Furia is not correct in that the pilots activating the flaps handle is an established fact, confused probably by all the press reports (in Spain at least) that flat-out refuse to speak of even the possibility of human error but of "flaps failure". Nowhere there are indications about that. Of course you can read the CIAIAC report yourself here: Preliminary report A-032/2008 - CIAIAC - Ministerio de Fomento

Indeed CIAIAC preliminary report point to the pilots, PERHAPS, going over the required checklist items and calling them ("ok"). Although PERHAPS not 100% according to regulations, but pretty close in the worst case, unofficially. The report doesn't say the CVR confirms the handles down (i.e. a noise is heard as it goes down) nor does the FDR have a way (AFAIK) of knowing the actual handle position (only the position of the flaps and slats, if working properly).

The flaps were down 11º on the first takeoff "attempt", but not on the second according to the FDR. The report states that the slats weren't likely out either (from recovered wreckage evidence), but CIAIAC lacks the confirmation by the FDR because it wasn't working quite right for the selected flight computer #2. Perhaps the QAR can "confirm" that now.

Regardless, the symptoms of the airplane stalling seem more consistent with a flaps and slats "deployment failure" than with only flaps, although both scenarios are possible, of course.

The report also says that they are trying to establish the procedures to try to determine the position of the flaps handle at the time of take-off. Nothing else.

The TOCWS, indeed, seems to have failed, as the configuration was incorrect (at least for the flaps) and the alarm didn't sound.

While we all still give the benefit of the doubt as to whether the flaps handle was lowered and both flaps and slats on both wings failed to deploy while the indicators for the slats properly lighted to the TAKEOFF position (while the rest of the lights remained off) and the analog dial indicators for both flaps signaled the correct 11º position, we all know that it is basically imposible and it is far more likely that the handle was never lowered, as it has happened many times before like in Nortwest, Delta, LAPA or MAP cases. Or, at least, even if it was lowered, that the indicators were never checked to be in the correct position. Either way, it would be a crew error. This action would've been carried out by the copilot in this case, rather than the pilot, it seems.

Also, the pilots noticing the RAT probe heater turned on came way late in the line up taxi roll for the first "takeoff attempt", pointing to probably having gone unnoticed until the temperature tripped over 99º, firing an autothrottle warning, rather than by reading the amp meter for the heater or doing a sanity RAT indication check early on, perhaps. I don't know if the SOP required such a test, but it wouldn't have been a bad idea that the crew checked the stuff anyway.

The recent spate of news stories in the papers cites a NASA safety data source reported by pilots with similar events as the Spanair crash. I was particularly interested in the data comparison between the crew error vs the TOW error rate in this data refernced below.

From my initial view with such a high crew error rate we need a much lower TOW error rate to achieve the presumed level of safety in the initial design of the aircraft.

If this can not be done with system design then it has to be addressed with operational changes. I really don't see this as unique to a given aircraft model (see news article below). But I'm not willing to walk away from this as a one-off "it-can't happen to us"

Human error stubborn snag in airline safety - USATODAY.com

justme69
Thanks for clarifying, that was indeed how I believed the "official" as opposed to the "press" version of events were.
No one wants to believe they, or someone close to them, is directly responsible for an event like this.
Unfortunately for Furia, his sadly departed acquaintance must shoulder some of the blame even if tech problems magnified the mistake from an incident to a fatal accident.
It would be interesting to run an anonymous poll to see what percentage of pilots have lined up & advanced the thrust levers without selecting flaps.
The results would open everyones eyes :eek:

IF you wanted to, you could stick your head out the DV window and see the slats/flaps.

I want it made clear. I didn't blame the pilots, I BLAME THE COMPANY THAT TRAINED AND TESTED THEM.
Is it remotely possible that the flaps were selected properly and the sleeve of the copilot moved it out of the detent and therefore up?

it is a very remote possibility, very remote.

But some bright guy might try it...maybe even his wristwatch caught the lever.

mea culpa . . . . . . .
 

I'll be the first to admit to that. OK, it is only a C172, but the take-off performance is still degraded. Just feel a bit sheepish inwardly as you stagger into the air much more slowly than usual.

I do not want to exclude any posibility.
There is no video camera on the cockpit so we only have the CVR.

The oficial preliminary report states that the crew completed the checklist.
They say nothing about rushing items or missing items. Anyone that has flown in Barajas knows the long taxi to the runway so they should have not rushed any items anyway.

The report concludes the crew was performing the appropiate checklist.
No comments there, nothing was rushed, ommited or neglected, but still some people wonders if the pilots may have been doing some wrong

Seems that for some people here it is easier to assume that the crew was just reading a checklist but not doing their job rather to assume that a not uncommon flap/slat extension failure happened.

You must forgive me but without discarding any possibilities I prefer to think that if one pilot was challenged with the "Flaps and Slats" question and he positively answered "Flaps and Slats OK" he meant that.

If you want me to change my mind about that, demonstrate it otherwise.

Well, I don't want to get in an argument here, but if indeed the response to the checklist item flaps/slats was "OK", then that's your first evidence that the crew wasn't doing their job properly.

They should've answered with the degrees setting and the setting, like "11º/Takeoff", as trained and required by the SOP.

Also, it wouldn't be the first proven case in the history of aviation of a rotten response, but it would be the first one of a multiple system failure involving a very simple and reliable mechanism that developed into no less than 8 (4 for each wing) simultaneous failures (flaps actuators, flaps sensors, slats actuators, slats sensors), that resulted in a lighted indicator and an analog watch dial indications TAKEOFF for slats and 11º for each of the flaps when indeed both flaps were at 0º and the slats (likely) retracted.

If you choose to rather believe in someone saying "ok" rather than both needles of an ANALOG indicator gauge pointing "mysteriously" to 11º (while the flaps were at 0º) and a lighted indicator receiving power from TWO switches (one on each wing) closed by "something" in the place of the slats while the slats weren't actually there ... well, that's your choice and indeed it's a possibility.

