lomapaseo;
Yes, I'm fully aware of that but thank you for making the point clearer, even if only some pilot starting out in his/her commercial career reads this and learns one more fact about aviation that isn't taught as a licensing requirement...

The key requirement has been amply stated in the thread. However, hands up those who haven't either been fooled only to realize it later or probably more likely at least had maintenance try to fool you into taking the airplane "under the MEL" when you know damn well the airplane doesn't belong in the air?

Like I say, these are traps for young players and I'll bet you more than one crew has taken an airplane that shouldn't have gone.

As someone here said, "It's all about the money" and absolutely nothing else. Management never sets the park brake; that is up to us.

Yeah,

At the very least, the light needs to tap on all sensors and indicate:
-Ground
-Air
-Disagree
-Off (light broken)

Unfortunately, if i.e. the Madrid case turns out to be a case of a malfunctioning single relay (R2-5), even if you make this more sophisticated logic, as you just mentioned, it will still confuse the heck out of the pilots ...

They will see an indicator lighted:
-Ground

Then, if they notice at all, they'll see a RAT probe indicating way too high temperature. Maybe they'll notice/figure the heater is on.

Maintenance will see the logic is "correct", so it must be a case of the heater "mysteriously" malfunctioning. Cut it out, MEL the thing, and out we go.

And we still get Madrid's likely inop TOWS takeoff condition ...

Boeing's recommendation of testing TOWS shortly before each take off is the best (and cheapest, mind you) solution. The alarm could still fail from the time it was tested til the time it was actually needed, but usually that would be some short period of taxiing time, so the risk is small.

Testing with a POSITIVE test, where you actually hear the alarm, not a test where you are suppossed to NOT hear the alarms, which is "worthless" in case of a "broken" TOWS.

The real "best solution" is a TOWS re-design where the alarm indicates both, possitive and negative results. Nowadays, with digital technology, I'm sure the change wouldn't cost all that much (at all). You push the handles and the TOWS will announce out-loud:

-Configuration OK (you are good to go)
or
-Beep - slats -- beep -- flaps (you are not yourself today -- drink more coffee and stop chatting on your cellphone with that cute flight attendant you are about to meet)
or
-Silence (TOWS is inop ... you are NOGO)

There is a definite disconnect between pilot and engineer in todays world.Didnt used to be.Engineers were once flt engineers but then they took the third seat out.Pilots used to have work the engineers panel before sitting in the right.Pilots used to get shown the ropes in the hangar during C check..now they learn by rote and do the 6 month answer A,B or C monkey check.Some today have never seen an EEC or PACK..if you see it you'll catch on..a picture tells a thousand words etc.CP's in the old days were tough SOB's who'd wouldnt give a damn for this modern BS(Captain isnt a pilot but a flight manager:hmm:)..they would have been on that Lanzarote incident like flies on dogsh*t and making sure data was disseminated to their guys..I know the powers that be will throw more SOP's at this as part of their answer..irony is you need less and a little more airmanship.Even if Madrid turns out to be the relay itself and not the cb,the lesson was check the TOWS every time..the full check at the gate during pre-flight.And if the SOP says the other guy checks this or that,doesnt matter,check it again..know the condition of your plane before you go flying.
Justme69,
Thank you for post 2133

FORUM WARNNG! This post implies no judgement/implication/hint/rumour on the cause of this accident.

100% with Ranamin. However, and not wishing to be 'trite', all these 'devices' - TOWS, EGPWS etc are 'backstops', and surely the important lesson is to get it right in the first place. If you need flaps/slats xxx for departure - make sure you have them. If there is high ground (or even just 'ground') around, make sure you know where it is and you are etc etc. It does not matter how you do it, and if your company does not try to ensure there is such thinking in place, develop it yourself. SOPS are not the answer to avoiding accidents, merely part of the building blocks. Sitting in front of these SOPs are pilots with brains and hopefully some sort of survival instinct.

All the warnings TOWS, AIR/GRND shift mechanism etc, still does not exempt any crew from visually checking the positions of the slats/flaps( including the postion of the flap selector) or,if applicable LE devices. Confusing that the A/C systems might not have worked, yes. But, to blame it on this alone, Hmm

CHECKLIST items
 

Just as a reminder of where the focus needs to be:

The Boeing checklist, printed on the chartclip that is affixed to the steering wheel in the B-767 and B-757 contains only the really important items:

Take-Off
FLAPS


Landing
SPEEDBRAKES ARMED
GEAR DOWN
FLAPS

The warning system is just there to alert the pilot in case he has forgotten to set the mentioned items in the correct configuration.
Having items in the wrong configuration is not the fault of the warning system.

(This is not written as accusation of the deceased pilots. If the final outcome of the accident investigation proves that the high lift devices were not properly configured for take-off, well, to err is human, it is as simple as that).

