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".

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.

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?

The link below to the BMJ states that 70% of aviation accidents have human error at the root.
But what is remarkable is:
A rush to institute legal proceedings is therefore entirely predictable. Sigh.:rolleyes:



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

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.

Rattler46
 

It does not work like that in Spain, see

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

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.

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

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

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 ..."

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.

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

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.

Courts Martial Are Real Courts
 

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.

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?

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.

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.

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...

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....

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.

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...

Blacksheep has it spot on. Think about it your £600 TV goes wrong how long does it take to fix when you take it in, 2 weeks maybe.
Your multi millon £ aeroplane goes wrong and it needs to be fixed yesterday.

Hey, it's slowing down. We should be able to reach 2,500 posts and 1 mil reviews by Halloween! Push it up!

Well, not much new.

The judge keeps demanding documentation from Spanair. Now he's concentrating on the ground engineers' permits, history of past repairs on other airplanes, repair manuals, etc.

Better news is that all the survivors from the crash have left the hospitals except for the two in more serious condition, who are nonetheless slowly recovering.

Justme,

you're kind as always in answering to 1Bingo, but I'm afraid his post was simply due to the need of "leaving a written sign at any cost", a bit like the ones that go like "let's wait for the official report", and "you guys are just speculating without a clue".

Of course both kind of "contributions" would be better to actually never happen, but such is the human nature for some, they can't paint, but are happy to just tag their name on a wall.

EDIT: tnx lomapaseo for suggesting the right word for "tagging".

it's called tagging. similar to a dog wandering between trees and a fire hydrant, it lets other dogs know that he's around. . and now I to am a worthless contributor to this thread

el # and lomapaseo,

There are occasions where, me too, I briefly lift my leg against the fire hydrant of a particular subject to leave a trace, without having anything significant to say.

The reason is, that PPRuNe lacks the simple function (which exists in many other forums) to be able to subscribe (for email notification) to a thread without first having posted in it at least once.

There are threads I like to follow, without necessarily having anything to contribute myself. Having to post a brief pointless remark to subscribe annoys me, but it's the only way.

CJ

Poor mechanics
 

Poor mechanics, it is probably the worst thing that could surpass one.

Will the mechanics be accused of having a responsibility for the defective TOWS.
And will the investigations find out that pilots did not use flaps, Then I could imagine that there are many mechanics who want to move to another branch.
Who will have such a responsibility on themselves, and be blamed for others' mistakes, and risk a penelty.
It is very exciting what the judge will concluded in this case.

Hopefully there will soon be a crucial track which can determine where the fault can be placed.

forget,
Gracias mucho!!
On most forums it's a small tag at the end of the topic, which is why I totally missed that one in the menu bar... which I normally have no reason to go to.
I mentioned it to a moderator, but he was not aware of the existence of that feature either. Issue closed for me, and thanks!

Christian

I am not sure I understand what the mechanics are being currently subjected to :
First : Are they just "imputaded " to be heard by the judges to find out what they actually did to the aircraft prior the accident ( I could go along with that ) or is there an attempt to use them as (low rank) scapegoats for that accident ?

Secondly , in the SOPs, is the TOWS a safety net , or a tool ?

In my area of work , the failure of a safety net warning system in our (ATC) systems cannot be used to justify an incident/accident. It may contribute to it, but cannot be the cause.

The same in real life I would say : the failure ( or non-vailibility ) of the ABS on your car will not be the cause of the accident you may have .

DISCLAIMER: this post is a theoretical rant.

Well, let's assume for a second (and I personally do not believe this is the case, it's just for the sake of conversation) that indeed the two engineers that did the "repairs" did their jobs carelessly and, as a result, they contributed to an accident that, should they have done their jobs as expected, the accident would've been likely avoided.

Again, just for the sake of this conversation.

Then, I wouldn't call the judge indicting them with criminal negligency "low rank scapegoating". After all, in that theoretical case, they would've done something punishable, right? I mean, the guys hold a degree in engineering, a vaild license for servicing these aircrafts and yet, the judge proves, they did their jobs without regards to the rules and neccesary diligence, resulting in loss of lives.

