I no longer fly Boeings but when I did there was a philosophy mostly ignored by operators that only critical (killer) items were included on the checklist. For example the Boeing takeoff checklist for the B744 was "Flaps ... Set". Everything else (Call the cabin, set the transponder etc) were procedures and did not show on the checklist. This made the checklist effective and more relevant and would, if this philosophy was to be adopted, more likely to be used and to be used correctly.
When the carriers pad the checklists with all the procedural items it is more likely that single items will be missed, and that item could well be the killer item that the checklist was originally intended to protect.
So one of the causes of this accident must be that the crew did not check the flap, or if they did, they did not do it in accordance with the checklist ("Set" would be defined as lever position, indications and lights). Why did they not do so? Were they distracted? Were they used to only paying lip service to the checklist? Had the checklist been padded with extraneous items so that it was really a mini-operations manual?

Lessons (to be) learned
 

The main contributors to this accident appear to be a human element (resulting in error) - the lack of flap/slat; and a system failure - the configuration warning. This does not exclude the other combinations in the 2x2 matrix, e.g. mechanical flap failure or human error preventing the config warning, but as currently reported the first option is the most likely scenario.
The accident was the result of the combination of these ‘rare’ events, which can represented by the Swiss cheese model. The failure of the warning system was a latent factor and the human element the ‘unsafe act’.
Safety would be improved by either preventing the contributors (close the holes), or in the event of one or both being present, preventing their confluence – another slice of cheese – a new defensive barrier.

Improving the weaknesses in the human element is difficult. The industry accepts that errors will occur (1 to 3 errors/hour); only a few (5%) are undetected, of which only half might have any consequence.
However, the required standard of safety means that HF, CRM, TEM training, etc are still required to avoid, detect, or deal with the consequence of error in order to minimize the risk of a major accident, but this does not prevent the human element being a contributor to accidents.

The latent factor appears easier to deal with; in this instance, the reliability of the warning system could have been better. Previous accidents had identified a weakness (and as indicated by this thread, a continuing weakness), which in airworthiness terms could have warranted a system redesign, but it was judged that an additional check would be adequate. Note that this course of action has several paths where the human element might also be a safety factor. First, the human judgment that the additional check vs a system redesign would be enough, second that the check involves a human, and third, that the need for the check is both communicated and implemented as envisaged; all have opportunity for error.
In some instances, the certification process does allow ‘grandfather rights’, i.e. no need to meet a later standard of certification due to an earlier design/certification, MD-80 evolved from DC-9. This could have been an issue in the decision to use a check.
Thus, with humans involved in the system’s aspect too, it is not wholly possible to eliminate the system contributing to an accident.

The other option of preventing the combination might require identification that either of the contributors was present – use another crew member to monitor or a config-warning system failure detection.
In hindsight, and with concerns about human reliability, an improvement in the aircraft design by addiding config-warning system failure detection might be the better solution. The certification requirements (#2104), states that some aircraft already have ‘config warn inop’ or similar alerting. However, even this option is not totally error proof.
The EBR example in #2201 might have a weakness in that ‘Takeoff’ is announced by someone (thing) other than ATC – (Tenerife?). In other installations, the failure condition might be given during the test, which could be embedded in crew’s memory enabling a real event to be misinterpreted or ignored (Helios?).

There may not be a single safety solution – if there is, it might only prevent ‘this’ accident from happening again. In order to avoid similar, generic accidents, then a broad base of activities is probably required. The industry needs continued effort on HF training (CRM/TEM) and with management (certification) awareness of HF, but equally improvements in the certification and continued airworthiness processes would be required, and in a time scale matching those of operational training.

Ref: 1 to 3 errors/hour – Amalberti. ‘The paradoxes of almost totally safe transportation systems’. Also, see Helmreich et al. LOSA reports.

FAA Certification process study.

Good and bad news in the case.

On the bad side, the judge has decided to charge the two maintenance technicians that did the probe heater "repair" and the chief of maintenance for Spanair with involuntary homicide and criminal neglicency.