John,
And who or what is going to test the " 'TOWS Untested' warning system"?

Where should we draw the line about adding untested equipment to an airplane?

Just to answer that question requires a deliberate process of analysis and verification.

ECAM - takeoff memo has a line: T.O CONFIG.......TEST (with 'test' in cyan) which turns into green T.O CONFIG NORMAL when test is pressed. My takeoff checklist has three items: 1. checking that entire take off memo has turned green 2. checking actual config on E/WD 3. checking the state of AC packs, and it's done by both pilots.

OTOH, ATR has a similar TOWS to MD80 and I had to test it with flaps retracted, before each and every flight per company policy.

Seems like a quick advancing of throttles asking for take off flaps should verify TOWS working. Simple and flows with the initial taxi procedure. It would have saved all of those lives. In their case apparently no one asked for take off flaps so may have not worked. Interupted normal flow as they had can really mess up a routine. I always tried to start from scratch when an interuption of our normal routine made us backtrack on our checklist.

Yep, and those two lights should be on a big toggle switch, so that the pilot can always tell the computer that it is wrong, and toggle the mode to the one that is correct. (to keep the pilot from messing with that switch, each use should be recorded in the computer as a system fault and trigger an investigation within the company)

please
 

I’ve been reading this thread from post No.1, I’ve been posting in a similar thread on a Russian pilots’ forum. I’ve been always eager to participate in any major accident thread out there. But it probably takes a real-life involvement in an accident to realize how inappropriate, how leisurely, careless and “just-posting-for-fun-while-sipping-my-nice-hot-tea-and-not-giving-a-damn-to-be-honest” all these discussions are.

I came back from Perm (Boeing 737-500 crash) more than a week ago. But everything I saw and everything I felt is still with me. I saw relatives sitting and crying just a table away from us while we were eating and talking. I’ve been at the crash site, I’ve looked down the hill, I’ve looked across the railway, I’ve looked to the left where the wreaths and the plaque are, I’ve walked around the wreckage area, I’ve come across a kid’s shoe, a cell phone, a belt, a backpack, a book, an album “Watches”, a CD with English audio course. It hurts. That kid’s shoe will stay with me forever. No, there were no body fragments, no blood, no hairs, nothing like that but I think it would not give me so much pain as did those signs of life, those things still breathing with life, still belonging to someone. Seeing this makes you silent, makes you shut up. Makes you respect what you’ve seen with your silence.

It also makes you respect the work of investigators you’ve seen. It was the first (and I hope the last) time I saw how they work and I am probably too emotional but watching their work filled me not just with respect or admiration but with something more than that. Worship is the right word, I think. Serious, dedicated, thorough, intent, professional is how they look when you watch them work. Now when I look at this thread and other threads like this the contrast is stark.

Please, let us honor the relatives, let us honor the work of the investigators, let us honor the gravity of the event with our silence and let us wait patiently and silently for the official report.

This is not preaching. Me being there did not make me more special or better or cleverer than everybody else, it just made me say what I have just said. And I really feel the urge to spread these words to you and to share what I’ve seen and felt with you.

Your allowed your view.
It's tainted by your first view of an accident. There are many on here who have seen more than one, and at closer quarters than you did.
The thread is still valid.
People are free to choose what they post. The moderators will moderate.

Xolodenko,
Even though I appreciate your emotive words, I think that the whole thing it to save lives and learn from the experience.
Don´t you think that many of the pilots who follow this thread may have changed their own procedures; understanding minimally what´s happened contributes for aviation safety. And think about how many lives may have been saved since pilots follow this and other aviation forums and threads, where accidents and many other questions are questioned. These are very good reasons for continue with this thread respectfully.

We all respect and care for the victims. I don't really appreciate suggestions that, out of respect for the victims, all we should all do is NOTHING AT ALL until some "experts" tells us "officially" what THEY think happened and then take it as the absolute truth. Whatever they feel we don't need to know, they can then just not share with the world and keep it secret.

If myself or my daughter would've been in that airplane (and she actually had just flown round trip on Spanair from the Canary Islands to Madrid on an MD-82 the week before the accident), I would not want to have "no news whatsoever until a final investigation concludes, possibly years from the accident".

Actually, I would be doing exactly what I'm doing. Trying to spread as much information as possible so that people I trust know better than me could help me understand what happened, tell me who (if anybody) is at fault, and what is gonna be done so that it doesn't happen to others.

