Spanair accident at Madrid
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I will add my thanks to Justme69 and to all who have contributed to this sad but interesting thread which I too have followed from the beginning. One thing I have taken from this discussion is a greater awareness of the fallibility of humans and their machines. Human factors are ever present in aviation.
Paul.
Paul.
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Read and do check list?
Hello!
Thanks for that update, and the new bit of information from the CVR
As stated, the after start check list looks like a "read and do" check list. 
Not the best practice for standard routine actions, IMHO.
Who needs reading a book to accomplish simple actions such as setting the flaps? The check list should be called upon when the job is done by the crew member in charge, to check it was done! And this check is a two persons job ...
Thanks for that update, and the new bit of information from the CVR
Originally Posted by JustMe69
It seems that right when the time to set the flaps/slats on the after start checklist came, the pilot can be heard on the CVR tell the copilot (running the actions) something like: "Take this chance now" meaning to take advantage of a gap in the tower radio busy communications to ask for taxiing clearance, so the checklist was interrupted at that point and permission asked over the radio.
Not the best practice for standard routine actions, IMHO.
Who needs reading a book to accomplish simple actions such as setting the flaps? The check list should be called upon when the job is done by the crew member in charge, to check it was done! And this check is a two persons job ...
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Blame
Sorry can't make the quote work. Justme69 said.
"At this time, the investigation officially hints to what we know: crew error due to "rushed" and not 100% "professional" operation of the checklists and procedures coupled with a recent hard-to-diagnose malfunction that wasn't properly noticed or corrected on time and made the configuration alarm inoperative for the takeoff."
So rushed departure created the problem & the failed system didn't warn them. If that's the case then it is easy enough to point at the people who initiated it but I'm still interested in why.
We all know about pressure put on engineers & we all know that pilots must put professionalism before being rushed for departure. I'm not talking about simple mistakes but cutting corners. How many here would say that the culture in their company would ensure this didn't happen? How many would say it could happen easily?
I've flown for both dodgy & highly professional outfits - all under the same regulator - and known damned well the company culture affects professionalism. Will the judge look any further or is this going to be another case of finding the obvious without asking why?
"At this time, the investigation officially hints to what we know: crew error due to "rushed" and not 100% "professional" operation of the checklists and procedures coupled with a recent hard-to-diagnose malfunction that wasn't properly noticed or corrected on time and made the configuration alarm inoperative for the takeoff."
So rushed departure created the problem & the failed system didn't warn them. If that's the case then it is easy enough to point at the people who initiated it but I'm still interested in why.
We all know about pressure put on engineers & we all know that pilots must put professionalism before being rushed for departure. I'm not talking about simple mistakes but cutting corners. How many here would say that the culture in their company would ensure this didn't happen? How many would say it could happen easily?
I've flown for both dodgy & highly professional outfits - all under the same regulator - and known damned well the company culture affects professionalism. Will the judge look any further or is this going to be another case of finding the obvious without asking why?
“Will the judge look any further or is this going to be another case of finding the obvious without asking why?”
A necessary and very sensible question.
“Now we can let it RIP.” #2521
So now knowing what happened, do we leave industry/public to allocate blame by default without considering why. No, not good enough!
We are members of a professional, well respected industry, which has an exceptional safety record. In part, this success is due to asking ‘why’ in previous accidents.
One aspect in this accident appears to be that lessons from similar accidents were not learnt – actions not implemented. Failure to ask why or implement the answers yet again might contribute to further events.
Even if the legal responsibilities are met by establishing what happened or by allocation of blame, it is not, nor can it be the way in which our industry is to progress.
In the absence of a formal report as to ‘why’, then everyone in the industry should consider what this accident might mean to them.
There is plenty of evidence in this thread and in ASW Dec 08 that the form of human error in this accident has and will continue to occur. Also, there is evidence that a TOCWS will detect error and benefit safety.
Thus for me a lesson learnt is to ensure that the TOCWS is serviceable for every takeoff; either by checking or by use of a robust monitoring / warning system.
