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Spanair accident at Madrid

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Spanair accident at Madrid

Old 17th Sep 2008, 20:57
  #1821 (permalink)  
 
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Thanks Bernd. Gracie mile wings1011 I understand now the way it works
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Old 17th Sep 2008, 23:09
  #1822 (permalink)  
 
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Ref post 1818 by wings1011, if you are referring to post #919, the notorious c/b was in, the fault was in the throttle position sensing as I recall.
Aircraft did not return to ramp, only turned off runway, then turned back on to runway. The checks were already completed "down to the line". The only problem was habit... turn off runway, retract flaps. Action not noticed by PF, who thought checks were still uncompromised.

I have heard the saying "habit can kill you" and I could not agree more.
Any time anything, however small, interrupts the expected flow of a procedure it is necessary to raise mental antenna immediately.

Classic example is a go-around.. I have seen myriad errors on go-around because two or three checklists follow in rapid fire ( especially engine-out), and things are not positioned where they normally would be. People tend to "see" what they expect or are accustomed to see, despite clear visual evidence to the contrary. Ask any trainer.
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Old 18th Sep 2008, 02:07
  #1823 (permalink)  
 
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It seems the copilot was the one performing the take off.

He was 31, 2 years working at Spanair, as July 31st he had 1.276 hours of flying experience, 1.054 on the MD aircraft.

Pilot (38) had 5.776 hours on the MD-82. (over 10.000 h total flying experience). 9 years in Spanair, 10 years military rescue squad pilot.

DATA recorder has been found to have reliability problems registering data coming from one of the two on board flight computers. The cause of these problems is unkown yet.
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Old 18th Sep 2008, 09:46
  #1824 (permalink)  
 
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WOW problem versus C/B or same?

NOD:

In short, if the takeoff was Flap/Slatless and the TOCW was not working, the accident was not "caused by" the TOCW, IMHO. It might be a "contributory cause" but if you have to reject a takeoff because the TOCW stops you, there should be a form of inquriy into just this... because the TOCW likely saved a lot of lives, and the rest of the "system" had failed.

Thanks for the patience. I do fully understand that this was the actual cause and that the TOCW is a secondary hole in the cheese. I was just trying to understand WHY the TOCW failed.

As discussed already, the RAT probe temperature was a SYMPTOM and disconnecting the heating circuit would not solve the CAUSE. That appears to be that the A/C thought it was in flight mode, presumably because of a failure in the WOW switch?

My question was if the problem was with the WOW circuit, then the infamous C/B would appear to be a red herring. Unless it also is connected in the same circuit.

If simply the WOW switch it seem incredible that such a small failure can result in the loss of a critical system (TOCW).

Sorry if I am not making myself clear.
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Old 18th Sep 2008, 11:06
  #1825 (permalink)  
 
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Though I have read almost the entire thread I am still confused:

Is it it either R2-5 closed or is it CB P40 opened that diables the TOCW.

Or is it that both can disable the TOCW?

As I read it R2-5 remained closed and left this particular line in flight mode. This heated the RAT probe and disabled the TOCW. Then P-40 was pulled that disabled the heater. But there are some references (DTW accident) that this would also have disabled the TOCW directly.

So the TOCW was disabled "twice" because of the flight mode AND the CB pulled?

Thanks for clarification.
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Old 18th Sep 2008, 11:38
  #1826 (permalink)  
 
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Yawn.........
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Old 18th Sep 2008, 12:22
  #1827 (permalink)  
 
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Cool Good thread folks!

Just stepping back for a moment at page 93, I'd like to say that I'm very impressed with the way this thread has developed. Sure there's a lot of noise on it from people apparently following Farrell's guide and others flaming them, but in amongst that there's been a very intelligent and informed debate that has found its way to what looks like the same conclusion as the investigation impressively quickly. So well done PPRUNERs!
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Old 18th Sep 2008, 12:26
  #1828 (permalink)  
 
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Yawn indeed...

But 3miles makes the point, inadvertantly maybe, that a system whose effects are possibly interconnected like this, is a system likely to be misunderstood... let us hope this was not such a case by a professional on the day.
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Old 18th Sep 2008, 14:02
  #1829 (permalink)  
 
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The "political" "blaming" BS game keeps on going.

Seems Boeing did a "Flight Operations Support" to Spanair between Nov 5 and 14th 2007, and declared Spanair procedures "excellent" as well as the degree of compliance by their crews, pointing out that the degree of coordination (CRM) between crew within Spanair "exceeded world standards".

Some CIAIAC members have resigned after what they consider is excesive "blaming" of Spanair for not following Boeing's recommendation of TOWS alarm verification prior to each flight issued 21 year ago after Detroit's accident, which, let's remember again, was neither mandatory anywhere in the world nor was ever made known to Spanair.

Those members feel that more "blame" (another way to say "more important in the circunstances leading to the accident") was the de-energizing of the TOWS system itself (i.e. why the TOWS didn't work to begin with).