I even think that, if I found a thread like this, I would be most grateful to all, experts and "inmature afficionados", for each sharing their views, experiences and speculations. I rather visit this forum than hit "refresh" on CIAIAC's website only to find that, as it happened in Lanzarote's case, after 15 months all you can read is:

05-06-2007. OE-LMM. McDonnell-Douglas MD83. Aeropuerto de Lanzarote (Las Palmas) - CIAIAC - Ministerio de Fomento

A single paragraph that, basically, says nothing at all on why or how 150 people had their lives hanging from a string that day. That's the "offical investigation" (so far) in a case where they had an intact plane, the crew was alive and a company investigation that concluded the likely cause 10 months ago.

Because the Madrid accident actually had a large number of victims and initiated a judiciary investigation, the CIAIAC is going to take it a bit more seriously and the burocrats that run it (some of them not very bright, by the way, it's my personal opinion) are going to meet tomorrow to vote on the agreement of the current preliminary report to be then published. They were required by international safety organizations and their own regulations to have done that two weeks ago. The report, in its current state, although still missing some important information, at least is brave enough to point out the causes of the accident and appropiate action.

Even worse is the pitiful show put on by the press, where they've run headlines such as: "Turbulences caused the accident", "An engine fire caused the accident", "A wing malfunction caused the accident", "A wrong repair by a technician caused the accident", "Spanair's procedures didn't follow Boeing recommendations and caused the accident", "The airplane reverser was broken and could've caused the accident", "The plane had a miriad of malfunctions and still tried to fly", "The RAT probe heater was broken ... and it's needed to make sure the engines don't freeze on the air", "The airplane's flaps had failed a few days before ... and maintenance did 'nothing'", "The probe repair deactivated vital systems for the take off", "The airplane crashed because it thought it was in air mode on the ground", "The flight was overweight", "Spanair didn't check take off devices", ...

Truly sad.

If I was family of the victims, I would be angry at the press for such careless "wide" speculations that large population take as "truth". On the other side, a "small", private forum of professional pilots, under the "Rumours and News" chat room, I don't see why they couldn't make speculations probably 10 times better informed than some newspaper reporter decides to print.

I understand some people feeling offended by comments on this thread. That is fine. All they have to do is not read/participate in it. They can also express their view that they are feeling offended by it. Fine. But we already know that some people feel this way. We don't need to be reminded over and over. We understand, politely disagree, and each is free to stop reading it or continue posting on it under their own moral standards.

Only 7 survivors remain hospitalized in Madrid. The state of 2 of them is not made public by desire of their families. Out of the other five, they are all evolving favourably, with two remaining in serious condition, one of which is still in intensive care and assisted respiration. I wish for their prompt and complete recovery.

To the families of all those that perished in this tragic accident, my deepest condolences.

Litigation
 

US judge orders Boeing to release information on Madrid crash plane
Submitted by Sahil Nagpal on Tue, 10/07/2008 - 09:56.
Source: www.topnews.in


Madrid - A US judge has ordered aircraft maker Boeing to hand over all available technical information on the MD-82 jetliner that crashed in Madrid on August 20, killing 154 people, Spanish press reports said Tuesday.
A US law firm has filed a complaint against Boeing and its subsidiary McDonnell Douglas in the name of 18 families that lost members in the accident.
The judicial proceedings started Monday in the US state of Illinois, where Boeing has its headquarters.
Ribbeck Law Chartered was initially seeking technical information on the plane in order to decide how to proceed, lawyers representing the law firm were quoted as saying.
The lawyers want to find out which company made the wing flaps that were not deployed on take-off and may have contributed to the accident, according to a preliminary report by an investigating commission that was leaked to the Spanish press.
The flaps help to lift aircraft on take-off.
If the flaps were not made by Boeing or its subsidiaries, the court case could be extended to the company that manufactured them, lawyers said.
Judge Ronald Davis gave Boeing six weeks to provide the requested information.

"Lawyers want to find out which company made the wing flaps"
 

".... if the flaps were not made by Boeing or its subsidiaries, the court case could be extended to the company that manufactured them..."

Hmmm. The rivet makers will be next in line.

xolodenko wrote:
I’ve been reading this thread from post No.1, I’ve been posting in a similar thread on a Russian pilots’ forum. I’ve been always eager to participate in any major accident thread out there. But it probably takes a real-life involvement in an accident to realize how inappropriate, how leisurely, careless and “just-posting-for-fun-while-sipping-my-nice-hot-tea-and-not-giving-a-damn-to-be-honest” all these discussions are.

I Write:
We all have a great respect and care for the victims.
Pilots who reads this thread will be better pilots, how many times have we not heard of pilots who forget to put down the flaps, then think of all the times in which we have not heard about this, because of the TOWS have warned the pilots.
I am sure that pilots flying MD80 and have read this thread, thinking "flaps" before take off.
It is very likely that some investigaters reading this thread that he / she will have information which may help to solve the problems of the accident, or get a different approach to the real problem.

