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Spanair accident at Madrid

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Spanair accident at Madrid

Old 16th Sep 2008, 18:05
  #1761 (permalink)  
 
Join Date: Sep 2008
Location: Sweden
Age: 52
Posts: 1
speculation is...

For some reason , it looks like the ground shift relay was in
airborne mode during the take off roll. This would inhibit the take off
warning , which among other things , gives you a warning if taking
off in the wrong configuration.

If the flaps - for same reason - were not in the correct postion ,
there would be no warning in this case!!

Considering the TOW with 178 pax onboard and if they rotated at the
correct take off speed , but with wrong configuration , they were
some 15 kts below stall speed......
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Old 16th Sep 2008, 21:13
  #1762 (permalink)  
 
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For those looking to expand the number of holes in the cheese or for those looking into human part of the accident's scenarios that are opened by the preliminary findings (i.e. pilot pressure, training, management, etc.), here are parts that COULD be of interest or COULD be totally inconsecuential.

The "simple" scenario COULD be:
1) Crew forgets to set flaps/slats. They don't check the indicators that show they are not set.
2) Crew doesn't check config alarms/circuit breakers for that flight. They were either not working/not set.
3) Config alarms don't sound, so the crew is never aware of their mistake(s).

If any of those three points wouldn't have occurred (specially number 1, the real "cause" in this hypothetical scenario), the accident wouldn't have happened in all likehood.

Background:
-Spanair was wholly owned by Scandinavian Airlines group SAS. A large company, but with financial trouble in the past year or two.

-Salary range for an opening crew possition (i.e. copilot) would be around €3,000/month plus benefits (health, unemployment, housing, transportation, food).

-Pilot was 38 years old, with >9000 hours of flight time. Had spent 10 years as military rescue squad pilot, 9 years with Spanair. First upgraded to commander in 2007.

-Copilot was 32 years old, with >1000 hours of flight time. Incidentaly, he was in charge on that flight to physically command the flaps deployment.

-Both crew were under 40 hours of work for the current month (accident occurred on the 20th). They have been found to never exceed their work schedules according to regulations in the prior months.

-Copilot was in the list of personnel that the airline was going to dissmiss as part of the plan to reduce personnel shortly (affecting some 1,100 workers).

-The copilot knew about this and also knew he would be offered a job inside the company as "assistant" if he wanted.

-It was "rumored", that Spanair pilots were initiating a "japanese strike" on that same day or the next day, as talks between unions and company seem to have "scalated" to pressure. A full out strike was also rumored to start soon.

-Crew had made together a prior aprox. 1.30h long flight that day on the same airplane. They reported to airport in Barcelona at aprox. 8:00am. That flight was uneventful, and actually arrived some 7 minutes early to Madrid.

-Crew had a rest period of aprox. 2h between flights.

The flight itself:

Was going to depart at 13:05 and be aprox. 2h 35m long in good weather. A bit hot in Madrid though, at around 29-30ºc (86ºF) outside.

13:06:29 - Authorized to taxii out

13:26:41 - They inform of a small technical problem to ground control (RAT probe)

13:33:26 - They request to ground control to go back to parking due to the problem (Probe measured excessive temperature. Heater was noted active on the ground). They were instructed to go to R11 parking at airport's T2.

-The pilot called the Spanair coordinator: "Tell maintenance that the RAT heater is on while on ground"

-Waiting for them when they arrived to parking 11 were already two airline's tecnicians. The problem appeared in the ATLB. Heater was to be disconnected according to MEL.

-Pilot carries a conversation with the airport ground coordinator assigned to assist him, who arrives minutes after the technicians. It was clear to him that the pilot thought they were going to have to change airplanes.

-The pilot tells the ground coordinator to start getting ready 2 busses to move the PAX to another plane.

-It was hot inside the cabin as PAX complained about no air conditioning (or excessive heat, nonetheless). The engines had been turned off and the door opened.

-Two or three PAX openly complain about the delay, the heat, etc.

-The crew made at least two, probably three, public announces to the PAX about the problem and the repair's proceedings.

-Another plane was requested and available for the change, if necessary. Spanair personnel informed the airport of the probable change of planes for the new flight plan authorization.

-By the time the busses to move the PAX 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. Pilot knew the actions taken by the technician and both signed the plane fit to fly. The busses leave empty as the PAX remains on board.

-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 refueling worker declares to have carried on an informal conversation with the copilot through the window while re-fueling. He noticed, for the first time in his 9 years career, that the airplane had the anti-collision lights on while on the ground (distracted crew forgot to turn them off?)

