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-   -   Spanair accident at Madrid (https://www.pprune.org/rumours-news/339876-spanair-accident-madrid.html)

fireflybob 16th Oct 2008 20:27


Sometimes the biggest mistakes are the easiest to make (in an environment full of background noise, invented by A.N Other)
aux vaches, how I agree! There are so many edicts and procedures coming from who knows where these days. So many acronyms to remember (is flying an a/c safely really that complicated?).

We often need to take a step back from what we are doing to see metaphorically where "the ship is heading" or, as my dad taught me, "hurry slowly".

rattler46 16th Oct 2008 22:57

To be correct, it is involuntary manslaughter thruogh negligence (sounds different ?), if convicted they will be getting off on a fine.

Also, but on the same line, accusation is *NOT* an automatic conviction here in Spain no matter what uninformed sources might tell ya.

From the judge´s point of view, all he needs is indication for a crime (felony) to take action, and he has made it clear that he figures there are plenty of them (personally, I agree, but do not think it will lead to conviction as the main cause seems stll to be the misconfiguration in first instance).

Think of it a a court martial, keeping up the spirit while performing to the public, plenty of room still and nothing perjudicary stated with just the accusation.


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

Litebulbs 16th Oct 2008 23:12

I have thought about this all day long, after seeing that the Engineers are to be called to answer and may be punished for their actions.

Whose shoes would you rather be in? The flight deck, who, God bless, are no longer with us, or the Engineers, who are living this every day?

ZQA297/30 16th Oct 2008 23:51

The link below to the BMJ states that 70% of aviation accidents have human error at the root.
But what is remarkable is:

The US Institute of Medicine estimates that each year between 44 000 and 98 000 people die as a result of medical errors. When error is suspected, litigation and new regulations are threats in both medicine and aviation.
A rush to institute legal proceedings is therefore entirely predictable. Sigh.:rolleyes:



On error management: lessons from aviation -- Helmreich 320 (7237): 781 -- BMJ

puddle-jumper2 17th Oct 2008 07:58


Whose shoes would you rather be in? The flight deck, who, God bless, are no longer with us, or the Engineers, who are living this every day?
Seeing as you asked.......I'd rather be in the engineers shoes, I'd rather be alive, able to still see my wife and kids and them still able to see me.

blackboard 17th Oct 2008 08:37

Rattler46
 

To be correct, it is involuntary manslaughter thruogh negligence (sounds different ?), if convicted they will be getting off on a fine.
It does not work like that in Spain, see

http://www.pprune.org/rumours-news/3...ml#post4416677

justme69 17th Oct 2008 09:16

Of course, lots of fuzz over the judge's decission to turn the maintenance technicians and Spanair's chief of maintenance into accused parties instead of witnesses.

BTW, the chief of maintenance for Spanair wasn't even aware of "anything" going on with the airplane involved in the accident until after the accident had happened. Technically, the airplane was never "out of service", as the maintenance action happened with the passengers on board, etc, and he is only required to be informed and "sign off" maintenance actions being taken while the aircrafts are "out of service". Technicians and field supervisors have the authority to do the minor repairs of airplanes that are not technically "out of service" without consulting anyone.

All the survivors of the accident have left the hospitals already except the two still in serious condition.

Wirelock 17th Oct 2008 15:32

what is the source of this information??

if you are a pilot, i wonder does the chief pilot sign the acceptance of your plane everyday??
I think that it is not possible for the Spanair head of MX to sign off all AOG's at all airports of spanair network.
normally maintenance engineers sign off work that they have performed according the relevant documentation

dicks-airbus 17th Oct 2008 15:36

One source here: Mechanics subpoenaed after Spanish air crash - Aftenposten.no

justme69 17th Oct 2008 16:20

The source of that information is, mostly, from the part of the declaration of Spanair's chief of maintenance, Jesús Torralba A., made to the police on Aug 23rd where he says:

"I came to work at 6:45 that morning .... At the moment of the problem (the RAT heater issue) I wasn't told anything (nobody informed him about it). I was never involved in the resolution of the case, since the airplane was never out of service (AOG, Aircraft on ground, where the airplane is not fit to fly) ..."

"... The certifiers as well as the local supervisors in service can resolve this type of incidencies w/o informing the chief of maintenance, since they hold a licence for servicing this type of aircrafts. In the case that the airplane was AOG, it would've had to be reported to the chief of maintenance .... I was at the office of the company in Dique Sur when my local supervisor on service told me he had received a call from operations of a possible accident of an Spanair a/c. I looked outside the window in my office and I noticed the smoke mushroom. I went to the area and I reported back to my superiors that, indeed, the airplane was a Spanair ..."


The link below to the BMJ states that 70% of aviation accidents have human error at the root.
Basically all studies about aviation accidents cite human error as the main cause in the majority of cases. The ones I've read with the lowest number estimates over 60%. The ones with the highest: 80%.

It seems to be accepted in the industry that at least 66% of them are due to human error as the main factor. Roughly 25% due to mechanical/electrical malfunctions and roughly 10% due to weather and other issues as the primary cause.