Hopefully, a tread as this can save human lives.
It's just my opinion

CIAIAC vocal members are meeting right now and will decide on the publication of the current preliminary report draft, likely later today.

It will presumably include indications from the CVR that the pilots did (try to) follow the checklist. Although the audio is particularly bad and it can not always be 100% conclusive, it is believed they did go over the flaps/slats items and said they were "ok".

Obviously they weren't reading the indicators properly, as the FDR and other evidence shows the flaps weren't extended at that time or later.

It will still point out to a failure of the SOP to require testing TOWS on each flight as the main point that must be changed to improve safety. Other operator's SOPs don't include this recommendation either, so it's important that it's made mandatory worldwide. Needless to say, Spanair has already changed the SOP a few days after the accident.

Being a preliminary report it can not include final conclusions or recommendations.

Flaps
 

Justme69, thanks for your always informed and excellent posts, without them I would have been unable to get such a full picture of the event & for sure we have all had our awareness raised by it.

Re your last post, does anybody know if there could be any link between the TOWS disablement & the flap indications? Whilst I agree that it's SOP failure not to have the TOWS check in the system, it has also been known for pilots to read & call an action yet not actually look to ensure things are what they should be - another SOP failure.

I'm reluctant to suggest that these guys failed to follow SOPs thoroughly but does anybody know what training / SOP standards were/are like in Spanair? It's certainly an area I'd want to look at if I were investigating this.

Incidentally, Spanish media reports that Spanair have lost 11 million Euros worth of business since the crash. A reminder of that excellent saying, "If you think safety is expensive try having an accident." Given the SEPLA letter that preceded this event, I hope Spanair (& other airline's) management reflect on just how good their, "cost saving & efficiency measures," have been.

DISCLAIMER: This whole post ASSUMES that the crew failed to correctly deploy the flaps/slats. This still hasn't been proven, so it must be taken as purely speculative and not based on facts.

Others could answer more authoritatively than I could. But, to the best of my knowledge and in my personal opinion, I'm sure there is no "electrical/mechanical" link between TOWS being disabled by the lack of energy from R2-5 and flaps AND slats indicators failing in any way. The indicators in the instrument panel (flaps degree watch dial and slats takeoff lighted indicator) are mechanically set.

From the manual:
The first settings of flaps AND slats (mid, 11º) are set mechanically, and the possibility of failure is almost zero. Also, in this flight, the flaps did deploy correctly (as recorded by the DFR) some 45 minutes earlier when they first tried to take off (before they returned to gate).

Even if they BOTH (flaps and slats activation) failed for whatever reason, another mechanically linked independent indicators read back the position and informs the pilots positively (there is virtually zero chance of this also failing) the position of both wing's slats and the angle of deployment of both flaps. If the actual flap or slat doesn't physically hit the sensor/push the dial sensor that signals its position, there is virtually zero chance that the indicators would show the correct setting while the device actually being in the incorrect position.

If both, the flaps and slats weren't out before take off, there is virtually no other explanation than the crew failed to properly read all the indicators that would've signaled the faulty condition.

It's not so "incredible" that a pilot could forget to deploy necessary systems (i.e. landing gears, brakes, flaps). After all, it was proven to have happened in Detroit's Northwest case, in Buenos Aires' LAPA case, in Lanzarote MAP case, and no less than 8 others "unofficial" (read this thread) cases. Human error is the main cause in over 60% of aviation accidents.

Actually, the Take Off Warning System was put into airplanes by manufacturers precisely because crews weren't correctly checking that vital systems were in the correct configuration 100% of the time. If one could trust that pilots ALWAYS checked thoroughly things like "landing gear down" or "speed brakes armed" or "flaps down", then things like TOWS wouldn't be needed at all.

Spanair is part of the Star Alliance, and performs sharecode flights with United Airlines, Air Canada, Scandinavian Airlines and Lufthansa. This was actually also Lufthansa's flight LH2554 for some passangers.

Standards of training and operation on Spanair, a Scandinavian Airlines company, were very high, as far as I've been able to study. Way over world average, I'm told by people I trust. On par with western european countries, which are above those of, i.e., the USA. SAS moves over 3.5 million passengers a month.

Boeing had reviewed just recently Spanair procedures and issued certificates of quality, declaring their procedures excellent. Spanair has twice the recommended number of pilots training refreshes in the first world. Their SOP called for up to 3 checks of take off configuration and a TOWS test at the beginning of the day or when pilots changed or were absent from the cockpit for extended periods.

Pilots unions will ALWAYS complain for fewer working hours, more free training, less work pressure, more investment in security and maintenance, zero MEL items, etc, etc. This is obviously normal. It will still not prevent pilot error, and at some point the line has to be drawn.

