Spanair accident at Madrid

[E. Mach]

Slats/Flaps not in takeoff range - Red Warning
Pitch Trim not in takeoff range - Red Warning
Rudder Trim not in takeoff range, (A319, A321) - Red Warning
Speed Brake not retracted - Red Warning
Sidestick Fault - Red Warning
Brakes Hot - Amber warning
Doors - Amber warning
Park Brake ON - Red Warning
Flex Temp not set - Amber Warning

FLEX TEMP NOT SET- AMBER WARNING ???????????

What airbus do you fly?

In the one I fly you can use a TOGA takeoff and do not need a Flex Temp inserted, and of course you do not receive any Amber Warning when you press the Takeoff Config....


Well who can trust these French aircrafts...... everyone is different

[FrequentSLF]

PJ2

Thanks for your clarification.

Regards

[iceman50]

E-Mach

Try doing a take off with the thrust set to FLEX and no FLEX temperature set - then you will get and Amber warning! It does not know whether you want a Flex or a De-rate.
(I agree the amber warning will not come from the T.Off config check - could have been a typo).

[snowfalcon2]

In my view we ought not to even need a TOWS, but there it is. Aside from the human factors involved, we might broach the question as to why these systems have indeed actually grown more involved and "active". Why is that?, one wonders...

Good discussion. I wonder if there are any good links or other pointers to actual studies about the general effectiveness of safety enhancement systems [of which TOWS is one example], vs. cultivating safe attitudes.

I vaguely recall a conclusion that a safety system which is visibly advertised and promoted will in fact not add to safety that much, because operators tend to take more risks or act more sloppily in the belief that the safety system will save them from any mistakes. Whereas a safety system that just is there in the background without any advertising, will have a real positive effect, basically because operators are not aware of it and thus do not rely on its capability to save them from trouble. As examples from the road traffic sector we have ABS brakes in the former category and ESC (ESP) in the latter.

[HarryMann]

I vaguely recall a conclusion that a safety system which is visibly advertised and promoted will in fact not add to safety that much, because operators tend to take more risks or act more sloppily in the belief that the safety system will save them from any mistakes. Whereas a safety system that just is there in the background without any advertising, will have a real positive effect, basically because operators are not aware of it and thus do not rely on its capability to save them from trouble. As examples from the road traffic sector we have ABS brakes in the former category and ESP in the latter.

Makes good sense to me... noting that it is more likely Operators, as PJ2 hints at more than once, have 'assumed' time honoured practices can be safely shelved when using their SOPS combined with such warning systems.. they then become less of a third-man/back-stop and more vital, being directly in the safety chain.

When engineered to be as fault tolerant as other primary systems and not open to inadvertant abuse (CB pulling etc), then modern-day SOPs and these systems can maybe provide the absolute level of safety sought - but to use that combination with legacy 70's & 80's warning systems seems to be putting the cart before the horse.

[Frangible]

The checklist discussion and Boeing's rec on the TOWS test begs the question yet again. Why is anyone allowed to change the manufacturer's version of the FCOM?

[noelbaba]

Spanair accident in Madrid

Judge investigating Spanair crash turns to Interpol
El País on Saturday published details of the summary of the judge’s investigation into the Spanair accident at Barajas Airport in Madrid on August 20 which resulted in the death of 154 people.

The judge has turned to Interpol to supply the information which Spanair, Boeing and the Ministry for Development on the instructions and warnings over the airworthiness of the MD-82 craft given by the constructor.

The newspaper considers that the judge has centred his concerns on the TOWS alert system, which should detect any problems ahead of take off. The manual says that the system should be revised ahead of each take off, but it seems that Spanair was allegedly only doing so before the first flight of the day. Had it done so the judge considers the tragedy could have been avoided as the possible fault in the working of the flaps would have been found.

[GearDown&Locked]

Problem is that the humans operating any kind of machine which has some form of "safety watchdog" don't think much about the risks involved in that machine operation because they know other humans (sometimes lot's of them) have previously thought on how to check for a fault or a bad configuration with that installed lifesaving watchdog device. Operators leniently remove themselves from the "fear of unattended failure" state of mind, stepping outside the danger loop, having more time to contemplate other stuff related or not with the machine operation.

