'Scathing' report on BA Maintenance practices

[flying brain]

UK investigators have again criticised maintenance practices at British Airways (BA) after a lengthy investigation into a serious incident in which errors during work on a Boeing 757-200 led to roll-control problems during a diversionary approach to London Gatwick two years ago.

It marks the latest in a series of serious maintenance-related events at BA which have already prompted concern from inspectors.

In a scathing report into the 757 event, released today, the UK Air Accidents Investigation Branch (AAIB) reprimands the airline for ineffective supervision, poor standards of maintenance, and an inadequate safety culture. The AAIB adds that BA’s quality assurance programme was “not effective” in highlighting these “unsatisfactory” maintenance practices.

Shortly after the 757, registered G-CPER, departed London Heathrow for Paris on 7 September 2003, the crew opted to divert to Gatwick after detecting the smell of hot oil in the cockpit.

But during the approach the crew discovered that the twin-jet drifted to the right of the localiser after its flaps were deployed. Its pilot needed to use about 40° of left-hand control column input, applying some 75% of left aileron, to keep the wings level and prevent the 757 turning to the right. This situation remained all the way to touchdown although the aircraft landed safely at Gatwick with no injuries among the passengers and crew.

Investigators found that the 757 had been performing its first flight following a 26-day maintenance check, and determined that errors had led to personnel servicing engine oils incorrectly and failing to re-install two access panels on the aircraft’s right-hand outboard flap. Asymmetric aerodynamic effects caused by the missing panels led to the roll-control problems.

“The events were the result of a combination of [maintenance] errors on the part of the individuals involved and systemic issues that had greatly increased the probability of such errors being committed,” says the AAIB.

It says that the task of refitting the panels to the aircraft was “not performed to the required airworthiness standard” and adds: “Ineffective supervision of maintenance staff had allowed working practices to develop that had compromised the level of airworthiness control and had become accepted as the ‘norm’.

“There was a culture, both on the ramp and in the maintenance hangar, which was not effective in ensuring that maintenance staff operated within the scope of their company authorisation and in accordance with approved instructions.”

The 757 problem occurred just three months after another serious maintenance-related incident involving a BA Boeing 777 which lost a large access door in-flight. During the investigation into that event the AAIB highlighted three other serious events, across a ten-month interval, involving similar maintenance issues at the airline.

In a high-profile incident in June last year a fuel-tank door left open after maintenance on another BA Boeing 777 resulted in the aircraft having to return after trailing a stream of fuel vapour.

BA, which disputes some of the findings, has acted on seven AAIB safety recommendations directed at the carrier in response to the 757 investigation. It says that it has raised awareness of the problem of maintenance errors and discussed possible preventative action in open forums. Specific procedures for servicing the 757, it adds, have been reviewed and amended for clarity.

It has reviewed its quality management structure, as well as its internal maintenance error investigation process, and is implementing an enhanced supervisory structure to oversee maintenance standards.

“The supervisory function will provide team leadership and technical guidance to less-experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks,” says the airline.

“Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.”

BA says that quality issues are discussed regularly in forums to ensure that all maintenance areas have a good understanding of where working practice might be improved.

Courtesey ATI

[cirrus01]

Not only that................. BA are pressing ahead with implementation of EWS , a computer system that makes an Engineers life and workpractices considerably more difficult than it was already. BA have already suffered lack of aircraft due to EWS problems, notably the Summer 2004 fiasco at LHR when repair overruns were refused by the CAA. The reason ? Lack of parts sourced by the EWS spares ordering system.

Recently BA have introduced EWS to control the hangar checks (all the paperwork , defects and work recording ) and the situation is that many people have not been trained to operate this system,in its current form, it has been forced through , due mainly because of embarrisment of the senior management ( EWS is many years late , vastly overbudget , circa £300 million and still does not deliver the product that was promised ) and confusion reigns................ hardly a re-assuring scenario for maintaining safety ! :ouch: :ouch:

[PondLifeMan]

Not only that Mk2................... BA removed the supervisor grade back in the early 90's. A large amount of the former, and more experienced, supervisors were promoted into "management" positions. This, with the introduction of "A3" personnel made life hard for the few remaining licenced people. Because of the new pay structure (and other factors) this meant that fewer newly licenced people were coming through. What was the point in studying for licences when you can earn almost as much as a mechanic.

Now 10 years later we have a situation that was so predictable it makes you want to cry. The number of licenced people has slowly declined. The statement from BA..........

“The supervisory function will provide team leadership and technical guidance to less-experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks,” says the airline

..............Is only putting us back to where we were 10 years before. Where will they get these supervisors??

And this..........

“Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.”

Is rubbish. It will never happen!

If the management had spent more time dealing with safety, airworthiness and airmanship over these past 10 years or so rather than demotivating, demoralising the licenced people. Perhaps none of these incidents would have occured.

Please forgive this rant. I'm tired and its late.

I'll probably read this in the morning and edit/add to it

PLM

Oh... Please read THIS (http://www.pprune.org/forums/showthread.php?s=&threadid=71919) from 2002.... More of the same really!!

[apaddyinuk]

OH MY GOD....I WAS A PASSENGER ON THAT FLIGHT!!!

[ShortfinalFred]

But, of course, "Safety is our first Priority at British Airways".

What a crock it is all becoming. BA HAVE MISTREATED ITS ENGINEERS FOR YEARS - they have had to endure more debilitating and demoralising rationalisations than I can count, and now the inevitable result.

Ah, but we are in a culture where Big BA can never be wrong, so I am sure all will turn out for the best - cue an avalanche of lies and spin about how brilliant it all is - just read "The Firelighter" for a taste of how nauseating BA's self - delusional lies can be.

[OzExpat]

Management seems to have forgotten the lessons of the windscreen blow-out on a BAC-111 that resulted in the Captain being outside the aircraft all the way down to the ground.

[Joetom]

Any company that has an active Blame Culture and fails to Learn from Problems will just make more Problems.

History shows many times that some can only learn after a high price has been paid and the legal process force change.

From my understandings, in a Blame Culture, many problems do not get fixed because people do not report problems and do not record actual work that takes place incase they get the Blame.

I think all airlines should adopt a proactive safety culture and remove blame culture.....

[Hot Wings]

The snag is that BA suffers from a "latte" culture ie. headoffice is so far removed from the front line that many of the 1,000s of hot deskers in Waterworld don't even realise that they work for an airline!

[cod liver oil]

BA HAVE MISTREATED ITS ENGINEERS FOR YEARS
Actually, engineers from many carriers have been mistreated of late. Most are underpaid and underappreciated for the responsibility that they undertake. They are reminded that their futures are uncertain with threats of outsourcing work to third parties.

None the less, I don't believe it was management that serviced the oil incorrectly, or failed to install those two flap panels which lead to the incident.

Of course they do make easy targets don't they?
:yuk:

These remarks are not directed at any one person.

cod

[PAXboy]

Joetom History shows many times that some can only learn after a high price has been paid and the legal process force change And this will continue to happen because the vast majority of human beings do not learn any other way - irrespective of the busienss that they are in. For example, did anyone hear about a problem at Buncefield fuel depot this week?

--------------------
"I tell you, we are here on Earth to fart around, and don't let anybody tell you any different." Kurt Vonnegut, Jr.

[Say Mach Number]

Trying not to be cynical but God forbid this thread had been about Ryanairs maintenance procedures or some other lo-co I would put money on that this thread would run to about 20 pages.

As well as the hysterical pontificating that would accompany it.

Curious to see how far and how long this thread runs seeing its about a traditional airline and our so called Flag carrier.

Just curious!

[matkat]

In reference to licensed Engineers I could not agree more as I used to be one,at one point I held approval on the F100,L1011 and B747-100,200 and 300,alas no more I got fed up with all the hassle that went with it and after 9/11 found myself out of a job so I simply moved into maintenace planning and tech services approvals have now lapsed but what the hell I am now in QA better paid easier life and treated like a human,its not only BA that have shaffted the Engineers as I have never worked for them but from what I have just read They are no better or worse than the ones that I have worked for.

[L337]

Curious to see how far and how long this thread runs seeing its about a traditional airline and our so called Flag carrier.

