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Spanair accident at Madrid

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Spanair accident at Madrid

Old 15th Sep 2008, 19:43
  #1701 (permalink)  
 
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My first post, I don't see posted before... be kind with me...

Heard from cadena SER 10 minutes ago.

Cadena SER had access to the draft of the preliminary report about the accident.

I will put in quotes the literal translation.

"The report says that the flap/slat didn't work at the takeoff, also the warning system didn't work at takeoff"

"After an accident at (don't rembember), MD issued a AD about the flap/slat revision. The spanair manual was outdated because It specified that MD issued an AD that the flap/slat must be checked prior every fligth, Spanair checked the flap/slat only one time at day".


This is more or less the info, at 22:00 is the full information.
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Old 15th Sep 2008, 19:50
  #1702 (permalink)  
 
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I don´t like to say nothing before the investigation reaches but the behaviour of the airplane during the take off roll doesn´t sound like a bad configuration for take off, at least not only.

What I mean is, you can forget to set the flaps for take off but that only affects your take off roll and climb so why the airplane ended to the right of the runway if the engine failure is not confirmed.
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Old 15th Sep 2008, 20:08
  #1703 (permalink)  
 
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Grrr

Oh god, give me strength, take a deep breath, nope, that didn't work either AAAAAARGH. . . . .
Professional Pilots Rumour Network.
What is so difficult about that to understand
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Old 15th Sep 2008, 20:10
  #1704 (permalink)  
 
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Now the full info is in the web.

El MD-82 accidentado en Barajas no llevaba desplegados los flaps y el sistema de alarma no funcionó en CADENASER.com


The previous incident is in Detrioit in 1987. This is where the recommendation comes from.

They mentioned air/ground mode, but didn't make any sense (jounalists...) and there seems to be evidence that the FDR recorded 0 degrees of the flaps/slats in all the operation from the gate.

Also, says that the crew (maybe..) revised the system from barcelona, but not from madrid....


Greetings....
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Old 15th Sep 2008, 20:17
  #1705 (permalink)  
 
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El MD-82 accidentado en Barajas no llevaba desplegados los flaps y el sistema de alarma no funcionó en CADENASER.com

sorry my spanish is not up to scratch...
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Old 15th Sep 2008, 20:32
  #1706 (permalink)  
 
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Una comprobación recomendada por Boeing pudo evitar el accidente del MD-82 · ELPAÍS.com

Preliminary report of the accident
An audit recommended by Boeing was able to avoid the crash of the MD-82
A fault in the control systems of takeoff caused the tragedy
Lara Otero - Madrid - 15/09/2008

An audit recommended by the manufacturer could have prevented the crash of Spanair plane that crashed on August 20 at take off at Madrid-Barajas, in which 154 people died. The draft report of the Commission of Inquiry into Accidents and Incidents of Civil Aviation (CIAIAC) on the accident said that the MD-82 did not maintain the flaps deployed (flap giving lift to the plane on takeoff) and that the system that should warn the pilot did not adverted of the anomaly that would have prevented the fatal accident.

A similar failure occurred in the crash of another MD-82 in Detroit in 1987. According to one's own draft report of the Accident Investigation Commission, the manufacturer of the aircraft, McDonell-Douglas (now Boeing) "recommended" to companies that always check security system that alerts anomalies for each flight before takeoff . But Spanair only specifies in its testing protocols that must be done before the first flight of the day or when changing the pilots. The airline declined any comment until a formal report.

The commission investigating accidents and incidents of Civil Aviation (CIAIAC) recommended in its draft report on the crash of the MD-82 that the U.S. authorities as the European give binding instructions to all companies operating with such appliances for their pilots to check it before every flight that the control system is running normally.

The recommendations, contained in the last page of the preliminary report, are as follows:

It is recommended to the FAA in the United States and the Directorate General of Civil Aviation of Spain to establish mandatory instructions to ensure that operators of MD-82 aircraft or other designs with similar warning systems configuration inappropriate for takeoff (TOWS) under their supervision, establish in its operational procedures to check the system before each flight.