But realistically, we all know what is far more likely.

Also, it has been proven in the past that crews failed to deploy flaps and slats in at least 4 more cases (Detroit, Delta, LAPA, MAP). So it is not so "unusual".

And the CIAIAC CVR preliminary analisys doesn't say the pilots completed the checklist, only that there is evidency of SOME ITEMS of the checklists being performed. Exactly, what it says is:

"The conversations of the cockpit voice recorder (CVR) revealed CERTAIN EXPRESSIONS corresponding to the before engine start checklists .... the normal start list, the after start list and the taxi checklist ..."

It doesn't say anywhere that the pilots called flaps/slats and the response was "ok", which still would've been a wrong response, but at least it would show that they were trying and they probably thought they had set it.

And UNOFFICIALLY, sources close to the investigation say that you can perhaps, with foreinsic CVR analysis help, indicate that indeed the pilot called flaps/slats and the copilot answered ok. But that's unofficial and would still not prove that the actual flaps and slats were commanded to deploy and the indicators verified, only that they thought they had set them.

The alleged response of "OK" (instead of 11º/Takeoff) could also mean that the copilot understood a different item to be checked instead of the flaps/slats and replied to that, while the pilot calling the item didn't verify or requested the proper response.

Quest for continuous improvement
 

Hello !

justme69

Quote:

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I've said it before. Better training never hurts, but I also think that it's each pilot's responsability to learn as much as he can about the machine he is driving past the point of "reasonable performance" that he obtains together with his license.

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I fully agree … and not only to learn more about the machine, but also about other very important aspects of his job. It is part of the required « enthousiasm » that is a character of good pilots. It is pure « airmanship ». If you are interested, I recommend « Flying kow-How » and « Flying the weather » by Robert N. Buck (Macmillan).

However, not all the pilots have the proper culture to progress by themselves in the several « improvement » paths. That is the reason every airline has a « training » department, even if they don’t provide basic training or type rating. Instructors, chief instructors, head of operations … should have - collegially - the required culture, experience, airmanschip and information (error reporting litterature) to design an appropriate « continuous improvement » program.

It is nowaday recognized that the initial type rating could not provide all the in-depth kowledge of an aircraft. You have to build that in-depth kowledge by adding layers of kwowledge above layers of training and operational experience. With proper supervision an progressive checking.

The fact is that there is litlle or no « standard » about that continuous improvement of competency and airmanship. Its rests upon the shoulders of the chief pilots and instructors.
So each time you hear « Our airline is fully complying with the standards » … it means NOTHING.
Or , in fact, it means : « we are satisfied with minimum standards » L

justme69
1. Obviously, MacDouglas and Boeing should have done better ...


2. Better human knowledge (of the aircraft systems and other safety related toppics) doest not come from « more » training, it comes from better training … Better training is given by better instructors, using appropriate tools and a better syllabus. You don't need the latest multi-million simulator to train better pilots, what you need is :
- first class instructors (instructors with extra airmanship, instructors who think ) – not the kind of « repetitors » that are so frequent among sim instructors …
- selected pilots … applicants selected and trained not for their parents wealth, but for their smartness and enthousiasm for flying.

When airlines used to train their future pilots ab-initio and for free , their first objective was to select « the right stuff » ;) .

Only a very limited percentage (5% or so) of applicants made it to the right seat of an airliner.
Today, training is given by commercial subcontractor, and paying trainees are indeed « customers ». You won’t reject customers …
Selection is a joke. It is just a selection by the money … So, only a very limited percentage of applicants are rejected in commercial FTO’s and TRO’s.


3. Better technology can help … to some extend. Airbus was supposed to provide that cutting edge technology improvement towards flight safety. You think they made it ?

Actually, the best improvement in flight safety came with the introduction of CRM and scenario based recurrent training. A real improvement from the previous « macho » philosophy. Still a long way to go (at least with Spannair) :
- A properly CRM trained crew member would "never ever ever" accept a sloppy challenge and response check list. (Just considering it as an insult ...)
- A properly scenario trained crew would know better about stress and distractions …

justme69

Quote:

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I've already stated that my opinion, given the impossibility to trust the pilots to NEVER EVER EVER forget the killer items, is to improve the reliability of the warning systems by requiring more frequent tests by the crew, improving the design and improving the maintenance manuals to help recognize failures.

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I do not agree with the "more frequent test" remedy.
The main business of a pilot is not to test again and again his parachute … The main business of a pilot is to make sure not to have to use that last ressort safety net.
Before take off, there are much more important items to check, rechek and cross-chek … The system tests should really be kept to the minimum (I agree with a test during the prestart scan ... as a normal pilot habit!)
But, once the aircraft starts moving, chek list should be restricted to the killer items, and to those items that were impossible to set/check while the aircraft was at the stand.

sevenstrokeroll

Quote:

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I BLAME THE AIRLINE(spanair) FOR NOT TEACHING< TESTING< the pilot's and mechanics in the same knowledge area that I was taught and tested in.

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I fully agree.
For the same reason that the maintenance manager has to report to justice, I think the chief pilot and a few other managers should be involved as well.

An airline his supposed to have a strong structure garanteeing safe operation :
- a trainging departement and a flight ops department working in close relationship. They are supposed to be headed by very competent and experimented « responsible managers »
- a quality manager, a quality system and a safety officer working in close relationship, and coordinating/supporting other managers efforts.
- scheduled quality management meeting, examining audit reports and propositions for improvement.

Let us not forget the triple mission of the quality system :
- make sure that mandatory standards are complied with. We know that lobbying by short sighted cost conscious airlines have reduced those standards to a level well below what was previously in force by first class airlines. Just a paper work challenge ...
- seek for continuous improvement above those bare minimums. It means of course … see at it that the "responsible managers" really work in that direction ! A very exciting challenge indeed, provided that all the managers are willing to play and that they have the time and smartness to be honnest players.
- keep the top management "in the loop".