ROFLMAO.

BA has thousands of pages of abuse on these hallowed pprune pages.

A cough from BA and Pprune vomits bile.

L337

[Joetom]

This is like another topic on R and N.

A320 with elec power problems in flight at night, AAIB were only advised as MOR paperwork run the course.

Me thinks that aircraft should have landed ASAP and inform the AAIB ASAP, change of culture reqd I think.

[Krystal n chips]

Quell surpise ! Before I comment, let me say this is not a "BA bashing" post, not that I would be overly concerned if it was construed as such--however.

The incident itself is the tip of the iceberg I feel. BA "managers" are simply the holders of a job title--nothing else. Which is but one of the many reasons why the standards have been in decline for years now--fortunately without a major incident. To compound the problems, there is the very pervasive and intrinsic problem of the culture that prevails. Change that, as other have suggested and you might, just might, begin to resolve some of the issues that plague Engineering. BA "managers" are immune from faults and failings--the workers are not--- hence the Blame culture. However, outmoded working practices also contribute---ever seen 6, yes 6 people attempt to change a 737 mainwheel ? Get real. Two max. and even then 90% of the work can be done by one engineer. Just one example I could offer. As for the flexibility of the stamp--hardly a first in any airline I agree, but more flexible than most seems to be the case within said organisation.

The whole organisation needs the equivalent of a "D" check--there's enough human corrosion in there anyway ! ---but unless the culture across Engineering changes pdq, then I have a nasty feeling that sooner, rather than later, the front pages will have the wrong and tragic headlines that nobody wants to read.

Lets not forget that, at one time, before they sold off the "family silver" BA Engineering, despite it's many failings, could actually offer a world class service compared to many others. Not anymore.

[PondLifeMan]

None the less, I don't believe it was management that serviced the oil incorrectly, or failed to install those two flap panels which lead to the incident.

Good Point Cod.....

However there is no proof that it was a licenced person who serviced the oil either. There are so few licenced people now in BA that the licenced guys HAVE to take the word of the mechanics.

Lets not forget that, at one time, before they sold off the "family silver" BA Engineering, despite it's many failings, could actually offer a world class service compared to many others. Not anymore.

How true Krystal.....

We still do offer a world class service on our line stations. A service that could and should be making money. But, as the bosses only want to reduce our numbers, we cant compete. We are so top heavy that it just isnt viable.

Here are some rough figures taken from the 2003 Airline Personnel Costs Survey (CAA 2003 (http://www.caa.co.uk/docs/80/airline_data/2003Annual/Table_1_14_Airline_Personnel_Cost_UK_and_Overseas_2003.pdf) )

Airline .............. Flt Crew ............ Engineering
BMI ................... 600 ........... 650
Britannia .............. 420 ............ 530
BA ...................... 3300 ................ 7000
Virgin .................. 520 .............. 890


These figures speak volumes. BA has around 300 B1 licenced engineers. Who are the rest??

PLM

[Bomber Harris]

pondlife....you didn't report the full facts:

Airline .............. Flt Crew ............ Engineering
BMI ................... 600 ........... 650
Britannia .............. 420 ............ 530
BA ...................... 3300 ................ 7000
Virgin .................. 520 .............. 890
Ryanair.................800................2

:p :p :p

[PondLifeMan]

Yup, and Easyjet have 0 engineers.......

So your point is???

[Jet II]

It has reviewed its quality management structure, as well as its internal maintenance error investigation process, and is implementing an enhanced supervisory structure to oversee maintenance standards.

More BA 'spin' I'm afraid - yes there was a review but it has now stalled and nothing is going to change in the foreseable future - unless you include the proposed 10% reduction in Engineering staff???


Airline .............. Flt Crew ............ Engineering
Ryanair.................800................2

And both of them left BA to join Ryanair :ok:

If anyone wants to read the whole report it is here (http://www.aaib.dft.gov.uk/publications/formal_reports/3_2005_g_cper.cfm)

seems that BA is also telling porkies to the AAIB


5.4 Safety Recommendation 2005-119

British Airways Maintenance Organisation should review the level of supervision on the \'shop floor\' to satisfy itself that it is adequate to maintain the required standards of airworthiness. -

Recommendation reviewed and implemented. !!!!

All full review regarding the role and responsibilities for enhanced supervision of maintenance standards has been carried out. The review has included the scope of technical decision-making, responsibilities for team leadership and supervision of maintenance standards. Additionally a review of feedback from LAE\'s following maintenance incidents, together with visits to other BA partner airlines, to carry out \'best practice\' reviews of LAE duties has been carried out. All true

Implementation of the enhanced supervisory role is expected in Autumn 2005, this will provide a clear definition regarding the scope of LAE responsibilities, including renaming of the grade as \'Maintenance Supervisor\' to differentiate from other certifying grades who are licence holders. The supervisory function will provide team leadership and technical guidance to less experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks. Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.Never happened:{

[PondLifeMan]

This is fun now.....

From the AIIB report

Section 5 - Airline's response to Safety Recommendations



LAE Safety Symposium, attended by over 600 certifying staff and their local management
Dont know anyone who has been to one of these!

Systems and Procedures booklet issued to all 6,000 staff in Engineering describing systems for safeguarding maintenance standards
Not had one of these

Examples of maintenance errors included in bi-annual Continuation Training for certifying staff as awareness of human error events
Blame culture at work!

Addition of an engineering related section in the 'Flywise' periodical issued to all flight crew to review significant maintenance issues.
Excellent idea. Tell the pilots all our errors but make sure we dont get a copy!

PLM

[gas path]

Ah ha! that explains why they came and dumped a big pile of 'Flywise' in the crew room the other day.

[magman]

Flywise was distributed not 'dumped' in the engineering crew room because as the editor I thought as engineers you may be interested. That is the only reason.
I was not coerced, but as a Licenced Aircraft Engineer, ex-OSE and Flight Engineer of 35 years in the company, I have a real belief in BA Engineers and want to share any safety related information that I put together in the magazine.
When it was the Air Safety Review I found the incidents useful, so believed others may feel the same.
I have tried to make it more reader friendly and any comments to make it better are well received.
If you do not want to read it, leave it to my engineering colleagues who do!

[Le Pen]

Have to say Flywise IS pretty cool.

I'm an OSE and get an electronic version.

What a shame, though, that BA didnt think to circulate it amongst Licenced Engineers.

Love

Le Pen

[BOAC73]

Thanks for that....I did wonder why I had not seen the publication for ages. Please continue with this initiative.
This thread has been a bit of an eye opener to me...... which illustrates, at BA Engineering we need to improve.

[Le Pen]

Magman

Just looking at issue 165.....

What pages are the "Engineering Related Section" (BA's words not mine) on??

Thanks

Le Pen

[JW411]

We are constantly being told by the likes of Hand Solo and BHTSM how wonderful BA is and how everything is regulated to a perfect standard.

This report is truly frightening.

Thank God that our maintenance department is a long way from lowering themselves to BA standards.

[gas path]

Don't get me wrong magman, as it happens I often get a copy to read from the flight deck:ok:
Maybe I should change the 'dumped' to 'deposited' :O
Wasn't the original Air safety Review withdrawn from general viewing as it was felt that it was aimed at (and should only be seen by) the pilot/FE community only?

[BOAC73]

JW411,

What organisation do you work for?
This incident happened over two years ago.
BA have one of the most qualified group of engineering staff, licensed under the current EASA regulations.
Leaving panels off an aircraft is not unknown, but it should not happen.
I wonder why it is that engineering did not know what a potentially devestating effect, this omission could have such an impact on the control of the aircraft?
Bottom line is, come to work and do your job properly.
I bet the routine card that said the panels were fitted was certified by qualified staff.
The question is why did it happen?
B73

[Fargoo]

The aforementioned booklet distributed to the engineering staff was entitled EWS.
Unfortunately this is also the acronym for the new engineering computer system that we've been struggling with so it may well have been totally overlooked.
Also, the photograph on the front of this glossy booklet pictured an engineer from another company leak checking a running engine with no run guards in place.
Not ideal but certainly not the best way to start a booklet on safety.

