Report
 

Summary report of the experts appointed by the judge investigating the crash of MD82 Spanair EC-HFP, which occurred on 22 August 2008 that killed 154 people.


The experts concluded that the accident resulted from a series of errors that attended sequentially or simultaneously causing the accident. The report is especially tough on the TMA and is aimed primarily at them, the drivers, the manufacturer and aviation authorities.

MAINTENANCE
For Aircraft Maintenance Technicians will be a before and after following the crash of a Spanair MD.
The responsability of the signing of a relevant charge of flight and the resolution of an incident must be pondered before being released on-premise or on-time economy.
In this regard, the report notes that maintenance "did not identify the cause of the damage and sent the wrong plane, invoking paragraph 30.8 of the MEL" prevailing approach to reduce the delay against the decision of the fault.

According to experts the TMA at no time came to identify the cause of the fault and they sent the wrong plane. The mechanics work "focuses directly to find support in the MEL to defer repair, without trying to approach the location of the cause that produced the fault and its remedy."

The report makes clear that the manuals were written "in a misleading or uncertainty in the performance of maintenance." Even recognizing that the documentation called "incorrectly" fuse and disconnected the favored technique to tackle the "wrong way" the fault.

In any case, it ensures that material "does not introduce new risk factors to the operation" after disconnecting the fuse Z29.

PILOTS
In aviation referred to human error and therefore the flight operation is designed to avoid mistakes of the pilots. But do not allow the failure of any essential equipment, and by MEL flight is prohibited by the label NO-GO if any of the equipment or automation stops working properly.

The pilots were unaware that the alarm of misconfiguration for takeoff (TOWS) did not work and there is an unacceptable situation: at the time of the accident, pilots fail to determine the cause of the plane not sustained. That is, it crashed without knowing what happened.

There are criticisms against the pilots for failing to properly perform checklists. The cabin is not kept sterile and conversation about topics unrelated to the transaction with a third person distracts the crew due attention and concentration.

In addition, the deactivation by the TMA system auto engine thrust (TRS) casts doubt on the drivers and distracted their attention repeatedly, from leaving the platform until you reach the runway threshold.

MANUFACTURER AND AUTHORITIES
There was an amazing coincidence precedent: in 1987 there was the accident in Detroit threw an MD82 that 154 people, the same as in the case of Spanair, and whose origin was a mistake wheelseat flaps on takeoff, taking off the TOWS, as in the flight JK5022.

After the accident in Detroit, the Federal Aviation Administration (FAA) has recommended changing the system to have a visual warning if the TOWS was not receiving electricity, but Boeing did not act and MD remained unchanged in the message system to takeoff.

To the experts that the alarm system "admits failure modes that should be incompatible with the significance" of that device. That is, it's so important you should take extra security measures.

Moreover, after the Detroit accident analysis by the manufacturer sent a telex to all the companies operating the MD to modify their operating manuals with the corrections recommended by the NTSB.

There is a security issued by the U.S. authorities or the European or Spanish as required by law "to ensure it reaches all operators (present and future) and applied effectively," the recommendation, which would become an obligation.

Iberia received a notification from the manufacturer because it operated the MD, but Spanair, as it was years later. The manufacturer despite the recommendation sent to the companies, did not modify the aircraft's operational manual, so Spanair documentation did not include recommendations in its operating manual.

The report concludes that "the TOWS failure in EC-HFP accident could have been avoided if, following the accident in Detroit, had dealt decisively with the modification of the system design."

A "perfect" example of the Swiss cheese theory I'm afraid.

Personally I would still and foremost blame the crew on this one. I also find it very troubling that the lessons of the Detroit accident where not learned :(

the last people to blame are the crew. They just made a basic human error. The type of error that has happened so many times we install a take off warning system.

The blame lies elsewhere.

The article below was posted on the AF447 thread. A DC-9 was badly hammered by hail.

AOPA Online: Too Close for Comfort

I noticed ...