It is a fine structure ...
But that structure did fail ...well before the crew entered the airplane that day.
There was a latent defect somewhere ...

BIS,

I agree with most of the points you raise. When we post here, we all obviously try to be brief and shortcut our explanations a bit.

So just to clarify, when I said "increased training" I meant "more, better training". I disagree that knowledge doesn't come from "more" training but only from "better" training. I think that it comes from both, but that's just semantics.

When I said "more frequent TOWS checks" I meant more than just once a day and whenever pilots changed or were away from the cockpit for a long time. In more practical and specific terms, I meant "once a day by maintenance and shortly before each takeoff by the crew". Obviously TOWS check is an important safety measure, as shown in this an other cases, second to killer items, of course, but not far behind, lacking a better solution (i.e. technologically super-reliable TOWS which gives a big and clear indication when it fails)

I fully agree with the "right culture" against the "macho" culture. I think there is a LOT of that in Spain at least (Iberia, Spanair, Air Europa, Binter, Air Comet, etc). I have no problems pointing fingers where I think they are due.

I, nonetheless, disagree that training or "corporate culture" in those companies promote or condone this kind of behavior, but SOME pilots engage on it right away shortly after their license/rating is granted.

Firing someone with a powerful union behind is not easy or cheap in Spain. And with closed-door cockpit policies, other than consistently spying on your own pilots through CVRs and QARs I don't know how they can figure out the good apples from the bad.

I'm all in for planting videocameras in the cockpits and have one person in the airline reviewing everyday random flights and suspending pilots left and right. But I can see hell being raised by them and their unions, so it probably won't happen and the "machos" will continue to dominate the skies.

I have two relatives that are in the aviation industry. One is an ATC and the other is an airline captain for a major airline in Spain. The horror stories he tells me of while travelling around in jumpseats are not for the faint of heart.

DISCLAIMER: Obviously there are very fine, top of the line worldclass pilots in Spain. But we have ALL seen what some less stellar ones do around here. And not only here, of course. Look at the CVR from LAPA or Delta (etc, etc) in similar accidents for much much worse.

And on the good side of news today, all survivors have left the hospitals in Madrid, although one of them would still need local medical supervision for a while. All 17 PAX and 1 avan crew member that survived have been able to recover favorably.

I encourage you to see a movie, Whisky Romeo Zulu, from Enrique Piñeyro, former pilot of LAPA. The movie has its name as it was the LAPA plane, LV-WRZ
I don´t know if there is any version of it in English, but those who know spanish will appreciate it.
The case of the LAPA plane was not only about pilots forgetting to put the flaps/slats and not giving attention to the TOWS (that in that case worked fine).
It infoms precisely the many layers of swiss cheese that were aligning in that company that lead to the disaster.

Besides all, we are forgetting the particular circumstances of that day, the copilot in charge of the take off knew that he would be fired or offered an administrative work; also a press comunicate from the sindicate pronouncing some facts about the risk in the operations in Spanair (that never saw the light as a consecuence of the accident)...

I have seen the movie and considered it too biased. But what would you expect from a movie made by a pilot unionist.

Otherwise, except for a couple of times when I thought it was being overly one-sided, it raised many vaild issues to public awareness that basically shows the caos in Argentinean civil aviation industry.

And all of you are going to excuse me, but I still fail to see how management or training etc can have much to do with a basic, simple human mistake like not lowering flaps.

I would understand that undertraining and generally unsafe practices unsupervised could lead to pilots making mistakes during complex maneuvers or extreme situations.

But something as basic as lowering the flaps handle while taxiing on the ground for 20 minutes by a rested, non-overworked crew?

Isn't every single pilot in the (first) world taught to never ever skip the checklists, do them right, and never forget the flaps/trims/spoilers/landing gear/etc like a million times?

How come when they fail to do that is NEVER their fault but "the company" for not firing them/training them (even) better?

I guess I have a question to make.

When is a pilot's mistake ONLY his fault and nobody elses? Never?

In that case, congratulations to all of you who are pilots. You can never fail because when you do, it's not your fault, it's somebody elses that apparently is human, unlike you.

the whole point is this:

if you are taught to use a checklist, but don't...it is vital that you be found out ...but if the management doesn't look for problems, they won't be found.

I would like to listen to the CVR and try to hear the movement of the flap handle into the detent. Or the actual movement of the slats...I've heard them at idle thrust when selected.

I would also like to know if the CVR picked up the stall warning horn.

I think the crash would have been more survivable if the use of the ''snatch'' rotation had been discouraged. Waiting for the plane to ''fly'' off might have given a better chance of surviving the crash. rolling off the end, right on centerline certainly would be better than slipping off the side into a ravine.


I wish that spanish judge would chat with me.

justme69

Quote:

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When I said "more frequent TOWS checks" I meant more than just once a day and whenever pilots changed or were away from the cockpit for a long time. In more practical and specific terms, I meant "once a day by maintenance and shortly before each takeoff by the crew"

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I’m not type rated on the MD’s …
As far as I know, the actual procedure for testing the TOWS is to advance thrust levers while the flaps are up or the airbrakes are out.
Nobody wants to do that while taxying, and nobody wants to be in an abnormal condition « shortly » before take off … just to test the warning system !
But this is so easy to perform (at least partially) before start, that I don’t see any reason not to perform it before each start up. (Let it be a partial check : the airbrakes « out » condition would not be checked …)
« First flight of the day » checks are a pity … A test is either important and then it is wise to make an habit of checking those systems before each flight … or that test is not really so important, and then let us forget about it and concentrate on more important items directly affecting safe operation.
Then, giving a look at the RAT indication before departure would give a clue about air/ground mode if the reading is abnormaly high. And there are other good reasons to observe that instrument shortly before departure ...
There are other ways to improve proper take-off configuration set-up :
- do it as soon as practicable, as a priority action. Say - typically - just after push back …
- keep the taxi checks to a strict minimum
- ask for before take-off check list before calling « ready for departure » and keep that check list short ! … By the way, a captain should silently review the killer items just for himself before asking for the check list (IMHO – and that is my personal private safety net, my « pride » not to be saved be the check list).