We may not be able to eliminate human error, but every effort must be taken to reduce the occurrence of these errors.
The industry should look closely at the surrounding factors which contribute to rush, distraction, complacency, or violation of procedures. Perhaps it is time to re-evaluate the befit and risk of initiatives such as slot times, or the ever increasing commercial pressures on the ‘sharp end’.
We are told that error is more likely in times of change, but in the aftermath of this accident, unless we change, error will prevail.
A necessary and very sensible question.
“Now we can let it RIP.” #2521
So now knowing what happened, do we leave industry/public to allocate blame by default without considering why. No, not good enough!
We are members of a professional, well respected industry, which has an exceptional safety record. In part, this success is due to asking ‘why’ in previous accidents.
One aspect in this accident appears to be that lessons from similar accidents were not learnt – actions not implemented. Failure to ask why or implement the answers yet again might contribute to further events.
Even if the legal responsibilities are met by establishing what happened or by allocation of blame, it is not, nor can it be the way in which our industry is to progress.
In the absence of a formal report as to ‘why’, then everyone in the industry should consider what this accident might mean to them.
There is plenty of evidence in this thread and in ASW Dec 08 that the form of human error in this accident has and will continue to occur. Also, there is evidence that a TOCWS will detect error and benefit safety.
Thus for me a lesson learnt is to ensure that the TOCWS is serviceable for every takeoff; either by checking or by use of a robust monitoring / warning system.
We may not be able to eliminate human error, but every effort must be taken to reduce the occurrence of these errors.
The industry should look closely at the surrounding factors which contribute to rush, distraction, complacency, or violation of procedures. Perhaps it is time to re-evaluate the befit and risk of initiatives such as slot times, or the ever increasing commercial pressures on the ‘sharp end’.
We are told that error is more likely in times of change, but in the aftermath of this accident, unless we change, error will prevail.
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I have also been following this thread since the beginning and I join my thanks to Justme69 for very informative and correct information posted here.
The failure ( or more correctly unavailibility) of any warning system is not a problem per se. But fact is we all start to rely on them and reduce our alertness. Same for ATC with Short Term Conflict Alert (STCA). Everybody is supoposed to be able to work without one, but if you get used to it over many years, and suddenly ( and/or unknown to you) it is disabled, errors can turn into accidents. Ueberlingen comes to my mind of course.
Check and re-check and never asume .
The failure ( or more correctly unavailibility) of any warning system is not a problem per se. But fact is we all start to rely on them and reduce our alertness. Same for ATC with Short Term Conflict Alert (STCA). Everybody is supoposed to be able to work without one, but if you get used to it over many years, and suddenly ( and/or unknown to you) it is disabled, errors can turn into accidents. Ueberlingen comes to my mind of course.
Check and re-check and never asume .
ATC Watcher, you appear to overlook a key human factors point that no human can be expected to have ‘perfect’ alertness. There will always be errors; the safety objective is to reduce the frequency of error occurrence, or the severity of their effect if not detected.
Error detection, even with dual crews cannot be relied on, thus there is a need for ‘systems’.
I agreed that the operating human must not rely on these ‘error detectors’, and when they fail there must be a clear indication of their unavailability, e.g EGPWS.
I don’t think that the human aspects can be discussed in isolation. Safety defences involving human behaviour can only complement a range of other ‘error’ defences.
Also, it is not necessarily the number of defences that there are (defend in depth), as the quality of the existing defences. Many posts have identified many excellent defences in existing operations.
The current range of defences involves systems, management aspects such as procedures and safety culture, and at high level, input from the regulators.
In the latter instance the regulators could research contributing factors in this accident, as above (#2525), or mandate a new warning system. An earlier post identified AMC 25.703 Takeoff Configuration Warning Systems (Page 368) which discussed the philosophy of TOCWS including the latest ‘high reliability’ systems already - voluntarily, in some aircraft; a simple retrospective mandate would improve this aspect.
Error detection, even with dual crews cannot be relied on, thus there is a need for ‘systems’.
