lomapaseo;

I am rarely cynical but always skeptical. This may be one of my cynical moments where optimism is defeated by experience.

That said up front, I fully agree that the lesson(s) is(are) important. The difficulty is, and this is an issue not limited to aviation, many times, "learning the lesson" is set aside in favour of those other factors.

Today it is almost trite to state it, but I have always been and remain, deeply mistrustful of corporate interests and therefore of corporate governance in all its forms, private and public whether intentional or through inability or plain incompetence. This stance has proven correct but requires an ameliorating clarification. I think that true malfeasance such as cutting corners with knowledge of increased risk, something Diane Vaughan called, "amoral calculation", was rare if it occured at all. Accidents occur when people are doing exactly what they think is the right thing, under the best of intentions and a "clear" understanding. That is the lesson here, not this SOP or that MEL procedure but in the "Not Learning", (I know you know this but I am speaking broadly here, not "in response"). In fact, some who are writing now regarding the "meta-themes" being discussed on a number of different threads on PPRuNe are turning from "training, experience, pay, fatigue" to the larger issues of "why accidents?" and finding it in the "not learning"; it is not found in intentional avoidance of solutons however they may be conceived. I think the notion of "Special Interests" captures far too narrow a field of vision to be helpful in resolving complexity and the addressing of risk and the very notion of "accident".

I think the upcoming ISASI conference will have something on this.

This April, 2003 article from AW&ST states very well, what I mean:
AW&ST April 28, 2003

re your comment,
Yes. Many even now must be contemplating what will be said in the AF447 "Final" Report...

Excellent post PJ2, very well said, unfortunately for us all, this is the real world , where the " how much will it cost" and " how long will it take and who will pay for the delay ?" are now the norm..

link to the interim report of 17/08/2009 (in english)
 

http://www.fomento.es/NR/rdonlyres/9...INO_01_ENG.pdf

Haven't read it yet, but leafing through chapter 2 "Discussion" and the 13 Safety Recommendations, it looks like a pretty thorough and wide ranging approach that the Spanish investigation Board took, not sparing Spanair, as an airline, at all.

Why immediately these cynic reactions by people who obviously have not yet read a single word of it ?

ATC Watcher;
And that is in large measure, why airlines are struggling with costs. They think employees are the ATM from which they can transfer cash from the liability column to profit column when in fact working smarter...works. Penny-wise means you dismiss or negotiate down, those highly-dedicated, competent, "expensive resources" that airlines used to have like pilots, aeronautical engineers, maintenance people who knew nuts and bolts and had the time and rest to do the job right. In many cases those people have left or been "retired" or the entire departments of engineering (including sheet metal work, heavy maintenance) have been shut down because "it can be done cheaper through outsourcing". There is a huge gap now where entire generations of experience used to reside at a major airline. Too expensive.

Instead, we have "quarterly-thinking" and a "what has your department done for the bottom line lately?" No one likes to be in the line of fire so people will cut costs to make the boss happy, comfortable in the knowledge that it is "the boss" who will take responsibility if something bad occurs.

Also, airlines hit, ding, smash into and otherwise wreck airplanes on the ground while servicing and taxing them to the tune of hundreds of millions of dollars. That is directly off the bottom line and that number has not changed in decades because, while organizations know why and have the data, they are not learning - the expertise is either rare or non-existent. Part of it is management-labour issues (where "soldiering" (working slow) and sabotage are minor issues; the vast majority is "accidental" due to competency (training) and production pressures (rushing, lest one get blamed for the delay, making one's department "look good").

Airline delays drive these kinds of losses, but are a curious thing. Passengers focus on minutes and airlines watch their stats like hawks. However, most delays are shorter than the time we all voluntarily stand in line at Starbucks for our morning latte. Do we rag on the girl behind the counter? Nope. Do we phone Starbucks' headquarters and does Starbucks keep statistics about lineups and "delays"? Does any sales organization? How long do each of us wait on the phone, pressing number after menu number and never once hang up and tell the company who's wasting your time, to Get Stuffed!?

Yet a 30-minute delay is HUGE.

That creates production pressures that translate into accidents - each minor, but...hundreds of millions of dollars per year because airplanes are expensive to keep on the ground and repair.

