Flaps not extended on ill-fated Spanair jet

[Hacker15e]

The "perfect" airplane flight -- the one on which there are no human errors from beginning to end -- still hasn't happened since Orville and Wilbur first took to the skies.

 

[BugSmasher]

Read this re a similar incident when I was looking for info on the Spanair disaster. Pretty detailed post.

http://www.pprune.org/rumours-news/339876-spanair-accident-madrid-75.html#post4374228

RIP to the victims of this terrible tragedy.

 

[Orange Anchor]

The "perfect" airplane flight -- the one on which there are no human errors from beginning to end -- still hasn't happened since Orville and Wilbur first took to the skies.

You do remember that Orville flew with Lt. Selfridge on the first military flight and Orville was badly injured, Selfridge killed when the aircraft threw a prop and crashed. No doubt, it was quickly determined to be 'pilot error' which today would be 'human error'.

 

[IrishSheepdog]

Awesome thread. Much kudos to Orange Anchor for name-dropping Sidney Dekker! We used his theory of "Drift Into Failure" as the basis for our Recurrent CRM program in 2007.

In respect to doing it right 100% of the time, I remember hearing a quote somewhere that said, "A true professional pilot is one who always attempts to fly a perfect flight, all the time knowing that feat is impossible." As professionals, we should try to get it right 100% of the time. However, we are human beings, so that is practically impossible. That is why the airplanes we fly, and the environment we operate is, is filled with "checks and balances." Whether it is a takeoff configuration check built into the airplane, or the paper checklist, we have procedures and alarms that should help correct the mistakes that we do not catch ourselves.

However, the system we operate in is defenseless again blatant disregard for those safeguards. In the case of NWA Flight 255, the pilots ignored the checklist (safeguard one), and also removed the airplane configuration warning by "possibly" pulling the circuit breaker (safeguard two). So, they removed all opportunities for the "system" to correct their mistake of not setting flaps properly for takeoff. Could the same have happened in the crash in Madrid? Possibly. The actual cause remains to be seen.

Thing is, it is never one thing. James Reason came up with a "swiss cheese" model which is great for analyzing accidents like this. Any crash (even with NWA Flight 255) is never just pilot error. Sometimes it can be organizational influences, training issues, the pilot group culture, and so on. So in the case of the Spainair accident, maybe the pilots did override the system safety by pulling the circuit breaker. But they likely did not do it just that one day, and they likely did not come up with that themselves. Just like the Captain of the Garuda crash in Indonesia... That Captain is not likely a rogue who decided to "push it" to "make it work."

Great commentary from Orange Anchor about "Captain Ace Dazzle." There was a great quote in our Recurrent CRM program that asked the definition for Murphy's Law. In aviation, it seems we have re-written it to say, "What can go wrong usually goes right, and we draw the wrong consequences."

For those of us in the airline industry, soon you'll be seeing safety being analyzed from this angle, since we are all beginning to move towards SMS (Safety Management System) in 2009.

You can read about it here in AC 120-92: http://rgl.faa.gov/Regulatory_and_G...6485143D5EC81AAE8625719B0055C9E5?OpenDocument

 

[Orange Anchor]

Awesome thread. Much kudos to Orange Anchor for name-dropping Sidney Dekker! We used his theory of "Drift Into Failure" as the basis for our Recurrent CRM program in 2007.

I've met and talked with Dekker a number of times. Very interesting fellow and his Field Guide to Human Error along with Dismukes Limits of Expertise are must reads. Vaughan wrote on the Challenger accident and the quote I really enjoyed was when she went to Florida to begin her research. She said she expected to find ineptitude, cover-ups and skullduggery (there's one you can use next week) and instead she found highly trained, highly experienced, highly motivated, highly intelligent people working very hard to do the right thing. And while you are at it, for a short but insightful read, find Steve Swauger's study of why experienced pilots perform like novices.

That is why the airplanes we fly, and the environment we operate is, is filled with "checks and balances." Whether it is a takeoff configuration check built into the airplane, or the paper checklist, we have procedures and alarms that should help correct the mistakes that we do not catch ourselves.

Which is essentially Reason's swiss cheese theory which you reference however we have frequently demonstrated that no matter how many 'barriers' we place along the path, man is creative enough to defeat occasionally even the best of programs.

However, the system we operate in is defenseless again blatant disregard for those safeguards. In the case of NWA Flight 255, the pilots ignored the checklist (safeguard one), and also removed the airplane configuration warning by "possibly" pulling the circuit breaker (safeguard two). So, they removed all opportunities for the "system" to correct their mistake of not setting flaps properly for takeoff. Could the same have happened in the crash in Madrid? Possibly. The actual cause remains to be seen.

Correctly called as possible. But it wasn't shown to be a habit at NWA and it hasn't surfaced at SpanAir so it may well not be part of the culture.

Thing is, it is never one thing.

And that is why Dekker and others have suggested that building defenses for unique accidents may be very difficult if not impossible. Accidents are the exception, not the rule as noted by the fact that thousands of airplanes, including the one we did 2 legs in today, didn't wind up in a smokin' hole.

In aviation, it seems we have re-written it to say, "What can go wrong usually goes right, and we draw the wrong consequences."

Ever thought of how much goes into a bad consequence?

Situation. You perceive the situation correctly/incorrectly, know/don't know the solution, apply/misapply the solution and you do/do not have enough time to implement the solution. There are so many avenues to err. And one only has to go to the NASA ASR website and use the search engine to find just about any type of error you can think of.

For those of us in the airline industry, soon you'll be seeing safety being analyzed from this angle, since we are all beginning to move towards SMS (Safety Management System) in 2009.

That is why FOQA and ASAPs are so important. But here's the kicker. Many of the error management programs are distinctly a western concept and like many language idioms, they do not necessarily translate readily into other cultures.

There are plenty of books out there on decision making and how we decide. But one of the best and most accurate quotes IMHO is the one that says, "We are constantly moving from ambiguity to ambiguity." meaning we never have all the info when we are making the decision.

 

[mooneyguy]

And this one.... (only one year later)

http://en.wikipedia.org/wiki/Delta_Air_Lines_Flight_1141

I won't say anything about the Spanair flight since it's still under investigation; but regarding the 1987 and 1988 accidents, did people just not run checklists back then or something???

If I'm not mistaken FL 1141 was the one where you hear the captain on the CVR talking with an FA and joking (during the preflight) about their "conversation" being left on the CVR so their wives and children would have something to hear!