I agreed that the operating human must not rely on these ‘error detectors’, and when they fail there must be a clear indication of their unavailability, e.g EGPWS.
I don’t think that the human aspects can be discussed in isolation. Safety defences involving human behaviour can only complement a range of other ‘error’ defences.
Also, it is not necessarily the number of defences that there are (defend in depth), as the quality of the existing defences. Many posts have identified many excellent defences in existing operations.
The current range of defences involves systems, management aspects such as procedures and safety culture, and at high level, input from the regulators.
In the latter instance the regulators could research contributing factors in this accident, as above (#2525), or mandate a new warning system. An earlier post identified AMC 25.703 Takeoff Configuration Warning Systems (Page 368) which discussed the philosophy of TOCWS including the latest ‘high reliability’ systems already - voluntarily, in some aircraft; a simple retrospective mandate would improve this aspect.
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For those not willing to google it, basically the article says that Boeing has officially answered the question the judge made about whether Boeing ever informed Spanair of the need to check TOWS before each take off.
Boeing's answer: No.
Boeing's says Spanair's SOP is a slight deviation from their current one. But they also admit such tests weren't part of their original operating procedures, but a modification after Detroit's accident.
Boeing didn't inform Korean Airlines either, from whom Spanair purchased the aircraft. Boeing says there is no system in place to inform each subsequent owner of individual airplanes for which some safety recommendation has been issued.
Spanair sustains their SOPs are safe (safer than the originals, they say) and include 3 check points for wing configurations before each take off. TOWS checks by the crew are also mandatory on first flights of the day or after pilots enter a cockpit they have been away from for a long time. They argue their SOPs had been approved by Spanish air regulation authorities and that they had no knowledge of safety warnings asking for additional TOWS checks previous to each take off. Such changes in procedures for additonal TOWS checks were never mandatory by any civil air authority in the world before the accident, and remained a safety *recomendation* only.
Regardless, Spanair made mandatory as per SOP for crew to check TOWS before each individual take off nine days after the accident.
Boeing was also asked by the judge if the procedure employed by the technician (engineer) in charge of the "repair" shortly before the accident was correct according to their repair procedures. The pilot had reported excessive RAT temperature readings due to the RAT probe air intake heater being turned on while on the ground. The technician pulled out a fuse to disable the heater and dispatched the aircraft by MEL. AFAIK, Boeing hasn't answered yet.
Spanair has a solid insurance policy to cover individual accidents for up to 1.500 million €uros (almost $2billion). It is estimated that if the main cause of the accident was crew error, the indemnization to the families of the 153 victims would be in the order of 150.000€ each only (about $200k). It would be much greater if an important part of the fault was laid on either Boeing or Spanair.
Scandinavia's SAS, owners of Spanair, was thinking of putting the financially troubled branch for sale right around the time the accident occurred. It seems to be finally closing on a deal to sell it to a Spanish investment group based in Catalonia.
Spanair transported 8,9 million passengers on 2008, down about 10% due to weaker global travel and probably some impact from the accident. It operated at about 68% occupancy. The company had downsized recently, laying off about 800 employees and reducing their fleet and routes.
Boeing's answer: No.
Boeing's says Spanair's SOP is a slight deviation from their current one. But they also admit such tests weren't part of their original operating procedures, but a modification after Detroit's accident.
Boeing didn't inform Korean Airlines either, from whom Spanair purchased the aircraft. Boeing says there is no system in place to inform each subsequent owner of individual airplanes for which some safety recommendation has been issued.
Spanair sustains their SOPs are safe (safer than the originals, they say) and include 3 check points for wing configurations before each take off. TOWS checks by the crew are also mandatory on first flights of the day or after pilots enter a cockpit they have been away from for a long time. They argue their SOPs had been approved by Spanish air regulation authorities and that they had no knowledge of safety warnings asking for additional TOWS checks previous to each take off. Such changes in procedures for additonal TOWS checks were never mandatory by any civil air authority in the world before the accident, and remained a safety *recomendation* only.