Justme69

Quote:

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I, nonetheless, disagree that training or "corporate culture" in those companies promote or condone this kind of behavior [macho culture], but SOME pilots engage on it right away shortly after their license/rating is granted.

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It is part of the chief pilots responsibilities to see at it that a « macho culture » does not survive in the company. Many tricks are available during sim checks to have macho's regain some humility ...
Yes, spying crew as much as practicable is a chief pilot duty … and a common practice by top companies. Crews are aware that recorders are going to be checked, either by their chief pilot or by state inspectors …
Firing an undisciplined pilot is difficult, or expensive ? Try an accident !
In any way, that will hold true for the first firing, less so for the second one … and then, there will no longer be any need to fire somebody ...

Justme69

Quote:

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And all of you are going to excuse me, but I still fail to see how management or training etc can have much to do with a basic, simple human mistake like not lowering flaps.

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I do excuse you … You cannot realise the accident prevention intricaties and subtilities if you are not « in charge » in the real world …

Thank you, Bis

Just for the record, I do understand some of the "subtleties" involved, like checking the RAT reading and RAT air intake anti-ice heater having more to do than simply showing potential air/ground logic faults. The autothrottle computers would appreciate having the correct temperature readings for the calculations.

I do not know if the MD80 have alarms for when the heater fails while on the air, but I know some similar (but more vital) devices like the pitot do.

Again, for short, I guess I didn't specify that by testing TOWS shortly before takeoff, I meant right before the engines are started is close enough if that's the most convinient time to have the flaps up and move the throttle to switch activate position w/o bothering/endangering anyone.

"Overnight" daily checks done by maintenance are, from my point of view, a good thing as it provides with a less stressful and rushed enviroment in which an engineer expert rather than a pilot can test systems more deeply. Some times, I understand other systems are better tested while flying and/or performed by the crew.

And I do understand that a better managed, very supervising company, where knowledge is spread and advanced during time, etc, etc, can strongly contribute to a safer operation where a "simple", "silly" mistake like forgetting to lower the flaps is LESS LIKELY to happen.

I guess I didn't make myself clear. My problem is with "inmediately" blaming the company/management with something that COULD be the sole fault of the pilot. Granted it's not always the case. Perhaps even not the most common, I concur.

My problem is with those that do not believe that the pilots EVER can do anything wrong because, if they do, it's only because other humans working in the airline, regulatory bodies, or at Boeing, or at a maintenance subcontractor made them.

My problem is with those that think that fogetting to set of the flaps at least 55 times in the USA in the past 7-8 years (voluntarily reported), means automatically that in all cases tons of airlines must have crappy training, bad safety culture and poor supervisory skills, and they should all be put in jail for that. Except the pilots, who simply "followed along" blinded from the dangers of not lowering flaps.

We are all humans and we all make mistakes. As long as pilots only forget to lower flaps once in their career, I'm ok with that. I can not, in good faith, demand for much better. Hopefully, when they do, the TOWS won't be inoperative. I can, though, reasonably demand for a better TOWS than the one involved in this case.

Furia,
According your hyphotesis:

1 After start checklist was properly performed. Therefore:
i) Flap/slats were selected according TO performance calculation
ii) Slat secuence was checked as: disgree/TO/disagree-auto/disagree/TO
iii) Flap position indicator was checked to agree with selected flaps (both)
iv) Slats T/O light was checked to be ON and all other slat advisory lights
to be OFF.
v) Auto slat fail caution light on annunciator panel was checked as off.

2) Take off briefing during taxi was performed and flapp setting was checked.

3) Take off inminent C/L was properly performed and so:
Flap/slat position was verify( needles + light) during final/killer items check


Even though procedures comply 100% with SOPs, in FACT flap/slats were not deployed.
This scenario being true, I guess no MD pilot all over the world might trust this machine and the MD fleet should be grounded inmediately.

Now, to be honest, I'm appalled at the aviation industry for a couple of things that were permissable 30 years ago but I no longer think they should be today.

Granted I haven't seen the operations inside a cockpit on large airliners (some small commuter planes don't even have cockpit doors) for a while, but last I saw say only 9 years ago or so (Spanair, Aviaco, Alitalia, Usairways I remember specifically), and they still were holding a crappy piece of folded paper as their checklist, going through the items from my point of view faster than neccessary.

I know that checklists are computerized in some airplanes, specially new ones, and I understand that older types like the MD80 don't have that luxury.

But would it be too much to ask to print out some decent (instead of crumbled) checklists and asks the pilots to put checkmarks on the items or use a little lighted electronic board to check them off as descibed before in this thread?

Also, while I was reviewing old Spanair checklists I noticed how the most important item was in the first position in larger type. Well, because of this, I did miss the Flaps/Slats in the inminent takeoff checklist on the first look, subconsciously thinking it was a header rather than an item. I'm not a pilot, though, so I guess I'm excused.

Frankly, I thought the whole checklist system was far below anything needed since the invention of the inkjet/laser printer. The typeface, colors, etc. It can all be done so much better by a 12 yo (I'm exaggerating, of course).

Also, from the checklists I have seen carried out, most of the time it looks like one pilot is simply reading and the other setting/verifying, with the first one taking whatever the second one says for granted while he concentrates mostly in taxing rather than double checking (except for crosschecks, usually).

And last, very few times I have seen a pilot actually truly checking the flaps indicator while lowering the handles. The one flying during landing would call "flaps 20" and the other would lower the handle and inmediately answer "set" w/o ever looking at the indicator. This always caught my attention. Sometimes the one lowering the handle wasn't even looking at the position it was (actually looking out the window), just trusting it was the right detent by the "feel".