If anyone tries to remove all the "danger" sense of any operation (because it's so freakin' safe nowadays), people will tend to leave the machines dangerously to their own devices; when operators spot a problem they usually get in to the loop at a later and stage, unless they keep themselves consciously on alert i.e. using the watchdog device as a confirmation tool for an earlier recognized problem.

GD&L

[Idle Thrust]

Just to clarify the Airbus "TO Config" test, Iceman is correct - the warning will only occur when the thrust levers are placed in the Flex detent (with no flex temp inserted). If you select TOGA, there will be no warning.

Also I think PJ2 ought not to have included the parking brake in his list - the warning for it only comes on when takeoff thrust is selected. This allows the TO Config test to be done with the parking brake set - clever, what?

IT

[philipat]

Lost in translation?

Had it done so the judge considers the tragedy could have been avoided as the possible fault in the working of the flaps would have been found

.

Translation issue or does this imply direction towards a possible conclusion of mechanical/system problems rather than human error? This seems difficult to believe in view of available facts? Perhaps the judge is just trying to avoid the inevitable until all possible facts have been established but this language does seem to be of concern?

[justme69]

About 3/4 of the spanish press refuses to speak of human error with the flaps not being down.

I'm not sure the political motives behind it, but every single article and word is carefully worded so that mention of human error as the likely (or proven) cause of this or other ismilar accidents is ALWAYS avoided at ALL costs.

Therefore they always speak of "problems with the flaps" rather than "pilots forgetting to deploy them".

Very misleading if you ask me. They way it's done, it's very, very, very, very, very misleading. Downright inches within a blunt lie. They even say that of other accidents where the "proven" cause was the pilots never lowering the flaps.

I PERSONALLY think the reason is that it allows more "mystery" and "controversy" to leave the door open to airplane problems rather than the more "boring": "well, the pilots simply forgot to flip a switch and that was enough to bring a whole ariplane down".

I'm exaggerating, but you get the point. The press wants a flashier show, and "simple, unsophisticated" human error doesn't cut it.

I may be wrong. Just my opinion.

[PJ2]

(edited to address correct poster, thanks)
Idle Thrus;

Also I think PJ2 ought not to have included the parking brake in his list - the warning for it only comes on when takeoff thrust is selected. This allows the TO Config test to be done with the parking brake set - clever, what?

Thanks for the response.

The T.O. Config test works as you suggest. What I posted was a list of what it monitored. I did not post how the system worked and the "correction" supplied by others assists in understanding how it does indeed work.

E. Mach;

Excess finger-wagging, head-banging and cheering/clapping from a fellow airman when in a collegial dialog between two professionals is discourteous - your point made regarding ECAM messages has been cleared up quietly and respectfully by others and I have clarified above what was meant by my post which was clearly "for information" to advance discussion on various TOWS systems extant and not intended as a detailed description for those who may not even know what an ECAM is. I thank others for providing more details.

PJ2

[Bis47]

Operators privilege

Originally Posted by Frangible

Why is anyone allowed to change the manufacturer's version of the FCOM?

The manufacturers business is to build airplanes, not to operate them ...

The manufacturer's responsibilty is to publish limitations and other technical informations (including performances, failures etc. ) about theyr product. Sometimes they provide recommandations that protect their liabilities but are not aimed at a real - practical - safety improvement.

Operator's business is to fly as safely as possible, making money in the process. And sometimes, first class chief pilots know their business (operating an airplane in the real world, with real pilots) much, much better than manufacturer's test pilots and lawyers ... Those guys desserve some respects, they are not "anyone".

[philipat]

Misleading Language

JM69:

I PERSONALLY think the reason is that it allows more "mystery" and "controversy" to leave the door open to airplane problems rather than the more "boring": "well, the pilots simply forgot to flip a switch and that was enough to bring a whole ariplane down".

I hope you're correct, especially with teams of US lawyer crawling all over Spanair and MAD airport.

Why can't they just say that the slats and flaps were not "Correctly deployed" for reasons still being investigated? Perhaps the translation is difficult and this what they did actually say. Unless, of course, they know something that w don't know regarding mechanical issues?

Have Boeing issued anything more?