There have been a couple of incidents recently, panels being missed is always serious but unfortantely the work packages are poorly documented and often ask for the same panels to be removed, refitted, removed, refitted several times over the course of a single check. We have asked time and time again over the last 10 - 15 years for this to be rectified but the company is unwilling to spend the money or manpower on the task.

The 757 oil debacle is inexcusable as there are strict instructions on refilling now and many procedures in place to stop it happening. It should not still be going on.

In my area of the engineering base we most definately feel the squeeze but standards are kept high by the men on the tools.

Just my tuppence worth. Safety is MY first priority but not always the company as a whole.

[JW411]

BOAC 73:

Why indeed!

[Krystal n chips]

BOAC 73, This is NOT a personal attack, but would you mind please, offering an insight concerning your discipline within engineering as an occupation ? I ask this because, being a former engineer, your posts don't quite make sense in terms of your statements--notably your comments re the failure to re-fit panels and the adverse effect on the controls as a result--this is basic stuff after all. Actually, your posts speak volumes because if you are, as you say, within BA Engineering and cannot, or could not, see the problems within the organisation then clearly this fact alone serves to confirm the problems that exist.

With regard to the Air Safety Review--as was--I have to say that when I came across a copy, it was always a first rate magazine--there again I have always read FS mags with interest anyway--being "thick" ( as defined by a "manager" ) and having a life long interest in all aspects of aviation. However ( and here I apologise in advance if I have the wrong magazine ) I seem to recall reading an article about the Airbus fleet--( the original ex B.Cal ones ) in which two young ladies gushed on about how excited they were to be joining the fleet--albeit in a non-flying capacity and that they were coming from engineering but "don't worry, we are not a couple of oily rags". The fact the magazine actually printed these comments is the point here. The word "culture"has been mentioned once or twice on this thread and this was a classical example I feel as to how engineers were perceived. That said, being ridiculed by a "manager" for reading the mag in the first place also speaks volumes for the engineering "management" does it not ?. There is a relevance in this post conerning the event in question and that relevance concerns the lack of management skills within the organisation and the resultant effects of promoting people who are / would be unwilling to challenge or question the perceived status quo as to how standards are maintained. Diversity of opinion is not a welcome asset I feel.

[Irish Steve]

However, outmoded working practices also contribute---ever seen 6, yes 6 people attempt to change a 737 mainwheel ?

Slight thread drift, but I've seen better and quicker.:E

Delta arrived from SNN a while back, and the crew changes at DUB.

Line engineers did arrival walk round, and there was 2 minutes of frantic activity. Wheel was jacked up, turned 90 degress so that the "hole" down to the canvas was now on the ground, and the jack lowered again, to a comment of "it only needs to do one more landing, they can change that back at base in Atlanta".

They were "safe" in the knowledge that the outbound crew were not due to report for another hour, so there was no chance of them being seen by the crew during an early walk round!

[BOAC73]

From my experience,

If you had a panel that had a serious contribution to the airworthiness of the aircraft you would be pointed to this by the AMM.

In recent years, this would result in a verification check at least.

Hope you see my point..... I have a sprog who is CC.... and I believe "it" is perfectly safe as long as we do our jobs properly!
B73.

[Sunfish]

BOAC read the *&876 $% report!

Christ on a Crutch! What a mess. And as far as a reading of the report can tell the management response is ........more management, renaming LAE's as "supervisors", and expanding the size of the quality control empire which didn't and can't pick up behavioural issues in the first place! My guess is that the net result will be that LAE's will have more paperwork and even less time to devote to technical matters. Reading between the lines, it seems obvious that BA needs more LAE's, but the "work smarter not harder" brigade will not allow it.


There is no bloody way to tell if the system is fixed either! Do BA techs still batch stamp job cards? I will not make an obvious observation otherwise it will probably be deleted by a moderator.

The bits that made my blood boil the most are here. If they do not make your blood boil BOAC, you should not be working in the airline industry. If anyone had behaved this way at AN they would have been sacked. Furthermore, and although it is not relevent to this thread, how is it possible that anyone could accurately determine maintenance costs under such a system?



"By certifying for the fitment of the panels, a task that he had not performed
himself, the technician exceeded the scope of his company authorisation.
However, the investigation determined that his was not an isolated case. The
lack of discipline in certifying for work in a timely manner meant that it was not
unusual for individuals to be in a position where they would be asked to certify
for a task performed by someone else, who had gone off shift without certifying
for the work completed. Faced with this problem, rather than incur potential
delays in production, maintenance staff would attempt to verify that a task had
been completed before certifying for it themselves."

"However basic the error may appear with hindsight, such errors cannot be
entirely eliminated from human performance and aviation history is filled with
accidents caused by fundamental errors caused by misinterpretation or relying
on assumption. It is recognised in the aviation industry that human error cannot
be entirely eliminated and where an error could prove critical, systems and
procedures are put in place to capture it or mitigate its effects. Examples of this
include the cross-checking of instrument settings by both pilots, or duplicate
inspections in maintenance on flight critical systems."

"Quality compliance audits are not
particularly effective in identifying behavioural issues that have the potential to
compromise standards of airworthiness, as they look at the outputs of the
processes and not necessarily how they are performed. These issues can only be
understood through spending a suitable amount of time in the maintenance
environment and working with staff to understand the factors that influence their
working practices. It is therefore not surprising that the Quality Engineers were
unaware of the actual practices in use on the shop floor and the detrimental
effect that such practices might have on airworthiness control."

"61
This was not a conscious, deliberate
compromise of standards, but rather an invisible erosion of standards based on
the more pressing need to 'get the job done' in as expedient a fashion as possible,
which is a natural trait of engineers. The implications on standards of
airworthiness of adopting certain procedures and methods are not always
obvious at first sight and an awareness that standards might be compromised
requires a certain degree of training, experience and awareness of airworthiness
issues in general. Without a continual focus on airworthiness standards, through
training, effective supervision and adequate quality monitoring, it is inevitable
that staff will deviate from best practices."

"Since the incident, Safety Services as a department has been expanded
to include Corporate Quality and has been renamed as Corporate
Safety & Quality."

[keel beam]

From Fargoo "The 757 oil debacle is inexcusable as there are strict instructions on refilling now and many procedures in place to stop it happening. It should not still be going on."

Servicing is not the problem!! Has any one heard of other Airlines with RR B757 with oil smell problems.... I do not think so (I am prepared to be advised otherwise:ok: )

BA engines are over hauled by GE in Wales, and they have had a number of quality problems over the last couple of years or so ( Remember the -524 problems?) That is where I believe the problems lie.

[BOAC73]

Sunfish.....
Where the hell did you learn your trade?
Continue please!
BOAC73.

[PondLifeMan]

Keel Beam

Servicing is not the problem!! Has any one heard of other Airlines with RR B757 with oil smell problems.... I do not think so (I am prepared to be advised otherwise )

I have handled LY and their 757's are filled to the very top of the tank. They have not had this problem to my knowledge.

Le Pen

What pages are the "Engineering Related Section" (BA's words not mine) on??

Maybe its on page 3.... Who Can We Blame!

PLM

[Sunfish]

BOAC, professional engineer and part of the management of an 1100 strong maintenance division that didn't do the sort of things that BA stands accused of doing. That good enough for you?

[Krystal n chips]

I think Fargoo pretty much summates matters with the comments re the paperwork and the fact that in 10-15 years it has not been updated due to costs----that, and the fact that BA's beloved Omega system--if it's still around that is ?--was regarded as near perfection--when the reverse was true !----I recall that for an APU health monitoring check about 90% of the cards were basically "how to start the apu". A complete waste of time when all you needed was to record the relevant parameters under various loads. As for the contradictions with regard to removal./ refit and removal of panels--this applies to just about every fleet and frankly is a recipe for distaster in itself.

BOAC 73----er, could you tell me please, which panels are not relevant to airworthiness then ? I know that there are certain panels which are not deemed critical, but even then the penalty for leaving them off is sufficient to incur a reduced operational capability---but nowhere have I ever seen in an AMM the fact that "please don't leave these panels off by accident because it sort of causes a problem or two"---which is what you imply in your post. Just what is your engineering discipline please?

