Spanair Flight JK5022 Accident involving aircraft McDonnell

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Spanair Flight JK5022
Accident involving aircraft McDonnell Douglas
DC-9-82 (MD-82), registration EC-HFP, operated
by Spanair, at Madrid-Barajas airport on 20
August 2008
ESASI, Amsterdam
19-20 April 2012
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SUMMARY
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1.
2.
3.
4.
History of the flight
The relevant data
Investigation challenges
Design aspects. Take Off Warning System
(TOWS)
5. Overview of maintenance factors analysis
6. Overview of operational factor analysis
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HISTORY OF THE FLIGHT (4/4)
COMISIÓN DE INVESTIGACIÓN DE
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G:\ESASI\Spanair 5022.avi
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THE RELEVANT DATA
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• The physical evidences. Flaps/slats
– Wing control surfaces and associated elements.
Flaps/slats
– Flaps/slats control lever
– Slats indication lights
– DFDR data
– CVR data
• The TOWS failure
– CVR data
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WING CONTROLSURFACES AND ASSOCIATED
ELEMENTS
FLAPS/SLATS
• Several flap actuators were recovered.
Each was extended by a different
amount.
• In the case of the right outboard flap, its
inboard actuator was extended five
inches and the central actuator 1.1
inches.
• The flaps were easily extended and
retracted, making it impossible to
determine the position they had on the
aircraft.
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WING CONTROLSURFACES AND ASSOCIATED
ELEMENTS
FLAPS/SLATS
SLATS DRUM ACTUATORS
The part of the piston that was
extended was not covered in soot.
The actuators were not blocked and
could be moved freely.
TRACKS FOR THE NOS. 0 AND 1
SLATS PANELS ON THE LEFT SIDE.
They were found locked in the fully
retracted position.
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FLAPS/SLATS CONTROL LEVER
THE LEFT STUB ON THE FLAPS LEVER WAS
CONSIDERABLY DEFORMED.
THE SLOT CORRESPONDING TO THE UP/RET POSITION
ON THE FIXED FLAPS GUIDE HAS A MARK THAT
CORRESPONDS TO THE DAMAGE MADE BY THE LEVER
STUB.
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FLAPS/SLATS CONTROL LEVER & SLATS
INDICATION LIGHTS
Take off conditionCG/flaps selection
indication panel
Flaps/Slats
control lever
Slats indication
lights
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DFDR DATA FLAPS DEFLECTION
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Second taxi and take
off was with flap
setting 0º.
Flaps sensors send info directly FDAU
Slats sensors send info to DFGC and then to FDAU.
A problem in bus connecting DFGC and FDAU prevented to
record Slat parameter in DFDR.
Flap sensor
Slat sensor
DFGC
FDAU
Flight Data
Acquisition
Unit
DFDR
Flight
Data
Recorder
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CVR DATA TOWS
Throughout the takeoff run and until the end of
the CVR recording, no sounds were recorded
coming from the Takeoff Warning System
(TOWS).
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FINDINGS
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1. Flaps and slats remain retracted during take
off which it is a non approved configuration.
2. Crew did not actuate flap/slat control lever.
3. TOWS failed to provide a warning to the crew
of the improper aircraft configuration.
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INVESTIGATION CHALLENGES
COMISIÓN DE INVESTIGACIÓN DE
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WHY
1 did not TOWS work?
DESIGN ASPECTS
2 did not crew select and verify flap/slat position
in spite of having procedures and checklists
intended to?
OPERATION ASPECTS
AND
3 Were there any previous conditions that might
have prevented the accident?
MAINTENANCE ASPECTS
DESIGN ASPECTS. TOWS FAILURE
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• The relationship between the TOWS and the RAT
probe. The R2-5 relay
R2‐5 Relay
AC Power
K‐33
Breaker
Coil
Ground‐Flight Switches
Landing Gear
TOWS
Section “A”
Section “B”
Section “C”
Section “D”
AC Power
Heater
Ram Air Temperature (RAT) Probe
Z‐29
Breaker
Thrust Rating Panel (TRP)
13
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DESIGN ASPECTS. TOWS FAILURE
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The R2-5 relay
Comparison between the recovered relay
R2-5 and a new one of the same model
Flight
condition
Ground
condition
R2-5 operation diagram
14
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COMISIÓN DE INVESTIGACIÓN DE
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DESING ASPECTS. TOWS FAILURE.
