Spanair accident at Madrid
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In aviation is there a similar move to a ''Professional'' managerial class that hasn't necessarily a background ( deeper understanding ) in the industry ?.
This is one of the obvious precursors to the current disaster in the finance/business sector.
Very ''clever'' people making apparently ''clever'' decisions about older practises that were there for a good reason.
Bah
This is one of the obvious precursors to the current disaster in the finance/business sector.
Very ''clever'' people making apparently ''clever'' decisions about older practises that were there for a good reason.
Bah
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Not a similar move, but a quite long standing trend already. Many management types knew zero about aviation before becoming involved, and are very diligent about maintaining that status as they ignore all the good lessons of the past 60 or so years to preach the profit-above-all mantra. 
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Alf posted:
You already know that in the case of the LAPA flight: even though the TOW sounded all time, the pilots ignored it.
The comission who studied the accident stated that the pilots were not familiar with such kind of alarm, they had not enough experienced it before just to understand that they had to stop.
You are damn right...!
...
Thus for a probe failure, full understanding of the situational aspects might require a pilot to have experienced ‘the specific failure’. However, probes can fail for many reasons – with or without TOCWS implications, that’s one reason we call maintenance to determine the nature of the failure;- CRM, use all available resources, provided that they too have the required knowledge and know-how.
...
Thus for a probe failure, full understanding of the situational aspects might require a pilot to have experienced ‘the specific failure’. However, probes can fail for many reasons – with or without TOCWS implications, that’s one reason we call maintenance to determine the nature of the failure;- CRM, use all available resources, provided that they too have the required knowledge and know-how.
...
The comission who studied the accident stated that the pilots were not familiar with such kind of alarm, they had not enough experienced it before just to understand that they had to stop.
You are damn right...!
PJ2 (#2369 SMS aspects) I believe that we agree on the fundamentals of the problem, but for clarification I prefer to use ‘devolved regulation’ to describe the modern implementations of a State’s safety oversight responsibilities, instead of the generic SMS. There are many values in the concept and processes of SMS when used by an organization or individuals.
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern. Many other concerns have been outlined, but additionally the relative ‘remoteness’ of the regulator can reduce their knowledge-base and the opportunity to communicate knowledgably with other operators (and other countries). These are essential qualities in the process of continued airworthiness.
Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?
Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.
More words, more questions. However, in a supposedly well regulated industry (possibly over regulated) who will seek answers relating to this accident. Hopefully the independent investigation team, providing that they are really intent on identifying a ‘root’ cause (as above) and providing the industry with something which will improve safety; something that I doubt that the lawyers will do.
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern. Many other concerns have been outlined, but additionally the relative ‘remoteness’ of the regulator can reduce their knowledge-base and the opportunity to communicate knowledgably with other operators (and other countries). These are essential qualities in the process of continued airworthiness.
Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?
Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.
More words, more questions. However, in a supposedly well regulated industry (possibly over regulated) who will seek answers relating to this accident. Hopefully the independent investigation team, providing that they are really intent on identifying a ‘root’ cause (as above) and providing the industry with something which will improve safety; something that I doubt that the lawyers will do.
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Is That It?
It seems to me that this thread has PROBABLY, despite the variable quality of inputs over the pages, highlighted several highly important issues regarding Crew disciplne and various technical weaknesses with the MD8X series, including the TOCW system architecture.
I don't know, but it seems to me that the deceased and families are owed a little more of a sense of urgency than that being presently demonstrated by the various investigations in terms of reaching conclusions and being proactive in addressing same?
Yes, the relay problems are known and have already been communicated by Boeing to operators. Yes the need to check the TOCW warning ahead of EVERY departure was ADVISED (But not received by some carriers who received the aircraft AFTER the advisory. Are there others?) Yes, the failure to deploy slats/flaps was previously known and officially communicated.
But, ASSUMING, there is already enough data to confirm the PPRuNe conclusions, and I concede that this is speculative, perhaps in the extreme, I just wonder why more is not being done by this stage to re-visit and reinforce some of the earlier advisories.
My thoughts and prayers remain with the deceased and their families. I believe they deserve better.
I don't know, but it seems to me that the deceased and families are owed a little more of a sense of urgency than that being presently demonstrated by the various investigations in terms of reaching conclusions and being proactive in addressing same?
Yes, the relay problems are known and have already been communicated by Boeing to operators. Yes the need to check the TOCW warning ahead of EVERY departure was ADVISED (But not received by some carriers who received the aircraft AFTER the advisory. Are there others?) Yes, the failure to deploy slats/flaps was previously known and officially communicated.
But, ASSUMING, there is already enough data to confirm the PPRuNe conclusions, and I concede that this is speculative, perhaps in the extreme, I just wonder why more is not being done by this stage to re-visit and reinforce some of the earlier advisories.
My thoughts and prayers remain with the deceased and their families. I believe they deserve better.