This is perception on the part of the airline, in fact business, nothing more. They focus on such statistics and it drives the monthly agendas at departmental meetings where "results and goals" are discussed and pressures are created.

This is absence of learning how to deal with information that is available through data gathering programs like FOQA, LOSA, ASAP etc. Airlines get rid of the "expensive resources" but those resources have experience, knowledge, depth, patience and comprehension, none of which have a column in an organzation's balance sheet.

If an employee saves the company some money, there is no column in which that saving may be entered. Each saving is "invisible" precisely because it is always, "what have you done for us lately?" accounting.

So, if a flight data program saves an airline ten million dollars in engine downtime and repairs because of turbine overtemps, the "savings" are not entered against costs. The program never gets formal, accounting credit in the sense of "what would have been the costs had we not....(fill in the substantial blanks) but when discussions about "cost control" arise as they do, it is always to cut without thought or undertstanding.

Safety programs are all about telling an airline when they are too close to the bone. But if the executive can't even understand the information because the airline doesn't have sufficient resources to interpret the data or create reports, the program is a box-tick and a further waste of the organization's resources.

Sending expertise packing because they are an expensive resource and great bang-for-buck in the cost-cutting department, is, in a complex, technical, risk-intensive enterprise, while it may look good to stock holders, is seriously pound foolish.

Until some courageous executive with more knowledge about aviation than marketing and advertising come, about what makes aviation tick and what makes it safe, comes along with a longer-term vision than mere bottom lines, the statistics and what I call "The Turn" in aviation flight safety will continue.

Much of this, including flight saftey work, can be summed up thus: Nothing succeeds like failure, and nothing fails like success. PJ2

Because rather than reading it themselves, they choose to believe the rather witless interpretation, made by clueless mediaperson. As to their motives - beats me.

Dutch Bru, Clandestino;
Regarding judging before reading, you are right - post removed. Lomapaseo's response was very helpful I thought. My views on the larger organizational matters stand.

Rightly focuses very much on TOWS failure and cockpit procedures & checklists

Seems quite possible that the crew never realised their error
Reaction to stick-shaker was not to immediately lower the nose (although thrust was eventually increased to max)...
Early wing drop/loss of symmetry/roll control not commented upon

And, unfortunately, PJ2, I think you might be right.

With probability approaching one.

I hope that final report will mention actual stalling speed for config and weight. This might prove or dispel my suspicion that they were so deeply stalled that no crew action could save them.

Basic aerodynamics, really.

I've just skimmed through the report and it seems to be very well written, with plenty of interesting HF considerations and technical recommendations. This is one of the summations:

There's a good discussion of checklist design, execution and interruption, leading to this conclusion:

Which is considerably overdue, IMHO, having been subjected to all sorts of rotten procedures over the years. Things are getting better with ECLs but there's still some way to go.

Well worth a read.

Reading the report I´m amazed in the first part, the co-pilot only had 222 hours real flight time on other aircrafts and it seems that the MD-80 it´s his first real one flown.

and what about this one
 

Having gone through it, the report indeed seems really thorough and covers a lot of ground.

Having said that, I was struck by the way the apparent absence of data from the QAR is covered in section 1.3.2. The for me at least somewhat cryptic language used seems in stark contract with the overall clarity of the report. So is imo the apparent ease with which the Spanish investigation board, without further ado, steps over the question marks this QAR issue raises.

Here is the text:
"The QAR was recovered from the aircraft wreckage some days later. The optical magnetic disk where the QAR records information had been installed on the aircraft in early August 2008. The equipment manufacturer, Teledyne, downloaded the information contained on the disk at its facilities only to discover that the data were from another of the operator's airplanes and from previous flights. There was an incompatibility between the recording formats used by the equipment and those used to record to the disk."

What are they trying to communicate exactly here ? Where the data only from another aircraft, including the stored data from the previous flights, or does the "data....from the previous flights" bit refer to the accident aircraft ? And the sentence that "there was an incompatibility between the recording formats used by the equipment (ed. the actual QAR?) and those (ed. recording formats?) used to record to the disk (ed. so of the equipment, i.c. the QAR ?) is utter gobbledegook.

Are they actually saying as much that the QAR retrieved could not have recorded the data on the disk retrieved from the QAR ?