Not to mention the "macho" pilots who would go down fast and high and straight to flaps 30 after a 180 at 70º roll... (or who knows what angle, I'm bad at estimating these things, but at least 45º), but that's another story and the exception rather than the rule.

These are the words of Spanair's chief of operation, Javier Muela, extracted from an interview and translated by me:

In relation to procedures for checking the takeoff devices he said: "from the time the engines are started until take off, the takeoff configuration is tested up to three times, specially the flaps and its indicators, to make sure it's the correct one" .... "This triple check is even more effective than a TOWS check recommended by the manufacturer, which nonetheless is made during the first flight of the day or, in consecutive flights, if the crew changes or if they have left the aircraft".

He said that the first (TOWS) check was done (should've been done by the pilots) in the previous flight from Barcelona and again in the next one, Madrid-LPA, where the airplane remained for over 2 hours in the stopover, as the crew had left the cockpit for a long time, so "the crew made (should've made) another (TOWS) check upon entering the cockpit".

They weren't required to check the TOWS again for takeoff after the Return to Gate due to the RAT "problem", as they had not left the airplane and (theoretically) had tested them already for that flight (about 1 hour before, if the SOP was followed). This does not follow Boeing's recommendation of testing them before each (attempt to) takeoff. Spanair has since changed the SOP and now requires a TOWS check for the MD's before each takeoff, not just upon both pilots entering a cockpit.

Because the CVR only records the 32 minutes prior to the accident, and the airplane suffered the "RAT heater problem" delay and long taxi times in excess of 15 minutes each way, a lot of the data for analyzing previous crew actions can not be properly known.

Justme
If this statement is true, then we have a clue. It is very possible that the TO configuration was checked only once.
If so, we can presume that the pilots were used to do this only one time, not three times, so the procedures were not followed, and in this case we can talk of poor management and training, as nobody noticed what they were doing.

While I personally think that it's not easy at all to "catch" pilot's bad behavior, specially if it is only sporadic, I'm all for forcing airlines to install voice/image recording devices in the cockpits that last longer than the 32 minutes of the CVR which, best case scenario, would only allow to evaluate pilot's behavior for the landing part of the last flight.

That way airline supervisors can figure out what goes on behind the locked doors of the cockpit and catch bad apples before their actions becames a danger. Don't we all agree that this would be an easy, cheap and really effective way to monitor progress and compliance of crews with training?

After all, the last 8 large accidents with victims in the US have all been due to human error. This was Spain's worst accident in a long time, the first one with victims in Madrid in 25 years and the first one for Spanair in 20. Over 65% of aviation accidents are due to human error as the primary cause.

In that case, those within the company in charge of supervising could also be held responsables for repeated risky conducts of the pilots under their supervision/training.

It looks a bit like "who watches the watchman" to me, though.

So a pilot (consistenly, lets make this easy) fails to do his job as trained and the person that hired/trained him is to blame. Therefore, they failed too and all "four" go to jail. And it's OK to end it there. We don't need to hire someone to supervise that the supervisor is actually supervising the pilot, or that the trainer is actually properly training the pilots.

And if we establish such a position in an airline, then when a pilot fails, we send to jail also the supervisor for failing to catch him and the supervisor of the supervisor for failing to notice that the supervisor that failed to catch the pilot wasn't doing his job correctly.

I'm all for that too.

But why stop there? I would put a smiley face if the matter wasn't serious.

While I would totally understand the chief pilot/chief of operations/training of Spanair being charged by a judge if he never allowed the pilots to know how to properly deploy the flaps and how to follow the checklist, or if he had knowledge that they weren't routinely following the proper procedures, I don't see how he can be responsable if he never found an indication of that being the case and the training included more than sufficient information on the importance and proper procedures of flaps deployment.

You would only have noticed that something is wrong as soon as you had left the ground effect. Until then you would have used the same Vr and therefore required almost the same amount of runway to get the wheels off. Bouncing back to the runway is certainly not an option once the iron lady tells you stall especially when the plane starts rolling unexpectedly. What makes you sure, you would have saved the day?

Crappy airlines by the tons? Yes
 

Hello!

Justme69I'm among those that think that [...]
Yes sir, that is the real world.
Tons of lifetime examples ...
Demonstration?
Let it be given by a sharp occasional observer ;) :
Now, to be honnest, taxying is not the best time for Challenge and Response check list ... So the necessity to restrict it to very essential items.

In short, there is a real need to improve the useability of check list, as well as to promote a good "tempo" for calling "Check list!".

- subtilities/intricaties of accident prevention
- need for smart people ...

Please, don't take me wrong, I do appreciate "strong" safety devices ... but I hate seeing them used as an argument to dispense with "strong" crews, witch is the modern tendency ...

Hi Bis,

I think that, deep inside, we agree more than we disagree.

What I was trying to say is that I object to those that state, in cases similar to this, that they do NOT blame the pilots but the airlines for these accidents.

A pilot is a grown adult and knows very well that he is not doing his job right when he doesn't follow checklists as trained. The fact that nobody has caught him acting that way, doesn't mean that he is not responsable and, like a child, is not liable for his own actions.

Other people in the system may have also failed in their responsability (to catch and fire him), but you can't say: "I don't blame the pilots, I blame those who trained him", when those who trained him DID teach him correcly how to follow checklists and how to lower flaps and how important it was to do it right.

I'm ok with "I blame the pilots and I ALSO blame those who trained him". In most cases.

But to pretend a pilot is always "blame free" because, if he does something wrong knowingly and against his training, it's still some supervisor working at the airline's fault for not catching him ... hmmm.

No matter what he does, he is never responsable.

If he doesn't lower the flaps because he was never taught how to do it right, it's because he wasn't trained better.

If he was very well trained on how to lower the flaps and all its safety implications but he still didn't comply/made a mistake, it's because he was hired/never caught/not fired on time.