Mine was Mil. / Civil Line / Hangar and Casualty plus some bay work and ad hoc flying spannering before you ask.

[TheShadow]

In a recent high profile accident where a switch was left in a "wrong" position by an engineer, the AMM had simply said: "Return aircraft to initial condition".

Now I had always thought that that might mean to uncollar and reset all circuit breakers, return all switches to their "normal" positions and leave the airplane as the pilots would normally expect to find it. However Boeing has now (in their infinite wisdom) come out with an S.I.L. (I believe) as well as an amendment to the AMM saying specifically that this potentially (and actually now) lethal switch should be positioned to AUTO.

That would seem (also because of what's specifically said in the covering letter to the AMM amdt) to be a liability admission by Boeing that the AMM was wrong before (by not specifying said switch uniquely). That will possibly open up Boeing to all sorts of litigation and liability.

So were they right or unwise to have said & done this? How many other unopened cans of worms does that leave them with? They may have simply been being wise and conscionable after the event and recognizing it as an area ("cleanup") where some engineers are not as punctilious as others, but their act has already given rise to some libel lawsuits..... by the "switch-leavers".

I personally thought that they'd been unwise to say what was said in the covering letter.

[screwdriver]

Humans make mistakes
They will continue to make mistakes
Therefore you need robust systems in place to cope with this fact. If there is a blame culture within BA Engineering then this is counterproductive to any form of safety/quality/awareness. The Flywise magazine is just one part of the open reporting culture that exists within the BA Flight Ops division. It works.
Anectdotal "evidence" that I have heard points to this not being the case in BA engineering. I was told that the reason that a former head of Engineering/Technical (CM) left BA was due to his belief that this culture could not be changed before a serious incident occured.It works

[BOAC73]

Scewdriver,
your anecdotal evidence is totally wrong in the case of the senior chap who left engineering.

B73.

[Panman]

I have handled LY and their 757's are filled to the very top of the tank. They have not had this problem to my knowledge.

No doubt that have had a problem with blown seals though from topping up the reservoir to the very top? I find it hard to believe that they dont even account for oil hideaway.

[AMF]

If I ever forget to put the gear down I've gotta remember to blame "management's policies and the resultant lowering of my morale".

Apparently, there are those who would actually buy this.

[HOVIS]

If I ever forget to put the gear down I've gotta remember to blame "management's policies and the resultant lowering of my morale".

If it happend on a regular basis and your management point blank refused to do anything about it then I guess you're right.

[Jet II]

Apparently, there are those who would actually buy this.

Yeah who would have thought that the CAA would buy into that nonsense:rolleyes:

They even publish books about it

CAP 718: Human Factors in Aircraft Maintenance and Inspection

[AMF]

Actually, I'd be wrong if I made that claim, and being guilty of either negligence or gross incompetence for forgetting something so basic and fundamental at this stage of the game, they'd be right to sack me.

Some things just aren't that complicated. If they were, we'd have gear-up landings and forgotten access panels every day.

Jet ll,

Well perhaps in it\'s infinite wisdom the CAA should publish a book entitled \"You\'re Not Supposed To Have Pieces Of An Airplane Left Over After You Reassemble It And Don\'t Expect Someone Who\'s Having A Bad Day To Remember This\".

If one has to be spoon-fed everything (including a good attitude) by management, can they really be considered a professional at what he/she does?

[BOAC73]

AMF,
Thank you for your posts!
I was starting to feel very isolated with my "old fashioned " opinions!
B73.

[Jet II]

Sorry AMF (& BOAC) I cannot agree.

The next time we are staring at a smoking hole at the end of the runway to explain it away to the relatives of those killed with - "Oh we found out who's at fault and he's an unprofessional idiot case closed" - is not in my opinion (and the opinion of the CAA, AAIB, FAA & NTSB) a professional response.

Considering that maintenance errors are increasing as a cause of accidents then the type of investigation by the AAIB into the causes of the error (rather than just blaming the individual as an idiot) seem to me to be the best way forward for flight safety.

If you have ever been involved in a post-accident investigation then you would know that there are many causal factors that come together to create one failure - there is no single cause. Yes sometime the cause may well be failure by the individual concerned, but then you need to investigate as to why he failed - did he have enough or the correct type of training?, did he have the correct tooling?, was he/she in a fit mental state to do the job, etc.

There are many factors involved - the culture of blaming individuals had, I thought died out years ago, maybe not..

[AMF]

Jet 11,

As I said before, there are some things that are so fundamental and basic they don't rise to the level of causation you are speaking of. I'll repeat..."fundamental and basic". Remembering to lower the landing gear is one of those things. Replacing access panels is another.

Much of what you refer to is the failure of a system to idiot-proof itself, which is entirely different. Many of the post-accident recommendations made by the authorities are attempts to do just that.

Case in point; the Pinnacle Airlines CRJ crash a little over a year ago...a smoking hole while trying to make a runway after flaming out both engines. Investigations and recommendations are the result, but in the end no system devised in aviation can be failsafe against such negligence and willful recklessness displayed in that cockpit from the moment of T/O. Had they killed anyone on the ground in addition to themselves, it would have been nothing less than negligent homicide.

Other basic, fundamental things; There's at least two accidents on the books where pilots tried to take off in twin jets on a single working engine in the hopes of air-starting the other one after T/O. Both attempts resulted in smoking holes off the end of runways. I think you'll find that in both cases the consensus of all the investigators was "we found out who was at fault...the pilots...and they were unproffessional idiots"

Case closed.

[Techman]

AMF, you choice of examples as comparisons would suggest that you know very little of how maintenance works. Particularly when it comes to large/lengthy checks.

[Sunfish]

AMF, I hope I never see an investigation regarding a maintenance error, but let me tell you about one I was taught about when working at Ansett.

It happened in 1966. An AN Viscount had an engine fire and the wing failed before they could get on the ground. there were 24 fatalities.

Now the Viscount had an accesssory gearbox on the wrong side of the firewall connected by a quill shaft to the Dart. On the gearbox was mouinted a generator, alternator and a cabin pressure supercharger.

The proximate cause, I was told, was that the order of thrust washers in the Supercharger was wrongly assembled when the unit was overhauled. The manual was subsequently found to be ambiguous. The unit overheated and caught fire.

The hair of the Component overhaul department is said to have gone completely white during the three month of the investigation.

I've had to read two Coroners reports recently involving drownings during yacht races. The devastatingly simple questions the Coroner asks would make you cry.

You BA people are bloody lucky you are not having to answer a Coroners questions. You can play "lean and mean" for quite a while, maybe ten years or so, but eventually the rot will have set in and things will start failing.

Thats what happened to Ansett long after I left. Maintenance was gutted, especially the planning functions. One day someone woke up that a Boeing 767 AD had been missed. Subsequent investigations ended in the suspension of the AOC after it was demonstrated that AN could not guarantee it was complying with its own manuals.

Read the special report here and read between the lines. Do you ever want to see a report about BA that reads like this? Thank Christ they were grounded before an aircraft went in.

http://www.atsb.gov.au/publications/2002/sir200211_001.aspx

[Jet II]

AMF

As I said before, there are some things that are so fundamental and basic they don't rise to the level of causation you are speaking of. I'll repeat..."fundamental and basic". Remembering to lower the landing gear is one of those things. Replacing access panels is another.

I agree that instances such as these are pretty basic - which makes it all the more important to discover exactly why they happen.

Aircraft have been landing with gear down since retractable undercarriages were invented, to simply say that when accident of this type happens its down the crew are unprofessional idiots is the easy way out.

To try and stop it happening again you need to look at the causes - was the checklist followed?, if not why?, if it was , is the checklist correct?, was there a breakdown in communication between the crew?, if so why? - does the airline have a hierarchical culture where the junior crews do not question the decisions of the Captain?, does the CRM system need attention?

With regard to panels - within BA the check papaerwork is in such a state that there can be several job cards for the removal and refit of each panel - it is quite easy at the end of a check for all the work to be completed and a decision made to panel-up the wing - at the end of shift the Engineer stamps up dozens of cards for the repaneling of the wing, then when he comes in the following day there is another routine card lying around for a panel refit - the Engineer knows he fitted the panel yesterday and assumes he missed it in the final stamp up. What he doesn't know is that the night shift found the cards in another area and trying to help removed the panel he had refitted earlier that day. So we end up with a panal not fitted but several cards stamped to say that it was..