[Frangible]

Only the manufacturer gets feedback on the fate of all its aircraft. Your fleet may have 50 of them and learn much from that, but the manufacturer made every single one. They may not have the operational experience, but they do learn and intensively study every single accident. They issue their manual on the basis of all this accumulated experience and it seems strange that deviations should be allowed. I can easily see how this has arisen historically, but I would be genuinely interested to know the type of operational demand would require a change from manufacturer's recommendations that could have safety implications. (Granted the TOWS check was recommended by Boeing and not mandatory).

[lomapaseo]

Originally Posted by Frangible
Why is anyone allowed to change the manufacturer's version of the FCOM?

Biz47
The manufacturers business is to build airplanes, not to operate them ...

The manufacturer's responsibilty is to publish limitations and other technical informations (including performances, failures etc. ) about theyr product. Sometimes they provide recommandations that protect their liabilities but are not aimed at a real - practical - safety improvement.

Operator's business is to fly as safely as possible, making money in the process. And sometimes, first class chief pilots know their business (operating an airplane in the real world, with real pilots) much, much better than manufacturer's test pilots and lawyers ... Those guys desserve some respects, they are not "anyone".

believe what you want but follow the FCOM regardless of who writes it.

[safetypee]

Bis47, you have a very jaundiced view of manufacturers.
In addition to the test pilots, most manufacturers have many training Captains, highly experienced in airline operations. Furthermore, many operators (flight and ground crews) will participate in the final certification flight trials involving workload, reliability, and ‘operability’
To design and build a successful aircraft the manufacturer must have a sound grasp of the market, which is normally centered on safe as well as economic operations.

The manufacturer’s initial checklists are approved by the certification agency; operators may change these with the regulatory authority’s approval (no technical objection), but normally the operator is referred to the manufacturer as the content and order of checks may have been chosen to meet certification requirements, e.g. frequency of first flight checks vs forecast system reliability.

If, as is possible in this accident, the reliability of a system is questioned, then the frequency or order of a check can be changed. However, the manufacturer and certification authority has to ensure that no new problems are introduced by the change, e.g. if crews should check the config warning system (test the horn) before each fight in addition to the pre take of config check (no horn), what are the safe guards against crews becoming so familiar with hearing a horn they mistake it as the normal condition where there is actually a failure.
Many might argue that this ‘could not’ happen – it wouldn’t happen to me … (the old view of human error). However, the same might be said for the probability of taking-off without flaps, either due to both crew members suffering error and/or a system failure; checklists are designed to prevent this, to achieve safety in proportion to the risk of introducing other problems.

If a major contribution to this accident is human error, then the investigation needs to look deeper for the reasons why the human(s) suffered error. What is the frequency of system failures, how often are system faults misdiagnosed /inappropriately repaired, mal-use of MEL, and how often do crews forget to set flaps – to be caught by someone/ something - ‘last minute checks’? This is best achieved in a no blame environment.

All of us should review our normal operations – not what the SOPs say, but what we actually do, our norms / habits. Amongst these might be some examples of the defenses which achieve the required level of safety in operations, even though we face the same problems identified in this accident, i.e. what do we every day to ensure safety.
How do we identify mis-selection of flaps, how often do we detect other mistakes, and how is this achieved – we have to identify the successful ‘norms’ and the reason for them, and then if necessary, change the checks.

[Bis47]

Theory versus practice

Originally Posted by safetypee

In addition to the test pilots, most manufacturers have many training Captains, highly experienced in airline operations. Furthermore, many operators (flight and ground crews) will participate in the final certification flight trials involving workload, reliability, and ‘operability’

Hmmm!

Did boeing seek advice from all those experienced people to react to a design flaw (TOWS) by a simple (and ineffective) recommandation?

Did Airbus really care about airline pilots defiance against their "engineers" philosophy ? How many accidents (stupids accidents) or serious incidents in Toulouse?

Sure, manufacturers know their aircraft. Sure they compile most accidents/incidents reports, worldwide.

Chief pilots are interested too, and they have their own analysis. They can have better solutions to avoid new occurences in view of the specific context of their own operations ...

[paull]

Got any stats - How often do people forget.

Surely someone on this thread knows how frequently a TOWS saves the day.
I thought that flight data was routinely downloaded and analyzed so
"How often do people forget?"

[rafacub]

TOWS

Good point. I also think that it could be interesting to know how often the TOWS prevents pilots from taking off insecurely.