-Having those lights on was against regulations while re-fueling, but since he was already almost done when he noticed, ignored it.

-14:08:15 Almost exactly 1 hour after its scheduled departure time, the flight is once again authorized to taxii out for take off.

-14:23:22 Plane is ready on runaway to take off and authorized to do so. The flaps at that time had not come down.

Last edited by justme69; 17th Sep 2008 at 03:49.
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Old 16th Sep 2008, 21:16
  #1763 (permalink)  
 
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Interesting words Rainboe and Nigel on Draft about rotating and not waiting to fly off the ground.

There is a danger in hauling the nose up to an attitude and hauling the plane off the ground...while this may give you the test pilot's performance scenarior, the real world often has little dangers like contamination on wing (ice/snow) or a myriad of other things that can make things go wrong.

every flying attempt is imperfect...there must be a "fudge factor" or whatever you guys on the other side of the pond call it.

so be careful out there.

by the way, we were taught on takeoff if the stall warning/shaker etc activated to go:

firewall power

flaps 15

that simple and the plane will fly ...if the slats weren't out there.
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Old 16th Sep 2008, 21:18
  #1764 (permalink)  
 
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In the coal-fired old 4-jets I used to fly, we also had a 'Take Off Configuration Warning' system.

This was ALWAYS checked for operation independently of the actual configuration by operation of a test switch. If the 'TOCW test' was OK, the system was assumed to be operating correctly. But if it warned, then a checklist was consulted and every item which was required to be set was re-checked. Usually a sticky spoiler lever switch was the culprit.

The TOCW system was inhibited above a certain throttle lever angle. But someone who thought he knew better had decided that we should take-off with lower thrust whenever possible, to save engine life. Which meant that the throttle levers could well be inside the 'TOCW range' during take-off.

I thought that a silly idea. But was overruled.

One fine day, at around 100 KIAS and 20 KIAS or thereabouts below V1, the TOCW horn suddenly went off. Since we practised aborted take-offs several times per month in the simulator, the rejected take-off was no snag - but what really annoyed me was the fact that several other crews had experienced the same snag but hadn't bothered to snag the jet!

The cause was later established to be a fault in the horn interrupter unit and thus spurious. But our sound teaching, plus frequent practice of aborts at up to V1 in the simulator meant that this was merely an annoyance, rather than a life-threatening danger.

Sorry to have rambled on, but I think that the philosophy of a formal take-off configuration warning test on EVERY flight is essential (and not just by throttle movement on take-off!) - as are instinctive reactions during an aborted take-off. In addition, our check lists were all 'challenge and response' and had to be word perfect for our instructors - none of this 'flap set, we're good to go' bullshit. It was CHALLENGE - Flaps and Slats, RESPONSE, (point at flap lever) 'Take-off' (that was the indication), (look at flap indicator) '20' (that was the flap angle), (look at slat indicator) 'Out' (that was the indication). If the full 'Take-off, 20, Out' response wasn't given the challenge would be repeated.

Rushed preparation + poor SOPs + lazy check list responses delivered in an "I sound cool" manner = DEATH.

Not saying that's what happened at Madrid; the result of the enquiry will determine that.

Last edited by BEagle; 17th Sep 2008 at 16:12.
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Old 16th Sep 2008, 21:21
  #1765 (permalink)  
 
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There is a question running around my head. I have read the complete draft of the accident analysis. You can find it here, in spanish of course. The first chapter says that the engineer poped out a breaker to turn off the RAT probe heater, acording to the MEL, but it doesn't say wich breaker. The chapter 5 is a safety recomendation. There we can find a complete description of the R2-5 relay function. It also says that the TOWS is a NOGO by MEL and MMEL. Therefore the RAT breaker has nothing to see with the relay IMO. Why then the whole recomendation chapter talking about the relay? Do that mean the relay was also faulted or disrupted by another breaker, the famous P40 at Detroit accident, causing the TOWS fault? In other words TOWS must be independent from the RAT probe heater breaker because it would be a NOGO. So what in earth caused the TOWS to fail? Other question. Was the relay R2-5 causing the RAT probe to be heated while on ground? Why the draft doesn't specify it clear? Could be linked to the wings1011 post [+] talking about engineer's bad habit to pop out a breaker for the daily check? Could be the same reason at Detroit, Madrid and Lanzarote?
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Old 16th Sep 2008, 21:27
  #1766 (permalink)  
 