So in each case its easy to say that those involved are unprofessional idiots but doing that will not stop it happening again. But if you look into the real causes of each incident you can find failures in the system that, if corrected, can prevent further safety incidents.

Obviously its cheaper to blame individuals which is what companies would rather do than addressing structural issues...

[spannersatcx]

..."fundamental and basic". Remembering to lower the landing gear is one of those things.

Bearing in mind most modern a/c will tell you, you are "TOO LOW GEAR" or get a config warning.

[JW411]

What I cannot get my head round is why it is that BA pilots on pprune are not exactly rushing up to the wicket to defend their engineers.

I have a hell of a lot of faith in the engineers who have looked after me for 47 years and I have only ever been let down once and on that occasion I was given "another opinion".

By that I mean that the despatching engineer had doubts but all the "experts" considered the problem solved. They were wrong!

[AUTOGLIDE]

AMF.

Flight Deck - tiny self contained environment, generally only contains 2 people. Also has been study of human factors since WW2. Has multitude of warning systems in case you mess up.

Hangar - huge multi-shift environment containing possibly hundreds of people. Has a mountain of paperwork/job cards which often contradict/duplicate. Has managers running around telling Tech's to do/leave tasks without their Surpervisor/LAE knowing anything about it. Usually under funded and unwanted by airline and every one there knows it. Not subject to any kind of work hours limit. Been study of Human factors for about 5 years.

Spot the difference.

Safety is about systems and people. The best professional in the world is only as good as the syetm they work within, by the same rational, a poor professional can be kept safe in a system that has the necessary checks against error.
It's not about the stand alone professional. You may not realise it, but when you are there in your little flight deck years of time and a fortune in money has been spent to make sure you don;t make an error.
As JETII states, it's about Human factors. Maintenance people do not have that investment or back-up.

[Joetom]

Remember.

Pilots work as a team, checking each other.

Cabin Crew work as a team, cross checking Doors Auto or Manual.

Engineers often work alone with no one around to cross check.

Engineers working hours are not well regulated.

Engineers often working many Aircraft at the same time.

Work it out for yourself.???

[AMF]

Wow,

This kinda reminds of that scene in the Blues Brothers movie where a groveling John Belushi is blaming his jilting of Carrie Fischer (while she's holding an M-16) at the altar on everything from "had a flat tire" and "ran out of gas", to "locuuuusts!".

Looks like I made a big mistake over all those years spending time on shop floors getting to know the engineers on a first name basis, babysitting various aircraft through routine, pre-buy, and pre-sale inspections, signing work orders, reviewing job cards, taking advice etc. etc....why, it was all a big waste of time.

I didn't know it then, but what I've learned here, is if something were to have gone amiss with the work they performed, or they made assumptions about work they guessed had been performed....why....."it would all be management's fault because they didn't devise a system that lets me...a self-proclaimed professional...assume and guess!"

Which was the issue, after all.

[AUTOGLIDE]

AMF.

Actually I'd say you haven't learnt anything 'here'. You also seem to know nothing of large scale aircraft maintenance, other than in theory.
No-one is saying that they don't take responsibility for what they do.
What you cannot do is take responsibility for something, like a panel, that has to be removed numerous times for access, yet is only in the system once and all it's subsequent removals are not recorded because the system doesn't do it despite 'management' being told this over and over again. We are not talking about single step part removal/replacements on Cessna's, but serious maintenance inputs on complicated transport aircraft. I'm afraid that even you wouldn't 'walk' these aircraft through any check, the Engineers wouldn't have time to talk to you and in any case they could be diferent people day to day as line/hangar workloads alter and they are picking up where others left off. Ah, the myth of the LAE in control of the check, must have been in some bygone era. You also wouldn't have time to all those differing paperwork tasks - because there's too much. Are you cloned?
Actually, your heroic actions above are exactly the scenarios when things do go wrong. 'Kinda' get it now? Probably not.
Hero's and smoky holes have a strange way of attracting each other. Actually the 'I'm a pro/can do attitude' is identified one of the primary causes of aircraft crashes.

[AMF]

Autoglide,

Don't know where you got the "hero" thing from, or that i was talking about Cessnas. You're the one who seems to think it requires heroic effort to do a job correctly.

An aquaintance of mine went through heroic efforts (probably) the day he, the other pilot, and airplane wound up in a hole. According to the findings of the investigation, the jackscrew on the horizontal stab was impoperly re-installed, something not detectable on a preflight since it backed out in-flight later on descent. Witnesses on the ground said the aircraft went through a few vertical up and down thousand-foot occilations before crashing vertically, killing everyone.

You see, that's where assumptions and guesses regarding job cards and the inconvenience of shift changes wind up. My desire, sitting in the seat, exceeds yours with regards to you getting it right.

So you can try and reduce my desire to learn more from engineering and do my job better...which in large part is knowing the airplane....to something akin to being "the problem" or an arrogant prick. Pretend I don't believe in causes like "human factors" etc when it comes to aircraft accidents if that's convenient. You'll not find anyone I've flown or involved with in 30 years of professional flying saying I'm not a firm proponent and hands-on user in dealing with potential problems on that level, CRM, or listening...all those things you apparently think you're giving me an elementary primer lesson but we use every day.

Saying "do your job" isn't the same as telling you how to do it. Flying or fixing, neither of them are rocket science. If you can't handle the focus, communication, organization, and paperwork that goes with it, then you're in the wrong business.

And by the way, how can one be a "poor professional".. The kind that a desirable system will have "necessary checks against when they make errors", as you put it? The "System" is just people after all, so who checks the checkers if they're "Poor professionals" too?

At some point, someone has to assume responsiblity for their own actions.

[Joetom]

AMF, I think I understand what you say, but.

Like for Like, Pilots and Cabin Crew work one aircraft at a time, some Pilots only work on one type of Aircraft for a period of time.

Engineers can work many Aircraft and Aircraft types in a single shift.

Managers can overload work on Engineers, eg, due sickness, you will cover 8 Aircrafts in the next 3 hours instead of 4, this system can't be applied to Pilots and Cabin Crew.

Engineers hours and shifts are not well regulated.

My view, at present Engineers do a good job in changing times and Aircrafts are very safe even when all is not well and correct, but when the numbers are right, Engineers will be regulated like others in the Airline Trade.

Interested to know more of that stab jack problem you talk about....

[Sunfish]

Autoglide, at the risk of this post and me being banned by the moderators here, I am going to say that if your attitude is typical of BA, as evidenced by the quote below, the your AOC should be pulled immediately. I am deadly serious.

"the Engineers wouldn't have time to talk to you and in any case they could be diferent people day to day as line/hangar workloads alter and they are picking up where others left off. Ah, the myth of the LAE in control of the check, must have been in some bygone era. You also wouldn't have time to all those differing paperwork tasks - because there's too much. "

Your entire maintenance system is based on the assumption that the LAE is in control of the check. If this is not the case, you are in breach of your own maintenance system manual.

You cannot argue "cosi fan tutti" - (everyone does it) with regard to maintenance irregularities. If you try to argue that then, by implication, you are admitting that you cannot comply with your own MSM and your AOC should be pulled immediately.

My evidence for this is again the Ansett ATSB report referenced earlier. Sooner or later your maintenance culture is going to allow swiiss cheese holes to line up. In Ansett's case, cracks in the B767 pylons and tailplane attachments were either missed or ignored due to a maintenance workforce that had been "pruned" (no pun intended) to the bone.

For a start, in my day, successive shifts deliberately overlapped by an hour so that there was a deliberate "hand over" of work rather than picking up where others left off". In fact the very use of this phrase enrages me to the point where I will never fly BA again.

To put it another way, what sort of cretin are you if you think "picking up where others left off" is good enough? You make me want to throw up!

And Danny if you think this is going too far, then too bad, because it's true.

[HOVIS]

Sunfish,
You are now understanding the problem.

BA's management deliberately altered shift patterns so that an overlap became impossible.

