Spanair accident at Madrid
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A NASA report, looking at the US confidential reporting system ASRS, found that flapless take-offs (unintended ones) happen more frequently than we realise, but because the crews fortunately get away with it on most occasions, we don't get to know. There's a summary at Distractions frequently cause flapless take-offs, NASA reveals
As for the reason, NASA says it's because the pre-take-off period is so unstructured and full of distractions.
As for the reason, NASA says it's because the pre-take-off period is so unstructured and full of distractions.
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Could somebody kindly post, in their own words, a brief summary of what the interim report told us?
Afraid some of the acronyms (TOWS?) have got this humble SLF beaten.
TIA.
Afraid some of the acronyms (TOWS?) have got this humble SLF beaten.
TIA.
A safety recommendation has been published by the NTSB, largely based on this interim report, concerning checklist updates and such:
http://ntsb.gov/recs/letters/2009/A09_67_71.pdf
http://ntsb.gov/recs/letters/2009/A09_67_71.pdf
Fly The Airplane!
The CIAIAC is also investigating another incident similar to the Spanair accident. On June 5, 2007, about 0945 universal coordinated time, a Boeing MD-83, registration EO-LMM, operated by MAP Jet as a charter flight, performed a takeoff without extended trailing edge flaps at Lanzarote Airport, Gran Canarie, Spain. According to the FDR data and pilot reports, the takeoff was performed without the proper takeoff configuration, and a TOWS warning was not annunciated to the flight crew during the event. The aircraft continued on its flight undamaged.
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Originally Posted by HarryMann
Early wing drop/loss of symmetry/roll control not commented upon
Of course, retrospective and academic... however, I canot help reflecting on the crew, who seem to have lost all sense of 'dangeritis' and situational awareness.
Running late, in and of itself, may have been the real killer in this accident. As well as what appears to have been a rather unfortunate crew combination.
The Captain seems to have self-stressed himself over the delay (unless there are hidden company stressors?) and not rise above it.
The FO did not appear to be compensating, indeed, becoming complicit in a joint exercise to leave the ground asap, re-arrange social/family life, regardless of duties, procedures and normal cockpit responsibilities.
Sorry, I cannot ignore those points, and am particularly disturbed at the emphasis placed on Maintenance Staff (a singleton it seems!) early in the investigation, when it was patently obvious within days, that there were serious problems with:
a) The RAT probe heater documentation & suitable Quick Access troubleshooting procedures
b) Design of the whole TOWS system, being interwoven into other sysetms, rather than completely stand-alone.
c) A poorly documented MEL item for this aircraft
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Reading the report I´m amazed in the first part, the co-pilot only had 222 hours real flight time on other aircrafts and it seems that the MD-80 it´s his first real one flown.
Anyway, for those like me not very well versed in aeronautical stuff, wishing for the very short version, it comes to confirm the preliminary report and what could be known by following this long thread:
-Seems that pilots forgot to set the flaps/slats lever to the correct position for their take off. In spite of being required to check it several times before take off and confirm the deployment on the panel indicators, it seems they just didn't follow the procedures/checklist and likely just "pretended they did". This type of human error in not all that uncommon, and has happened before on many occasions to arilines all over the world (at least over 50 times in the past 15 years in the US alone) to several types of aircrafts, several of which (about another 6 or 7 cases at least worldwide) have ended up in similar accidents.
This is the "single" most important reason for this accident. Trying to take off without the slats and flaps deployed in the correct position while having the maneuver planned for them to be, could have easily put this aircraft in an irrecoverable/near-irrecoverable position prone to disaster (not easily controllable low altitude stall fall under unfavorable circunstances such as tail wind or heavy weight).
-The alarm system (TOWS), that should have warned of such an incorrect take-off wing configuration in this aircraft, didn't sound, most likely due to a recent, intermitent, hard to diagnose (or shall we say "not with many very obvious warning signs") electrical malfunction, most likely in a single relay component.
This is the second most important reasons for this accident. Without the alarm, the crew probably never realized their mistake on time (if at all) and likely would've stop the airplane before trying to take-off if it would've worked.