Also, the judge is indicting the head of maintenance for the whole Spanair, a "high ranking" position, in case he was pressing his subordinates into doing a bad job. A person that wasn't even aware at all that the repair took place, as he is only notified when the airplane is "out of service" and this one, technically, never was, as it was deemed to suffer a minor issue, a simple RAT probe heater that wasn't even needed for this flight in good weather "failing".

So no, *IF* they technicians did something wrong, I do not think the judge is acting wrongly. What's more, he is putting on the line just as well the highest ranked person in charge with supervising the maintenance operation for the whole Spanair.

Who else do you want him to charge? The head of human resources that hired them for not realizing they weren't "good" but careless technicians? The CEO of SAS airlines for not overseeing the acts of every single technician working (or subcontracted) by them? The college that educated the technicians for giving out a degree to somebody incapable of doing a good job? The CEO of Boeing for not releasing better educational materials that can be followed even by careless people?

Sometimes a mistake is only the responsability of the person making it. I'm sure that there are doctors with the finest education in the finest institutions in the world that, once every 20 years, make a serious mistake that impacts the life of a patience significantly.

I'm sure just as well that there are highly experienced pilots, with the finest training available, in the best working conditions in the world, that also make mistakes every so many years.

And it's nobody else's responsability but their own. And no, it's not always that they are reckless and careless (although that's often the case). They are just human.

I'm not talking necessarily in this particular case with the Spanair accident. But I'm getting the feeling that some people in this board think that a pilot (or a techinician or an engineer working for Boeing designing airplanes) can NEVER make a mistake and that, when they do, it's the fault of some mega corporation for (pick your choice): hiring them, not training them, paying them too little, making them work too much, not investing more in safety, not getting their job reviewed 200 times by other professionals, not insisting on more laws and regulations passed, etc, etc.

I agree that, very often, that may be the case.

But we all must also agree that, sometimes, that is NOT the case and a single or a couple of individuals are the sole responsable for their actions and mistakes.

Again, not necessarily in this particular Spanair case, where a bunch of people made small mistakes that helped turn the big mistake made by the pilots into something worse than it needed to be.

(i.e. Boeing engineer's for designing a less than optimal TOWS, Spanair person in charge of SOPs for not insisting on more TOWS checks, Civil Aviation authorities in Spain and the rest of the world for approving these SOPs and these TOWS designs, CIAIAC investigators for not warning about MAP Lanzarote case on time, maintenance technicians for improperly MEL'ing a disconnected symptom instead of a fixing a problem, the person in Boeing in charge of writing the maintenance manuals for not making the connection more clear, etc, etc, etc.)

"And it's nobody else's responsability but their own. And no, they are not "careless". They are just human."

Responsibility comes from conciously following procedures and otherwise doing the best job you can in the way you've been taught. As you say we're all human and make mistakes, but that's not necessarily through being irresponsible.

If a responsible person makes an honest mistake that causes a catastrophy, then it would be far more productive to investigate why the procedures in place didn't prevent the accident. Punishing the individual does nothing to help stop the same thing happening again.

The increasing culture of the blame game is extremely unproductive.

Agree totally, nobody goes to work thinking, lets see if we can transform this ship into a pile of smoking debris.
A mistake is just that, a mistake. Living with the consequences of an oversight is probably punishment enough in a just society.
Will punishment bring the dead back ? . . . . obviously not, will it make the victims families feel any better ?I seriously doubt it. Most importantly, will it add yet more incentive to cover up future errors to avoid punitive measures? undoubtedly. As the other thread on justice vs safety discusses, these witch hunts serve only to keep solicitors and judges in employment. They have absolutely NO positive contribution to make to future air safety, and contribute nothing to the future welfare of any victim or family thereof.
Scandalous, simply scandalous short sighted eye for an eye knee jerk reaction ,which to me proves whether a nation should count itself as civilised or not, so that, I imagine, leaves a very short list that are. :(

It is clear that there are countries where accident investigations become perverted and undermined by judiciary investigations interweaving themselves to the point where it becomes impossible to distinguish the two.

The message to anyone having the misfortune of becoming involved in future investigations is to keep your mouth shut.

justme wrote
Sorry justme, but I completely disagree with your opinion.