Now, 12hr shifts start and finish on the dot with no overlap. Also, as management refuse to pay OT for extended hours (in some areas) engineers go home on the dot too.

So what happens? You get a scribbled written handover which tries to describe 12hrs of troublshooting and checks. Not good.



To put it another way, what sort of cretin are you if you think "picking up where others left off" is good enough? You make me want to throw up!

Me too!:yuk:

Unfortunately in the current climate engineers can't do anything about it. If I complain to my employer I will be overlooked for further training/promotion. The CAA refuse to tackle the issue. CHIRP is ineffective and the general public are not interested. :mad:

If BA flt crew are THAT interested in the servicability of their aircraft I suggest they take a good look at the hangars and line mantenance operations. YOU WILL BE SHOCKED!

Pilots and CC would not and do not work under such conditions. Good luck to them. They will need it!!

[AMF]

Joetom,

Reference for the accident report:

NTSB NYC00MA048

IAI 1124A, Registration N50PL

December 12, 1999

Gouldsboro, PA, USA

Most pertinent to this discussion would the investigators' reports generated by the accounts given to them by the various engineers they interviewed who either worked on the horizontal stab actuator assembly, were in a position to see the assembly being worked on, saw who might be working on the assembly or in the vicinity, and the usual mx paperwork trail to include job cards and billing records.

Draw your own conclusions, but my observation and question is this;

Any complex system depends to some degree on fundamentals. Nuclear power plants and power grids have a human element, but the ultra-high degree of mechanical reliablility of a few fundamental things such as sensors and indicators the humans in that system use for its operation that results in redundancy, brace the system for most contingencies. In fact, they are integral to the contingency.

For example, if the very last line of defense for a imminent meltdown after all the other complex options are exhausted is flooding the pile by some guy walking over to, and manually opening, a valve directly by hand, what happens if this last-resort valve handle breaks off in his hand? What if he has a heart attack at that very moment? We don't really think about that...we almost assume it won't because of such low probability. That's the root flaw in any system. Infintesimily small to be sure, but a weak point nontheless, because even though that valve has been functionally tested and replaced at routine interval a hundred or thousand times before, there is no 100% gaurantee it will work in the situation when you actually need it.

Yet, we come to a point where we depend on...alsmost assume the device's reliability because of it's simplicity within a larger complex endeavor, and it's a one-step process. Those attributes prompted us to place that mechanical device in the system where it's at in the first place. And it works very well.

If you buy a set of quality tools, every time you set an open-end wrench to apply force do you wonder if it will break in your hand? Of course not, because even though it is a remote possiblity, the simplicity and proven dependability makes it almost fundamental. You calibrate torque wrenches don't you?..don't you end up trusting the device you calibrate them with?

But other complex systems, such as aircraft carrier ops or aircraft mx inspections/inspecting and organizing work, involve humans (and thus "human factors") to a much larger degree. These systems depend primarily on human activity to function at all levels. There's no 99.99999% reliable switch to flip or valve to open that control a computers or a wrench-wielding robot that does the job, or more importantly, provide a last line of defense against failure of the primary functions. There's no simple mechanical backup to rely on. All you can do is try to assure a skill-level, maintain focus, and organize a series of warning triggers as assurance, and to alert if things aren't being done properly.

Unlike the first type of complex system, where very reliable machines do the work and humans are the stop-gap measure, in the latter, humans ARE the measure. That's just the nature of the profession and our tasks.

In response to this we've invented things like training, licensing, and certifications. Things that could be thought of as "calibrating" humans, perhaps. But unlike a mechanical device, every single one of these aspects involves, at it's foundation, human individuals' self-regulating to the higher standard of what we certify we are, in order for others to trust us in our work.

Integrity in one's own work...focusing on it, organizing it, never making assumptions...things that make one a "professional"....are the root that holds a necessarily human-dependent complex system upright, as opposed to a simple and ultra-reliable mechanics the nuclear plant operator has under his finger.

It's tempting to blame all failures on "management" in a human-dependent system, and many times they can be to blame in part. Devise a perfect system of any type and you'll be a billionare tomorrow, or show me one where the humans working within don't think they have a better idea. I'm not aware of any.

But every day a professional dons a uniform or badge and chooses to go to work in that imperfect system is another day that has no place for assumptions or guesses at the root level. And if something goes awry, shuffling blame to the easiest, vaguest, target of all ("management") or not being forthcoming with investigtators will no nothing to improve the system that relies on the front line troops' integrity to function.

If a management overworks you and you're fatigued...don't go to work. If they don't train you...refuse to work on something you aren't trained for. If you're hung over....call in sick. If, in your view, underpaid or demoralized to the point of not being able to focus on the task at hand....remove yourself from it and seek employment elsewhere. If the whole set-up is so systematically unsafe you wouldn't put your own family on the plane....blow the whistle.

We rely on you to make aicraft airworthy. Our lives are in your hands. The pax rely on us to not screw up, and trust they're sitting in a perfectly good airplane.

Management be damned, if we go to work, the buck stops with us.

[AUTOGLIDE]

Sunfish,

I didn't say I agreed with it, try reading my post, to comment on something you haven't read properly is certainly, to use your own terms, cretinous.
Also I don't work for BA, I have in the past as a contractor, and to be honest they are still one of the best outfits around despite their 'challenges'. This is why I object to all the armchair maintenance experts wittering on about the ideal world of aircraft maintenance and commenting on the professionalism of the people there. Aircraft maintenance Engineers do a good, professional job in spite of the environment/ethos they are immersed in.

AMF:

I agree with your view on professionalism, I never argued against it, what i am saying is that even with the most highly professional people things can still go wrong if insufficient systems/safeguards are not in place, that may be something we'll never agree on. Thing is though, you can't just leave if you don't like the way things are run - not enough jobs, whistle blowing? Been done, doesn't work. You end up doing something in-between, and just do your best.

[Allen Key]

Reading some of the posts on this forum I am somewhat disheartend. As an ex BA engineer, now a first officer for Ryanair I can honestly say that the standard of maintenance at both companies is very high. You only have to go contracting for a while as a B1 to see some low standards.

As most of you write the role of the LAE or B1 holder has slowly been watered down until only a handfull are required to keep an operation running legally. Its about time that engineers got their just rewards and with the lack of new blood entering the industry, it should be soon. Please let us stop this low cost v flag carrier arguement. BA should also kick out the dead wood on the shop floor. Too many people just turn up for the money and they would not last two minutes elsewhere. Also there are loads of B1 guys at Ryanair ! Where did you get the figure 2 from ? Thin air....

[PAXboy]

Pax speaking: From the outset of this thread, it all sounds like routine commercial life in 1990s/2000 UK. That is to say, everything being cut back until somehting breaks. As yet, BA have not had anything break. My guess is that the recent difficulty experienced at the Buncefield Depot will fall into the same category.

All the comments about the way in which BA maintenance staff now have no paid hand-over time and have to work on multiple a/c at the same time, indicates one thing. That corners are being cut. I have seen engineering resources cut in the same way, with staff having to chase all over the place to meet the statistics. In those cases they were fortunate that - if it all went wrong and the boxes stopped working - the boxes would still be sitting comfortably on the ground [Telephone exchanges, if you were wondering]

For any company the law of averages will catch up with them. Think of Herald of Free Enterprise as but one example: Staff were complacent AND senior staff had been asking mgmt for CCTV and warning lights on the Bridge to signal the status of the bow and stern doors. Mgmt had refused and folks got complacent.

After a public inquiry into the sinking in July 1987, Britain's Lord Justice Sheen published a report that castigated Townsend Thoresen, the ship's owners as part of the P&O Group, and identified a "disease of sloppiness" and negligence at every level of the corporation's hierarchy, thus proving that private entreprise cannot be trusted in matters of public security and need to be strongly monitored by regulating authorities. This led to the following act of Parliament:

Public Interest Disclosure Act 1998
From Wikipedia, the free encyclopedia.

The UK's Public Interest Disclosure Act provides a framework of legal protection for individuals who disclose information so as to expose malpractice and matters of similar concern. In the vernacular, it protects whistleblowers from victimisation and dismissal.