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bia botal re #1778, “… it has been proved time and again that it takes 7 holes in the swiss cheese to cause an accident. Ground/air CB pulled and flaps not set are but two …”

It would be interesting if you could provide a link or reference for your assertion.
Nevertheless, looking at the detail and considering latent conditions as well as active failures then it may be possible to identify many holes:
CB pulled (no config warning), + was this procedure approved (error/violation), + CB not checked.
Flaps not set, + not checked by setter (lever and gauge), + flaps not checked by checker (lever and gauge).
+ Possible poor practice of calling ‘set and checked’ – management/training oversight, + possible poor checklist design / SOP wording.
+ Possible rush / hurry (ill discipline – training/personality, or human weakness – natural wish to satisfy passengers), + possible distraction (human weakness, or weak training – start checklist again, or poor discipline – company culture), etc, etc.

As with most accidents the path to the event is riddled with holes, the key features are those which cause the critical holes to line up (the contributors to the accident), the failure to close holes which are a potential accident path, or the failure to detect an already open path. And of course in hindsight, the failure (of everyone) to report these weaknesses (open holes) so that they could either be closed or be mitigated with suitable defences.
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Old 16th Sep 2008, 21:39
  #1767 (permalink)  
 
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Sorry about my previous post, getting a bit taken away by all the nonsence written here.
That's a pity because this is one of those threads where the whole pilot community (from the greenest to the most experienced and not only the maddogs) can learn an extremely valuable lesson which is only drowning in loads of rubbish written by the armchair pilots.
I learned enough, not going through this thread again.
Special thanks to justme.
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Old 16th Sep 2008, 22:15
  #1768 (permalink)  
 
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Those surprised by the reactions to "flying it off" may not realize that the wing loading of an MD-82 is about nine times higher than on a Cessna 172 (595 kg/sqm vs. 67 kg/sqm). So not only does the MD-82 need an almost three times faster airspeed to lift off, it is also much more dependent on its high-lift devices. Imagine a C172 with a wingspan of 2 metres and you get the idea.
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Old 16th Sep 2008, 22:50
  #1769 (permalink)  
 
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Flying It Off Dangerous?

Why endanger each takeoff to "cater" for the 1 in a few million times someone forgets something pretty fundamental?
I fail to see how flying the airplane off the runway endangers the takeoff. If you haul it off like Spanair apparently did, and if the configuration is not properly set for the conditions, you will stall. Then you don't have anything to work with. If you fly it off, you at least can judge your situation and act accordingly. True, if you have a short runway, then you don't have any slack but MAD is not that short. A gentle hand on the controls beats jerking the plane around. Jerk it around and you limit your options.
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Old 16th Sep 2008, 23:06
  #1770 (permalink)  
 
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Smilin Ed
A gentle hand on the controls beats jerking the plane around
sevenstrokeroll
There is a danger in hauling the nose up to an attitude and hauling the plane off the ground...
Don't worry - I get picked up on some annual checks for too "gentle" a rotate...

However, there is a limit for what one can/should cater for - in fact very little There are plenty of built in safety factors, and "on the day" (icy, long runway) you might build in some of your own. That is very different to altering the taught and certified techniques to cater for the grossly abnormal

As above, please read the NW MD-82 report. There is no realistic way you could cope with that on an everyday basis You need accurate figures, and the SOPs / discipline to ensure that the requirements of those figures(clean wing, configuration, power setting) are met. Very few (if any?) types call for you to pause rotation until the aircraft is airborne...

Smilin Ed - please note that if you do perform low rotation rate takeoffs outside the SOPs, and unstick at high speed / even just achieve excessive speed in the first segment, you will get nicked by the monitoring systems and called to account

NoD
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Old 16th Sep 2008, 23:08
  #1771 (permalink)  
 
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And, of course, reactions unfold as investigation continues.

-Spanair declares: procedures call for three checks of the take off systems before each flight, specially flaps. And they check the alarms every morning and every time pilots change or are away from the airplane for "a long time". They say that many airlines in the world follow this procedure currently for this MD-82 model.

-Spanair didn't receive any recommendation from McDonnell Douglas for checks for the take off configuration alarm for each flight, according to them (this was expected). They never knew the recommendation was made, or that it even existed. Regardless, the recommendation wasn't mandatory.

-Spanair's procedures are approved by the Civil Aviation authorities in Spain.

-CIAIAC still not commenting on the slats.

-Samples of the JET A-1 fuel taken from the tanks that the airplane used to fuel have been analysed and were found compliant with specifications.