It is recommended that the European Aviation Safety Agency to propose to the national civil aviation authority of the states of the European Union responsible for the supervision of air operators that have MD-82 aircraft or other designs with similar warning systems configuration inappropriate for takeoff (Tows) the issue of mandatory instructions for verifying operation of the system before each flight.
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Old 15th Sep 2008, 20:46
  #1707 (permalink)  
 
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ok, for us poor gringos

the flaps/slats were not set for takeoff

the warning system which would detect the slats not properly set for takeoff wasn't working

AND

spanair didn't get the word that they were supposed to check the takeoff configuration warning system prior to each takeoff.

that's about it, right?
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Old 15th Sep 2008, 20:46
  #1708 (permalink)  
 
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Unfortunately the term "killer items" has lived up to its meaning. RIP
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Old 15th Sep 2008, 21:02
  #1709 (permalink)  
 
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Yeah, that's about it. It seems the Accident Commission Preliminary Report will state that:

-The airplane gave signs of "not being in ground mode" (i.e. RAT probe heater on while on the ground), which weren't properly "interpreted" by the pilots/technician. In that mode, the take off configurations alarms wouldn't have sounded.

-Nobody checked if the configuration alarms were set/working for that flight. And they weren't. Spanair procedures calls for mandatory checking on the first flight of the day or everytime both pilots are changed. This was the airplane's second flight of the day and with the same pilots. Boeing recommends they are checked prior to each flight. The commission is going to recommend that the manufacturer's recommendation becomes "mandatory".

-The pilots didn't set the wing configuration for take off (i.e. forgot to deploy slats/flaps). Because of the above, the alarm to warn them of the mistake didn't sound.

And your usual "a bit of bad luck".

End of story.

The exact nature of when/why the airplane was not in proper "ground mode" (i.e. if the ground config CB was tripped or something else), doesn't appear in the press articles I have seen. Perhaps, I'm speculating, it's still being investigated and the conclusion won't show up in the preliminary report.

But the chain of events leading to the accident is stablished as: Aircraft in wrong configuration mode/Take-off config alarms not working in that mode/Take off improperly configured.

And the preliminary recommendations:

"It is recommended to USA's FAA, and to the Spanish Civil Aviation Authorities, to relay mandatory instructions to MD-82 operators or those with Take Off Warning Systems of similar designs under their supervision, to include in their operational manuals checks for the proper function of said system before each flight."

Same recommendation to the European Agency for Air Safety to relay to their members' countries.

Last edited by justme69; 15th Sep 2008 at 22:08.
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Old 15th Sep 2008, 21:05
  #1710 (permalink)  
The Analog Kid
 
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Originally Posted by agusaleale
Originally Posted by justme69
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).
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 !!
I think you've misunderstood JM69's point - he's saying, if I understand correctly, that Spanish drivers leave a lot to be desired even though they have a substantial amount of training.
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Old 15th Sep 2008, 21:33
  #1711 (permalink)  
 
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Please, please let's not go any further on the way of judging pilots (individuals or classes due to nationality, etc). Not even posts expressing a view in that area should be further commented - and I agree some are not only misinformed, but also offensive.

As the preliminary report is released, it's the time to put a lid on any individual bickering and talk in respect for the lost ones, and the ones that now have to come to terms with their changed life.

If repeating 1,000,000 time the killer items (I've learned them very well by now) can help preventing future tragedy, even if just a bit, at least this discussion has achieved something - beside anticipating correctly on the facts that caused the accident.

I want to thank justme69 for the reporting the Spanish media and the related lucid analysis. Also thank you to the too many to list that brought data and objective information and experience.

Personally, I will move on now...
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Old 15th Sep 2008, 22:32
  #1712 (permalink)  
 
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More details from the draft of the Accident Commission preliminary report (to be made public in a week or two):

Everytime you see something in parenthesis, it's my own "opinion" to try to make sense out of the not-completely-clear reporter's interpretation of the CIAIAC's document.