He is pissed nodoby took proper care of the heater problem in a period of over 24h spread in two days (albeit in different cities). Also, nowhere did it say in the manuals that the working air intake heater could just be disconected, only that a faulty heater could be delayed for maintenance if the flight conditions didn't pose risk of ice formation (good weather).

The judge took this decision late today as a result of the declaration of the first round of witnesses that he was interviewing.

Also, the judge decided NOT TO TRUST THE CIAIAC to carry out the "official" investigation and has ordered a new technical investigation to take place parallel to the CIAIAC's.

He ordered to recruit two pilots, two maintenance engineers and two aeronautics engineers to investigate for him. He ordered the official professional pilot's association to send the court a list of 30 suitable professional pilots with over 15 years of experience. Same thing with the association of aeronautical engineers. There isn't an official association of professional maintenance technicians in Spain, so he requested from the Ministry of Development (Fomento) a list of 30 wide-experience, certified mechanics that specialize in MD-82.

The first round of witnesses included some members from the rescue squads.

Next Friday he will call another 6 witnesses, including some workers of ground services for Spanair's subcontractor Newco. Another 4 witnesses on oct. 27th and more on the 31st.

My personal position is that, although there is no doubt the technicians could've done a much better job, it's understandeable that they felt the problem was minor and could've been easily isolated temporarily and taken care of later. If the pilots wouldn't have forgotten the flaps/slats until the airplane arrived at another location with Spanair's ground engineers, it would've gotten fixed and everything would've been ok (sort-of).

Also, it was the pilot's decission to fly the aircraft and not use the other one that was fully ready, with a gate assigned and personnel present, with the busses to move the PAX already in place waiting by the aircraft. Even more, the crew could've made another "start of the day" check (i.e. TOWS check) if they weren't sure the airplane was in perfect shape.

Also, the issue with the probe heater turning on while on the ground, seemed to be an intermitent problem, so perhaps it didn't show on the times the technicians checked it the prior day, as they declared in the maintenance log that all tests with the probe went normal. And, theoretically, the crew run a TOWS test in the previous flight from Barcelona, as required by the SOP.

But a real smart engineer would've questioned how it was possible the heater was switched on while on the ground, and quickly realized that the only way was if there was an inop relay or faulty ground/logic system. Tracing it back, would've questioned the ability of the airplane to safely fly until many more sub-systems were checked, specially the TOWS.

If the heater had really malfunctioned, then there is no doubt in my book that the technicians wouldn't have done anything wrong by isolating it and signing off the a/c. But in this case, the heater was working just fine, except it did when it wasn't suppossed to. In my book, that deserves a little bit more attention and there is a (small) part of responsability in the results of those actions. I wouldn't go as far as to classify it as criminal neglicency, as a significant number of ground engineers would've done the same action given the situation. But not all of them, of course. Boeing also needed to make the maintenance information for that case more clear, I think.

On the good side, only 5 survivors remain hospitalized. The condition of one of them is not made public by desire of her family. The other four are getting better, but two still remain in serious condition, one of which is still in intensive care.

justme69
Flight safety should not be based on having a real smart engineer.

I would prefer to put my trust in an average engineer who follows the book. I'll let the investigators decide if the book was adequate in ths regard.

I have accepted an airplane with an item MEL'd, read the requirements to the FO with him agreeing, flew the flight and found out later we were not legal. No jeopardy that time but after that I always handed the log book to the FO to concure we were good to go.

It sounds like this accident will also prove the MEL was not used as intended by Boeing. If the heater failed to heat they were legal. If it heated on the ground and they disconnected it, that was not the intent of the MEL.

The judge charging them with a homicide seems a bit extreme.

Absolutely true.

Smart engineers
 

Flight safety should be based on employing smart people, using smart procedures written by smart people, trained by smart instructors, being themselves checked by smart officials.

In this accident, I don't see any smart people, all the way up to the top of the scale ... :(

Problem? Smart = Expensive.

For some years now, the official position (authorithies and operators) is that you can dispense with smart people, provide you meet the official standards ... which, by the way, were not written by very smart people ... (IMHO - based on facts I'm very familiar with)

I tend to agree with the need for "smart people".