First of all, you seem to blame exclusively the mechanics. If you take into account that the main problems seems to be the slats/flaps not deployed by the pilots, then this last ones are the first one in being guilty.

Second, I think that the mechanics, even if the have a degree or a license in engineering, were hired and worked for Spanair, so the company is responsible for their actions, under the legal point of view and under the practice, as they should have been supervised by their actions in a better way.

For sure it is very possible that the mechanics did things wrong, I don´t know, and that the pilots did things wrong, just to be proved.

But the company will not be excused, even though you seem to do that in your arguments.

The only way for that would be that the accident were caused by something external, and it doesn´t seem to be this situation.

Were the mechanics responsible for the aircraft taking off with no flaps?

Well. If we IMAGINE a FICTICIOUS scenario where:
-A) The pilots were trained (and allowed by SOP/regulations) to blindly trust the TOWS would catch any configuration mistakes and
-B) The mechanics KNEW (or should've known if they were doing their jobs right) the TOWS were broken and yet didn't do the proper repairs ...

... then yes. They would be responsable. If they would've fixed the TOWS, the pilots wouldn't have taken off with no flaps.

But this is a FICTICIOUS scenario.

I guess for some people it wasn't clear that my position in the previous post was a THEORETICAL position.

I do NOT believe that the mechanics are responsable for the accident.

I do believe that they could've done a better job diagnosing the failure and perhaps that would've saved the day. But I don't know to what extend their actions or lack of REQUIRED ones actually contributed to the outcome.

So, again, if I must say, so that it becomes clear for everyone, I PERSONALLY believe that the contributing factors were the ones I'm listing below. If the CVR recording proves the pilots were more distracted than reasonable (i.e. the LAPA case), then that would shift my opinion even further. Same thing if they were following checklist in that "fast and furious" automatic way I have seen done many times in the past, where the pilots would answer non-standard things, put off some items to come back to them later from memory, etc, etc. That's not the way they were trained and encouraged to do it.

If you have NEVER seen a pilot carrying out a checklist way too fast like it was some kind of race, and you have ALWAYS seen them following the items carefully, writing checkmarks to each item, pointing to the instruments as they read the answers, etc ... then good for you. Please let me know the name of the airline so I can book safer flights for my family.

-The copilot: he was the one in charge of lowering the flaps/slats. He was also the one doing the takeoff maneuver. Although he had been working on the MD-82 for about 2 years and had some +1000h of experience on that aircraft, he can be considered somewhat of a rookie. W/o the exact CVR transcript and actually recording, I don't know how much of his mistake was the result of a "legit" oversight or of a "careless" attitude. Nonetheless, on him goes 50% of the "blame" at this point in MY opinion.

-The pilot: his +10 years of experience and +10000h of flytime should make him now better than trust a "rookie" copilot without double checking the important stuff. For me, he holds another 40% of the "blame".

-The other "highly contributing factor", the failure of the TOWS, from my point of view, COULD be considered an "act of God". Although in this particular case there were other circunstances, the TOWS could've theoretically have failed EXACTLY 1 minute before takeoff. TOWS is an electrical machine. There is NOTHING anybody can do to avoid failure 100.00% of the time. With that kind of design, whenever it fails is up to "God", no matter what maintenance or anybody does. If they allow that type of design to exist in an airplane, failure can occur at any time whatsoever w/o ANY warnings. I'm pretty sure the pilots kind-of-new that, but we all prefer to think it will never happen to us. We all know that, at any time, the brakes in our cars can fail. But we know it's so rare that this happens, that we trust them like if the were never going to fail. Until they do.

-In THIS particular accident, the other 10% of the blame is spread among all those that could've made the TOWS less likely to fail or the pilots less aware than optimal about the importance of correct takeoff configuration (i.e. a SOP requesting to triple check killer items, etc).

Say something like 6% of the "fault" would go to Boeing for not making a better TOWS design/better diagnosis/better maintenance manuals/better spreading the frequent TOWS test recomendations, a 1% to the person in Spanair responsable for failing to include the latest recomendations on the SOP or a SOP with a killer item double check right before takeoff, a 1% on the technicians for not taking a better look at the consecuences of their "repairs" and a 2% to the rest of the people/companies/regulatory bodies/CIAIAC/training systems/etc that allowed the plane to fly with pilots that overtrusted their TOWS (the pilots didn't even tested them prior to this flight, which wasn't even required in their SOP, indicating that they trusted them more than they should've. Somebody should've warned them better of the real danger.)