-The airplane didn't have the flaps deployed when it tried to TO.
-The CVR didn't register any configuration warnings/alarms.
-"The (I'm assuming WOW) sensors went from ground mode to air mode"..."but the wings sensors (I'm assuming the flaps?) indicated zero degrees during rolling". They conclude, the flaps weren't deployed at the time the plane was taking off.
-The commission says that the airplane's manufacturer's recommendation on checking cfg alarms on every flight was issued 21 years ago and may have not reached Spanair ever as they didn't operate MD-82's at that time and wasn't mandatory. The alarms were not tested for that flight.
-The TO employed aprox. 1950m of runaway.
-Crew calls out VR at 14:24:10 (it seems they don't call out V1).
-Airplane elevated 12,2 meters
-While on the air, it rolled succesively to the left and right twice (i.e. on two occassions, that is, left, right, then left right again).
-Fifteen seconds later after take off, the stick shaker activated.
-Four seconds later, an aural warning alarm went off (terrain?).
-No warnings/alarms on flaps/slats.
-First indications show engines behaving properly according to situation. No signs of prior fires or malfunctions found so far.
-Investigation still hasn't concluded why the airplane was not in the right configuration (i.e. why not fully in ground mode).

Last edited by justme69; 15th Sep 2008 at 22:54.
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Old 15th Sep 2008, 22:44
  #1713 (permalink)  
 
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Are the moderators asleep on this thread? I cannot believe the rubbish posted recently.
This was clearly a human factors failure which resulted in an attempted takeoff with an incorrect flap/slat configuration. This was recognised, as such, some time ago in this thread. Not just my interpretation, but that of many professionals. Of course, we may be completely wrong in our assessment, but we know more than most.
Why don't we all await an official report on what actually happened. Now that Spain is in the EU one might hope that a reasoned, rather than an emotional, summary might ensue.
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Old 15th Sep 2008, 23:16
  #1714 (permalink)  
 
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Let's be careful about judging manufacturer recommendations regarding crew actions.

It's one thing for a manufacturer to issue technical changes in operation, but quite another to issue recommendations relative to crew behavor. Of course preventive operational recommendations are easy to issue and then to walk away from.

The role of the regulator must be considered first. It is the regulator's job to mandate recommendations according to criticality and effectiveness. This side of it must be examined before deciding on the significance of what Spanair crews did or did not do.

If the majority of MD80 operators really do follow this recommendation faithfully (do they?) then it's a fair question to ask if it was a part of this accident cause and why so?
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Old 15th Sep 2008, 23:33
  #1715 (permalink)  
 
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Here is a link to the last page of the draft of the preliminary report by the accident commision and a translation:

http://img241.imageshack.us/img241/7...pboard1jx1.png

"… meant for all the operators of this type of airplanes in which it recommended the checking of the TOWS to be made prior to each flight. In the accident’s report (Northwest) it was said that all operators had included this change in their operational procedures.

As mentioned earlier in this report (see point 1), during the take off roll of the EC-HFP, the CVR didn’t register any sound coming from the TOWS system, the values of flaps deflextion transmited to the DFDR by the sensors on the wings was 0º during rotation and the take off that ended in the accident and the signal coming from the front wheel did switch from ground mode to air mode at the moment of take off. On the other side, data known at this time seem to confirm a problem with the RAT heater during the flights previous moments. The explanation for these facts is still under investigation, but the possibility that a problem existed affecting the function of the TOWS is feasible, considering that the RAT had shown an abnormal behavior and that there is no redundancy in the activation of both systems (RAT probe and TOWS), this last one depending on the last instance on the R2-5 relay. In that case, the testing of the configuration system prior to flight could’ve detected a possible failure. Nonetheless, according to the company’s procedures, the functional test of the TOWS was not part of the tasks before the flight from Madrid to Las Palmas, as the pilots were the same ones that had done the prior flight from Barcelona. In this matter, the instructions given by the manufacturer’s 21 years earlier were different from the ones given by the operator. The Telex in which McDonnell Douglas informed the change in procedures after the MD-82 accident in Detroit may have not been effective in companies such as Spanair that initiated their activities with this type of airplanes later on. It would be advisable, therefore, to require the test of the TOWS before each take off to all the operators for this reason."

(The last two paragraphs are roughly what was mentioned above, about recommending all authorities to make the recommendations mandatory and known to all operators of similar planes.)