I'm obviously missing something in that line of thought.

But anyway, as I've said before, "whose fault" is not the most important part but "what can be done to fix it".

At this point, I vote for a (much) better TOWS design, a (slighty) improved checklist system, a (?) better maintenance manuals/MEL/etc and to plant AV cameras on the cockpits with 8h recording time digital DVRs (total cost $200) that are reviewed often by the airline to make sure pilots make good use of the training.

Improved training, as I've said before, can never hurt either.

Justme wrote
I am certainly suprised if airlines don´t do this.
I work in a non critical job(such as pilots do) and I am strictly supervised daily.
I fully agree with you !!

Well, if pilots don't want to be responsable for their mistakes, and the responsability must be found on those who train/supervise/hire them, then they must allow those people to closely monitor them at all times, obviously, and be willing to cheerfuly accept all corrective measures for any and every mistakes noticed.

Personally I don't think it's that great of an idea, as it would be like if I had someone constanly looking over my shoulder while I work. But then again, I do accept responsability for my own mistakes and don't blame my college professors when I fail to do correctly what they have taught me.

Justme69, don't forget the camera in the airline management's desk...

I'm all for that too. But who watches that camera?

Because the person that is watching the manager's camera, probably needs another one too to be monitored. And somebody to watch the person watching it.

Or perhaps, each adult professional should be reasonably left alone and be held responsable for his own mistakes.

When management/training makes a mistake, they should be held responsable. When a pilot doesn't lower the flaps as instructed, I do not believe that this would be the case (generally, in airlines that teach safety to good standards). Training obviously encouraged him to follow the checklist properly. That he didn't do it it's not due to management (under reasonable circunstances).

A different story is when a complex or caotic situation arises that is indeed due to bad training or bad management.

But a simple one like not following checklists correctly by a rested crew that is not "incredibly pressed" (and even if they are, a pilot needs to know that no matter what, for his own life, he can not stop to try to follow the checklists to the best of his abilities) and has been trained on how to do it properly, I still fail to see how it can be directly related to irresponsable management/training.

Somewhat related, maybe. *Necessarily* directly related, no.

And even if it is directly related, unless the pilots were actually trained and encouraged to not follow checklists (and they complied? Isn't that accomplicement?), that doesn't exempt pilots from the error's responsability.

It merely extends the responsability to include both, the pilot and the management/training.

That's my objection. In a case like this, of a reasonably good airline with reasonably good safety and resonably good training and reasonably good working conditions, a sentence like this can not be said: "I do not blame the pilots, I blame the training/management departments in the airline".

I have no objections with: "I blame the pilots and I also blame the airline", until more information can be had to see to what extend training on correctly following checklists or really bad work conditions were factors.

I think a scenario for this accident where the pilots had no responsability at all for their actions and it was all the fault of other workers (be Boeing engineers, SAS management or Spanair's training subcontractors), is very unlikely.

I have already stated, that besides the pilots, in this accident, in my opinion, there are many other factors and the people that produced them, that SHARE some (small) responsability (maintenance, Spanair's SOPs, CIAIAC, civil aviation authorities, MEL, Boeing, etc). And I have already said that, depending on more information from the CVR to see to what extend they were careless, I do not blame the pilots for what it looks could just have been an "honest" oversight.

All this, of course, assuming the pilots neglected to lower the flaps under the known conditions and the TOWS didn't work due to a recent unnoticed failure.

Don't remember anyone asking the question, did this flight have to respect a CTOT ( slot time) on it's 2nd departure, as that for sure adds a degree of stress/urgency to the start-up & taxi phase. Of course, in MAD, taxy time is never short time wise, but people can sometimes become very wound up, concentrating only on reaching that R/W before expiry of the slot to the exclusion of everything else ( cabin secure/ de-ice hold over time etc) I have seen it too often, and that could provide an explanation ( but not an excuse) for the rushed / skipped / screwed-up checks.
With apologies to anyone who feels otherwise, the F/O may be the one who lowers flaps, but the guy with the 4 stripes is in charge and ultimately responsible for the safety of the aircraft. If they tried to take-off with no flaps I can't see how anyone else can carry the can. Sure McDonnell Douglas the Spanair engineers ( and by failing to find out about/implement the cx before each T/O the Chiefs of Spanair) made it easier to turn an omission into a tragedy, but finally the "blame" if as a society we absolutely have to identify the "culprit", lies firmly on two guys who have paid the ultimate price for their mistake.
This thread is going round and round in circles now, surely it is time to realise the simple facts. Pilots are human, they make mistakes, when they do lots of people can die, they are included in this toll so don't want to make mistakes.
Designers Regulators and Managers don't have this immediate exposure to death, but they too make mistakes. The Pilot is always the one left holding the Baby, sometimes it slips from his hands. Everyone says how did he drop it? less people ask why did you hand it to him covered in soap and wrapped in cellophene. This is the nature of the profession of Pilot, you can die, you can kill others. Some will villify you, a few will understand, a few will even try to defend you and find excuses for your mistakes.
Finally, Sh@t happens, and you are the last link in a very long chain so expect to be blamed whether you were good or bad and whether you survive or not.

I agree.

But remember that, if you are handed out a soap-covered baby and you accept it, it is certainly to great extend your responsability to not drop him. If you don't want the responsabilty and want it to remain with the person handing you out the baby, don't babysit. Choose another profession.

But if the baby handed out to you only had a small band-aid in the forehead, and you dropped him with fatal consecuences, don't blame exclusively the person handing it out because he had a previous minor head injury.

Sure, "without the previous band-aid" the baby had more chances to survive the drop. But he probably would've perished even w/o it anyway if you dropped him like that, and he certainly would've survived just fine with the small band-aid if you didn't drop him.