THE R2-5 RELAY.
High RAT probe temperature.
Cases involving other MD operators
•
•
Data from five MD-80 operators
Sampling of over 100 airplanes spanning 15 years
Cases compiled by
Boeing (2000-2008)
REPLACEMENT R2-5 RELAY
(80%)
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DESING ASPECTS. TOWS FAILURE.
R2-5 RELAY INSPECTION.
Comparison between
the recovered relay
R2-5 and a new one of
the same model
Functional test of R2-5 relay
•
•
Reference to Leach and Boeing specifications
The results did not reveal any defect
CT scan
• Performed at ZEISS facilities in Aalen (Germany)
• No abnormalities found in internal components in
this exam
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DESING ASPECTS. TOWS FAILURE.
R2-5 RELAY TEARDOWN.
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COMISIÓN DE INVESTIGACIÓN DE
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Design aspects. Conclusions
• R2-5 findings
Given the importance of the R2-5 relay to the operation of the
TOWS, an evaluation should be conducted of the relay’s operating
conditions, its real service life, its reliability and its failure modes.
Specific maintenance instructions should be defined for this
component based on the findings of said evaluation.
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COMISIÓN DE INVESTIGACIÓN DE
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Design aspects. Conclusions
• TOWS in airplanes of the MD-82 generation
TOWS design should be reviewed in MD-82 generation airplanes.
The goal of this review should be to require that the TOWS
comply with the applicable requirements for critical systems
classified as essential in CS 25.1309 and FAR 25.1309.
19
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Design aspects. Conclusions
• Certification of TOWS systems
ƒ Regulations CS-25 and FAR 25 should be revised to add a requirement that
ensures that TOWS are not disabled by a single failure or that they provide
the crew with a clear and unequivocal warning when the system fails.
ƒ Guidelines and the clarifying material for the CS-25 and FAR-25
regulations should consider the human errors associated with faults in
takeoff configurations when analytically justifying the safety of the TOWS,
and to analyze whether the assumptions used when evaluating these
systems during their certification are consistent with existing operational
experience and with the lessons learned from accidents and incidents.
20
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COMISIÓN DE INVESTIGACIÓN DE
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Overview of maintenance factors analysis
Local conditions
• There was another airplane ready for replacement of
•
•
aircraft if deemed necessary.
Self-induced pressure for mechanic:
9 People on board waiting to departure after a delay.
9 High temperatures inside the cabin.
9 Ground assistance and flight crew waiting for a
decision from maintenance (replace or not the
aircraft).
The MEL was available on board
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Overview of maintenance factors analysis
• Individual actions
– AMM was not consulted
– Maintenance personnel performed an incomplete analysis of
the RAT probe heater malfunction on the ground.
• Maintenance personnel actuation analysis
1. To place more importance on the most immediate
information available
2. To adopt only a few theories
3. Once a theory is adopted, they tend to look for evidence to
support it and reject information contrary to it.
Tunnel vision phenomenon
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Overview of maintenance factors analysis
MINIMUM EQUIPMENT LIST (MEL) CONCERNS
•
Go straight to MEL looking for alleviation is not restricted by
rules but is not in line with good maintenance practices.
•
MEL is used
9 As first option to try to dispatch an aircraft in detriment of
a troubleshooting and/or malfunction correction.
9 Under conditions of dispatch pressure and few time to
make a decision.
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Maintenance aspects. Conclusions
• MMEL should be modified in items that may be related to RAT
probe heating on the ground so that said items include
maintenance (M) and/or operating (O) instructions to check the
TOWS.
• Troubleshooting contained in AMM only consider the case in
which the heating system does not supply heat to the RAT
probe in flight.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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According to factual information:
1.
CHECKLISTS.
Spanair
checklists
didn’t
require
TOWS to be checked prior to
every flight.
2.
CRM. There were several
deviation from the SOP’s.
3.
