THE TRAGEDY at MADRID BARAJAS -The Blame Game Has Started.

Yesterday a Spanair McDonnell Douglas MD82 crashed on take off at Madrid Barajas airport killing 153 of those on board. There may have been up to 20 survivors.

Understandably the world’s media is frantic to get broadcastable information in the aftermath of a major event such as this but it is always a confused picture and sadly uninformed speculation always seems to rise to the surface.

An eyewitness reported seeing flames coming from the left engine as the aircraft accelerated down the runway and so, inevitably, it became an established fact that engine failure had been the cause of the crash.

Eyewitnesses are notoriously unreliable and there certainly was fire after the plane left the runway and so fire became rooted in many a consciousness. I was interviewed on BBC Television news during yesterday (Wednesday 20th) evening and commented on the unhelpfulness of much of the speculation and that we did not know very much at this point, however desperate we were to have answers. 

Immediately after me came an, “Aviation Expert,” who stated that, “engine failure was undoubtedly the cause.” Before going on to spout explanations of what pilots need in order to survive such an event. He was wrong on many counts and pilots are once again angry at the complete rubbish fed to the public by bandwagon jumpers who have never flown an aeroplane. Media people please beware of impostors; get a pilot who knows what they’re talking about.
Of course you now want some answers too, so here is what I can say so far with a degree of certainty. An aircraft certified for public transport must be able to sustain an engine failure at the most critical point in the take off run, continue safely, clear all obstacles and fly to an acceptable destination on its remaining engine or engines – no matter how many that is.

Performance calculations are made prior to each flight, based on weight, temperature, and the specific runway data and providing these limits are observed an aircraft must be able to stop within the available runway before the critical point is reached. So did any of this apply to the Spanair MD82?

We cannot say because we have insufficient information. Were the crew trying to stop? Fly? Or did they leave the ground briefly and then fail to fly away? Theoretically all of these could be possible and none of these scenarios should cause a crash. So we seek some additional factor or factors that changed the situation into an unmanageable one. I have no doubt such factors exist.

Update 16th September 2008.

Now it seems we can answer some of these questions. Today Spanish media reported limited details from a preliminary report due to be released on Monday. What I am able to establish is as follows.

The take off flaps were not set, as they had been at the first attempt before the return to the stand due to a technical fault. There was also no warning from the Take Off Warning System (TOWS) this appears not to have been working. TOWS is a mandatory requirement for all flights but was only tested in Spanair on the first flight of each crew in a specific aircraft, not before each flight as the manufacturer recommends following an accident in the 1980s.

Whilst this is interesting, we need to know why these problems arose before finding the true, underlying cause of the crash. We now know that the lack of flap prevented the aircraft from flying away safely but how did the take off run begin without them?

It seems that the aircraft accelerated to the correct speed (for an aircraft with flaps set) and then left the ground, reaching 40 feet before rolling first one way then the other a couple of times before ceasing to fly. The one functioning thrust reverser (one was legally inoperative, awaiting maintenance) was deployed suggesting that the crew was attempting to stop or slow the aircraft as it left the runway on the way to the ravine. Without flaps it could not fly and so far as I can tell no flaps were set once the sequence of events began. Little time was available to rescue the take off at this stage. Some observations can now be made even if we cannot set the whole event in concrete.

We have an aircraft with a temperature probe fault, which returns to the stand so that engineers may attempt to rectify it. On a complex aircraft such as this warning systems may be interlinked and use the same electrical power supply. In this case the temperature probe and TOWS shared a common electrical relay.

The pilots, now late and under pressure to get the flight away (I expect to discover more about this particular angle soon but commercial pressure is a common issue for airline pilots in such a situation) accept the aircraft following some kind of technical fix for the faulty temperature reading that caused them to reject the first take off.

Somehow during the pre departure checks the flaps did not get set for take off (did the previous action of setting them produce a feeling that they had?) and for reasons we cannot yet say, no further checks or airmanship issues detected the wrong flap position.