The Act received Royal Assent on 2 July 1998 and came into effect a year later in 1999; need for such protection became evident from enquiries into disasters and crimes such as the 1987 capsise of the Herald of Free Enterprise, the 1988 Clapham Junction rail crash, and the 1991 Bank of Credit and Commerce International scandal. In each, employees could have prevented the occurrence had they felt that they would have received any support in raising allegations.

The scope of the Act extends to the raising of "genuine concerns about crime, civil offences (including negligence, breach of contract, breach of administrative law), miscarriage of justice, danger to health and safety or the environment and the cover up of any of these" and extends to all employees in almost all professions; some, such as the army, are excluded.

Protection in the event of infractions by employers is available through the industrial tribunal system; remedies include unlimited financial compensation and orders requiring companies to retain the employee in his or her job.

The time will come for some folks in the Airline biz to think about using it.

[Sunfish]

Autoglide. The only wittering going on is your own. I don't care how "professional" a maintenance engineer may be. If you are a professional, no matter how good you are, you can still be let down by a bad maintenance system.

That is the lesson of Ansett (read the report). The good folk at Ansett were working their @rses off and doing an excellent job, but if the paperwork isn't as professional as the engineers, then sooner or later someone is going to be provided with the wrong information, and then all the professionalism in the world isn't going to save you.

Next thing I suppose you'll tell me is that the receiving and issuing stores functions have been combined to save money. Now as a "professional" I'll bet you can tell it's a legitimate idea isn't it?

[Joetom]

AMF,

Lots of info, thanks.

But you are correct, when the cheese holes line up, things will change. Will happon a few times me thinks.

But until change, The way Engineers are treated will keep having a great effect on Pilots and Cabin Crew doing their jobs with ease. (Pilots and Cabin Crew will get blame when things go wrong due to Engineers not fixing the Aircrafts)

As for the Stab Jack problem you mention, a sad story.

Was thinking of a Stab Jack accident beween SEA and SFO I think about 5/6 yrs ago, to save money, Lub was reduced and Stab Jack failed, all were lost I think.

An old saying, if you thinks, Engineering is costing many dollars, check out the cost of a Hull or two.????

[scarebus03]

Hi all

1. AA DC-10 wrong engine change procedure
2. Air Alaska MD-83 Stab trim jackscrew fail
3. AirTransat A330 Wrong component modified and installed
on one engine.

There are much more maint. involved incidents throughout the jet age. In particular the Air Alaska report makes horrifying reading for the failures in their maintenance procedures. There is no excuse for this B.A. maint incident but I have seen worse in other places. Regulation of duty hours is a must for engineers we have the same responsibility as the Captain in relation to the safety of people and the machine If maint. make a mistake people can die, it's that simple. The bean counters choose not to see it this way as for them maint. is only a mundane necessity. Gradual erosion of the standards and the constant derating of the a/c engineer to semi-skilled status along with t's and c's all play as factors. If the same applied to pilots I wonder would we be reading "thats no excuse" Read some of the posts in relation to crew rosters!

Brgds

SB03

[BOAC73]

You are such a "Drama Queen"

Withdraw the AOC....I'll never fly BA again.....Ansett...."long after I'd left". I don't think.

Hovis...you have a personal axe to grind with BA. Best to vent it on the airmech website...but then you probably have.

B73.

[HOVIS]

CONGRATULATIONS BOAC73!:rolleyes:

You have just proved my point.

Anyone starts to make a noise on this side of the industry and the old cliche comes out every time.....

....you have a personal axe to grind with BA....


I believe the chap at Alaskan who tried to blow the whistle was accused of the same thing.


Oh well, if you want to bury YOUR head in the sand.....


Merry Xmas.

[Blacksheep]

There was once a time when LAE's held only type rated licences. There were no LWTRs and company approvals only covered the Certificate of Compliance (e.g. CRS). The licence authorised the holder to certify all levels of maintenance although, for most maintenance activity, the LAE used his company approval, granted on the basis of his licence. Every once in a while the crunch came, when it was necessary to issue a "Certificate of Maintenance" - signed using the individual's licence number not the company approval, which didn't cover the C of M process.

Then it was decided that, under MSG2, aircraft maintenance had become too complex for an individual to be able to issue the C of M and the CMR was invented, theoretically monitored by the whole maintenance system itself. Theory aside, in practice the Maintenance Review is conducted by an individual QAE who issues the CMR when he's done. So, its just the same as issuing a C of M, except that now its done under company approval by a company servant instead of a maintenance supervisor exercising the privileges of his own, personal licence.

Did the supervisor have true independence in signing the C of M? Of course not - he still needed a job! But his independence of the company approval did make a big difference to the way the company organised its maintenance. That was why the airlines were so eager to get rid of the C of M and type ratings.

So, after nearly 30 years since his disappearance the maintenance supervisor is to make his return? Not before time, I say...

[yachtno1]

I seem to be aware that 60% plus of accidents are attributable to Pilot error and 18% to maintenance. These are both too high IMHO. I wonder if any fellow BA engineers would agree with me when I say trying to work to BA Proceedures as they are written is neigh on impossible!:eek:

[brookhouse]

>>>I was told that the reason that a former head of Engineering/Technical (CM) left BA was due to his belief that this culture could not be changed before a serious incident occured<<<

I worked directly for CM who was breath of fresh air for many of us in Flt Ops. He understood and set perfectly clear safety and commercial targets which, for want of a technical term, drove members of the recently demoted Leadership Team bananas - i.e. how could CM possibly manage or understand 'our' pilots. Traditionalist members of The Board caved in to old-school lobbying and CM, as talented people tend, wandered off to greener pastures. A great loss and just the man needed now.

[Krystal n chips]

It seems to have made the front page ---at last. Better this way though than the headlines nobody wants to see I suggest.


http://www.timesonline.co.uk/section/0,,2086,00.html


The only inaccuracy I can see is numerical They got missed out a 1 on the timescale they propose. Shame they didn't comment further on some of the other relevant issues raised on this topic--such as intimidation, bullying and victimisation for example----and the culture overall.

And NO BOAC 73, I don't have an axe to grind ( I say this because you seemingly assume that any criticism is unwarranted and not valid per se ) just simply pointing out the obvious flaws in a once world class organisation as I said before and which are clearly evident to most observers, internal or external. Maybe you should open your mind a little hmmm?

[Sunfish]

From today's "Australian". Someone must be reading Pprune.


Cracks appear in British airline safety
Steve Creedy, Aviation writer
January 02, 2006

A STRING of midair incidents involving British Airways, one of the three European airlines servicing Australia, has raised questions about widespread safety problems at the airline.

A report by Britain's Air Accident Investigation Branch found BA jets suffered mid-air failures because of "systemic" problems with the carrier's maintenance.

After inquiries into four mid-air incidents, investigators said safety problems could be "widespread within the organisation", The Sunday Times newspaper in London revealed yesterday.

Investigators warned that shoddy work practices appeared to be accepted as the norm by some BA maintenance staff.

The newspaper listed a series of incidents, including a door that ripped off a Boeing 777 at 6000 feet.






The door gouged the plane's fuselage and narrowly missed a couple walking below when it hit the ground.

In another incident, fuel gushed out of a plane that had just taken off from Heathrow Airport, leaving a two-kilometre vapour trail, because screws and a cap that should have plugged a hole were left inside the tank.

And the pilots of a Boeing 757 were forced to put on oxygen masks and land as their cabin filled with oil fumes. It was later confirmed that engineers put too much oil in the jet.

Maintenance workers in late 2003 also forgot to properly reattach two wing panels on a Paris-bound Boeing 757 that then responded abnormally to the flight controls.

As the captain prepared to land and the autopilot was disconnected, the plane started drifting to the right, forcing the pilot to take corrective action.

And investigators said the failure to check the wing panels were installed did not appear to be an isolated incident.

"Ineffective supervision of maintenance staff had allowed working practices to develop that had compromised the level of airworthiness control and had become accepted as the norm," they said.

"Maintenance errors were not the result of wilful negligence, or any desire to perform a less-than-satisfactory job, but the result of a combination of systemic issues that had increased the probability of an error being committed."

The criticism from the AAIB is unprecedented for an airline that has claimed a reputation for having one of the best-maintained fleets in the world.