Regardless, Spanair made mandatory as per SOP for crew to check TOWS before each individual take off nine days after the accident.
Boeing was also asked by the judge if the procedure employed by the technician (engineer) in charge of the "repair" shortly before the accident was correct according to their repair procedures. The pilot had reported excessive RAT temperature readings due to the RAT probe air intake heater being turned on while on the ground. The technician pulled out a fuse to disable the heater and dispatched the aircraft by MEL. AFAIK, Boeing hasn't answered yet.
Spanair has a solid insurance policy to cover individual accidents for up to 1.500 million €uros (almost $2billion). It is estimated that if the main cause of the accident was crew error, the indemnization to the families of the 153 victims would be in the order of 150.000€ each only (about $200k). It would be much greater if an important part of the fault was laid on either Boeing or Spanair.
Scandinavia's SAS, owners of Spanair, was thinking of putting the financially troubled branch for sale right around the time the accident occurred. It seems to be finally closing on a deal to sell it to a Spanish investment group based in Catalonia.
Spanair transported 8,9 million passengers on 2008, down about 10% due to weaker global travel and probably some impact from the accident. It operated at about 68% occupancy. The company had downsized recently, laying off about 800 employees and reducing their fleet and routes.
Last edited by justme69; 14th Jan 2009 at 18:47.
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Thanks JustMe, kept us well informed all along
A small point on Ground Effect:
Say 'Ground effect' to an aerodynamicist and the the first thing he thinks of is 'reduced induced drag', not increased Clmax.... because Clmax doesn't 'necessarily' improve, in fact can go either way, even reduce if circulation is reduced with some wing/ground configurations.
The intuitive effect that I imagine pilots feel, sense, and commentators are meaning, is 'dynamic stall' - that is the momentary Clmax increase due to 'rate of rotation' - an effect that birds and especially insects (operating in a thick air medium with thin wings) utilise to get instantaneous Cl's (up to 2) way over steady state ones.
So 'yanking it off' the ground at a significant rate of rotation, could, even can, give a false impression.. and get the aircarft airborne below steady-state stall speeds. As the starting vortex sheds and flow settles down, the true situation then asserts itself.. which is not necessarily because you are 40 or 50 foot up!
I happen to agree with those that are suggesting more instinctive flying responses might have reduced the casaulties in this awful accident... nose down, firewall the throttles and keep it straight - what an horrendous airfield to lose directional control on - yet something else to be factored in to the 'blame game'!
And failing the production of a clear systems flowchart for those awkwad relay failure symptons, that indicates a clear course of action, the engineer on the spot should be treated with a bit more respect by the investigating judge?
Quite why straightforward failure flowcharts for critically linked MEL/non-MEL system items aren't always to hand is beyond me -
A very, very sad and sorry story.
A small point on Ground Effect:
In practice, ground effect came into play, allowing both aircraft to reach a low altitude, where the loss of ground effect, and the high drag, took over.
The intuitive effect that I imagine pilots feel, sense, and commentators are meaning, is 'dynamic stall' - that is the momentary Clmax increase due to 'rate of rotation' - an effect that birds and especially insects (operating in a thick air medium with thin wings) utilise to get instantaneous Cl's (up to 2) way over steady state ones.
So 'yanking it off' the ground at a significant rate of rotation, could, even can, give a false impression.. and get the aircarft airborne below steady-state stall speeds. As the starting vortex sheds and flow settles down, the true situation then asserts itself.. which is not necessarily because you are 40 or 50 foot up!
I happen to agree with those that are suggesting more instinctive flying responses might have reduced the casaulties in this awful accident... nose down, firewall the throttles and keep it straight - what an horrendous airfield to lose directional control on - yet something else to be factored in to the 'blame game'!
And failing the production of a clear systems flowchart for those awkwad relay failure symptons, that indicates a clear course of action, the engineer on the spot should be treated with a bit more respect by the investigating judge?