You can read about the pilots in previous posts, but basically they had reasonable training/experience (9 years in the company, +7000 hours on the MD, the copilot, in charge of the take off and of lowering the flaps, 2 years and +1000 hours on the MD), they weren't overworked (under 40 hours a month, consistenly in the prior months), etc, etc.

Truth be told, the copilot knew he was probably going to lose his job in less than a month, although Spanair had agreed to hire him in a lesser position if he so wished. There was even talk of a "disgrunted employee" sabotage earlier on:

http://www.washingtontimes.com/weblogs/aviation-security/2008/Aug/20/was-todays-crash-sabotage/

... which the judge doesn't really buy as the TOWS failure would seem to be casual.

Unemployment benefits in Spain are substantial, so the copilot had, at VERY LEAST, 60% tax free of his full salary available for 8 months without the need to work, plus an additional substantial one-time penalty payment if he was fired before his contract expired, likely equivalent to at LEAST two full months of pay.

In western europe, unions (air controllers, pilots, airport personnel) like SEPLA are constantly "complaining" and demanding even better work conditions although they are already above average and among the best in the world. Spanair was about to fire 1100 workers (they finally fired 950 recently), so no wonder everybody was upset and complaining. But this has little to do with "forgetting to deploy the flaps", or improperly following checklists for which you are well trained.

I'm sure the crew didn't do it right. But I'm also sure they were very well trained to do it perfectly and weren't particularly pressed to do things otherwise. They simply made a mistake (hypothetically).

Although they had a delay in the flight due to the RAT probe "acting up", another plane was already called in and available. You can listen to Spanair operation requesting the change of registration plane for this flight and a delay. They already had a gate (C49) with personnel already present to unload the passengers and reload them. The return flight for this plane wouldn't even require a time change. Cattering was already on the move.

YouTube - Conversacion entre Spainair y Barajas antes del accidente

But the technicians figured, with the full knowledge of the pilot, that the issue was probably minor, and they got it quickly "fixed". In exactly 1 hour from scheduled time, they had taxied to T2, "fixed the problem", taxied to T4 and were again ready to take off in the runway. And there was no huge need to "rush". Delays of 1 or 2 hours are so common nowadays, that they are the staple of the norm.

The malfunction probably made them distracted. But it was still their job to complete the checklist as trained and not forget the flaps.

I do not believe that Spanair was putting more or less pressure than other western airlines on unsafe practices or that they were implementing cost-cutting measures that significantly reduced safety. Even if they were, what does it have to do with pilots forgetting to deploy flaps/slats? If they have a license to fly a MD-82 I'm sure they have been trained on how to do it right.

The TOWS inoperative is not the pilot's fault, but nothing prevented them from checking the TOWS system if they so wished. It's (basically) as simple as pushing the handles to takeoff, listening to the alarm, and quickly putting them back.

I do feel that Boeing is a bit to blame for not making a better TOWS design and for not making sure the SOP's were requesting frequent TOWS tests worldwide. I do feel that Spanair is a bit to blame for not making sure their SOPs reflected the very latest safety measures recommended, even if they weren't mandatory and they were never told about their existence. I do feel that Boeing also deserves more blame for not making maintenance manuals more clear on implications of "faulty" RAT heater. I also feel that Spanair's technicians deserve a bit of blame for not figuring out in 2 days what was going on with the plane.

Although it's not proven and it is totally speculative, the crew may also possibly be to blame for not testing the TOWS in the earlier flight from Barcelona, this time as required by Spanair's SOP. And, of course, they would carry the burden of most of the fault for failing to properly check if the flaps and slats were correctly placed.

CIAIAC vocal members finally voted today to unanomously approve the preliminary report with a few changes. Those changes will be written within the next days (Friday, most likely). It will then be available from their web page:

http://www.fomento.es/MFOM/LANG_CASTELLANO/DIRECCIONES_GENERALES/ORGANOS_COLEGIADOS/CIAIAC/INVESTIGACION/2008/default.htm

Reportely, it will state that pilots went over the checklist even though the flaps weren't out and it will NOT include safety recommendations, as it is not final.

SOPs & Training
 

Thanks for that Justme; informative as ever. However whilst I accept many of your points re the accident & you are probably about right as to the main reasons, it still leaves us with the question why well trained experienced pilots made such an elementary mistake? Yes we know pilots do but there is usually one of the other well known factors involved, stress, time pressure, distraction, fatigue or whatever; you are saying none of these applied.

One things I would query is this line, "If they have a license to fly a MD-82 I'm sure they have been trained on how to do it right." We all know it isn't as simple as that. If the atmosphere - safety culture - in which you work is not robust & non standard methods are accepted then it builds a basis for cutting corners. I have worked in airlines where the paperwork was legal but it was a box ticking culture and good solid training was minimal in order to keep the show on the road & costs under control. We all had licences to fly our types but always felt under trained. You are clear that was not the case here & I must accept that as I know nada de nada about the company. However there's world of difference between good training, adequate training & just legal requirements, so I remain curious why such well qualified experienced pilots did - or did not - what they did, there are always reasons in the background & they are ones we really need to understand.

