really checking.

Decades ago I recall an RAF poster which said "Vital Actions require Conscious Thought" (or words to that effect) to emphasise how important it was to confirm such parameters were correctly set.
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Old 15th Sep 2008, 14:28
  #1696 (permalink)  
 
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Quote:
If the flaps and slats were not extended and the crew announces that they are set (by rote memorization of the checklist) the problem is not with the individual crew,

Cetaurus


Strongly disagree. You might as well say a drunken driver crashing his car and killing people is not really his fault but the fault of his parents for not teaching him as a child how to drink in moderation...
OK with the rhetoric, but what is there left to fix? to prevent the next accident.

Certainly not the crew.

If there were similar rote responses in a statistical sample, then perhaps training changes and checklist changes.

However if this is just a 1 out of E-4 then we need another line of defense that is more effective.

I would love to know what the true error rate is using configuration warning horn data that catches almost all of these just-in-time. Only by matching the crew cheese layer against the warning horn cheese layer can I begin to understand what can reasonably be fixed.
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Old 15th Sep 2008, 14:30
  #1697 (permalink)  
 
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justme69,

He also witnessed the MD's roll to the left followed by "an abnormal and sudden roll to the right" of the plane before it started to fall. During the fall it yawed to the right. He also says he saw some flash on the left side of the plane (i.e. around the left engine/tail area).
The ground tracks confirm the Iberia pilots observation of the plane
being in a strong slip to the right on touchdown.
Indicating strong lateral forces in play.
This just doesn't look like a "normal" plain stall to me.

XPM
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Old 15th Sep 2008, 16:48
  #1698 (permalink)  
 
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Communication clarity essential

Post 1720

As I read your post...XPM
Just Me 69 quotes a Spanish pilot
"Then the aircraft yawed to the right...."

XPM says in a confirming way...
" the aircraft was slipping to the right..."
Do I misunderstand your implication?
That is NOT the same thing.
.........Think about it the next time you give or receive a "Flaps " response, or in fact any check list response next time -if you are still in business.
I dont know how check list philosophy has changed in the last 30 years . but the change to 2 pilot crew, each doing his own half of the checks without a controlling check by the other pilot was a serious retrograde step and blah , blah , blah.
I feel very strongly about sloppy check list use, and I am still alive!
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Old 15th Sep 2008, 17:59
  #1699 (permalink)  
 
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Just Me 69 quotes a Spanish pilot
"Then the aircraft yawed to the right...."
My bad there. I used "yawed" while the news piece just uses a term that, following the context, must be different from roll but would make the forward direction of the airplane change.

Literally, for those with better aeronautics translation skills:

"Dijo que en el momento posterior al despegue, el avión tuvo primero una caída del ala izquierda y acto seguido una caída brusca del plano derecho, totalmente anormal. A partir de ahí, siempre según la declaración de este experimentado comandante, el avión comenzó a virar a la derecha mientras iba perdiendo altura. Añade que, pocos instantes después, observó un fogonazo por la zona del motor izquierdo y de la cola del avión."

The best I can LITERALY translate it is:

"He said that in the moments after the take off, the airplane first suffered a drop of the left wing and right away an abrupt fall of the right surface (wing), totally abnormal. From that point, according to the declaration of this experienced commander, the airplane started to TURN to the right while it was losing height. He adds that, an instant later, he observed a flash in the area of the left engine and the airplane's tail."

Regardless of what happened exactly, from what little I know about physics, the engines were probably not very "happy" in the "low speed/near stall/hot air/tail wind/heavy weight/steep angle of attack" situation the airplane seems to have been, right?

Last edited by justme69; 15th Sep 2008 at 19:02.
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Old 15th Sep 2008, 18:11
  #1700 (permalink)  
 
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lomapaseo, you are quite right to ask “… what is there left to fix? … to prevent the next accident.”
However, one safety defense, the take-off config warning might have been disabled by maintenance action. Thus in addition to the “ 1:10-4 error ” by the crew (possibly a multiple as it could be assumed that each crew member individually suffered at least one error), there could be a similar multiple from maintenance error.
This might only illustrate the nature of accidents as being combinations of rare circumstances; where the absence of any one could have prevented it. Problems occur if the circumstances become commonplace – complacency, bad practice, poor checking/checklists, management oversight, etc.

If the circumstances are really rare, then the probability of an accident becomes extremely rare (not necessarily acceptable). Thus, the defenses should seek to minimize the occurrence of ‘individual’ error circumstances, thus further reducing the chance combination. Whilst crew and maintenance CRM, TEM, and airmanship can help, so too can the organizational safety climate and safety culture, none of which we have details of.

Inf: “Revisiting safety and human factors paradigms to meet the safety challenges of ultra complex and safe systems.”
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