Spanair accident at Madrid

[XXXavier]

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

[vanHorck]

MD82 pilots/engineers

are the slats/flaps linked mechanically or is it posible for the crew to set TO slats/flaps in the cockpit and the flaps/slat on the wings not deploying(either one or both sides)?

[forget]

WOW Disagree.

What surprises me here, in view of the critical importance of WOW signals, is that there is no WOW Disagree Warning; for example, between Nose and Main Gear.

The only time that they should disagree is on Rotate or initial Landing.

The simple answer is to feed all WOW signals to a simple Comparator, with a 10 second ‘disagree’ time delay to a WOW annunciator. Does any manufacture already do this. Surely!

[MD83FO]

i used to fly the md80 series, it has a green light to indicate slats extended, they reduce the stalling speed by 50 knots aprox, i believe if you were able to overcome the tunel vision in such panic situation as it must be ( desbelief ) , and extend slats/flaps, lower nose to have roll authority + firewall thrust.
the deck angle is also limited to 20 deg to prevent compressor stall.

[FrequentSLF]

Air mode

I am a bit confused, I hope same expert could help me.

After the first take off attempt, I assume, the engines were stopped, doors open and air speed should have been zero. I wonder how the aircraft logic could still be in air mode with all those conditions. If so is a poor logic design.

Thanks

AN

[captplaystation]

ZQA297/30,
Just re-read your post number 919, I can only imagine the shiver that runs down your spine when you see the likely cause of this one.
Lady luck is indeed one of our greatest allies in this game.

[Rananim]

Two stages to rote responses:
a)you respond before checking,then self-correct almost immediately.Probable cause:distraction from low level of alertness,sleepy.Everyone has done it.Important to stop,think and recognize it as it can be a prelude to (b)
b)you respond and dont check(visual,tactile).Probable cause:distraction from pressure,stress,being rushed.

SOP's-know them,respect them but take them for what they are,a guideline,a framework.Never split the cockpit in half and work exclusively to your area of responsibility.This sing-song of steps/call-outs from push to shutdown is all very well but its only purpose is to facilitate a smooth operation between 2 strangers.Actual safety is directly proportional to airmanship and judgement alone,NOT SOP compliance.Even if the SOP says x or y doesnt need to be checked every flight,let your good judgement decide that,not the book.Ive witnessed a check pilot remonstrate with a skipper for checking a non-mandatory item.The skipper didnt back down and he was damn right.

Justme69,
Im not a MD pilot but I believe the procedure is set/call FLAPS 15/MAX POWER,lower nose below stick-shaker and avoid secondary stall.Two things were against them:
a)startle factor
b)probably rarely trained

Thanks once again for your updates.

[the flyingenglishman]

Lookforshooter, just in response to your earlier post.

There is a slat position indicator located just next to the flap position gauge, which has a series of couloured statements that illuminate depending on the configuration. 'Takeoff' illuminates in blue, when the slats are correctly positioned for take off. For this particular flight the indication should have been given if the flaps had been selected to 11 degrees, with the slats in the mid-sealed position.

There are 3 positions for the slats: up/retract, mid-sealed or fully extended.

There is an autoslat facility on the aircraft. The limitation with this, is that you must have the flap/slat handle out of the up/retract gate and the slats be in the mid-sealed position. Upon detection of a stall, the slats are fully extended. When this occurs the slat position lights illuminate 'Auto' in blue and 'Disagree' in amber. Once you are out of the stall, the slats return to their original selected position. Unfortunately, if you haven't any slats/flaps selected you get no autoslat.

[Beavis and Butthead]

Spanish media today are reporting that the aircraft had "wing flap failure". It is only media reports but does this now suggest technical failure and not crew error?

From the BBC:

The wing flaps on a plane that crashed in Madrid last month did not open properly during take-off, investigators have found, Spanish media say.
The investigation discovered that the pilots were unaware of the problem because a cockpit warning alarm did not go off, El Pais newspaper reported.
The Spanair plane plunged to the ground shortly after take-off, killing 154 people on board. It was the deadliest air crash in Spain in 25 years.

[forget]

It is only media reports but does this now suggest technical failure and not crew error?

Not the easiest things to overlook.

[IMG][/IMG]

[Christodoulidesd]

It's recycling of the previous press reports, imo, as it doesn't clearly state if they were selected but failed and thus didn't deploy or if the crew forgot to select them pre-take off.

[ECAM_Actions]

BBC NEWS | World | Europe | 'Wing flaps failed' on Spain jet

I think it's more likely flaps/slats weren't set for takeoff.