There are times the responsability is 100% with the "handler" and 0% with the "parent" (i.e. the baby was in perfect condition and you just were overly careless). There are times when it's 80%-20%. There are times when it's 1%-99%. But there are very few times when it's 0%-100% (it would be irresponsible and liable to accept a baby you know is gonna fall w/o remedy -- you would only be excused if you had a gun pointing at you and forced to accept him).

I'm quitting now. This baby analogy is giving me the goosebumps.

- sorry for the delay - been a bit busy.

I agree, I have been and no doubt will be again, and sadly a lot of folk were indeed 'dissapointed' that day. I insist, however, there has to be trust in the system - are you so certain of you and your crew's abilities that you don't think the pax should be checking your fuel loads or approach speeds (or flap settings, come to that) or are you exempt from this - you need to confirm the engineers' actions but the pax just have put up with you? It appears you benefitted from an unusually deep airline systems training regarding the RAT heater which I doubt is universal.

I would still maintain that before this incident there were not many MD drivers who knew the A/G gotchas we have discovered here, and that it is unreasonable to attach blame to them, or to the LAE who 'fixed' the defect if HIS/HER training (including the MEL) also turns out to be inadequate. Indeed I suspect this thread has been invaluable in that respect.

It still looks as if the a/c would have taken off safely if correctly configured despite the rectification actions. Whether or not a crew should be trained/able to recover a stall following mis-configured flaps, I prefer not to comment.

You would only have noticed that something is wrong as soon as you had left the ground effect. Until then you would have used the same Vr and therefore required almost the same amount of runway to get the wheels off. Bouncing back to the runway is certainly not an option once the iron lady tells you stall especially when the plane starts rolling unexpectedly. What makes you sure, you would have saved the day?

We did a no flap takeoff in the sim at SNA (5700 ft) to demo this using flap 11 V speeds. We lifted off late but even with the flaps up did not have any control problems. Of course we didn't over rotate knowing what that would do to controllability with no flaps. The Spanair pilots didn't have the luxury of knowing their flaps were up at rotation.

Admitting pilot error
 

Hi Just You!

justme69
Not only inside ! It is just that I wanted to add a "plus" here and there to your most valuable posts ...

Generally speaking, pilots are "without pity" against their colleagues ... except in public, and especially when those colleagues died due to their own mistakes.

Blaming dead pilots seems indecent ... In fact they already paid for their mistakes ...

And, it is not "fair" either ... Because pilots are human being, and as such, they do mistakes. Every day ... They will put the flaps to 11 instead or 15 ... or things like that. They will set up wrong frequencies, wrong heading bugs ... Not too serious, and almost every time, they will correct by themselves, or be saved by the other pilot, or by the check list, or by a "back up" safety device (TCAS ...) or by sheer luck .

Human failability is a part of the safety equation ...

When the mistake ends up in a fatal accident, it means that the pilots made an error, of course, but also that all the accident prevention program failed.

Since it is too late to improve the pilots, it's time to look at the system!

Many pilots are not of that kind of reasonnable, wise, humble, persons ... If they do it their own way, they think they are doing a better job ... (sometimes, it could be true ... cfr those pilots silently reviewing killer items while lining up). Pilots are gods, you know ...

In big, safety conscious companies, it tooks a pilots generation to fully appreciate the benefits of a good CRM "spirit" ... God is no longer infaillible, a baby copilot can save the day!

Ok, pilots are humans, they do mistakes. Every day ... They will put the flaps to 11 instead or 15 ... or things like that. They will set up wrong frequencies, wrong heading bugs ... Not too serious, and almost every time, they will correct by themselves, or be saved by the other pilot, or by the check list, or by a "back up" safety device (TCAS ...).

When an accident happens : "pilot error" - most of the times. Or : ATC error. Or : hardware failure (wing spar, rudder, fuel tank explosion ...).

Do you blame a cargo door for failing?

No, you want to investigate why that cargo door failed, and ultimately put the blame (and the responsibility) on the shoulder of those persons who ultimately approved the design, with the full knowledge it was flawed ... (Consider the infamous DC10 cargo door problem : the cargo door initial design system was flawed, the "design supervision people" caught the flaw and refused to approve the flawed design ... But the head of the FAA finaly approved it, after a minor correction ...

So when a crew proceed to take off without flaps and ends up into flames, the big questions are :

1. Understanding how such a mistake did happen ... and that is in fact looking at the system around the pilots, putting blame on some flaws of that "error prevention system".
2. How to improve things ...

Of course, recognizing the fact that the pilots made an error is crucial ... because it opens the question : how came they made that mistake?

But "blaming" the dead pilots ... is too indecent, unfair, useless.

I'm sure that, despite my poor english, we understand the nuance between "admitting the fact of a pilot error" and blaming a dead pilot for making an error ...

For myself, I admit many errors, and I blame myself for those errors. I also improved a lot as a pilot looking at my own errors, at other pilots errors, and - with very great interest - looking at students errors ...

When the day comes when we have acces to CVR transcript, I think that we all shall learn a lot about "how to make a big mistake" ...

Courts Martial Are Real Courts
 

(Sorry, dont find a "Quote" button, so just highlighting it it manually):

Quote Rattler46:
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. /EndQuote

Quote Similin_Ed: 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./End_Quote

Sorry if that came along the wrong angle: By no means did I want to disqualify court martials in any way, I fully understand they are real courts (I am ex mil myself).

What I wanted to express with my post was that the inquisitionary juridical system in Spain (I live here, just FdR) with an "instructional" judge heading the *criminal* (and none else) investigation has some similarities to court martials in as that you can get accused of just about anything fairly easily (and much easier than in traditional common law "civil" criminal procedures) as long there is just a hint of "reasonable suspicion" of a criminal responsability, more or less along the lines of "...better be on the safe side...".

AFAIK (at least in Germany, where I served 8 yrs), about 95% of the court martials, long before oral trial, terminate w/o accusation (i.e. no formal charges brought against the defendants), from what I understand this is the same in an instructed criminal investigation case in Spain, as said in the name, this is an investigation and nothin more, after all.