-Weather was always good around the time, perfect visibility, soft winds always between 2 and 7 knots, temperature between 28 and 30 degrees celcious.

Last edited by justme69; 17th Sep 2008 at 00:25.
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Old 16th Sep 2008, 23:28
  #1772 (permalink)  
 
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If the airplane doesn't feel right, then don't force the rotation. A pallet may be shifting, your trim may be wrong, your flaps may not be configured, etc. Any pilot who doesn't have ham fists can tell you that.
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Old 16th Sep 2008, 23:41
  #1773 (permalink)  
 
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Maybe I missed something buried in the messages after my hasty look, but has anyone caught this BBC report:

Wing Flap 'Problem' on Spain Jet

These two paragraphs really jumped out at me:

" The pilots had detected the high temperature as they readied the plane for take-off, having already deployed the wing flaps, the plane's black box recorder showed. They aborted the take-off to get the temperature gauge looked at by technicians, the draft report says.

By the time the plane resumed its position on the runway, the flaps - which make it easier for aircraft to get off the ground at take-off speeds - had been retracted, data from the black box is said to show."

With all the usual media caveats etc, if true, this means the flaps were properly deployed on the first attempt to depart, and later retracted.

I think it is a significant statement if true. I leave it to the expert MD pilots and CRM experts to analyze the implications. But it certainly indicates that the flaps were functional and set on the first departure attempt.

If this has already been covered, feel free to flame or delete!

Beech
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Old 16th Sep 2008, 23:43
  #1774 (permalink)  
 
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Sorry about my ground roll question.....

I didn't mean to get people upset. It seems the cause for the plane not flying has been well argued over and over....I thought an examination of braking performance during the extraordinary 15 second plus ground roll off concrete would at least help me understand more.

Someone said I would not be able to stop an auto traveling 140kts within 1100m, on dry grass....and I'd have to say that would be easily done. Dry grass is not glare ice.
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Old 16th Sep 2008, 23:54
  #1775 (permalink)  
 
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Beechnut,

Not sure of your inquiry. When you have to gate return, the appropriate action is the After Landing Checklist. It includes retracting the flaps. Completely normal and good technique.
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Old 17th Sep 2008, 00:10
  #1776 (permalink)  
 
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The point of my inquiry was that prior to the RTG, they were working.

Does that make a technical fault less likely as a cause for failure to deploy on the second departure?
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Old 17th Sep 2008, 00:14
  #1777 (permalink)  
 
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They may have simply forgot to move the lever. Or a malfunction could have occured.. Technical things foul up at the darnedest times. The investigation will tell.
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Old 17th Sep 2008, 00:36
  #1778 (permalink)  
 
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Yes, the FDR shows the flaps deployed at 11º when they were aligned on the runaway before they returned to gate for the RAT probe's problem.

They would've retracted them as normal when they taxied to parking.

Once they were aligned to take off again, the sensors indicated they were at zero degrees (fully retracted).

That's all it's been said. Again, why they were that way is not mentioned (still under investigation).

Also, the preliminary report doesn't mention that "supposely leaked" CVR conversation where "flaps ok, slats ok" is reportely answered during a challenge.
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Old 17th Sep 2008, 01:57
  #1779 (permalink)  
 
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Probable expalnation

Reading thru the post and thinking of the episode of someone writing a close call taking off with flaps up due to the F/O retracted them when they returned to gate to leave a passanger but turned back to start again,and the they forgot to set them again for the new emminent take-off. The take off warning were not working due to C/B pulled. And then refering to my own text I wrote earlier from own conclutions and experience and then thinking of this Spanair thing just make me more certain of the probable explanation of this accident. Plain Human factors ! it happens must faster and easier than one would think but that is ofcourse why we have the famous checklists that should be followed before EVERY flight. There are there for a reason...And as wisely said before just pure airmanship and will to survive nomatter what type of aircraft you operate would make you check the essentials in your head before advancing the throttle: like are we on the correct RWY ?? think.. then did we have clear for take-off ?? then flaps/slats +trim+power ,then take-off accidends are very very highly unlikely


Regards

Wings1011
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Old 17th Sep 2008, 02:09
  #1780 (permalink)  
 
Join Date: Aug 2008
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wings1011: were you crew on that Lanzarote flight? If not, could you tell me the crew's "origin" (i.e. were they spanish Air Comet crew or austrian MAP?)

BTW, thanks for your posts. I started researching this Spanair accident after seeing how the CIAIAC hasn't mentioned any details about OE-LMM in over a year.

Last edited by justme69; 17th Sep 2008 at 02:33.
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