Spanair Plane Crash

*Kol*

Preliminary information from Spanish investigators details for the first time the sequence of events prior to the Spanair Boeing MD-82 crash, and the dynamics of the 20 August accident.
The Comision de Investigacion de Accidentes e Incidentes de Aviacion Civil (CIAIAC) has compiled a draft report containing initial data.
After arriving from Barcelona the aircraft parked at gate T21 of Madrid Barajas' Terminal 2, and took on 10,130 litres of fuel in preparation for operating flight JK5022 to Las Palmas, scheduled for 13:00.
Its first attempt at departure, at a weight of 64.5t, proceeded as follows:
§ 13:06.29 With 166 passengers and six crew members on board the MD-82 leaves its gate, and the pilots deploy the flaps to a standard 11° setting for departure on runway 36L.
§ 13:25.11 Flight JK5022 receives take-off clearance.
§ 13:26.41 Crew reports a 'small problem' and, a few minutes later, opts to return to the apron.
The aircraft returned to park on remote stand R11, which is situated almost opposite gate T21.
Engineers checked the ram air temperature (RAT) probe which, according to flight-data recorder information, was showing an "excessive" reading of 105°C. The decision was taken to open the RAT probe heating circuit-breaker. The flight-data recorder subsequently detected a reduced maximum probe temperature of 30°C.
The RAT probe is linked with a relay, designated R2-5, which also has a common electrical link with the radio-rack cooling system, alternating current cross-tie, and - perhaps most critically - the configuration-warning system.
This warning system is normally active only on the ground, and is inhibited through the R2-5 relay once the aircraft is airborne. Similarly the RAT probe heating is normally only active during flight.
After the engineering work was completed, flight JK5022 made a second attempt to depart:
§ 14:08.15 After taking on board another 1,080 litres of fuel the MD-82 leaves the remote stand R11 for a runway 36L departure. From this point onwards the flight-data recorder registers zero flap deployment, up to the end of the recording.
§ 14:23.19 Brakes released. From this point onwards the cockpit-voice recorder reveals no evidence of a configuration warning.
§ 14:23.28 Take-off roll commences.
§ 14:24.06 Pilot calls 'V1' and, four seconds later, 'Rotate'. Length of the take-off roll is 1,950m (6,400ft).
§ 14:24.25 Stick-shaker activates and, four seconds later, audio stall warning sounds.
Having struggled to become airborne, the MD-82 reached a height of just 40ft before descending. The aircraft rolled slightly left, then rapidly right by 20°, slightly left again and then rapidly right by 32°. During the short flight the aircraft reached a maximum pitch of 18°.
Flight JK5022 struck the ground with its tail-cone and, almost simultaneously, with the tip of its starboard wing and the cowling of its starboard Pratt & Whitney JT8D-217 engine.
Impact marks from this contact were discovered 60m to the right of the 36L centreline and 3,207m from the runway's threshold. Runway 36L has a length of 4,350m.
The aircraft travelled around 448m on a heading offset from the centreline by about 16°. Uneven terrain meant the jet lost ground contact, then regained it, the main part of the wreckage coming to rest some 1,093m from the initial ground strike.
Both engines separated from the aircraft. Investigators found the starboard engine's thrust-reverser, in the stowed position, about 235m from the first ground impact point. The port engine's reverser was found deployed, about 913m from this point.
At least one flap-actuator piston was found partly extended, by a distance of 12cm, but the inquiry has not yet attached any significance to the discovery.
Investigators do not suspect any fault from the engines, the thrust-reversers, control surfaces on the empennage, or the undercarriage.

pclancy

So sad that one little relay caused all those deaths.

Mr Benevolent

So sad that one little relay caused all those deaths.

The relay fault did not cause the crash, it contributed to it. The crew caused the crash by failing to extend the flaps/slats to the correct position which caused them to stall the aircraft on takeoff. This accident could have easily been prevented by proper crew co-ordination.

pclancy

Well yes correct a number of factors contributed and sadly the blame lies with the crew for not spotting the error, the takeoff config warning is a kind of last defence against the crew missing problems with the aircraft's config and they should have seen the flaps not being deployed. Its just such a waste of life when stuff like this happens.

Run_to_da_hills

pclancy wrote: »

Well yes correct a number of factors contributed and sadly the blame lies with the crew for not spotting the error, the takeoff config warning is a kind of last defence against the crew missing problems with the aircraft's config and they should have seen the flaps not being deployed. Its just such a waste of life when stuff like this happens.

Any observant passenger should have noticed these flaps not being deployed, If I am sitting near the rear side of the wing I would always watch the flaps extend before take off and also when about to land. Wasn't there a recommendation passed recently where the word of the passengers must be taken into account if they spot something unusual in flight, this happened after the British midland flight 92 crashed at kegworth in 1989 when the wrong engine was shut down..

pclancy

I guess you could try shout a stewardess but they wouldnt have really had a chance it seems from the sequence of events. It does sound good to take the word of the passengers if they see something of alarm but I imagine there simply wasnt time in this instance or nobody noticed it.

vigos

pclancy wrote: »

Well yes correct a number of factors contributed and sadly the blame lies with the crew for not spotting the error, the takeoff config warning is a kind of last defence against the crew missing problems with the aircraft's config and they should have seen the flaps not being deployed. Its just such a waste of life when stuff like this happens.