All this, of course, is a rough, brief, down-to-the-point, minimalistic interpretation of what most likely happened. The final report will contain a slighty more definitive conclusion and certainly more extensive analysis of other factors.
To try to avoid more similar scenarios in the future it's proposed in short:
-Even better and more strict checklists/procedures implementations by airlines to try to get crews to not skip-over items or "pay lip service" to checklists without really, truly, verifying them.
-More frequent tests of the take-off configuration alarm system, i.e. before each single take-off instead of once a day.
-Better TOWS designs/diagnosis procedures (i.e. failure sensors/alarms, revised maintenance manuals, more frequent replacements of prone-to-failure parts, more fail-safe overall designs, etc).
Personally, I'm factoring the human failure factor as "unovoidable". All pilots know how critical it is that they absolutely, no excuses valid, check wing configuration for take off/landing and they will all tell you that it would never ever happen to them. But still, it has happened to all kinds of pilots, seasoned and newbies, in all kind of airlines, from flagship to lowcost, in many kinds of airplanes, from 737 to md-83 to even 747's, in many countries, from the US to Argentina, etc, etc. And they were all heavily trained to follow checklists strictly and to set correct wing configurations for each part of the flight.
Still, we are all but humans.
Hope the families of the victims of this accident can get some relief from at least being able to know the likely reason of their tragedy and we all hope this time around the lesson learned can spare more innocent lives in the future.
The lanzarote case, discussed more in depth several pages back in the thread, placed the pilots on a slightly aerodynamically "better" plane (the MD-83, with more powerful engines than the MD-82) on a better scenario (nice front wind instead of fairly strong tail one in Madrid, weight some 15% less than maximun instead of Madrid's 100%, etc). The MAP crew probably also reacted better/sooner (max power, lower nose, rather than Madrid's first reaction which included briefly lowering power assymetrically at some point and keeping a somewhat high attitude throughout).
But it's all academic as it's being said, since it seems the Madrid flight found themselves in some random behaviour that perhaps stalled one side of the airplane substantially more than the other making it harder to control, etc.
In Lanzarote, the pilots and witnesses admited the airplane BARELY making it. They are speaking of clearing the airport barrier barely meters from one of the wings and people in front of the airport throwing themselves on the ground on fear of the aircraft colliding on their ceilings.
It would seem that not all these low altitude stall situations at limit aerodynamic capability (i.e. max craft weight, MD-8x series tendency to nose up attitudes when stalled, etc), even when given prompt and correct corrective actions from the pilots, who nonetheless I would guess often delay action a bit in initial disbelief, are necesarily recoverable and can depend substantially also on obstacles, enviromental and random behaviour (i.e. one side of the airplane being significantly heavier than the other, crossed winds, low air density, etc).
I'm not saying that most of these situations can not be saved if the crew and craft puts 100% into it quickly, but I'm saying that perhaps not all of these conditions can be easily saved even if the crew does all they can and do it quickly, specially with obstacles at the end of short runaways, as some small factors can play a critical role when we are talking about limit situations.
I agree that, in this case, the crew SEEMS like they could have been acting "carefree" overall, going on about their business, chatting to third parties in the cabin or on the cell phone, etc. Although the delay was substantial at the end, it was exactly 1 hour long total and not all that radical. I find this case may be more of a self-inflicted rush by the crew than a "real need to rush". They had reasonable time to check for proper configuration during the LONG taxi, but spent some of it taking to other airplanes, etc.
And the whole operation was far from perfect when it came to following checklists, etc. It looks indeed like a bad crew combination as each seem to allow the other slips in procedures, etc. Also a bit shocking that in such critical short time, one of the pilot's reaction is to ask how to turn off the STALL/TAWS alarm voice and to substantially lower the throttle in one of the engines, unclear from the report whether to verify their initial reaction to the stall alarm of suspected engine failure (as voiced on CVR) or to help counter act an uncommanded roll or someting.