I wonder. The first sentence doesn't really ring true unless .......

PS. I agree with Safety Concerns. This accident started life in the Douglas drawing office.

Of course the crew is at fault. Maintenance set them up by disabling the take off warning system, but if they had done their checklist everything would have been fine. We all need to think about how easy it would be for this happening to us if we don't stay disciplined. Don't ever rely on your checklist to do what needs to be done. Have a final scan of flaps, gear, trim and spoilers on every take off or landing, it only takes a second. Do it on short final or cleared onto the runway. I did it once at 200 ft once landing and noticed we didn't have the autospoilers armed then noticed we hadn't done any of the landing checklist. We had it all done in the last few seconds. It was basically all done except for arming the speedbrakes but checking the basics to back up everything can be good some days when you are snoozing.

Perfect example of the swiss cheese model, as someone pointed out already!

Which makes me think about the role of the lasf of that slice of cheese which is usually located at the end of the line: the pilots.

We are the ones who have a chance to stop the chain of events that has filtered through several other cheese slices.

The more the talent we have, the better the education we have had, the better the training we have had, the better the selection process in airlines is, the more experienced we are... the fewer holes that cheese slice has.

quality, good training, experience and good selection will result in good airmanship and hence more safety.

Recommendations in this direction should be made in any "swiss cheese" accident.

Report on Spanair Crash
 

From The Reader Daily news and information in English for Spain

Three directors of Spanair airlines have been indicted on 154 counts of homicide after the 2008 crash at Barajas airport in Madrid.

Judge Javier Perez, investigating the Spanair plane crash occurred on August 20, 2008, has indicted the three heads of area for reckless homicide and reckless injury resulting in 18 crimes and 154 homicides.

Antonio V., in charge of the Spanair Base in Madrid at the time of the accident, David T., responsible for Line Maintenance, and S. Alexander, director of quality control at the time of the accident, have all been charged by the judge. They have been ordered to appear before the Judge on 20, 21 and 22 June, along with Jesus T., the Spanair maintenance supervisor who was already charged in the case. (My emphasis).

The charges are produced following the conclusions of the expert report carried out by eight experts appointed by the judge and the expert report by a French expert in aircraft accidents.

Shortly before the crash, the aircraft had to return to the hangar after a first takeoff attempt after it detected a fault in the heater temperature sensor (RAT). One of the mechanics of the company consulted the minimum equipment manual (MEL) from Boeing and deactivated the RAT sensor heater. Since the beginning of the investigation, the instructor believes that "the failure of the RAT on August 20 was a consequence or manifestation of a multifunctional failure which also affect TOWS (that warn of an improperly configured for takeoff), fueled by same relay, which resulted in the crash".

(Note: The Reader is an online Spanish daily newspaper produced in English for expats)

In England we would normally call these people line managers and not Directors. The Directors are the people on the main board of the company who also usually earn the big bucks.

Spanair seemed to be renowned for having a general high level problem of complacency regarding safety and overall poor management procedures so if there was to be any sense in bringing criminal charges against anyone it ought to be the Chief Executive and any other main board director(s) directly responsible for Operations or Safety of the airline as a whole.

All that the bringing of these criminal charges will do is to make a few sacrificial heads roll whilst allowing the powerful individuals who earn the really big bucks from Spanair and who allowed this culture of corporate safety complacency to prevail to walk away totally scot free.

Unfortunately this Latin predilection for bringing criminal charges over airline crashes will only encourage people to cover up what has really happened rather than be open about it in future incidents so that the root causes can be established and addressed. Criminal charges are in my opinion only effective against the board directors of the company who are usually responsible for things like cutting corners budgetarily on providing enough money for maintenance. To make the guys further down the line responsible for the inevitable consequences of the corner cutting actually initiated by the main board directors is in my opinion quite ridiculous and grossly unjust.

Yes. The Europeans like to triumphant to the skies how their "systems theory" approach is so much better than the empirical approach of the Americans. See, as a perfect example, the quote from Safety Concerns above of this page about TEAM work.

