Spanair Flight JK5022 Accident involving aircraft ...
Transcript of Spanair Flight JK5022 Accident involving aircraft ...
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
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, Amsterdam19-20 April 2012
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. History of the flight2. The relevant data3. Investigation challenges4. Design aspects. Take Off Warning System
(TOWS) 5. Overview of maintenance factors analysis6. Overview of operational factor analysis
SUMMARY
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
HISTORY OF THE FLIGHT (4/4)
G:\ESASI\Spanair 5022.avi
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• 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
THE RELEVANT DATA
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• Several flap actuators were recovered.Each was extended by a differentamount.
• In the case of the right outboard flap, itsinboard actuator was extended fiveinches and the central actuator 1.1inches.
• The flaps were easily extended andretracted, making it impossible todetermine the position they had on theaircraft.
WING CONTROLSURFACES AND ASSOCIATEDELEMENTS
FLAPS/SLATS
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
WING CONTROLSURFACES AND ASSOCIATEDELEMENTS
FLAPS/SLATS
SLATS DRUM ACTUATORS
The part of the piston that wasextended was not covered in soot.The actuators were not blocked andcould be moved freely.
TRACKS FOR THE NOS. 0 AND 1SLATS PANELS ON THE LEFT SIDE.They were found locked in the fullyretracted position.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
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.
FLAPS/SLATS CONTROL LEVER
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
FLAPS/SLATS CONTROL LEVER & SLATS INDICATION LIGHTS
Take off condition-CG/flaps selectionindication panel
Flaps/Slatscontrol lever
Slats indicationlights
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
DFDR DATA FLAPS DEFLECTION
Second taxi and takeoff was with flapsetting 0º.
FDAUFlight Data Acquisition
Unit
DFDRFlight Data
RecorderDFGC
Flap sensor
Slat sensor
Flaps sensors send info directly FDAUSlats sensors send info to DFGC and then to FDAU. A problem in bus connecting DFGC and FDAU prevented torecord Slat parameter in DFDR.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
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).
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. Flaps and slats remain retracted during takeoff 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 crewof the improper aircraft configuration.
FINDINGS
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
WHY1 did not TOWS work?
2 did not crew select and verify flap/slat position in spite of having procedures and checklistsintended to?
AND3 Were there any previous conditions that might
have prevented the accident?
INVESTIGATION CHALLENGES
DESIGN ASPECTS
OPERATION ASPECTS
MAINTENANCE ASPECTS
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• The relationship between the TOWS and the RAT probe. The R2-5 relay
13
DESIGN ASPECTS. TOWS FAILURE
Z‐29Breaker
Ram Air Temperature (RAT) Probe
Heater
AC Power
Thrust Rating Panel (TRP)
R2‐5 Relay
Section “C”
Section “D”
Section “B”
Section “A”
K‐33Breaker
AC Power Ground‐Flight SwitchesLanding GearCoil
TOWS
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
DESIGN ASPECTS. TOWS FAILURE
14
Comparison between the recovered relay R2-5 and a new one of the same model
R2-5 operation diagram
The R2-5 relay
Groundcondition
Flight condition
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• Data from five MD-80 operators• Sampling of over 100 airplanes spanning 15 years
DESING ASPECTS. TOWS FAILURE.THE R2-5 RELAY.
High RAT probe temperature. Cases involving other MD operators
Cases compiled byBoeing (2000-2008)
REPLACEMENT R2-5 RELAY
(80%)
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
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
Comparison between the recovered relay R2-5 and a new one of the same model
DESING ASPECTS. TOWS FAILURE.R2-5 RELAY INSPECTION.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
DESING ASPECTS. TOWS FAILURE.R2-5 RELAY TEARDOWN.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
Design aspects. Conclusions
• R2-5 findings
Given the importance of the R2-5 relay to the operation of theTOWS, an evaluation should be conducted of the relay’s operatingconditions, its real service life, its reliability and its failure modes.Specific maintenance instructions should be defined for thiscomponent based on the findings of said evaluation.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• TOWS in airplanes of the MD-82 generation
19
Design aspects. Conclusions
TOWS design should be reviewed in MD-82 generation airplanes.The goal of this review should be to require that the TOWScomply with the applicable requirements for critical systemsclassified as essential in CS 25.1309 and FAR 25.1309.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• Certification of TOWS systems
20
Design aspects. Conclusions
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.
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.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
Local conditions• There was another airplane ready for replacement of
aircraft if deemed necessary.• Self-induced pressure for mechanic:
People on board waiting to departure after a delay.High temperatures inside the cabin.Ground assistance and flight crew waiting for adecision from maintenance (replace or not theaircraft).
• The MEL was available on board
Overview of maintenance factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• Individual actions– AMM was not consulted– Maintenance personnel performed an incomplete analysis of
the RAT probe heater malfunction on the ground.
• Maintenance personnel actuation analysis1. To place more importance on the most immediate
information available 2. To adopt only a few theories3. Once a theory is adopted, they tend to look for evidence to
support it and reject information contrary to it.