Lets face it neither humans nor machines function perfectly all the time.
Humans doing repetitive tasks sometimes "see" what they are accustomed to seeing, or are expecting to see, especially if momentarily distracted.
That is why most airplane systems and procedures have warning system and cross-check redundancy. TOWS, and challenge and response, for instance.

If machines could be trusted to fly aircraft without human back-up, the economic and and efficiency benefits would have had them doing so from long ago. So we have to put up with pilots.version 001.

Years ago at a Royal Aeronautical Society Air transport course I attended, there was a very informative lecture by a gentleman from the AAIB in which he demonstrated how easily a human mind can be programmed to commit stupid errors, and misread simple indications. Layouts, language, and a host of other small details can set traps that even the most experienced and qualified pilots fall into.

Human engineering is still in its infancy, but hopefully that will change soon.
The closest example of a perfect human died a couple thousand years ago, although we do have a few pretenders on this forum. ;)

May be possible that the pilots somehow got confidents about the TOWS when testing it that morning, and later the same system turned against them when not working.
I mean, if the confidence in the system may have produced that prior to the take off, the checklist has been done in a relaxed way.

for justme69

Is there any thruth in this information?

YouTube - Conversacion pilotos avion Spanair accidente Barajas

GEarDown&Locked:

No, those are false statements on that youtube video, blantently made up by some news program in Argentina even before the CVR recordings had been extracted by the labs.

Bears no resemblance whatsoever with the actual conversation. It has been discussed way earlier in the thread, some 50 or so pages back. The CVR recording is reportely of very bad sound quality in the moments previous to the impact. It did record all the way to the end, though, and a substantial partial transcript has been made part of the judiciary investigation.

The reporter, Guillermo Lobos, of Argentina TV channel "Todo Noticias" (TN, owned by Canal 13 of the Clarin media group), admited having fabricated the whole thing, which he shamelessly presented as "The last words of the pilots in the cockpit extracted from the black box" just a few days after the accident.

This is likely the last state of the preliminary CIAIAC report to be published any time now:

-The flaps probably weren't out.
-The investigation still hasn't been able to proof the position of the handles to activate flaps and slats.
-The R2-5 relay is still suspected of malfunction and the culprit that the TOWS didn't activate the alarm to signal that the flaps/slats weren't out. But its performance state still hasn't been established.
-From Sep 22nd til 26th the QAR (Quick Access Recorder) disc data was to be extracted at the manufacturer's facility in the UK.
-The manuals and procedures used to "repair" the RAT probe heater are being investigated.

You can see scans of the letter sent to the judge a couple of weeks ago about the advances in the investigation and main changes from the Sept 4th draft to the september 23rd revised draft:

http://img66.imageshack.us/img66/379...ardlastta5.png
http://img66.imageshack.us/img66/432...rdlast2ue3.png

Just came across this article:

Pilot error not to blame for Madrid air crash, say investigators - Telegraph

"flaps/slats set"
 

I'm wondering indeed what exactly the prelim report will say about the earlier reported "flaps/slats ok" or "....set", allegedly retrieved from the CVR (see LUALBA post 1478 and jutme69 posts 1487 and 1714).

If that would be confirmed the key issue is whether the pilot not only "just" called this, but at the same time really/consciencly had verified that what he called was in fact in accordance with the settings in the cockpit. In other words was it really a "check"-call or a call without the actual "check".

A large segment of the press refuses to speak of pilot error, but they have no problem whatsoever suggesting system malfunctions.

The preliminary report doesn't point fingers and doesn't mention either pilot error or system malfunction, other than the TOWS.

The "facts" to the best of their knowledge are:
-The pilots followed (reasonably) the checklist. They seem to have called flaps and slats as "ok". It is not known if they were sure, as it wouldn't be the first case found of a "rotten response".
-But the flaps were NOT out at that time, as per the DFR. It is not known why yet, but the procedures to determine the possitions of the handle are being studied right now.
-The TOWS alarm didn't sound, and it should've if the flaps weren't out. It is not known why it failed, but the workability state of the R2-5 relay is being suspected and investigated right now.

Now, think for a second. If the pilots called the flaps and slats as "ok" and, LET'S ASSUME FOR A SECOND that they were not "ok" (either system malfunction or forgetting to deploy them) ... how do you think it could've happened that, when the pilots "lowered the handle" to the first detent:

-Both, the left and right slat didn't go out to mid possition in the front of the wings.