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Why-Because Analysis
I have prepared a preliminary Why-Because-Analysis of the accident.
It is based mostly on information kindly provided by people on this thread, many thanks for that.
If you've never heard of this method the website about Why-Because Analysis is highly recommended.
A PDF file of the analysis of the case is available for download at the Causalis publications website.
Besides studying the graph I recommend reading the annotations in the provided detailed factor list.
Comments, either private or public, are very welcome.
Bernd
It is based mostly on information kindly provided by people on this thread, many thanks for that.
If you've never heard of this method the website about Why-Because Analysis is highly recommended.
A PDF file of the analysis of the case is available for download at the Causalis publications website.
Besides studying the graph I recommend reading the annotations in the provided detailed factor list.
Comments, either private or public, are very welcome.
Bernd
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Philipat, do you not consdier the AD issued by EASA is a prompt step in the right direction even without the CIAIAC final report? If your comment is aimed more at design changes to the TOWS/TOCW then I am afriad this will take a while longer........
alf5071h;
Thank you for your thoughtful response which takes the dialogue even further along an important road of understanding.
Re,
I couldn't agree more. I think SMS, as conceived, is a far better system than "blame/enforcement". But I do not believe (and have seen evidence for this) that it is being done, "as conceived. Assumptions such as the efficacy of a two-day course on SMS for all managers, and having all the "right" documentation in place, (the importance of documentation vice taking actual action is a very big issue in aviation management today - documents are cheap - action can be very expensive).
The issues in the United States with Southwest and United indicated that this concern was a reality. I believe the same conditions exist in Canada but have yet to be discovered.
All excellent questions which demand responses. Coordinating same such that effective changes may be brought about is, as we know, much more difficult. Some questions have ready, and good answers. Others, such as those dealing with certification, may not.
I have seen this first-hand and know that this circumstance exists even today and it causes great concern. When something is discovered in the data, conveyed to the appropriate internal airline departments and then is dismissed for "reasons", can occur even under SMS when there is little or no oversight and the documenation isn't followed and the audit processes do not reveal, or worse, tolerate such a weakness.
The non-use of FOQA/FDA data for example, by dismissing it when "inconvenient", (commercially), or worse, that the data is somehow not to be believed and is "wrong", is a real factor which governs operational decisions even now. Either the regulatory authority takes steps to protect safety information under SMS, and further, states that data from QARs used in FOQA/FDA programs is "the exact same" data as from the DFDR or such programs may as well stop and the money saved.
So I hear what you are saying and I agree that we view both SMS and the problems associated, in roughly the same way. For me, the term "devolution" may not reach far enough to describe some of what is happening, but be that as it may, the key is, the regulator is, in some countries anyway, beginning to examine what SMS means and, more to the point, what is being missed.
The risk in a non-robust SMS environment is, when no one is watching and there is little "danger" of discovery, commerical decisions can, depending on many factors, take priority over operationally safe decisions, which, because of such "success", can further result in the "normalization of deviance" and a continuance of the practice beyond the perview of the regulator. While that was/is always a possibility, under SMS, trust and integrity are absolutely fundamental keys that must be first demonstrated and then continuously proven to the regulator by the carrier. That is the only way SMS can work. The regulator who only "audits the audits" and not the air carrier's actions (which may or may not have been followed through on), may not discover a systemic weakness until an accident occurs, caused by quite different circumstances/pathways than the industry has experienced thus far.
Thank you for your thoughtful response which takes the dialogue even further along an important road of understanding.
Re,
There are many values in the concept and processes of SMS when used by an organization or individuals.
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern.
Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?
Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?
Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.
The non-use of FOQA/FDA data for example, by dismissing it when "inconvenient", (commercially), or worse, that the data is somehow not to be believed and is "wrong", is a real factor which governs operational decisions even now. Either the regulatory authority takes steps to protect safety information under SMS, and further, states that data from QARs used in FOQA/FDA programs is "the exact same" data as from the DFDR or such programs may as well stop and the money saved.
So I hear what you are saying and I agree that we view both SMS and the problems associated, in roughly the same way. For me, the term "devolution" may not reach far enough to describe some of what is happening, but be that as it may, the key is, the regulator is, in some countries anyway, beginning to examine what SMS means and, more to the point, what is being missed.
The risk in a non-robust SMS environment is, when no one is watching and there is little "danger" of discovery, commerical decisions can, depending on many factors, take priority over operationally safe decisions, which, because of such "success", can further result in the "normalization of deviance" and a continuance of the practice beyond the perview of the regulator. While that was/is always a possibility, under SMS, trust and integrity are absolutely fundamental keys that must be first demonstrated and then continuously proven to the regulator by the carrier. That is the only way SMS can work. The regulator who only "audits the audits" and not the air carrier's actions (which may or may not have been followed through on), may not discover a systemic weakness until an accident occurs, caused by quite different circumstances/pathways than the industry has experienced thus far.