What a joke. The systems theory approach is more about class snobbery than it is about safety. The only people who are safe in such a system are not the passengers but the corporate heads.

Hi,
To read
El accidente del JK5022 podra haberse evitado

This thread is an amazing example of fault tree analysis from aviation professionals and non-professionals alike (Justme69!), and should be retained in the annals of the PPRUNE archive for posterity . How very perceptive it was of the individual (#318) who identified from the first images from the crash scene that the flaps were in a retracted position. Lessons learned here have clearly come with a high human cost and it is for the industry to recognise that highly coupled events do not become safer by increasing complexity. Chief amongst this review should be the manner in which the FMS acknowledges inputs made to the critical control checklist items, in relation to a configuration calculated for take-off. The lack-of redundancy for supporting subsystems is also an issue here, notwithstanding the ultimate responsibility for ensuring that the basic safety principles are adhered to, which sadly fall on the human element in this tragic instance.

That's funny - I don't remember the executives and board members of McDonnell-Douglas and General Dynamics falling on their swords over the DC-10 cargo door clusterhump.

America has nothing to learn from anyone ... silly :ugh:, least of all anyone who questions axiomatic thinking.

Hi,

http://lasmentirasdebarajas.********...liot-ness.html

******** = b l o g s p o t (no spaces)

Debates en AviacionDigital.com - Noticias de Aviacin

Final report is now published
 

Final report is published now, see The Aviation Herald

Spanair accident final report
 

What a whitewash, passing all the blame onto the crew and never mind the failures in maintenance procedures, the question as to why the operating manual wasn't up-to-date, and all the other holes in this swiss cheese accident. Disgusting. Good, isn't it - crew dead so we can blame it all on them. And let's sneak the report out at the start of the summer when a lot of Spanish are on holiday - oh, and only in Spanish.

I really do hope the relatives of the deceased take this further.

I posted on my experience here over a year ago of a similar MD80 R2-5 relay being put in the airborne mode by a nose gear ground/air sensor sensing air mode because of an over inflated nose gear strut. Taxiing out at night the strobes were flashing, the idle was at approach idle and obviously my takeoff warning systems was inop but at the time I didn't know it. Knowing the strobes turned on with nose strut extention I used aggressive braking to compress the nose gear strut. Strobe lights went out and idle went to ground idle. Also even at the time I didn't know it I got back the take off warning system.

Sounds like the same thing happened to them but during daytime the strobes wouldn't be noticed and they might have missed the higher than normal idle. It would be easy to check though with the FDR. I don't think the crew was totally at fault. As in all accidents, if they are dead, they are the easiest and cheapest way out.

Madrid has a long taxi for takeoff, I had a short taxi at midnight in California so never got a probe overheat.

The report speaks clearly, the Engine Idle has been always at Ground Idle
The ONLY relays that was malfunctioning was the R2-5....

I never said the crew wasn't at faullt and, as far as I can recall, nor did anyone else. The point I was making was that it wasn't only the fault of the crew. The whole point - forgive me for teaching grandmothers to suck eggs - of safety systems is that they come into play when the human element fails. Pilots are human and they fail, so safety systems ensure that there is a second line of safety. TOWS should have been working - that's what it was there for.

humans
 

I am sure that the most proficient and expert over 20,000 hours experience pilots can recall at least one mistake that could have had very bad consecuences hadn't it been for a take off configuration alarm or a first officer, or similar, that warned them about their mistake.

Less experienced pilots maybe not, because it hasn't happened yet to them.

humans make mistakes. Even gifted ones. I've seen it happen.

Even Messi can shoot a penalty and send the ball to the 60th row.

The swiss cheese was there: maintenance, pressure, FO with low experience, bad company SOPs that didn't adopt manufacturer recommendations about an item in line with the maintenance cheese loaf and a mistake in line with the maintenance cheese loaf.
all together are to blame