Need to know at Madrid Barajas

Accident investigators have two tasks: one immediate, the other longer term.

The immediate task, following an accident, is to determine whether there is – or even might be – useful advice that should be disseminated to the operators of the type of aircraft that crashed. It’s not necessary to be absolutely certain of facts before advising operators to check a component or a procedure if a risk might exist.

The Spanair Boeing MD-82 accident at Madrid is one of those for which the number of plausible causes is almost infinite, given the very sparse data being made available by the investigators. We have been told the aircraft got airborne, but clearly it was unable to stay airborne, and it impacted the ground with a very high nose-up attitude.

At this point, therefore, because of the lack of information provided, intelligent speculation about the possible causes by experts and interested parties – like MD-80 operators - can still include the following: incorrect take-off configuration; de-rated power selected despite Madrid’s density altitude at the time and a tailwind of 9kt during the take-off run; incorrect speeds calculated or set;  engine failure or of loss of power; uncommanded thrust reverser deployment. Then there are all the potential combinations.

Two days ago Spanish investigators returned from their visit to the UK Air Accident Investigation Branch with the downloaded data in their possession. It is in their power by now, surely, at least to rule out some of that list, even if they are hesitant, at this point, about postulating the primary factors they believe might have contributed.

Accident investigators are public servants. They are paid by the public to serve the public. The information they hold does not belong to them, it belongs to the public. The public is not so stupid it would fail to understand information – even incomplete information – if it were provided.

One of the main problems here, as in most of the world’s countries, is that the investigators are taking second place to the judiciary in the investigation, and lawyers do not seek knowledge with the aim of preventing a recurrence of this type of accident; they seek evidence to use to prosecute individuals. Hence the silence, and the lack of information provided to MD-80 operators who need it.

3 Responses to Need to know at Madrid Barajas

  1. David Nicholas 29 August, 2008 at 12:41 pm #

    This may be an event where Just Culture (or lack of it) is the elephant in the room. Perhaps a number of people are covering their backs from fear of legal consequences. The flight crew are dead and therefore more susceptible to carrying the eventual can (if crew failings are found) than would have been the case had they survived. A number of human factors cross my mind – this flight was possibly crewed by pilots on a 4-sector day, of which this was likely to have been the third (unless this was the second return leg in which case it might have even been the fourth). They might by the time of the (final) departure have been tired, hot, possibly hungry and watching the Flight Time Limitations clock. They would have seen the ground staff reach the end of their early shift, and suddenly find themselves dealing with engineering, dispatch and loading staff who had just started work and found a delayed departure upsetting their routines and normal working procedures, and just wanted to get the flight away. Finally, commercial pressure can be subtly applied to encourage a crew to take an aircraft which is carrying allowable deficiencies. Airline or handling agency staff reading this might recognise the scenario. In hindsight (that wonderful thing…) this can provide a fertile ground for error and for links in the safety chain to be broken. More speculation of course, but I retain a gut feeling that there was little wrong with the aircraft that human carelessness could not make worse.

  2. Apollo 1 September, 2008 at 8:39 am #

    Not wishing to speculate on the cause of this accident I noticed in the Flight dated1st September that the engines (plural) were recoved and the Thrust reversers(plural) were in the reverse thrust position. I noted a picturer in the Spanish press last week of a detached TR laying on the ground quite a way from the crash site and with the buckets in reverse position. Was this removed from the engine after the recovery of the engine and is there any pictures of the other thrust reverser.

  3. Bart 4 September, 2008 at 1:28 pm #

    I read this morning on a Dutch website quoting the Wall Street Journal quoting sources close to the investigation, that the flaps (no quote on slats) have been in the retracted position during the take off run. They also state that the take off warning system was inop. This would allow the crew to commence the take off run with incorrect flap setting hence this terrible accident.
    The website reports that this data was all extracted from the DFDR readout. Any confirmation on this?