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Actions of maintenance personnel.
Factor list item no.39, 'Maintenance personnel de-activate rat probe heating'.
This is NOT exactly what they did,and is crucial to the causality and mindset leading to the accident.
They seem to have switched off a power supply ONE of the functions of which was to supply the rat probe heating.
They appear to have failed to consider the effect of loss of power to the other systems powered by the same supply,or considered that the lack of power to these systems did not constitute a MEL .infringement.
It is vital in a maintenance regime to consider the effects and consequences on other systems of ANY action taken,and to be sufficiently conversant with the whole system to properly analyse the effects overall.
I write this after 50+ years in designing and maintaining industrial control and safety systems,and I still approach any 'link it out/switch it off for now' fault solutions with great fear and trepidation and endless what else will it affect mind searching.
This is NOT exactly what they did,and is crucial to the causality and mindset leading to the accident.
They seem to have switched off a power supply ONE of the functions of which was to supply the rat probe heating.
They appear to have failed to consider the effect of loss of power to the other systems powered by the same supply,or considered that the lack of power to these systems did not constitute a MEL .infringement.
It is vital in a maintenance regime to consider the effects and consequences on other systems of ANY action taken,and to be sufficiently conversant with the whole system to properly analyse the effects overall.
I write this after 50+ years in designing and maintaining industrial control and safety systems,and I still approach any 'link it out/switch it off for now' fault solutions with great fear and trepidation and endless what else will it affect mind searching.
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atceng, thanks for the feedback.
Interesting. I'd like to know where this information comes from.
To clarify:
In the MD80 flight manual that I have seen, the RAT probe heater has a dedicated circuit breaker, called "Z29".
The problem is not that disabling the heater also disabled other systems (for all I know it didn't), but that the fact that the heating was operating on the ground was a symptom of something else wrong. And this "something else", most likely a failed relay, also influenced other systems. Most importantly it inhibited the Takeoff Warning System.
It's all in my graph. Some further information is buried in the annotations in the "Factor list Details". The annotations help clarify a lot of the factors in the graph, but were left out of the graph proper in order to limit its size.
Although the CIAIAC preliminary report wasn't quite on time, nor is it the best preliminary report I've seen so far, I still assume, also taking into account justme69's take on it, that the information it contains is established beyond reasonable doubt:
Bernd
Originally Posted by atceng
They seem to have switched off a power supply ONE of the functions of which was to supply the rat probe heating.
They appear to have failed to consider the effect of loss of power to the other systems powered by the same supply,or considered that the lack of power to these systems did not constitute a MEL .infringement.
They appear to have failed to consider the effect of loss of power to the other systems powered by the same supply,or considered that the lack of power to these systems did not constitute a MEL .infringement.
To clarify:
In the MD80 flight manual that I have seen, the RAT probe heater has a dedicated circuit breaker, called "Z29".
The problem is not that disabling the heater also disabled other systems (for all I know it didn't), but that the fact that the heating was operating on the ground was a symptom of something else wrong. And this "something else", most likely a failed relay, also influenced other systems. Most importantly it inhibited the Takeoff Warning System.
It's all in my graph. Some further information is buried in the annotations in the "Factor list Details". The annotations help clarify a lot of the factors in the graph, but were left out of the graph proper in order to limit its size.
Although the CIAIAC preliminary report wasn't quite on time, nor is it the best preliminary report I've seen so far, I still assume, also taking into account justme69's take on it, that the information it contains is established beyond reasonable doubt:
Originally Posted by CIAIAC preliminary report
[...] opened the electrical circuit breaker that connected the heating element.
Bernd
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Where next?
Quite a long winded recital but they forgot the flaps. The warning system didn't work and they crashed. It will happen again if they don't fix it. Simple as that.
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FixIT!!!
Quite a long winded recital but they forgot the flaps. The warning system didn't work and they crashed. It will happen again if they don't fix it. Simple as that.
1. Fix
2. It
3. FIX IT
Who?
Them.
FIX IT
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Well I wasn't going too but....
"The Circuit breaker for the RAT heating supplies the RAT heating. That is it, full stop, dead end, nothing further. There is absolutely no connection to any other system including the take off warning."
So the (as found on pprune) "guilty"
were actually guilty of nothing more than de- energising an authorised cct to enable dispatch, working against the clock and (most likely) being denied authority to further fault find due to the aircraft being manned and on the line, a practice that occurs dailly around the globe.
So lets just forget trying to find scapegoats and approportion the blame where is belongs.
So the (as found on pprune) "guilty"
were actually guilty of nothing more than de- energising an authorised cct to enable dispatch, working against the clock and (most likely) being denied authority to further fault find due to the aircraft being manned and on the line, a practice that occurs dailly around the globe.So lets just forget trying to find scapegoats and approportion the blame where is belongs.