In another words, they feel that, after the pilots themselves, Boeing is next contributor to the cause of the accident for the TOWS failure itself (not easy to detect without specific testing) and the failure to warn Spanair to update their testing procedures (where TOWS would've been found inoperative and the plane not fit to fly, as it's MEL).

You Mad Dogs out there: did/do you have to check TOWS before each flight by you companie's procedures?

For almost 5 hours the judge in charge of the judiciary investigation (and a judicial secretary and the general attorney) have been listening to the CVR recordings, in a process more difficult than anticipated. Within a few days, the relevant transcripts will be once again checked against the actual recordings by a judicial secretary and then will be incorporated to the judiciary investigation. No more actions are expected from the judge until he receives a copy of the preliminary CIAIAC's report, probably on Monday.

This finalised preliminary report will include any new proven facts / clarifications plus alegations to the draft made by parties involved (manufacturers, safety regulation bodies, operators, ...) to which the draft was made available a couple of days ago.

So far it seems that at some point somehow, the copilot, who is the one that performed the take-off, does call the flaps and slats to be in place (i.e. "slats ok, flaps ok" ... exact wording not known by me yet).

Quality of the voice on the recording (crew's channels) is quite low (I don't know why, but pbbly will be blamed on post-accident damage). Other channels have better audio quality.

So it seems it was either a rotten checklist challenge response or some malfunction that made him think the flaps were out, but they didn't deploy (less likely, of course).

Last edited by justme69; 18th Sep 2008 at 15:46.
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Old 18th Sep 2008, 16:44
  #1830 (permalink)  
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Over years C/B modified

Several slots prior, question about CB#'s alluding to the P-40 C/B cited in the DTW AAR:
"... or is it CB P40 opened that diables the TOCW ..."
In the past decades, several customers have modified circuit breaker panels, and in some cases that old # P40 CB is now elsewhere (various systems have had CB mod's).
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Old 18th Sep 2008, 17:04
  #1831 (permalink)  
 
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Video Now Available

Not much to see really.

Video: Así fue el accidente de Barajas : Vídeos en ELPAÍS.com

Sound is, apparently, from ATC calling (nervously; she confuses the runway where it happened) Security to see if they can pick it up on their cameras.

(I checked the last 3 pages of this thread to see if it had already been posted and found nothing. If it has been posted earlier, I apologize).
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Old 18th Sep 2008, 17:04
  #1832 (permalink)  
 
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Video of the accident

"¡Ha habido un accidente en la cabecera de la 33 izquierda, creemos que de aviación!" · ELPAÍS.com
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Old 18th Sep 2008, 17:40
  #1833 (permalink)  
 
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wings 1011
This unit the is linked to each slat section with VERY thick control cables that via a simple solution with wires and pulleys from both sides actually pulling the the slat either in or out and they are all linked together unlike say a 737.
The DC10 has the same idea, the cable is nearly one inch diam.
Anyway one day in about 1982, a KLM DC10 turned up on our hangar ramp in BAH. Went out to see why and it had a Nbr 1 eng failure. I could put my head up in the hole and look into the combustion chamber. One of the HPT blades had sheared the main slat cable in two! Sort of auto slats with engine failure I suppose
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Old 18th Sep 2008, 17:50
  #1834 (permalink)  
 
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Already in youtube and liveleak if anyone has trouble watching it from the source. The clip is from the airport security camera with audio from some airport ground personel close to the site that witnessed the accident and comunicated to airport security, I think.

In the audio, the person calling says they think there's been an accident, and are trying to relay what runaway they think it happened at. They are asked if they know if it was an airplane. She asks somebody else that seems to be the "real" witness, and answers that she is not sure but she thinks so and all they can really see is the smoke and flames. The person at the airport asks security to patch in a video feed from 36R urgently, and then she sees the smoke and goes: "Jeezz". It looks to her to be off the actual runaway. She says she'll call the fire squad. Meanwhile it's heard on the background how other worker's cars, tower, etc are also being called on in.

"Fortunately", the accident seemed to have happened very close to one of the firefighter's station. Two firefighters arrived within 4 minutes of the accident and pulled two survivors out of the water, one summerged to chin level with one arm trapped and unable to unbuckle and one unconcius (she wakes up, first thing she remembers she was being pulled up by her hair to keep her above water).

YouTube - Imagenes del accidente de Madrid "¡Ha habido un accidente en la cabecera de la 33 izquierda, creemos que de aviación!"

LiveLeak.com - SPANAIR ACCIDENT MADRID 2008 JK 5022

Last edited by justme69; 19th Sep 2008 at 00:14.
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Old 18th Sep 2008, 18:07
  #1835 (permalink)  
 
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Are you as full of BS as your "lower the nose and fly it off" comment implies?

If you have not set the flaps you are dead. If you are on a 10000" plus runway..... stop
Got this from someone going by the name of Dogma.

I tire of this whole site sometimes but persevere because flight safety is so important..Whos been moderating this thread,...the human factors is the key to this accident but you can bet that the Spanish will focus a good part of the report on factors affecting possible pilot recovery(the stage after Vr)..Dogma suggests an abort which goes against the V1 go/nogo rule..however,I agree an abort would have been better than what was tried ..the rwy at MAD is exceptionally long..however,what on earth is wrong with lowering the nose,selecting flap(any flap,just to get you some slats),firewalling the engines,and then trying the rotation again...far better to use that long runway for that than a high-speed abort after Vr...