That's my PERSONAL opinion so that I'm not accused here of defending other positions I do not.

And, of course, I may be wrong and/or there maybe other contributing factors which I failed to mention or which contribution to this accident may be more relevant than I estimate. Again, this is a "rough" PERSONAL opinion, nothing more. I RESPECT that others may have the view of this matter were the "blame" is almost the opposite reverse to my OPINION, and they think that the pilots only have a small percentage of the "fault" and other factors (training, regulations, pressure, etc) are the main culprits. I don't agree, but I respect the view.

And finding "who/what is at fault" is the least important part. The "how can this situation be improved" is more important.

Personally, I think that, no matter how much training, how much experience, how much required procedures (i.e. double and triple checks on the checklists), human error can never been "ruled out" from the equation. Sure better SOPs and checklists can be developed to reduce the chances, though, and better training never hurts.

But I think that technology has a lot to say in cases like this. The TOWS can certainly be made much better nowadays w/o much trouble or expense, so why not start there?

I see no point on not making (all) TOWS nowadays something like this.
When takeoff thrust is applied on the ground or a CONFIG button is pressed as part of the checklist, the TOWS should run a quick self diagnosis, tap all positive sensors and reply:

-A distinctive "musical tone" with the words OK in "happy tone" by i.e. a female synthetic voice (i.e. LA-LA-LEE- "Configuration OK")

-A distinctive alarm tone with the name of the failing configuration in serious tone by a male synthetic voice (i.e. OOOORRGG - Slats - OOOORRGG - Flaps - etc)". This alarm tone would also be used in case of an autodiagnosis fail (i.e. "OOOORGGG - TOWS failure" when a stuck sensor or other condition is detected)

-When silence is "heard", the pilots should notice something familiar is missing and hopefully will conclude the TOWS didn't work for whatever reason (i.e. blown loudspeakers, sound amplifiers, logic board, lack of power, faulty "air mode" ground logic). They should consider aborting the takeoff if they can or be extra alert if they are past V1 when they notice, as they don't have a working electronic watchdog for any unnoticed configuration problems/mistakes there might have been.

I know this is not as simple as it may sound, specially in 30+ year old airplanes, and that too many alarm tones etc can also distract from ATC communications or other more important alarms (fire, etc), or even that the pilots could still try to take off without TOWS "approval" (i.e. LAPA) but I still think that technology can be one of the easy, cheap, effective ways of reducing the likehood for this type of accidents.

justme69, you can have all the technologies you want with all the backups you hope but the most important for an airline is safety culture, resources, quality, training…
Remember the e-mails from the Spanish pilots' union SEPLA to Spanair management : "The lack of resources and their quality on the ground, the repeated AOGs in the fleet, the scarcity of crews and the system of movement of crew members, mean the general feeling is one of operational chaos that places the passengers at risk."

justme69,

I concur with your post.

But.... maybe there never should have been a TOWS?

There are a few 'killer' items, and wrong flaps-and-slats settings are one of them. Should those items have become 'routine', because the pilots (maybe subconsciously) 'trusted' the TOWS to alert them to any mistakes and omissions?

Or should the TOWS never have been invented, the "killer items" marked in red in the check-list, and the pilots have it hammered into them, that the red-line items can kill, and have killed before, and if they ignore them, nobody and nothing is looking over their shoulder, and they may be the next on the KIA list....

Does the TOWS give somehow, somewhere a false sense of safety?

CJ

So, to summarise:

http://i14.photobucket.com/albums/a3...rnet/zxzxz.jpg

1. No configuration warning check was conducted prior to the start of the take-off roll.

2. The aircraft commenced its take-off ground roll in an incorrect configuration.

3. No configuration warning was generated during the take-off ground roll.

4. After unstick, the aircraft departed from controlled flight, resulting in a fatal accident.

5. No clear cause of the incorrect take-off configuration has been positively determined.

Is that it?