Just out of curiosity how can the pilots verify the flaps are fully deployed from the cockpit? Is there someway for them to actually see them deployed from the cockpit via a mirror or something or else is just from the control settings?

pclancy

I'm not familiar with the Md80s specifics but on most aircraft there is both the position of the flaps handle/switch to refer to and an indicator on the instrument panel either on a CRT screen, guage or LEDs. This is often duplicated with a spare or backup indicator on the same or on the overhead panel.

Edit....Here's a good description:

http://www.hilmerby.com/md80/md_flaphandle.html

Foggy43

There are Flap and Leading Edge Slat position indicators on the pilots panel.

Flight control movements are normally checked just after push back. Every day at LHR, the Flaps/Slats are extended for take off before the aircraft taxi's out. I must admit on narrow body aircraft the flap movement to take off position is hardly noticeable to the untrained eye.
I find it so hard to believe the crew could forget to extend the flaps. In the past a serious case of 'getthereitus' has caused deaths. I suppose when that dreadful word 'delay' comes up and who it is down too will cause stress levels to raise and possibly cause errors.

Fratton Fred

Run_to_da_hills wrote: »

Any observant passenger should have noticed these flaps not being deployed,

I've flown literally hundreds of times and to be honest, I have no idea what is being talked about here.

I know what the wings look like and those two (Sometimes four) big things that hand underneath i presume are the engines. then there's there other bits that scare me when they move because they look like the wing is going to explode.

I'm actually shocked that in a multi million dollar aircraft, the pilot can still make a cock up that brings down the plane. Please tell me it's not that simple.

FlutterinBantam

No it's not that simple.

There are extensive check lists which are always gone thru prior to taxi/take off etc etc.There are indicators in the cockpit which display current a/c configuration.There are warning indicators also.

Thousands of take offs and landings are completed routinely all around the globe every day,and unfortunately the risk of human error or mechanical failure is always there.
Every precaution is taken to eliminate risk of error but,where humans are involved, it never can be eliminated totally.

Usually incidents and accidents happen as a result of a series of events rather than any isolated event.

Accidents thankfully are very rare and the travelling public should not be put off by what are,although terribly tragic,extremely rare occurrances.

Fratton Fred

FlutterinBantam wrote: »

No it's not that simple.

There are extensive check lists which are always gone thru prior to taxi/take off etc etc.There are indicators in the cockpit which display current a/c configuration.There are warning indicators also.

Thousands of take offs and landings are completed routinely all around the globe every day,and unfortunately the risk of human error or mechanical failure is always there.
Every precaution is taken to eliminate risk of error but,where humans are involved, it never can be eliminated totally.

Usually incidents and accidents happen as a result of a series of events rather than any isolated event.

Accidents thankfully are very rare and the travelling public should not be put off by what are,although terribly tragic,extremely rare occurrances.

Ah yeah, I know that. I guess I'm just being a touch dramatic.

I remember flying on a brand new Boeing 737 (I think) with monarch. The plane had only made five commercial flgiths and was the latest version in the Monarch fleet at the time.

The pilot took great delight in telling us that unfortunately there would be no "Airport 87" type dramas as not only would he and the first officer not being eating the same meal, the plane was quite capable of landing itself at over 200 airports around the world so there was no chance an ex Vietnam pilot would be called on to land the plane in a blizzard:D

I think nowadays, us passengers just expect the pilot to get in, turn the keys and the plane flies itself

highlydebased

Fratton Fred wrote: »

I think nowadays, us passengers just expect the pilot to get in, turn the keys and the plane flies itself

There are no keys but anyway

The yokes that extend off the back of the wing, more noticeable on approach/landing as they are extended between 25 and 40 degrees depending on aircraft type- they provide increased lift at lower speeds

There are speed brakes which lift up off the wing, like a barrier, they help slow the aircraft down and also aid in descent, once armed they delploy upon touchdown

Not particularly noticeable are the slats, which extend off the front leading edge when flaps are deployed

Fratton Fred

Neon-Circles wrote: »

There are no keys but anyway

The yokes that extend off the back of the wing, more noticeable on approach/landing as they are extended between 25 and 40 degrees depending on aircraft type- they provide increased lift at lower speeds

There are speed brakes which lift up off the wing, like a barrier, they help slow the aircraft down and also aid in descent, once armed they delploy upon touchdown

Not particularly noticeable are the slats, which extend off the front leading edge when flaps are deployed

I'll watch more carefully in future. Of course I've noticed, but not really paid much attention. I just presumed they happened automatically. I presume changing the shape of the wing would change the air flow and create greater lift but potentially cause drag slowing the plane down, correct?

maybe i should try a spot of flying myself, to learn how its done properly.