-That the lighted indicator that signals that the slats are in takeoff possition lighted up, while the rest of the slats indicators (autoslat fail, etc) remained off.

... and when they set the handle to the second detent:

-Both, the left and right flaps didn't deploy the 11º commanded on the back of the wings.

-That the ANALOG dial that shows the position the flaps are "positively" in (and independently of the possition of the handle), showed 11º for each wing and yet the flaps remained at 0º (as shown in the DFR).

That would imply that at least 8 independent mechanisms (4 for each wing), all very simple and extremely reliable, decided to fail at the same time (slats actuators, slats sensors, flaps actuators, flaps sensor) in such an incredible way that they signaled "slats ok for takeoff" and "flaps at 11º" for both wings while they were actually not.

And remember, some 45 minutes earlier, the flaps had come down 11º upon the first attempt to take off.

Besides being obvious that it was probably the pilots forgetting to deploy them (as in Northwest, LAPA, MAP and other "proven" cases), even if the flaps and slats failed by some "impossible" reason, the crew would still be at fault for not checking the indicators to make sure the devices were in the correct position before accelerating for takeoff.

The press continues, even as today, to twist and turn the facts to fit their "show".

Today I saw headlines in the like of "The preliminary report shows that electrical malfunction of a relay needed to deploy takeoff systems is the cause of the accident" :ugh:

The preliminary report has been made available:

http://www.fomento.es/NR/rdonlyres/9...preliminar.pdf

The main "news" are:

-Last Minute Changes were included in the cargo sheet, adding 555lb to the weight (5190lb PAX, 27655 cargo). ATOW reflected 141863lb.

-DFDR recorded RAT probe to 104ºC prior to first line up. After that, RAT didn't show over 30ºC.

-Some of the checklist procedures can be figured from the CVR (prestart and before start) and the taxi checklist. During taxi, they contacted ground control and received takeoff permission. Before take off, they run the take off inminent checklist.

-210º 5knots wind, >28ºC.

-DFDR has reliability problems on the recording of one of the two flight guidance computers (DFGC nº2), the origin of which is unknown. The DFRD doesn't use the DFGC to read the RAT temperature or the flaps angle setting.

-The DFGC selected by the crew was nº2 (there goes the investigator's luck).

-Part of the data on the QAR has been extracted and is being analyzed.

-3 right wing and 2 left wing flaps' actuators have been identified. 4 had lost hydraulic pressure and could be freely actuated. The fifth was heavily damaged from the fire and is stuck.

-2 slats control cilinders were found, as well as the mechanical elements for 3 of the sections. All fire damaged and consistent with RETRACTED positions.


The report concludes that ongoing investigations are being centered in finding out the state of wing configuration and cockpit controls as well as further analysis of the black boxes, etc.

And that's it. If it weren't for the leaked draft, we would know even less than we do know. So much for the wait-and-do-nothing until the official information is released. :\

You can (perhaps) get a google translated version of the report here:

Translated version of http://www.fomento.es/NR/rdonlyres/97C78A32-1428-4BC4-B70C-18DA3474E92C/38073/2008_032_A_preliminar.pdf

Digital Flight Guidance Computers 1/2
 

I have read the "translated" preliminary report - mostly "old news"!

The report mentions Digital Flight Guidance Computers (DFGC) 1/2.

A short clarification for the benefit of non MD pilots:

The MD series aircraft have 2 DFGCs - one is in operation, while the other one is in a standby state.
The chanceover is done via a selector on the glareshield panel (below the autopilot ON switch).

In my airline the standard procedure for operation of the 2 computers is:

Left pilot as handling pilot: DFGC 1 (selector left)
Right pilot as handling pilot: DFGC 2 (selector right)

Spanair procedure? (Acc. the report DFGC 2 was operative)

According the report the selected DFGC sends info about slats position to the flight recorder - I wonder why the system works in this way.

grebllaw123d

It looks like Spanair did basically the same.

Since the copilot was the one in control, they selected flight computer 2.

Unfortunately, the Data Flight Recorder had problems reading the data everytime that computer was selected.

As a result, most of the flight recorder data of interest for this accident is not readily available.

No idea why the slats' position goes through the flight computer and then to the data flight recorder.

But as a result, only things like the flaps position and the RAT temperature can be obtained from the FDR "as is", since they went directly to the recorder without going through the computer first.

But the slats position can not be conclusively obtained from the DFR in this situation, since it didn't properly record anything coming from computer nº2. It worked fine with computer nº1, but that was not the one in use during this accident.