STALL
RECOVERY
PROCEDURE. Crew didn’t
identify aircraft stall.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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SOP’s. CHECKLISTS (1/6)
1. There were differences between Boeing FCOM
and Spanair OM.
2. Nobody (authority, operator, audits) noticed
those differences, so the TOWS wasn’t checked
prior every flight according to Spanair
procedures.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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SOP’s. CHECKLISTS (2/6)
1. National authorities in Europe only accept the
checklists. They aren’t required to approve
them. It isn’t clear how in-depth it should be
the assessment to accept checklists (there
aren’t guides).
2. It is not required the operators to have a
procedure for controlling the changes in
checklists. There aren’t any guidance material
for the preparation or modification of
checklists.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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SOP’s. CHECKLISTS (3/6)
The Spanair checklists didn’t follow the best
criteria related to the design of checklist.
14.12.08 “After start” checklist
The item to check the flaps/slats was omitted. We can hear on the
CVR “Ask for taxi..” when first officer is about to read the item 9, the
last one.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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SOP’s. CHECKLISTS (4/6)
14:22:06 “Takeoff Imminent” checklist
Final items reading by the first officer: “FINAL ITEMS, WE HAVE, SORRY…
ELEVEN
ALIGNED
EIGHT, ELEVEN
STOWED
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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SOP’s. CHECKLISTS (5/6)
1. Best criteria to design and modify checklists
should be known by everybody.
2. Regulation and guidelines should be
developed for both, European authorities and
operators, related to the design and
maintenance of checklists.
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Operational aspects. Conclusions.
SOP’s. CHECKLISTS (6/6)
• Guidance material should be drawing up for the
preparation, evaluation and modification of
checklists associated with normal, abnormal and
emergency procedures that is based on the criteria
that govern safety management systems.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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CREW RESOURCE MANAGEMENT (1/3)
The circumstances of the accident revealed the
existence of several factors potentially related to
knowledge and training deficiencies resulting in human
errors:
9 stress induced by operational pressures,
9 hurry-up,
9 lack of coordination among crew members,
9 lack of assertiveness,
9 channelized attention,
9 expectation bias,
9 procedural adherence
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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CREW RESOURCE MANAGEMENT (2/3)
1.
Captain and first officer received initial and recurring
CRM training according to regulation.
2. Line Checks by the authority and operational
assessments didn’t reveal any weaknesses related to
CRM.
3. There is a mismatch between the improper CRM observed
in the accident and the efforts expended in the area of
CRM. We should ask:
4.
Proper training for inspectors.
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Operational aspects. Conclusions.
CREW RESOURCE MANAGEMENT (3/3)
•Research or studies should be conducted aimed to assess
how the requirements involving crew resource management
(CRM) in the European Union are applied and their
effectiveness. The results of these studies should reveal the
weaknesses that exist in this area and yield proposals for
correcting them.
•Regulatory initiatives should be undertaken intended to
require commercial public transport operators to implement
a program of line operations safety audits (LOSA), as part of
their accident prevention and flight safety programs.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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STALL RECOVERY PROCEDURE (1/3)
Just after take off, the stick shaker and stall aural
warning activated.
• The crew didn’t recognized the stall condition.
• So, they didn’t apply the stall recovery
procedure, although the stall recovery
procedure didn’t include the flap/slat lever
check.
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Overview of operational factors analysis
COMISIÓN DE INVESTIGACIÓN DE
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STALL RECOVERY PROCEDURE (2/3)
1. The need to train takeoff stalls has emerged as
a constant from most significant accidents
related to improper takeoff configuration.
2. Include a check of flap/slat lever in the stall
recovery procedure is key for an effective
recovery.
3. Simulator are
conditions.
capable
of
emulating
stall
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Operational aspects. Conclusions.
STALL RECOVERY PROCEDURE (3/3)
•Takeoff stall recovery should be part of initial and
recurring training programs of pilots.
•The stall recovery procedure in the (AFM) of large
transport airplanes should include a check of the
flap/slat lever and its adjustment.
•Requirements should be established for flight
simulators so as to allow simulator training to cover
sustained takeoff stalls that reproduce situations that
exceed those included in the flight envelope.
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THANK YOU VERY MUCH
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