If Boeing would've been "really smart" instead of "by the bare minimun of the book", they would've:

-Designed (or retrofitted) a TOWS that was easier to diagnose. One that, i.e., when it failed, gave a nice warning instead of the same sign as a "configuration ok for takeoff" (silence).

-Made absolutely sure all airlines in the world, in the absence of a better, more reliable, easier to diagnose TOWS, at least knew about it and was following the recommendation of making tests every flight.

-In the absence of all the above, they would've at least have made better maintenance instructions available on how to deal with a probe RAT heater that turns on while on the ground, so that less "smart" engineers can not confuse the instructions of "faulty"-heater=MEL is just fine.

If Spanair would've been really smart, they would've hired a smart chief pilot that, eventually, after studying TOWS for so many years (Spanair's been flying for 20y), would've realised that a TOWS check each flight was good safety operation to follow and needed to be included in the SOP.

If the pilots would've been really smart, they would've realised after so many years the same thing with the TOWS and run tests, required or not by the SOP, prior to each flight.

If the ground engineers would've been really smart, they would've realised the heat probe problem was actually the symptom of a larger problem, not the problem itself.

But, with the exception of the pilots that were (theoretically) the only ones to make a flat-out mistake (who knew they had to lower the flaps, who had been well trained to lower the flaps and yet, they didn't), everybody simply "followed the book to the bare minimun" and that was enough to avoid the prevention of this accident.

It's arguable that the ground engineers followed or not the instructions "by the book", but as others have written here, "the book", if not very clearly written and covering all posibilities down to the "T", allows for some interpretation that can be "less smart" than it was intended to. It's not the first case of a pilot, a copilot and two engineers agreeing that an item was OK to MEL when it actually wasn't (strictly or as performed).

So much for the safety of "stupidly" following a book that can be miss-interpreted as valid for 3-4 (smart or not so smart?) people ...

Here is part of the judge's reasonings in his proceedings:

-He believes there is strong evidence that the airplane could've fall at the flying conditions from a stall induced by the flaps and slats not being deployed.

-He believes there is strong evidence that the TOWS alarm didn't warn the crew of the configuration error.

-He can read from the maintenance manual that it shows that the RAT heater and the TOWS receive power (on a reverse logic) from the same relay R2-5.

-That there is a possibility that the RAT heater problem was a manifestation of a multi-system malfunction affecting the TOWS, and that such condition was not found by the maintenance technicians.

-He estimates that those actions could constitute criminal neglicency with the result of 154 charges of involuntary manslaughter and 18 of involuntary negligent lesions.

-He requests the two technicians and Spanair's chief of maintenance to report to court to declare as accused parties.

Lurking around the thread since its start and reading the later posts, I'm a bit surprised that the consensus opinion appears to equate the ommission to set the flaps and the inop TOWS as equal contributing causes to the accident.

IF (and clearly this is still the subject of the investigation) the crew indeed forgot to set the slats/flaps, then this is the prime and only direct cause of the accident. Setting flaps is a part of basic airmanship, no doubt the investigation will heavily focus on the particular and systemic causes for the crew to have made such a gross error.

The TOWS is a secondary system that while legally required to operate, technically is not essential to fly the aircraft. Had the accident not occurred, possibly the fact that it was inop would never have been revealed. That it did not work can only be considered a contributing cause, certainly not on par with the primary cause.

Comments ?

Here is a scenario. Early flight first leg everything is ok. Then the second leg:
1) RAT fault on taxi out or just before T/O.
2) Returned to ramp, problem fixed, book is signed off and was acccepted by the flight crew.
3) Needed more fuel and decided everything was ok, taxied out.
4) Tired and in a rush, ran through a checklist and checked everything ok.
4) Lined up for T/O applied T/O power and then at VR the bird does not fly!!
Many conclusions from this forum, up to the investigative panel, judge, the company and indeed all of us. Blame everybody except...... Hmmm this swiss cheese or manchego, cheese lined up in a very subtle manner and everyone involved failed to see it? I would like to see how much of this report/ investigation is influenced by the liabilty and responsability involved ( ie Spanair).:hmm:

Technicians face manslaughter charges for Spanair disaster
 

Here's a new twist . . .