Sorry if a repost:
BBC NEWS | World | Europe | Wing flaps caused Madrid crash

southernboy most of us are pretty good at responding to the honking horn and blinking red light and most of us aviators have done the tasks thousands of times without consequence even if we botched the task a bit.

and you can 'swiss cheese' your barriers, train over and over again, create policies and procedures, revise checklists, encourage everyone from the PIC to the plane spotter at the fence to point out errors and... still accidents are going to happen.

sorry to not be typing with capitals as needed by as of right now, I am working with a rebuilt shoulder from a recent bicycle crash which destroyed the shoulder. Now riding a bicycle is a fairly easy task and for someone who has been riding bikes for decades, one could say I was an experienced bicyclist. I have done many 50-75 mile bicycle rides without incident. But then recently I recently turned my head slightly to watch 3 riders go by as I approached the 50 mile point on a 66 mile ride and the next thing I knew I was going over the handlebars after hitting a pot hole large enough to swallow a tank.

One could say I was distracted and the obvious answer is to not be distracted by telling someone to not be distracted is 1) like telling someone they should advise you when they are asleep and 2) it is not realistic.

One could say ride more carefully and have better 'situational awareness'. I didn't see the pothole until I was almost in it. All this to say we make mistakes which are the exception to the rule and sometimes we incur significant consequence up to and including loss of life. or in my case, a new steel plate with eight to 10 screws holding together my reconstructed left shoulder.

CVR
 

We haven't learned much from the preliminary CIAIAC report that we didn't know already. I was particularly struck by the passage that relates to the CVR which says, and I translate quite literally now from the Spanish report:

"the CVR recordings allow to identify some expressions relating to the pre start, taxi and imminent take off checklists"

'some' expressions? does this mean to say that the recordings are so bad that they become unusable, or do they mean that the checklists were only partly complied with?? That sentence is extremely vague and yet the CVR recordings could shed some light on the sequence of events...

Very disappointing.

harry (PPL, frequent SLF and professionnal conference interpreter)

xolodenko,

I think I can imagine what you feel. I have been to a crash site where a friend of mine fell out of the sky including another person. When I arrived, there were just a crater and some really tiny pieces left, nothing more, nothing spectacular. That event will never reveal so much details like "Madrid", as a FDR was not on board - but exactly that creates an even more restless brain since years. I kept debating with people over and over who knew both and who knew the airplane that brought them to death, as my deepest wish was to just understand what could have been the cause(s).

Since then I am very much interested in valid thoughts about tragic accidents like the one discussed here, as I am eager to learn more about human factors, safety critical engineering design and the like, just in case it can tell me someting about my own flying. E. g. missed flaps you could have on almost every aircraft. I just try to get my bag of knowledge filled more than my bag of luck.

There are different ways to cope with deep impressions, some people keep talking, some shut up entirely. But I think it's ok if everyone tries his own way, so do I when I post here and speculate. This is entirely NO disrespect towards the dear souls missing, indeed perhaps just the opposite. We owe them to try our best to make sure it never happens again. First step would be to understand - and not to rely on just some people whose report is just as thin as in the Lanzarote incident. I for sure learned more about the latter on PPRuNe than from the official report.

BBB

Quote:

---

'some' expressions? does this mean to say that the recordings are so bad that they become unusable, or do they mean that the checklists were only partly complied with?? That sentence is extremely vague and yet the CVR recordings could shed some light on the sequence of events...

---

It seems to be a bit of both.

The CVR is both, of extremely bad quality in the inmediate moments previous to the accident to the extend that most of it can only be made sense of using foreinsic methods (carried out by the police sound lab, and therefore not 100% conclusive) and the checklist (unofficially) seems not to have been done 100% according to regulation, but pretty close. (i.e. flaps and slats may have been reported as "ok" rather than as "11º, takeoff").

It seems, that because the audio can not be fully made out, it can also not be conclusive whether the checklists were done 100% right, 99% right, or what, but they (unofficially) seem to be "possibly not perfect, but reasonably good". In another words, the pilots probably THOUGHT they had gone through it and they probably THOUGHT they had the flaps and slats set.

The "almost exact" transcript of the CVR will probably be known (outside the authorities) in a couple of weeks. It will then shed some light on exactly how distracted the pilots could've been during the maneouver and how closely they followed the checklist.

The judge will spend the next days calling a couple dozen witnesses, 6 on the 17th, 5 on the 27th, 5 on the 31st, some of them for the second time, to ask specific questions and check their declarations against their first ones. He will concentrate on the technicians that did the "repairs", the previous failures of the aircraft and how it could've affected the TOWS.

He'll also call the flight attendant that partially witnesed the accident from the air, the airport ground coordinators, the supervisor of airplane cargo loading, the supervisors of the crew in service on that flight, etc.

The CIAIAC has informed that, as it was expected, they won't speak a word again officially in public about the accident for between 1.5 and 2 years.

Thankfully, there is a public judiciary investigation going on and I'm sure the judge will request updates and evaluations from the QAR data, the flaps handles, and other important data within the next months.