Assuming, of course, that the QAR in question and the disk in question were indeed retrieved from the accident aircraft, it is to me at least not immediately clear, with the disk apparently installed a few weeks before the accident, any malfunction of the QAR/disk would have gone unnoticed before the accident. Doesn't Spanair retrieve the data regularly for a flight analysis programme ?

Perhaps this and the apparent lack of interest on the side of the investigation board has to do with the fact that QAR is not "mandatory equipment".

Perhaps it is nothing, but it made me think a second in an otherwise apparently very serious investigation.

Dutch Bru;

First, I have to say, as others have, what a thoroughly-conceived and well-written Interim Report this is by the CIAIC. There are a number of important areas covered as have been pointed out. The report indicates quite clearly under the last section, "3. STATUS OF THE INVESTIGATION" that the investigation is ongoing and will thoroughly report on those "softer", organizational issues which may yield deeper lessons.
Yes, they are saying that the QAR retrieved could not have recorded the data.

The Teledyne FDAU, Flight Data Aquisition Unit will be a specific installation with specific software for the recording medium including the LFL, (Logical Frame Layout) which specifies parameters captured. Normally, QARs record hundreds sometimes thousands of parameters more than the minimum DFDR parameters required by a country's laws.

The problem as I read it in this report is, the FDAU software was not compatible with the installed optical disc. There may be small differences in the LFL which prevents the recording of parameters into the frame layout. It would be like trying to put a 4x512-cell spreadsheet into a 4x256-cell spreadsheet - the data would be garbage. In very rough terms, it would be like trying to run a PC with a Leopard operating system.

As equipment is upgraded and better solutions to recording equipment and recording mediums emerge and as improved LFLs emerge, (if the airline is supporting their FDM program appropriately), such mismatches are normally resolved during the research, purchase and installation phases.

Regarding the delay in becoming aware of the problem, Optical and PCMCIA cards are typically not read every day and usually hold a week or more worth of flight data. They are typically removed from the aircraft, the data downloaded and stored every week to ten days. Discovering an "event", or a problem with the equipment would be affected by that time delay. This is not an uncommon nor untoward matter when doing FDA work.

Dutch Bru & PJ2

Translation woes make the QAR comment in Section 1.3.1 unclear in English.

The last sentence of the official Spanish version of Section 1.3.1 leaves no uncertainty as it states Teledyne verified a format incompatibility between the FDAU and the MO disc.

It does not detail the mismatch, but expanding PJ2's point on likely fleetwide mix of FDAU's, all optical QAR's use 90mm MO discs that look the same regardless of capacity or formatting.

The MO explanation makes complete sense. My thanks once again, Machaca. I'll standby further.

Unfortunately an inevitbable situation which could happen to any airline/crew at the moment.. 20 years ago it was far less probable, even with inferior technology aircraft... now it's on time departures, min fuel, bare minimum training, ignore the little things... dare not write things in the tech log in case the next departure is delayed, fiddle the pax weights for the right perf figures ... it all waters down the safety levels and airworthiness authorities turn a blind eye until something happens and it's time to allocate blame.. The FAA has a few faults but they really do come across far more competent than EASA / JAR ever will ... lessons to be learned maybe?

The similarities to the NWA DC9-50 takeoff from Detroit Metro many years ago are obvious.

Seems history DOES repeat to those who have forgotten it's lessons.

Alwaysairbus

I have read the report but I do not find any reference in regard to what your are mentioning in your post.
They return to the apron...
the report is referring various times to the tech log, therefore the entries were made
Unsubstantiated in this case

In matter of fact I found disturbing that the failure single relay R2-5 can disable the TOWS without the giving any alarm to the pilots. According to the report this happened several times in the past to different airlines. All aircraft with similar TOWS design have a single point of failure...
FSLF

A NASA report, looking at the US confidential reporting system ASRS, found that flapless take-offs (unintended ones) happen more frequently than we realise, but because the crews fortunately get away with it on most occasions, we don't get to know. There's a summary at Distractions frequently cause flapless take-offs, NASA reveals

As for the reason, NASA says it's because the pre-take-off period is so unstructured and full of distractions.

Could somebody kindly post, in their own words, a brief summary of what the interim report told us?

Afraid some of the acronyms (TOWS?) have got this humble SLF beaten.

TIA.

Take off warning system

WP