Judicially, the procedure is basically stuck, as the judge concluded that he wasn't gonna find impartial opinions from the technical panel of experts he assembled from the spanish union of aircraft maintenance technicians. He requested experts from the European agency but they declined to provide any to assist with the technical discussion to see if the two maintenance engineers indicted, the one that de-activated the RAT heater (his assistant was not indicted) and Spanair's supervisor for Madrid (who wasn't physically present or informed of the on-goings at the time), were guilty of any wrongdoing. They remain indicted and nobody knows how the judge is gonna be able to proceed now.
Last edited by justme69; 20th Aug 2009 at 13:12.
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New bit of information
It is not stated in the report who was the flying pilot ... I guess it was the young copilot. Most take-off accidents I studied in the past happenned while the copilot was handling the aircraft ...
The preliminary report give us a few additionnal bits of information about the crew poor airmanship (let us be straight about that, without diplomacy).
- The captain interrupting a check list ... without any need for that, without any external pressure.
- The copilot passing a phone call from the cockpit and putting himself "out of the loop"
- The captain not commenting about the copilot remark stating the unavailibility of autothrust during take-off ... so they tried it anyway
- The conduct of the crew during the long long long stall warning operation is amazing. They had indeed about 10 seconds to avoid the catastrophe. Just push the stick one inch or two forward ... This correction would come in less than one second ... Further more, they initially reacted to an imaginary engine failure ... and retarded one of the thrust levers ... (light piston twin typical reaction, in a hurry to feather ...).
Poor pilots ... for sure. Poor training, poor selection ? I think so.
Too bad that, at this stage, the report does not mention the training curriculum of the young co-pilot. It woud be worth looking at the records, all of them, including "ab initio" ...
Yes, there is one way to dramatically reduce "pilot error" : select the best ones (not the rich one), give them a decent training as pilots ... not as system operators !
The preliminary report give us a few additionnal bits of information about the crew poor airmanship (let us be straight about that, without diplomacy).
- The captain interrupting a check list ... without any need for that, without any external pressure.
- The copilot passing a phone call from the cockpit and putting himself "out of the loop"
- The captain not commenting about the copilot remark stating the unavailibility of autothrust during take-off ... so they tried it anyway
- The conduct of the crew during the long long long stall warning operation is amazing. They had indeed about 10 seconds to avoid the catastrophe. Just push the stick one inch or two forward ... This correction would come in less than one second ... Further more, they initially reacted to an imaginary engine failure ... and retarded one of the thrust levers ... (light piston twin typical reaction, in a hurry to feather ...).
Poor pilots ... for sure. Poor training, poor selection ? I think so.
Too bad that, at this stage, the report does not mention the training curriculum of the young co-pilot. It woud be worth looking at the records, all of them, including "ab initio" ...
Yes, there is one way to dramatically reduce "pilot error" : select the best ones (not the rich one), give them a decent training as pilots ... not as system operators !
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I just opened it OK
http://www.fomento.es/NR/rdonlyres/9...INO_01_ENG.pdf
its 92 pages, so it took a minute or 2.
http://www.fomento.es/NR/rdonlyres/9...INO_01_ENG.pdf
its 92 pages, so it took a minute or 2.
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For justme69
Sorry to say but probably the lack of CRM and low houred copilot was the result of the tragedy. I´ve had co-pilots that were good and a couple of them bad and the bad ones were really bad and normally are low houred co-pilots. I´m not going to enter in the discussion, I will have to open another post, but I prefer a pilot who has flown a lot before flying into jets.
We all have forgotten at least once a point on our checklist but we all learn and this accident should teach us many things. The aircraft is like a bull, you can never trust it.
Sorry to say but probably the lack of CRM and low houred copilot was the result of the tragedy. I´ve had co-pilots that were good and a couple of them bad and the bad ones were really bad and normally are low houred co-pilots. I´m not going to enter in the discussion, I will have to open another post, but I prefer a pilot who has flown a lot before flying into jets.
We all have forgotten at least once a point on our checklist but we all learn and this accident should teach us many things. The aircraft is like a bull, you can never trust it.
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You can see straight away why it's better I stick to my "Jurrasic" Boeings and stay well away from Scarebusses eh ?