What can we learn...if you dont unstick at normal BA,check config..if config is okay,suspect perf miscalc..simply abort,youre below real V1/Vr..if config is not okay,firewall and get some slats out(any flap setting!!!)..if rwy permits,stay on it and delay rotation!

This can be demonstrated and taught in the sim so that it becomes a trained maneuver..the Lanzarote incident proves that instinct is part of the equation..pilots instinctively keep the nose just below stick-shaker and firewall thrust..if the cross-check at failure to unstick becomes part of our training,there is not so much dependency on instinct..From Vr + 3secs on,the Spanair pilots were simply relying on instinct..thats all they had in the bank..this scenario has played out in 2 major accidents and one incident(afaik) prior to the Spanair..why was the data not disseminated,why was the TOCW check not mandatory for every flight(airmanship),why was stall recovery after rotation not trained,why was training not given on reasons for failure to unstick,why was the MD/s unreliable/vulnerable air-ground system not emphasized to crews and engineers alike..if the relay cb was pulled disabling the TOCW,where is the AD warning crews of this hazard...
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Old 18th Sep 2008, 18:28
  #1836 (permalink)  
 
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the video seems to show alot of sand being kicked up


I offer this theory.

we all know that wake turbulence is at its worst when you are slow, heavy, clean.

it seems to me that there is indirect proof that the flaps/slats are up as the wake seems to be making more sand kick up than usual.

follow my thought?
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Old 18th Sep 2008, 19:17
  #1837 (permalink)  
 
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This other video, perhaps, shows the details a bit better:

LiveLeak.com - Spanair Madrid barajas Accident 2008 JK5022 airport camera video show actual crash 2ND version

Any (subjective) comments on the attitude of the plane at that time? Does it seem a bit excessive to any of you for the last part of the rotation on those conditions?

Last edited by justme69; 18th Sep 2008 at 23:51.
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Old 18th Sep 2008, 19:46
  #1838 (permalink)  
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What use is a 'config' button if it simply stays silent when you press it?

In my present type we do a config check at the start of each taxi.

Press the button- no sound- announce "Flap x config check"

The config could easily have failed!

On my last type (Embraer 145) She (the aircraft config aural)used to say
" take off- OK"

So you knew:

1. Config system working.
2. Take off config OK.

On my present type you press the button- hear nothing _so you know:

EITHER:

1. Configured or
2. Config system gone tits up!

When people talk a bout 'lining up the holes in the cheese'- this is one hole that could easily be filled in- permanently!
 
Old 18th Sep 2008, 20:18
  #1839 (permalink)  
 
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we all know that wake turbulence is at its worst when you are slow, heavy, clean.
Below about 1 span altitude - vortex buildup is significantly less than
in free air due to ground obstructing the movement of air. This is why you get an induced drag reduction - or span dominated ground effect as it's called.

XPM
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Old 18th Sep 2008, 21:06
  #1840 (permalink)  
 
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No more speculations. The accident is an exact copy of this. Even the weight is almost the same. I would pay special attention at a couple of things.
First at page 40 says:
According to Douglas’ manager of aerodynamics and acoustics for the DC-9 and DC-g-80 programs, the roll stability is decreased significantly when the airplane is flying near its stall angle of attack. “It can be flown there, but it’s a very difficult thing to do.” The recorded data showed that, about the time of the first SSRS alarm, the airplane began a slight roll to the left which was reversed when a bank angle of about 8” was achieved. The airplane then rolled right about 16”, left about 33”, right about 35”, and then left; and initial impact occurred about 22” left roll as the airplane was rolling to the left. The data showed that the spoilers were used to counteract these rolls and that on two occasions almost full deflection (60”) was employed.
And at the next paragraph:
However, the airplane’s aerodynamic performance in this area was reduced by two factors: the rolls and the spoiler deflections used to counteract the rolling moments. During the last 6 seconds of the flight, the roll oscillations and subsequent spoiler deflections adversely affected the airplane’s climb performance by degrading the lift component by as much as 20 percent.

Second.
Moving to
pages 73. At chapter 3.-Conclusions, subchapter 3.1.-findings.
Point 7 confirms the roll inestability of the MD when close to the stall.
Points 8,9 & 10 talks about TOWS of the CAWS and at the next page, under chapter 4.-Recomendations:
- Require the modification of the DC-g-80 series airplanes to illuminate the
existing central aural warning system (CAWS) fail light on the overhead
annunciator panel in the event of CAWS input circuit power loss so that the airplane conforms to the original certification configuration. (Class II,
Priority Action) (A-88-65)
- Develop and disseminate guidelines for the design of central aural warning systems to include a determination of the warning to be provided, the criticality of the provided warning, and the degree of system selfmonitoring. (Class II, Priority Action) (A-88-66)
If an american lawyer read this, Boeing could have troubles...

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