Another bit of unconfirmed news (i.e., published rumor in mainstream media): The copilot was the one in charge of physically lowering flaps. The accident's commission doesn't speculate on why they didn't deploy.

Last edited by justme69; 15th Sep 2008 at 23:53.
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Old 15th Sep 2008, 23:59
  #1716 (permalink)  
 
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I don't fly MD-82s...so I have a question... Will this plane fly out of ground effect without slats? Is there any visual indication to the pilots that Slats are deployed? The planes I flew with slats deployed automaticaly once the decelerated speed was met, and conversely, went away once an accelerated speed was met...
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Old 16th Sep 2008, 00:01
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Surprising how similar to my incident back in the 1970s. (Post #919) Technology, techniques and procedures have progressed mightily since those primitive days, but the traps are remarkably constant.
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Old 16th Sep 2008, 00:12
  #1718 (permalink)  
 
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News already on TV:

Informe en exclusiva - laSexta|Noticias

More bits of information:
-Chosen take off flaps configuration 11º (which, as we know, was never set for whatever reason).
-First take off attempt, before RTG, had the flaps in the correct position.
-RAT probe now said to measure 105º (before it was thought to be 99º??)
-14:23:22, airplane ended taxiing the second time and got ready to TO.
-14:23:28, acceleration inititated, thrust commanded a few seconds before
-14:24:06, crew called out V1 (before it was thought only VR was called???)
-14:24:10, CVR records a pilot saying "rotate" (calling VR??)
-Data recording signals front wheel sensor change of state (front wheels off the ground??).
-No sound from TOWS.
-Data recording wing sensors indicate flaps at 0º at that time and before.
-Altitude reached 12,2m (40 feet).
-15 seconds after rotation is initiated stick shaker comes on.
-4 seconds later, aural stall alarm (synthetic voice sounds twice stall, stall)
-Slight left roll. Deep 20º right roll. Slight roll left again. Steep roll to the right.
-Tail cone hits the ground.
-Engines don't show signs of ingestion of foreign bodies or internal components or fire (that are believed to have happened before the accident, of course).
-Tail control surfaces don't show so far signs of fractures or problems prior to the accident either.
-Same with landing gear.
-Same with the reverser, where the preliminaries haven't found a reason to believe the only working one was deployed except later on by the pilots.

There is a question I would like to ask to MD-82's pilots. In the conditions we are all speculating this accident could've happened, what would've you done? Would you have commanded full thrust, lowered the nose (a bit) and go for the flaps lever? Do you think you could've gotten out of the situation on time given your reaction speed? (I understand that "not rushing out" decissions is also important, specially during takeoffs).

I guess what I'm trying to figure out is if the MD-82 can "somewhat easily" get out of the "stall" situation in a similar case if a pilot takes the decission to go "full thrust"/etc in, say, 4 seconds or if it really is very hard to get out of a situation like that unless the action is taken almost inmediately as soon as one feels the stick shaker and even then "success" is only, say, a 50/50 chance (under those conditions of weight, temperature, wind, ground effect, etc). I know a good analysis is not possible without more information, like airspeed, etc, but just an estimation based on your experience is all I need. Thanks.

Last edited by justme69; 16th Sep 2008 at 04:22.
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Old 16th Sep 2008, 04:40
  #1719 (permalink)  
 
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Compressor Stall?

jm69 on report from IB captain landing on parallel runway:

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).

The flash/bang reports continue intermittently and this was addressed many pages ago. The preliminary report suggests that there were no engine problems so it would seem, together with all other facts available at this time, this was indeed a compressor stall in the #1 engine as the plane yawed starboard?
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Old 16th Sep 2008, 05:55
  #1720 (permalink)  
 
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Justme69: thanks for your very informative and highly detailed post. The more I read about this, the more convinced I feel of the cause of the accident: a human error of the pilots, (deployment of slats and flaps forgotten) combined with a failure -it remains to be seen if purely mechanical/electronic in origin or yet another human error- of the takeoff configuration warning.

The 'La Sexta' info is not good. May I ask where have you got those abundant extra 'bits'?

Regards

XXXavier
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