Overview of maintenance factors analysis
Tunnel vision phenomenon
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
MINIMUM EQUIPMENT LIST (MEL) CONCERNS
• Go straight to MEL looking for alleviation is not restricted byrules but is not in line with good maintenance practices.
• MEL is usedAs first option to try to dispatch an aircraft in detriment ofa troubleshooting and/or malfunction correction.Under conditions of dispatch pressure and few time tomake a decision.
Overview of maintenance factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• MMEL should be modified in items that may be related to RATprobe heating on the ground so that said items includemaintenance (M) and/or operating (O) instructions to check theTOWS.
• Troubleshooting contained in AMM only consider the case inwhich the heating system does not supply heat to the RATprobe in flight.
Maintenance aspects. Conclusions
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
According to factual information:
1. CHECKLISTS. Spanairchecklists didn’t requireTOWS to be checked prior toevery flight.
2. CRM. There were severaldeviation from the SOP’s.
3. STALL RECOVERYPROCEDURE. Crew didn’tidentify aircraft stall.
Overview of operational factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. There were differences between Boeing FCOMand Spanair OM.
2. Nobody (authority, operator, audits) noticedthose differences, so the TOWS wasn’t checkedprior every flight according to Spanairprocedures.
SOP’s. CHECKLISTS (1/6)
Overview of operational factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. National authorities in Europe only accept thechecklists. They aren’t required to approvethem. It isn’t clear how in-depth it should bethe assessment to accept checklists (therearen’t guides).
2. It is not required the operators to have aprocedure for controlling the changes inchecklists. There aren’t any guidance materialfor the preparation or modification ofchecklists.
Overview of operational factors analysis
SOP’s. CHECKLISTS (2/6)
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
The Spanair checklists didn’t follow the bestcriteria related to the design of checklist.
Overview of operational factors analysis
SOP’s. CHECKLISTS (3/6)
14.12.08 “After start” checklistThe 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.
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
STOWEDEIGHT, ELEVEN
ALIGNED
ELEVEN
Overview of operational factors analysis
SOP’s. CHECKLISTS (4/6)14:22:06 “Takeoff Imminent” checklist Final items reading by the first officer: “FINAL ITEMS, WE HAVE, SORRY…
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. Best criteria to design and modify checklistsshould be known by everybody.
2. Regulation and guidelines should bedeveloped for both, European authorities andoperators, related to the design andmaintenance of checklists.
Overview of operational factors analysis
SOP’s. CHECKLISTS (5/6)
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
• Guidance material should be drawing up for thepreparation, evaluation and modification ofchecklists associated with normal, abnormal andemergency procedures that is based on the criteriathat govern safety management systems.
Operational aspects. Conclusions.
SOP’s. CHECKLISTS (6/6)
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
CREW RESOURCE MANAGEMENT (1/3)
The circumstances of the accident revealed theexistence of several factors potentially related toknowledge and training deficiencies resulting in humanerrors:
stress induced by operational pressures,hurry-up,lack of coordination among crew members,lack of assertiveness,channelized attention,expectation bias,procedural adherence
Overview of operational factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. Captain and first officer received initial and recurringCRM training according to regulation.
2. Line Checks by the authority and operationalassessments didn’t reveal any weaknesses related toCRM.
3. There is a mismatch between the improper CRM observedin the accident and the efforts expended in the area ofCRM. We should ask:
4. Proper training for inspectors.
CREW RESOURCE MANAGEMENT (2/3)
Overview of operational factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
•Research or studies should be conducted aimed to assesshow the requirements involving crew resource management(CRM) in the European Union are applied and theireffectiveness. The results of these studies should reveal theweaknesses that exist in this area and yield proposals forcorrecting them.
•Regulatory initiatives should be undertaken intended torequire commercial public transport operators to implementa program of line operations safety audits (LOSA), as part oftheir accident prevention and flight safety programs.
Operational aspects. Conclusions.
CREW RESOURCE MANAGEMENT (3/3)
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
Just after take off, the stick shaker and stall auralwarning activated.• The crew didn’t recognized the stall condition.• So, they didn’t apply the stall recovery
procedure, although the stall recoveryprocedure didn’t include the flap/slat levercheck.
STALL RECOVERY PROCEDURE (1/3)
Overview of operational factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
1. The need to train takeoff stalls has emerged asa constant from most significant accidentsrelated to improper takeoff configuration.
2. Include a check of flap/slat lever in the stallrecovery procedure is key for an effectiverecovery.
3. Simulator are capable of emulating stallconditions.
STALL RECOVERY PROCEDURE (2/3)
Overview of operational factors analysis
MINISTERIO DE FOMENTO
COMISIÓN DE INVESTIGACIÓN DE ACCIDENTES E INCIDENTES DE AVIACIÓN CIVIL
•Takeoff stall recovery should be part of initial andrecurring training programs of pilots.
•The stall recovery procedure in the (AFM) of largetransport airplanes should include a check of theflap/slat lever and its adjustment.
•Requirements should be established for flightsimulators so as to allow simulator training to coversustained takeoff stalls that reproduce situations thatexceed those included in the flight envelope.
Operational aspects. Conclusions.
STALL RECOVERY PROCEDURE (3/3)