How can pilots forget to set flaps on takeoff & cause fatal crash? Is it an annual or biannual event?

Question

ON August 20, 2008 Spanair Flight JKK5022 crashed at Madrid-Barajas Airport with 158 fatalities.

Spanish CIAIAC accident investigation commission issued a 92 page, exemplary report in 2009 and another recently.

The conclusion was that this accident was pilot error and the aircraft was not configured correctly for take off. I would now like to explain to you in simple terms on what should happen on taxi out and take off.

Firstly let me explain what flaps are. These are large airfoil shaped sections situated at the front and rear of the wing that can be selected to increase the area of the wing so that the aircraft can fly relatively slowly.

On taxi out towards the runway the pilots are reading and responding to the ‘Check List’. One of the most important items would be Pilot 1 “ Flaps to Take Off”, Pilot 2 would then put the flap lever down to Take off, check that the flap position indicator gauge shows the rear flaps are at TO position and check that the lights indicating the Leading Edge flaps are deployed, are on.

Pilot 2 replies “Flaps set, Leading edges deployed.” The wing has now been temporarily modified to allow it to lift the aircraft at low speed. If the flaps are not deployed then the Take Off Warning System (TOWS) is activated by the throttles and as power is applied a Klaxon sounds warning the pilots to check again before take off.

An intrusive but necessary Cockpit Voice Recorder is always running and on that afternoon the CVR did not record the pilots carrying out the flap selection part of the of the check list and, ironically no TOWS Klaxon was heard as the throttles were opened for take off. The aircraft got airborne for a few seconds, had inadequate lift (stalled) and crashed. It is impossible for an MD-82 aircraft to take off without the wing flaps deployed.

The Investigation report A-032/2008 stated that the flap selector lever was still in the up position and that the mechanisms to deploy the flaps known as screw jacks were in the stowed (up) position, The electrical parts that operated the TOWS were found and although with some fire damage tested extensively but could not be faulted. Of course everyone accepts this warning did not trigger on this occasion because apart from no recording I assure you if that Klaxon starts up in the cockpit you can’t even think straight you just want to stop it!

Apart from the Spanish CIAIAC highly professional and thorough reports, a number of ‘investigation committees” have been set up by Judges and others to try to revert the conclusion of pilot error; this is still on going. I will say that the TOWS should be improved, although no warning system is infallible and cannot be relied on totally.

Finally close to the time of the incident an Air Europa B737 took off from Tenerife without flaps but put them down in time to save the aircraft. The B737 if far more forgiving than the MD82.

Other incidents have been recorded, usually fatal.

I send my sincere condolences to family and friends of those that died.

By Geoff Jones
Geoff spent over 40 years working in the aviation industry
Photo credit: Javier Pedreira

Answer 1

That airplane was built before takeoff configuration warning systems were required and obviously the Spanish aviation authorities don't require that such a system be retrofitted. If it had been installed that crash probably wouldn't have happened.



In the US the FAA requires all airliners to have that system. All airliners built in the last 15 years or so have it and older airliners had one installed.

Answer 2

"Working in the aviation industry"? As what? A ticket agent? A baggage handler?



You don't sound qualified to make any determination about cause. Your explanations and descriptions are also inaccurate as pointed out by Trawler and others. Sounds like you are reading a government accident report and making your own conclusions. Many aircraft can take off and achieve flight without the flaps deployed. Why is a Cockpit Voice Recorder intrusive? How do you know the B737 is more forgiving than the MD82? Have you ever flown either one? Or is that what you overheard a pilot say an airport bar?



This forum is for questions, not for you to disparage and second-guess a deceased flight crew.

Answer 3

I've read too many several similar reports. Ego, fatigue, and sometimes workload, seem to play a part. I was riding jump seat when a distracted FO replied "flaps set", but didn't touch the flap lever. The Capt. (a former mechanic) caught it before the take off roll. Perhaps they actually needed that "featherbedding" second officer? No warning system will work if the C/B has been pulled to avoid the intrusive noise.

Answer 4

Over the past 75 years there have been tens of millions of airline flights, carrying billions of passengers. Mistakes are bound to occur. Fortunately they are extremely rare, especially incidents such as you describe. It's sad and it was preventable, but it is what it is. Get over it. From a statistical standpoint you could fly every single day for 400 years and not encounter a major flight emergency, much less a serious accident. In comparison, you have a 1 in 5 chance of dying of heart disease, 1 in 7 of dying of cancer, 1 in 80 of being killed in an auto accident, and a 1 in 500,000 chance of perishing in an airline accident. In other words, you should be worrying about your health and your personal driving habits, not 2 flights out of tens of millions..

Answer 5

You may have 40yrs in the aviation industry to where you think you can make judgement calls like this, but you obviously haven't been on Y!A longer than 5 minutes to know what you're supposed to be doing here.



How bout you just ask general aviation questions here like you're supposed to and leave the crash investigation stuff to the people who are also in the aviation industry but are actually trained and paid to do it, and stop wasting our time w/ your opinions on fatal accidents that happened years ago.

Answer 6

your point?



i guess you never left your keys at home.



"let me explain what flaps are. These are large airfoil shaped sections situated at the front and rear of the wing"

no. that's NOT flaps. that's flaps and SLATS



"..increase the area of the wing so that the aircraft can fly relatively slowly"

no. FLAPS are not there to enable to fly the aircraft at slow speeds. flaps are there to produce more lift, whenever needed. guess what.. wing mechanisation of F16 more or less continuously changes the wing's shape within maneuver envelope.

besides the only type of flap that DOES enlarge the wing area is fowler flap. majority of flap constructions simply vector the airflow/ shape wing airfoil.



"Pilot 2 would then put the flap lever down to Take off, check that the flap position indicator gauge shows the rear flaps are at TO position"

..apart from systems where you have continuous selection of flap position, right?

Answer 7

It's called "Human Factors" and there are hundreds if not thousands of similar reports.

Answer 8

your point?



have you ever flown a plane? everybody screws up occasionally. the systems aren't perfect, nor are the people who operate the planes. we try. we do the best we can.



later: i note that most of these incidents are in older planes (dc-9, md-82, etc.). newer planes have simplified procedures and more meaningful alarms, so the pilots are less inclined to disable them. people do in fact learn from their mistakes.