Technicians face manslaughter charges for Spanair disaster
From ABC Australia

The judge investigating the Spanair jet crash in August that killed 154 people is pursuing the technicians who checked the plane before it took off for manslaughter, a judicial official said.

Judge Juan Javier Perez has launched legal action against the head of Spanair's maintenance and two mechanics for "manslaughter and injuries caused by carelessness," the official said.

They have been summoned to attend a first hearing on November 3, the source said.

A report released last week into the August 20 crash that killed 154 people in Madrid said the wing flaps were not properly extended on take-off and an alarm failed to alert the pilots to the problem.

The MD-82, on a flight to the Canary Islands, crashed moments after lifting off from Madrid airport.

Only 18 of the 172 people aboard the aircraft survived Spain's deadliest air accident in 25 years.

I agree with everything except the "tired" and, to a reasonable extend, "in a rush" part.

The pilots had worked less than 40 hours a month. Consistently for the past 2 years. They had significant vacation periods as well.

They had only been working since 8 that morning, and had a 2 hours resting period right before this flight, and it was only "noon" on a flight that was going to take only 2:30h (3:30h if we account the delay). All in good weather and within the same timezone.

The whole issue with the RAT probe produced exactly a 1 hour delay from start to finish, hardly too much to induce an excesive need to rush.

Also, I do not believe that anybody was (particularly) "rushing" the pilots. Spain, for those few that perhaps don't know, is a country known worldwide for our relaxed pace.

Regardless, the pilots need to know that, no matter how much PAX or other factors may induce some (or a lot) need to "rush", they still need to follow the procedures adecuatly.

But indeed, from the point of view of the pilots, sans the "tired and rush" part, that is also what I think happened.

Once the CVR transcript is made public, perhaps we'll be able to see if they were carrying their job adequately and it was just a reasonable mistake (seems that way so far) or if they actually were engaged in too-lax, perhaps unaceptable behavior or if indeed they were overly tired or "rushed" for whatever unknown reason.

The responsability of Spanair (SAS, actually, they are wholly owned and managed) is also being investigated, but their SOPs seem to be according to worldwide regulations and manufacturer's original recommendations, their training and hiring programs on par or exceeding world standards, their safety record in 20 years impeccable, their safety culture on par with similar operators, their compliance with work conditions fully within western european regulations, ...

I fail to see how, other than not knowing the SOP was recommended (not required) to be changed to include more frequent TOWS tests on the MD-82, SAS could have any responsability for a licensed and experienced pilot's error (or errors), aided by a coincidental system malfunction that had been "serviced" by licensed technicians with significant experience.

CIAIAC's investigation may lean towards keeping happy manufacturer's or operators, but certainly I don't think anybody can (or should) suggest that the parallel judiciary investigation is biased and will not press charges against anybody or any company suspected liable for any voluntary wrongdoing.

I don´t agree the "problem fixed"-thing, thats what most of the discussions here is all about!

Well, I think that what MPH means is that, from the point of view of the pilots, they (and the engineers) thought the problem had been "fixed", at least well enough to sign the airplane fit to fly that flight.

Obviously they were both wrong. But they both were unaware that the TOWS was also inoperative on that flight, as nobody thought of giving the airplane a more complete test and the SOP didn't mandate a TOWS test for the conditions of that particular flight, nor did the maintenance manual suggested a TOWS test after a RAT probe heater problem.

So, from the point of view of the pilots, the plane was "fixed" (which it wasn't), they followed the checklist (which they didn't) and the aircraft refused to fly properly after VR for reasons that weren't obvious to them.

All this, of course, speculating that indeed what happened is that the crew forgot to deploy flaps/slats and the TOWS alarm had become inoperative due to an electronic malfunction since the last time it was tested in the previous flight.

Perhaps nobody was rushing the pilots, but I know from experience - as do all LAEs past and present - that everybody was rushing the engineers. The big curse of the industry is the accursed "Delay Meeting" driven by senior management and with BIG fingers pointing at the man on the front line with the screwdriver. There's not many that can resist the pressure.