SPA83 17th Oct 2008 17:20

Human errors for managers and regulators too…

The most important safety strategy today centres on the relationship between management and safety.
Managers play a fundamental role in defining and sustaining the safety culture of their organizations.
Regulators and airline management define the environment within which operational personnel conduct their tasks: it is they who determine the policies and procedures, allocate the resources, investigate failures of the system and take remedial action.
Human error should become a warning flag for regulators and managers, a possible symptom that individual workers have been unable to achieve the system goals because of difficult working environments, flaws in policies and procedures, inadequate allocation of resources, or other deficiencies in the architecture of the system.
Dr Kotaite. ICAO. 1997

justme69 18th Oct 2008 00:07

In case somebody has trouble finding it, there is now an officially-translated-to-english version of the preliminary report about this accident here: http://www.fomento.es/NR/rdonlyres/1...reliminary.pdf

Today's round of witnesess didn't uncover anything new. The woman supervising the cargo loading ratified her first account

...
Cargo bay 1: a live animal (the dog that didn't survive), 22 passenger's suitcases plus the crew's luggage.
Cargo bay 2: fresh fish (400kg) and apparels (Timberland).
Cargo bay 4: 115 pieces of PAX luggage
...

She handed out the cargo sheet to the pilot personally and recalls asking him: "Is there any problem with the aircraft?" and the pilot replied: "(no,) None".

More witnesses will be called to declare within the next weeks. The maintenance technicians will have to declare on November 12th.

Smilin_Ed 18th Oct 2008 00:21

Courts Martial Are Real Courts
 

Think of it a a court martial, keeping up the spirit while performing to the public, plenty of room still and nothing perjudicary stated with just the accusation.
If I have misread the above quote, I apologize, but at least in the U.S., courts martial are real courts and they are deadly serious. Courts martial have been established by acts of congress under The Uniform Code of Military Justice. They are not show trials for the sake of public opinion. Convictions in courts martial are the same as convictions in any other federal court and the punishments awarded, including imprisonment and death, are very real.

Litebulbs 18th Oct 2008 01:10

Just say that if the accident had not happened and that the correct flap setting had been made, would the Engineers now be being investigated for ATTEMPTED manslaughter, for not considering the possible implications of their actions?

Wirelock 18th Oct 2008 07:22

justme69.
The way the head of mx would be involved in an AOG would be to organise servicable parts, manpower tooling etc to get the aircraft fixed. it is the responsibility of the engineers to perform the work and release the aircraft to service.

for me they would need to investigate whether spanair mcc, informed the the head of mx about this. i have heard nothing about the role that spanair mcc had to play in this. a return to stand for an a/c for a mx event should be reported to the head of mx.

FrequentSLF 18th Oct 2008 08:10

I have a question.
Are the engineers charged or have they been notified that an investigation for involuntary manslaughter is going on. In many countries the judge has to notify the persons that are subject to an investigation, which does not mean at all that they are charged. I am asking because I am not familiar with the Spanish Law.

blackboard 18th Oct 2008 08:24

No formal charges yet, that comes later in the process, once they are 'acusados' for a formal trial.

Currently they are only 'imputados', i.e. there are 'reasonable reasons' to believe that these persons could be directly connected to a criminal event.

On the other hand, being 'imputados' gives them additional procedural rights which they do not have when they are mere 'witnesses': you do not have to testify against yourself, you hav eaccess to all of the data in the judges possession...which in one sense may be better for them.


The funny thing is that the judge actually based his connection to call them 'imputados' on non-official details coming from the CIAIAC investigation...which is clearly against Annex 13 and the EU directive on accident investigation...which call for separate judicial and aviation investigations.

The judge's commission, however, has not officially been created as a result of this requirement ?!! but as a result of his desire to speed things up...

have another coffee 18th Oct 2008 08:53

I know I should not react on a thread like this, but....

1. Without knowing all the fact there is no doubt in my mind the engineers went to work that morning with the mind-set of not doing their work to the best of their abilities.
2. Nobody in the airline industry working in safety critical places is going to his work with the idea of "let's have a crash today".
3. It's teeth crunching to see a judge (or juridical system) gets to draw the line in a safety critical industry. The negative effects of this involvement will be widespread (less volentary reporting, no cooperation with safety investigation etc).

I can only hope there will be european wide reaction to this involvement of the judge while the safety investigation is still ongoing....

agusaleale 18th Oct 2008 13:13


3. It's teeth crunching to see a judge (or juridical system) gets to draw the line in a safety critical industry. The negative effects of this involvement will be widespread (less volentary reporting, no cooperation with safety investigation etc).
Keep in mind, that at the same time the judge decided to indict the mechanics, lawyers asked for 154 million euros (1 ea victim) from Spanair as caution.

FrequentSLF 19th Oct 2008 09:00


Currently they are only 'imputados', i.e. there are 'reasonable reasons' to believe that these persons could be directly connected to a criminal event.

On the other hand, being 'imputados' gives them additional procedural rights which they do not have when they are mere 'witnesses': you do not have to testify against yourself, you hav eaccess to all of the data in the judges possession...which in one sense may be better for them.
Which means that the judge is doing his job. The engineers have been notified of the investigation on their actions... The judge cannot discount criminal negligence without proper investigation... and according to the law he has to notify the parties about the ongoing investigation...


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