EDIT to add: Quality of reporting these days is rubbish. All the BBCs sources for this article appear to be what they've read in Spanish newspapers, instead of picking up the telephone and asking the crash investigators directly.

ECAM Actions.

[Beavis and Butthead]

I agree. It seems like poor press reporting to me. I suspect that the actual finding from the investigators is that the config warning failed to warn them that the flaps were not set for take off.

[FE Hoppy]

I don't really see any room for debate here.

The Flaps/slats were not set for TO.

Regardless of warning systems and/or WOW systems the checklist was not completed.

This is a Human Factors accident nothing more or less.

We can skirt around the issue as much as we like but the truth is this was avoidable had the crew carried out the checklist correctly.

[Tiennetti]

There are separate squat switch on NLG and MLG but the main one is on the NLG
The "Ground switch" from NLG feed various relays, among others the 2-5 that feed RAT Probe & Heating, TO Warning System and Avionic Cooling Fan

[BoeingMEL]

Agree 100%

Yes, FE Hoppy, I agree 100%.... sensors,warnings, lights etc only of passing interest/importance if there has been a total failure in basic airmanship.
Tragic and wholly unnecessary imho.

[baftabill]

BBC

'Wing flaps failed' on Spain jet


The wing flaps on a plane that crashed in Madrid last month did not open properly during take-off, investigators have found, Spanish media say.
The investigation discovered that the pilots were unaware of the problem because a cockpit warning alarm did not go off, El Pais newspaper reported.
The Spanair plane plunged to the ground shortly after take-off, killing 154 people on board.
It was the deadliest air crash in Spain in 25 years.

It is a report of a report hence the quotes around the headline, and the phrase 'Spanish media say'.

'El Pais newspaper reported'

Is that not clear?

[XXXavier]

The wording seems right. It says, impersonally, 'did not open properly' and not: 'the crew did not deploy them properly...'.

After all, it may be possible that the lever was duly actuated, and -for some reson- the flaps did not extend... It's easier to believe in a distraction, a human error. But other explanations cannot be completely dismissed. At least, for the time being...

Regards

XXXavier

[agusaleale]

I agree with you that the first failure may have become firstly from the pilots. But warning systems are what they are. They are supposed to prevent this failures.


Did anybody know about the instructions from Boeing to check TOWS before every take off?
If it was issued 21 years ago, why the system has not improved since then?

[justme69]

The cause of why the flaps weren't extended (i.e. pilots forgot or some malfunction) or why the TOWS alarms didn't go off (i.e. malfunction or someone tripped the circuit breaker) are still under investigation and not being especulated upon by the accident's commission so far.

All it's been said, in plain terms, by the accident's commission is that:

-The FLAPS never reached a position other than 0 degrees right before or during the take off (i.e. they were never lowered). Data flight recorder shows that. Remains of wings found confirm that (i.e. flaps couldn't have retracted on their own due to the impact in the circunstances they were found). Circunstances surrounding the accident agree with that. As we all know, trying to take off under the circunstances of that flight without the flaps/slats extended, could likely have caused it to stall due to insufficient lift for the calculated speeds.

**NOTE: This information is preliminary and CONTRADICTORY within the draft itself, where it's mentioned both, that flaps were at 0º and that they were found extended by 12cm.

-Nobody checked to see if the "bad take off configuration" alarm, that would've warned that the flaps weren't extended, was working for that particular flight (i.e. was checked on the earlier flight, but not this one). Checking it on every flight wasn't mandatory, but recommended. It is now recommended that this check becomes mandatory before each flight.

-And that the "bad take off configuration" alarm that would've warned of that situation with the flaps, finally didn't sound. The cause of this "malfunction" is not determined yet, but likely had to do with the electrical configuration (i.e. a faulty sensor or simply, a circuit breaker switch that had been flipped off). This is inferred by the prior RAT probe heater abnormal behavior, which is electrically related to the alarm's (TOWS) mechanism (i.e. they feed off the same ground sensor logic and share power through a common circuit breaker).

And that's it on their side.

While it's likely that human error is behind all of these circunstances (i.e. pilots "forgot" to deploy flaps/slats, someone "forgot" to update/incorporate Boeing's recommendations on the manuals, someone "forgot" to reset a circuit breaker feeding the alarm), other possible explanations, including mechanical or electrical malfunctions, exist, even if less likely, and they have not been fully discarded yet, as the investigation continues.

This preliminary report, once completed, is scheduled to be sent to the judge in charge of the judiciary investigation by Monday 22nd. Should be made public around that time. Anytime after Sat. 20th.