Delays are inevitable when it comes to complex machinery; the greater the complexity, the greater the unreliability and its time we learned to live with it. Not many aeroplanes depart on flights today that don't have at least one page of ADDs lurking in the back pages of the tech log, simply because engineering are denied the time to investigate and rectify them before departure. An MD once said in my presence "You engineers are far too concerned with airworthiness items, instead of concentrating on the important things. That's what the M.E.L is for!" By important things he was referring to cabin trim, seat recline and on-time departure.

Justme69,
Can you be relax when your Flight Duty Time is just below your day limit?
In Madrid Barajas airport you cannot be relaxed while taxi out time is not less than 20 min, ground times are really shorts, particulary, when the airplane is full of pax and finally, your rotation is very tight. Actual flight time might be longer than calculated in the OFP mainly for south configuration.
MAD, BCN are not airports to be relaxed at all.

REGARDS

Gracias como siempre -69, yes that could be a "human kind of thinking/trusting".

I think most of us has been there; experienced on the type, many years in the company, knowing the maintenance guys and girls etc etc.
I have flown in spain as well and still working here, and enjoying it, BUT I have been in situations e.g I had to tell the Maintenance-guy/girl not to reset the computer but to read-out the code what triggered the malfunction....
This was on a turbo-prop, which is/can be much more foregiving. But this should not be a difference!
One day a (maintenance)-person told me; I rather work on a jet (not getting my hands dirty) then on a "prop-thing", (working in the engine, prop, oil etc etc)

Also true, its not funny to get your airway and startup clearance sometimes, blocked frequencies, long taxi routings etc etc.
And than Your company is asking you your delays??
You kind of feel pushed, its up to us to determine what is safe and what is not (how many of our spanish collegues are out of a job, as we speak?)

Fully agree, all what happened before MAY have been a contributing factor, but if investigated and they "forgot" the flaps..........

I remember 2 accidents in BCN last year, i think.
1. A contracted (no spanish registration) turbo-prop landed nose-gear-up in bcn.
2. Whithin 24 hours a "little"-jet (spanish registration) landed completely gear-up in bcn

In case of nr.1 a fully initial report is available (in no time) via the spanish DGAC.
In case of nr.2 some initial fact are known, while most of the spanish aviation-community knows that, "due to circumstances", they simply forgot to lower the gear.

I was told, case nr 1 was handled professional, pax informed, atc informed etc etc.
This was not the case in the nr.2

I don´t know, but I feel a little "protecting our own market"-thing in spain.
No, I didn´t use the words "cover-up".
But, its just an observation, which I hope will not happen in the spanair-case; "let the true but nothing than the true" come out.

wood versus trees
 

I am not a professional pilot - how do those of you who are - deal with the issue of distinguishing the wood from the trees in all this check, check, checking ?

I work in a safetly critical job (medicine) and have an ocean of SOP's to get through many times a day. Every time i take resonsibility for a patient and having gone through industry and company policies/SOP's - i then have my "own" checklist of killer items/gross checks to stop me doing something really stupid as i line up on the centreline. I also have training responsibilities and (quietly) try to impart some of this "supplementary" behaviour/paranoia to my younger colleagues.

Sometimes the biggest mistakes are the easiest to make (in an environment full of background noise, invented by A.N Other) like taking off and heading 020 instead of 200 - because no one told you to make sure the big yellow sun thing was in front of you rather than behind you (northern hemisphere !!).

Properly conducted 200 item checklists should work fine - but it's common for homo sapiens to see what they expect/want to see.

How do you stop extensive checking missing gross errors ? Nobody expects the spanish inquisition - but Cleese and Palin still turn up.


"aux vaches"

"correct patient, correct operation, oxygen flowing, ventilator on, chest moving, anaesthetic delivered and vital signs ok " (7 steps to avoid quadruple jeopardy !)

Spot on post Blacksheep.

However it isn't just maint managers that apply the pressure.
Airline station managers with maybe just one or two flights a day can really get their bonus' cut if the engineers/crew etc delay "their" aeroplane. :mad:

There for the grace of....etc. :(

"aux vaches"
A couple of pages back, boofhead in post #2206 made much the same point.