Quite why straightforward failure flowcharts for critically linked MEL/non-MEL system items aren't always to hand is beyond me -
A very, very sad and sorry story.
Last edited by HarryMann; 16th Jan 2009 at 02:20.
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FCOM & Investigations USA
Hello, anybody knows how to find in Internet the FCOM of a MD-82?
Also, I´m interested in knowing how are the investigations of the american lawyers going.
Many thanks.
Also, I´m interested in knowing how are the investigations of the american lawyers going.
Many thanks.
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Here is an interesting CVR recording of another MD-80 crash on takeoff for different reasons. However, the had an inop RAT that thet were dealing with just before takeoff roll and you can see how they handled it. You have to go to Appendix 2 and scroll down about halfway to the appropriate transcript.
Then again, they didn't go back and then forget their flaps the next time. Although if they had gone back, this accident would not have happened.
F-GHED G-SSWN
Interesting comments starting at 0 h 45 min 02 s and 0 h 49 min 57 s.
"We shouldn't depart we've only seen it in the air eh
Okay? When we're in the air there's no more MEL"
Then again, they didn't go back and then forget their flaps the next time. Although if they had gone back, this accident would not have happened.
F-GHED G-SSWN
Interesting comments starting at 0 h 45 min 02 s and 0 h 49 min 57 s.
"We shouldn't depart we've only seen it in the air eh
Okay? When we're in the air there's no more MEL"
Last edited by punkalouver; 4th Feb 2009 at 18:45.
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Safety recommendation of 25/02/2009
"It is recommended that the FAA and EASA require the manufacturer, Boeing, to include in its Aircraft Maintenance Manual (AMM) for the DC-9 and MD-80, the Troubleshooting Manual for the MD-90 and the Fault Isolation manual for the 717 series of airplanes, specifically identified instructions to detect the cause and to troubleshoot the fault involving the heating of the RAT temperature probe while on the ground."
Not unexpected or surprising, this is the Safety Recommendation which the Spanish accident investigation board made already on 25 Feb 2009.
The full text can be found here:
http://www.fomento.es/NR/rdonlyres/8..._01_09_ENG.pdf
It is perhaps surprising this was not posted here at pprune earlier on. Shows perhaps how quickly serious things as this disappear from our radar screens.
Not unexpected or surprising, this is the Safety Recommendation which the Spanish accident investigation board made already on 25 Feb 2009.
The full text can be found here:
http://www.fomento.es/NR/rdonlyres/8..._01_09_ENG.pdf
It is perhaps surprising this was not posted here at pprune earlier on. Shows perhaps how quickly serious things as this disappear from our radar screens.
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Quote from The Euro Weekly News, 23 April 2009:
Judge Juan Javier Perez has requested help from the European Air Safety Agency in Cologne (Germany) to assist his investigations into the Spanair air crash in Madrid last August. After rejecting six mechanics put forward by Iberia, Perez claimed he could not find sufficiently impartial and competent technicians in Spain.
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It´s almost impossible to find a good independent source to solve this accident investigation at Madrid. Just a couple of days ago the Manager director of Barajas airport affirmed that they have to revise the emergency plan for accidents/incidents at the airport.
I´ve been working on AENA for a while years ago, I know this director as he was my direct boss and can tell you that altough he is a really good professional AENA and the ministry of transport sucks. The airport is really bad designed, they focused on the beauty of the terminal and how to make money with the shopping center and set aside the safety of the operation on the air side.
From my point of view the problem arises when the insurance companies come into effect, a lot money involved and to many interests on not paying.
I´ve been working on AENA for a while years ago, I know this director as he was my direct boss and can tell you that altough he is a really good professional AENA and the ministry of transport sucks. The airport is really bad designed, they focused on the beauty of the terminal and how to make money with the shopping center and set aside the safety of the operation on the air side.
From my point of view the problem arises when the insurance companies come into effect, a lot money involved and to many interests on not paying.
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The airport is really bad designed, they focused on the beauty of the terminal and how to make money with the shopping center and set aside the safety of the operation on the air side.
A