Perhaps due to work carried out by the engineer, or a tripped circuit breaker that went unnoticed (easily done, especially in a hurry) or even a misunderstanding of the aircraft warning system (disable the faulty temperature probe and you also disable the TOWS?) no take off configuration warning sounds as the crew open the throttles and they are unaware that the plane cannot fly as it now is.

What was the safety culture like in Spanair? How good was their training? Was it a company that pressurised pilots to get the job done even though they had reservations about the legality of going with this technical fault? Was the engineering rectification work carried out properly and was the rectification method used a fully approved one? Or were corners cut to get the flight away?

These are the questions I would like answered and they are based on long experience of both operating airliners in a commercially pressurised environment and what other pilots currently tell me. We are in a cutthroat business environment and many airlines are struggling. My book covers these issues in greater detail but this has a horribly familiar feel to it and fits patterns I have already written about.

What is certain is that there will not be one sole cause. Accidents require many factors to combine in order to defeat well-honed safety procedures and usually more than that. It is exactly for this reason that companies should ensure they do add factors themselves by creating stress or fatigue in pilots or leaning on them to go when there is any doubt at all.

Anyone reading my book, “Cheap Flights – The True Cost,” will find most of the possible answers there, as accidents have a tendency to be based in patterns of human behaviour. That does not necessarily mean the pilots either.

What we do know is that the Spanish pilot’s union SEPLA issued a condemnation of Spanair management prior to this accident, citing, “chaos,” in the company as a real concern. There are airlines out there that do treat the regulations, say of pilot’s working hours, in a way that those who wrote them never intended. I note that pilot fatigue (possibly the biggest yet ignored issue in the industry) is mentioned by SEPLA as their major concern.

It is now common for airlines seeking cost reductions to cut pilot levels to the point where legal flying hour limits are set as targets. Something the rules were never intended to achieve. It is the cost driven environment in which we now live and explains the title of my book.

My reluctant view is that I have already written this story in another form and we shall see humanity play its part, as very few accidents are simply that; whatever we choose to call them. 

Addendum: 23rd September 2008

With the release of video and still footage of the Spanair crash it can be clearly seen that the aircraft becomes airborne without flaps, reaches approximately 40 feet before leaving ground effect (the cushioning effect of flight close to a surface, watch wildfowl who use it all the time) and so ceasing to fly. A trail of dirt and dust is then visible as the plane lands on the grass near the runway, followed by the plume of black smoke generated by the final impact. There was no pre-crash fire as early witnesses claimed.

It is confirmed that engineers did disable an apparently errant heater system and in so doing disabled the TOWS protection. For whatever reason the crew failed to set take off flap and no warning system was available to prevent the tragedy. It is now also clear that the Spanish CAA failed to ensure that the Spanair operations manual required a TOWS check prior to every flight (as per Boeing requirements) and so Spanair have been operating for around 20 years with this omission to their procedures.

One member of the investigating team CIAIAC (Commision de Investigacion de Accidentes de Aviacion Civil) has resigned due to the (leaked) preliminary report citing failures in Spanair rather than Boeing as contributory causes. In 2000 the then head of CIAIAC quit due to, “paraplieja,” in the function of this investigating body citing lack of resources as well. He and other critics charge that the body is not independent and is politicised. I have no personal experience of CIAIAC but am always concerned about investigators who are not completely independent, which CIAIAC is not.

The judge in charge of the investigation has decided to include evidence from a retired airline captain who accuses the operating authorities of Madrid Barajas airport of, “a multitude of barbarities,” in relation to the operation of its runways and classified, “protection zones,” (areas required to be clear for take off and landing due to Barajas not being approved of simultaneous runway operations.) as are other EU major airports such as London Heathrow and Paris Charles de Gaul.

My experience confirms this possibility as I have witnessed separation rules being breached regularly at some major airports around Europe, (including Paris) although I am not overly familiar with Madrid.

We must await the full report to discover why the pilots made the fatal mistake of missing flap selection but there must be some external reason, as it is covered in the pre take off checks of every aircraft type. Of course we know that humans are fallible – most often when under pressure – and that is why backup systems are designed in to pick up human error.

Whatever the details, this was no, “accident,” it was an avoidable tragedy as so many fatal incidents are.


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