FWIW, Rattler

justme69
I don't agree at all! Do you really think management have the time to watch or listen to a tape of every departure to catch "bad apples"? A waste of their time and talent. So hire people specifically for the task - can you imagine how well they would do such a boring, repetitive job?
Good SOP's, training and self-discipline are part of the solution - but we are all human.

Sorry, can't resist.:E
You mean like the airport security people?

TyroPicard:
I wouldn´t do it in that way. I´d only record certain parameters of the flight just to introduce them in a program. It would gave me lots of useful information to evaluate the behaviour of the pilots. May be it´s already in use ....in this case forgive me for my appreciation.

Well, if "blame" from the pilot's actions is consistenly going to be put in management, and I was one in an airliner, I would no doubt put a couple of "video ipods cameras" recording audio/video for several hours in cockpits and retrieve them "at night".

Then, I would hire someone to spend the whole day fast-forwading through to the important maneuvers (take-off, landing), going to normal motion when he suspected the crew was acting up.

And I would personally review a few of the "tapes" myself, at least one operation (i.e. takeoff) of each of my crews a month.

Just knowing that the cameras are there, would make a lot of pilots realize that "their system" is not better than the "checklist", i.e., or that looking at the flaps gauge is not optional.

The alternative is to have a system where the pilot is only nominally supervised (during training excercises, tests, QAR, inspectors) like we have now and, when he screws up for not following the training, it's probably only his "fault", not ONLY that of the ones that "didn't catch him not following trained procedures".

agusaleale;
That's what FOQA/FDA - Flight Data Analysis programs have been doing, in some cases (BA) for over fourty years, in other cases a few years.

A QAR - Quick Access Recorder records the same if not many more parameters than the crash recorder. It is analyzed by specialists, usually a small group of pilots designated for the task or an independant company, and the de-identified reports are provided to the airline's management.

Now, it is far, far more complex than this, so I might suggest you google, "FOQA" as a good place to start.

Data analysis is, as you suggest, proactive, and is looking for both trends and incidents/events. In many arrangements, calls to the crew are made not by management but by the pilots' own peers usually through an agreement with the airline. The program is extremely effective in discovering what the airplanes and crews are doing on a daily basis.

PJ2

More witnesses declare -- Nothing new
 

A couple more witnesses declared in front of the judge in charge of the investigation today. Nothing really new. You can skip this post.

The worker in charge of fueling the airplane before the RTG declared how much he put in an hour before departure, etc. He also declared that his co-worker, who was the one to later add more fuel after the RTG (and who will declare later), told him about the anti-collision lights being on while on the ground.

Nobody has strictly said what lights they were talking about, but the prior mention of this situation to the police was that he noticed the lights "on top and underneath the airplane", leading to believe that he didn't mean the wing's strobes.

It was said here by those familiar with the MD80 that those lights, as oppossed to the strobes, turn on and off only through a manual switch in the cockpit.

Having them on during the refueling while they were parked and right after the "repairs", probably only means that they never turned them off when they stopped the airplane to have it serviced.

The press, of course, is already jumping to the conclusion that the airplane was in "air mode" and that provoked the accident.

The witness also declared that he co-worker did talk to one of the pilots, who stepped outside of the airplane to give him instructions on the amount of fuel, etc.

Not related, but some may be interested in this article:
Airliner Repair, 24/7 | Flight Today | Air & Space Magazine

Maybe I'm wrong, but I get the impression that justme69 feels that the aviation industry has been asleep at the helm in scientific analysis of aviation safety.

As PJ2 says.
TEM, FOQA, etc, have been in use for more than a decade, along with several other equally important programs.
The Flight Safety Foundation is a good source of links to what has been, and is, going on.
Here is link to one (of many) TEM articles:
http://www.flightsafety.org/pdf/tem/...pt_12-6-06.pdf

Management Involvement in SOP
 

Some time ago (1 year?) the Ryanair boss made it public that he would fire any crew that would be caught as not being stabilized on final below 1.000 ft. (?)

I guess he meant it. :D

A pilot has to be bold ...
An airline manager too.

They need lots of that in Iberia.

Aviation Video: Airbus A340-300 - Iberia

Anyway, I indeed do not know much about FOQA and similar programs, but got up to speed and read a couple of articles, like Avionics Magazine :: FOQA: Training Tool, And More

Looks like it's slowly (not as fast as some people here seem to think) catching up with airliners and starting to become effective, specially with newer aircrafts where extensive computer use makes it easier to monitor many parameters.

I doubt it has made much in-roads in ATR's or MD-80's of small airliners, but maybe it'll get there.

Putting miniature solid state "mini-QARs" that in many cases even upload the information wirelessly (or manually on memory/PCMCIA cards) is a good idea and provide quite a bit of monitoring over flight performance to be then analysed by software and supervisors.

Still, crew "attitude" in their work place (closed cockpit) monitoring could still get a helping hand from similar solid state recording that shows the audio/video of the performance.

As I said, I'm not "all in" for spying on the pilots, but I'm also not "all in" for blaming the managers for "letting them do" unsafe practices they have not been encouraged to do during training.

This FOQA thing seems to be another great tool for increasing safety and a step in the right direction, but one that is quite recent, not as widely used yet, not 100% effective (but pretty good) and not too expensive.

So I'm all for a lot more of it.

Do you think that if such a program was being used on this MD-82 over at Spanair it would've prevented the accident?

Obviously, not necessarily, unless it was able to indicate that this particular crew was often not following all the checklists items like they should, which is likely not the case. They obviously (I'd like to think), never before neglected to lower the flaps or set any other important item from the checklist. But a video showing them rushing through items or not checking them properly would've raised a red flag.

FOQA can probably not detect, i.e., that a crew is hardly ever visually checking flaps/slats indicators when they activate the handles. A video showing how they lower the handles w/o hardly even looking at the handle itself and quickly moving to another item is a clear indication, though.