Article in SEPLA criticising Investigation
 

In the ongoing court case the Director of Quality face 600 years in jail


RTVC.es - Radiotelevisión Canaria - Noticias



The Errors in the System and Latent Errors not addressed enough in the report, apparently.

This accident needed and warranted a full blown Dryden style to change things and culture.
Time Pressure on Mechanics and pilots was a factor and still exists, this needs to be addressed. The hurry up syndrome.
So that maintenance guys are not pressured .

Human factor was huge in as by not hearing the Warning the crew felt they were safe.

Definitely DGAC and AESA had committed errors in their supervision that contributed to the accident.
What are the Spanish authorities doing to fix this now ?


Final Report in Spanish
http://www.fomento.gob.es/NR/rdonlyr...2008_032_A.pdf


One thing that is coming out is that there was complacency in Deferring Defects in general.

Extension of Deferred Defects in the MEL will not be given out so easily in Spain. Dont know if Extension of Deferred Defects will be affected in

No english report?

EC-HFP. McDonnell Douglas MD-82. Aeropuerto de Barajas (Madrid) - 2008 - Investigación - CIAIAC - Órganos Colegiados - Ministerio de Fomento:

Hi ALL,

Do not forget that there have been no final decision of the Judge.

Spanish Authorities ... Who?

Ministry: DGAC and AESA? They will not do anything from the standpoint of Civil or Criminal. Only a Judge can say whether civil servants and other individuals working for the Spanish Authorities, ie the Ministry (DGAC, AESA) are responsible for the accident, among other accused.

Unfortunately, it is much easier and faster blaming the dead pilots.

From my point of view, there is no doubt that there are responsibilities on the staff of DGAC and AESA. If they had been monitoring the matter as it should be, the accident could have been avoided. Unfortunately, there is much carelessness or complacency among the staff of DGAC and AESA as well as fellow drivers who did not check Slats and Flaps divices.

When operating with multiple inoperative items, what would you do?

Well, It must be subjet of pilot judgment:

-The inter-relation between those items
-The effect on aircraft operation and
-The crew workload.

Of course it was the pilots fault for not setting the flaps for take off. They got set up by maintenance when they disabled the take off warning horn system. The R5 relay had several functions, one was take off warning, the other was the temp probe. They disabled both. It happened to me one night but as I said on an earlier post didn't realize it disabled my take off warning system also. Yes, I did set my flaps even though the warning system was inop.

No ONE has deactivated the TOWS, NO ONE! :=

Report: CIAIAC publishes final report on fatal MD-82 takeoff accident Madrid, Spain « Aviation Safety Network's News

It's been over 3 years and they just came out with this final report. It doesn't help much. The R2-5 relay was the air/ground sensor getting it's information from the nose gear strut. It sensed air mode so the probe heater was hot causing their return for maintenance. The air mode was also thought to be why they had no TOWS since it was powered through the same relay. I agree, maintenance didn't disable it, they just didn't realize it was inop when they disabled the probe heater by pulling it's CB as I remember.

A couple of years ago someone posted a schematic of the circuits involved on this thread.

Thanks for the rferesher bubbers on the relay and CB'S.

Stated well, unanswered questions remain.

The Flight crew were the last defence in James Reasons Causal pathway, swiss cheese, yes its been discussed before,

Did the Spanish and European Air Transportation system fail the PIC and Flightcrew of JK 5022 ?

Is there going to be a commision of inquiry in the aviation system mandated by the Spanish ( EuropeanJAR ) judge in this ongoing case ?

No matter how professional flight crews can be and trained , can they be expected to outperform the system ?

One of the things that came out of the Dryden report is how profit and commercial pressures can take precedence over safety. Although companies state that it is primary.

What has changed and improved in the Aviation system since the accident in Dryden 1989 ? It appears that some lessons have not been learned

As per a report from the Rutgers Scholar perhaps the the Reason model can be improve upon,

" However, the Reason model does not fully account for the detailed role of the organizational system within which design and management decisions are taken and through which the consequences of such decisions are taken forward. That is, the Reason model, in its current form, fails to provide the detailed linkages from individual to task/environment to organization beyond a general framework of line management deficiencies and psychological precursors of unsafe acts. A review of the safety literature reveals that there is a gap between bottom-up approaches which start with the analysis of errors and safety events and top-down approaches that address the system from the level of the organization. Pidgeon and O’Leary (1994) note that if safety analysts do not understand the link between practical safety management initiatives and an organization’s safety culture it is impossible to begin to design initiatives to improve safety management practice except on a purely ad hoc and pragmatic basis. "



Below are the Organizational Factors in the Dryden Air Ontario Accident.
See any similarities ?

What about Deficient Inspection, Auditing and Control, Deficient checking, inadequate purchasing of Spares.?

Figure 2. "Organizational factors" in the Air Ontario 1363 accident. Disparate allocation of resources to safety and production activities (AO/AC) Deficient handling of information (AO) Inadequate management of change (AO) Deficient inspection and control (TC/AC) Deficiencies in operations and maintenance (AO) Inadequate purchasing of spares (AO) Deficient management of the F28 programme (AO) Low motivation (merger) (AO) Deficient lines of communication between management and pesonnel (AO) Inadequate policy-making (TC/AO) Deficient scheduling (overcommitment of the F28) (AO) Deficient planning in the introduction of the F28 (AO) Deficient monitoring and auditing (TC/AC) Goal-setting (failure to carry properly states' goals into deed) (AO) Deficient checking (TC

Folks need to remember that flying aeroplanes can get you killed.

That is why it is important to have your own mental checklist lining up for takeoff, flaps set and speedbrakes retracted, and landing gear and flaps for landing. Quite simple and eliminates checklist mishaps. I had the Madrid fault happen to me in an MD80 because of a nose gear strut overinflation making it put us in air mode taxiing out with the strobes flashing and no TOWS operative. Sometimes things don't work as they should so take care of yourself. Especially in an MD80.

Bubbers, you had not the same fault, as your airplane was completely in flight mode, while the jk5022 had only 2 (+2) system in the wrong configuration.
Out of this 4 systems, only 1 can be detected with normal pilot scan (RAT as it happened ). TOWS misfunctioning can only be detected if you do an unscheduled system check advancing the throttles. The others two systems (avionic cooling and ac x-tie) are backed up by others relays, and thus will be funcioning as normal
It's curios to see how an unessential (for safety) system like the avionic cooling has 1 or 2 backup relays, while the TOWS relies solely on 1 relay...

In your case you would have many and many systems misbehaving on ground, triggering something in your mind (as they have probably done)

You are probably right. The R2-5 relay was only one of several relays affected by the a/g sensor. The R2-5 relay failing by itself could have caused their problem. The final report wasn't very conclusive on what caused the R2-5 relay to be in air mode. Corrosion in the socket could have done it, or a faulty relay which should have been easy to check. Being put in a situation as they were kept me interested in the outcome but guess this is all we will know.