OPENROAD

Run_to_da_hills wrote: »

Any observant passenger should have noticed these flaps not being deployed, If I am sitting near the rear side of the wing I would always watch the flaps extend before take off and also when about to land. Wasn't there a recommendation passed recently where the word of the passengers must be taken into account if they spot something unusual in flight, this happened after the British midland flight 92 crashed at kegworth in 1989 when the wrong engine was shut down..

Why would a passanger notice that the flaps were not deployed


Re the British Midland incident one of the safety recommendations was better communication between the cabin crew and the flight deck, so not necessary the word of a passanger.

pclancy

Fratton Fred wrote: »

I'll watch more carefully in future. Of course I've noticed, but not really paid much attention. I just presumed they happened automatically. I presume changing the shape of the wing would change the air flow and create greater lift but potentially cause drag slowing the plane down, correct?

maybe i should try a spot of flying myself, to learn how its done properly.

You should, its amazing fun!

wydmond

The investigation commissions seems to hush up something. According to the voice recorder the copilot shouted: "Fire! The left engine!" The pilot shouted back: "More pedal! Give me more pedal!"
These words are telling.

Foggy43

This was circulated to us today! Nothing we really did not know allready

'Wing flaps caused Madrid crash



The Spanair jet that crashed in August had faulty wing flaps and a warning system that failed to sound, an initial report has found.

The MD-82 plane reached an altitude of just 12m (40ft) before flopping back down on to its tail and careering off the runway. It shot across 1km of scrub before falling into a ravine and bursting into flames at Madrid’s airport, killing 154 people on board.

The investigators’ preliminary report does not apportion blame, saying that the pilots carried out routine checks.

The investigators, who studied voice and flight data recorders, found no evidence of prior engine problems and concluded that the plane had caught fire only after hitting the ground.

It is unclear why the wing flaps failed to deploy, but the error was compounded by the failure of the cockpit alert system, which should have sounded a warning to the pilots.

A judge will now decide whether anyone can be held criminally responsible.'

*Kol*

https://www.youtube.com/watch?v=84MFvNYk88o

JupiterKid

McDonnell Douglas airplanes don't seem to have a brilliant saftey/accident record, compared with Boeings and Airbusses. Scrap the lot of them I say.

*Kol*

JupiterKid wrote: »

McDonnell Douglas airplanes don't seem to have a brilliant saftey/accident record, compared with Boeings and Airbusses. Scrap the lot of them I say.

Thank you for that gem of wisdom.

Mr Benevolent

McDonnell Douglas airplanes don't seem to have a brilliant saftey/accident record, compared with Boeings and Airbusses. Scrap the lot of them I say.

Ridiculous. This accident was caused by pilot error compounded by caution & warning malfunctions. MD aircraft are excellent at what they do. 737s had unexplained crashes for years until the problem was found.

pclancy

Another point is that Boeing own McDonnell Douglas. They're not by any means unsafe aircraft or more prone to accidents.

Kevster

It wasn't pilot error as far as I was aware. Wasn't the problem that the flaps wouldn't extend fully, but the warning light for this didn't come on in the cockpit. Without the flaps, an airplane won't have enough 'lift' at take-off. Hence, the airplane got up a small bit but came crashing back down.

*Kol*

Kevster wrote: »

It wasn't pilot error as far as I was aware. Wasn't the problem that the flaps wouldn't extend fully, but the warning light for this didn't come on in the cockpit. Without the flaps, an airplane won't have enough 'lift' at take-off. Hence, the airplane got up a small bit but came crashing back down.

The flaps were not extended at all. The DFDR showed the flap setting was zero from engine strat up until the time that the aircraft crashed.

ImDave

Is there no CONFIG alert for takeoff on the MD-82?

FlutterinBantam

There is but it malfunctioned.

Mythago

ImDave wrote: »

Is there no CONFIG alert for takeoff on the MD-82?

There is a config warning BUT rather unfortunately when the circuit breaker for the original fault (temp probe i think) was pulled it also disabled the config warning.

Foggy43

Last Thursday a Spanish judge was to interview the mechanics involved with the return to stand. Here are two newspaper's reports......

http://www.guardian.co.uk/world/2008/oct/16/madrid-plane-crash-spanair-mechanics

http://www.theaustralian.news.com.au/story/0,25197,24509629-12377,00.html

I think the request by the judge is probably routine. The press maybe speculating.

I am aware of an incident on an aircraft where a CB was pulled to isolate some doorway lights. It wasn't until the aircraft was about to line for take off a side effect was discovered. It wouldn't have caused a major incident but resulted in no control of the entire cabin lighting system. They had stayed stuck in the last selected position, all areas on. Nothing in the Maintenance Manual or Fault Isolation Manuals about this happening. The Wiring Diagrams proved it could happen.

Mr Benevolent

It wasn't pilot error as far as I was aware.

It was pilot error. They never checked that the flaps were set for takeoff. This has happened before, even with a functioning config warning system. It was just bad luck that the config warning was inop after they f*cked up. Could happen to any crew.