Spanish investigators have just released more information about the Spanair MD82 take-off accident at Madrid Barajas in August last year. If you remember, the crew attempted take off having omitted to set the flaps, and there was no take-off configuration warning to alert them to their mistake. The aircraft was destroyed and almost all on board were killed.
The new interim factual report makes it clear that three opportunities to prevent the tragedy were missed. Twice the crew were distracted during their pre take-off checks, and then there was a technical anomaly whereby tripping a circuit breaker to overcome a minor fault appears – unbeknown to the crew – to have disabled the take-off configuration warning.
In March we revealed a new NASA study that looked at more than 50 events in which crews had inadvertently taken off without setting flaps, and mostly they got away with it – just. NASA’s purpose was to find out why it happened, and they did. In a Comment at the time, Flight International said: “Another of those uncanny studies has been produced. The type that produces a conclusion that – once you have read it – is so obvious that it’s suddenly amazing the industry has not noticed why a clearly imperfect way of operating has been allowed to continue - since the Wright Brothers - to permit by default the fatal mistakes it does. Like unintended flapless take-offs.”
What they “discovered” was that distractions and interruptions between pushback and take-off are legion. This, they say, should be taken seriously for what it is: a very uncongenial state of affairs during a safety-critical sector of the operation. There is no equivalent of the “sterile cockpit” pre take-off. The only reason why, presumably, we have ignored this fact is that it is far too obvious, and there is very little you can do about the R/T chatter on the ground frequency, that late clearance or departure amendment, the “cabin secure” report, etcetera ad infinitum.
But maybe there is. Just a new level of pilot awareness of the fact that the whole pre-take-off period is a minefield of distractions and – literally – an accident waiting to happen – would be a good start.
This subject is one of many that will be examined at the 2009 Flight International Crew Management Conference in London, 30 November-1 December, at which the theme is Pilot Best Practice .