Although BA has recently relied increasingly on codeshare flights with Qantas to get its passengers to and from Australia, it still flies its own planes to Melbourne and Sydney.

A spokesman for the Civil Aviation Safety Authority said yesterday the Australian regulator was unaware of the report and was unlikely to take action.

He said CASA would leave any action to the British regulator, which it recognised as the competent authority.

A Qantas spokeswoman could not say whether the airline had work done on its aircraft by British Airways Engineering, BA's maintenance section.

However, BA told The Sunday Times it took the safety report "very seriously" and had addressed the problems in its maintenance processes.

"British Airways prides itself on safety and recognises that we are always ready to learn from incidents and encourage open transparent reporting," said the airline's head of safety, Captain Rod Young.

The airline now has only 6000 engineers, compared with 9500 in 1995, despite its fleet remaining at a similar size to 10 years ago, with 288 aircraft.

[Krystal n chips]

There is an interesting post on the airmech site which, if true and I would state here that I am not questioning the integrity of the poster for one minute, far from it in fact, that really does summate matters and also shows a very negative approach to Flight Safety.

The poster states that the technician involved was swiftly punished and still is being so---quelle surprise !--despite co-operating fully.

Now, I have to admit I am slightly old fashoned here. To me, one of the central tenents of Flight Safety is this. We are all human and therefore fallible. We make mistakes. However, if we make a mistake, admit it and rectify the problem, plus analyse how the mistake occurred in the first place, then why, oh why ( other than cover their own ineptitude and prove how "strong" they are as "managers" ) do those whose job titles define them as "managers" have to launch into disciplinary actions against an individual(s) when they have admitted the mistake----which, as I say,to me defeats the whole objective and ethos of Flight Safety.

In contrast of course, are those who are simply blase about matters and their errors and cannot, or will not, even consider they have made an error. Even then, I suggest that disciplinary action should be the last resort given that once you go down that road, as a manager you have clearly failed in your role anyway.

As for the case in point--well the knee jerk reaction of punishment neatly encapsulates the many problems that currently seem to be endemic within the organisation--to me at least.

[BOAC73]

K&C,
I find it very sad that you are prepared to take all the rubbish you have read on here, in the Times and on airmech as gospel.
Only last month we passed a CAA audit.

I say to anyone on here....if you have any serious doubts about the integrity of BA Engineering you should do something about it.

Those of you who are proffesionals within the industry will know what action is availble for you to take.

B73.

[Krystal n chips]

BOAC 73

May I, politely, suggest you read my last post again--this time in detail--and then review your comments. May I further suggest you also take the time to read the other posts on this topic, again, in detail, and then, possibly, you will grasp the relevance of the comments / observations and, heaven forbid, criticism of BA Engineering.

For you information, the article in the Sunday Times is, had you bother to read it, a compilation of events which are all readily available in the public domain. The fact it was the lead story on Sunday may have escaped your attention I feel. As for the airmech site, well I have know way of telling here, but, and it is a relevant but, given that I probably know considerably more about the system than yourself (but not the case that produced this thread though ) then shall we say I have no reason to doubt the integrity of the poster or, far more pertinently, the comments made.

BOAC 73---that's an interesting handle--the year you joined perhaps as a BOAC apprentice ? and,if so, may I politely ask once again, what exactly is your discipline please?. You see, and here I would like to make an analogy rather than a speculation, you remind me of a very good Giles cartoon c1945. It shows a group of scruffy GI's slouching through Berlin but at the back are two very smart GI's marching in step. The caption shows two MP's one saying to the other "Y'now, there's something very un American about you two guys at the rear".

[Clipper7]

[QUOTE=Sunfish] British Airways, one of the three European airlines servicing Australia /QUOTE]


That's it: 3 ???

1) BA
2) Virgin
3) Austrian

I did some research and was pretty amazed that only 3 Europeans flew down under, and even more so that one of them was OS !

[Bus429]

A few key Human Factors:

Latent error - can be a management policy or decision made before an incident (and separated in time and space from the active environment).
Latent error - can also be a technical problem or practice waiting to happen and, when combined with an active error, could form the incident or accident chain.
Active error - that having a (perhaps relatively) immediate effect.
Engineers, like those in other walks of life, are subject to a variety human issues.
Violations can be broken down as:
Routine - we've always done it this way (norms and complacency)
Situational - we are forced to do it this way (lack of resources, tooling, time etc)
Optimising - violating for kicks (rare)

With the exception of the latter, all these factors seem to have been present in this incident.
It could happen to any of us.

[fabricpatch]

The Sunday Times



The Sunday Times January 08, 2006

Safety in the skies



The Association of Licensed Aircraft Engineers (ALAE) was not at all surprised by your excellent article (Watchdog slams BA’s air safety, Insight, News, last week).
Your statement: “BA employs 6,000 engineers, compared with 9,500 in 1995 but its fleet remains at a similar size as 10 years ago” hides some shocking truths.



Our figures show that only about a third of the 6,000 engineers employed by British Airways are in fact fully qualified licenced aircraft engineers.

The aviation industry has seen the numbers of licenced engineers dwindle from 24,000 in 1979 to 12,000 today.

Yet during the same period, aircraft numbers have more than doubled. BA, like other airlines, is under financial pressure and staffing levels are stretched.

BA operates a policy that involves the licenced engineer only appearing at an aircraft if requested to do so. Something that was unheard of in the past.

Even pre-flight inspections, the last line of defence in uncovering anything untoward, has been taken away from the licenced engineer. The Australians refused to accept such a policy on the basis that it clearly affects safety.

Robert Alway
ALAE, Bagshot, Surrey




Any coments, is it just BA ?

[Wodrick]

At work I deal with several Maintenance providers, both in the U.K. and Overseas. Subjectivly, it seems to me that this is a widespread problem, certainly not confined to B.A. but conversely not an overall problem. Notably those employers that have a reputation for good employee relations seem to have enough staff - strange isn't it ?

[BOAC73]

I wonder how old Mr Always numbers are?
JAR 66 has brought about many more licenced engineers within BA.
Worthy of note is that not all of our engineers work on aircraft, but have workshop qualifications.
For many years BA maintained their aircraft on there own maintenance schedule (approved by the manufacturer and CAA). They have now almost fully switched over to MPD.
Not surprising then that the load v capacity ratio has changed quite dramatically over recent months.
B73.

[matkat]

I wonder how old Mr Always numbers are?
JAR 66 has brought about many more licenced engineers within BA.
Worthy of note is that not all of our engineers work on aircraft, but have workshop qualifications.
For many years BA maintained their aircraft on there own maintenance schedule (approved by the manufacturer and CAA). They have now almost fully switched over to MPD.
Not surprising then that the load v capacity ratio has changed quite dramatically over recent months.
B73.
Care to give Us some figures of how many licensed engineers there were under section L compared to JAR/EASA 66? as I am sure there are a lot less now than then I am not interested in how many workshop People there are just LAMEs.

[Blacksheep]

The aviation industry has seen the numbers of licenced engineers dwindle from 24,000 in 1979 to 12,000 today.
I don't think so. Licence number 17270 was issued in February 1978 and at that time, not all of the preceding licenses were still in use - although I've had the pleasure of working under numbers 6 and 27.

The situation is quite serious enough without exaggerating the numbers though... :(

[Bus429]

Blacksheep - it is indeed serious. I have included this in current Human Factors training.
What was a Cat A certifier doing using his authorisation in base maintenance?

[spannersatcx]

You might want to look at the statistics issued by the CAA issued oct 04 here (http://www.caa.co.uk/docs/177/srg_eld_statistics_02.pdf):sad:

[TURIN]

It seems that BA's big idea to reduce maintenance errors is to give the LAEs a name change to ..... wait for it....


SUPERVISOR!

Also, they think the best way to improve standards is to remove the supervisor from the hangar floor by giving him more clerical and administrative duties such as monitoring absence and carrying out disiplinary processes AND be responsible for investigating maint errors by his peers!

Can't wait for that one.

Dear self, buggered up last weeks A check. Don't do it again.

Sincerley,

Self.

[Krystal n chips]

It seems that BA's big idea to reduce maintenance errors is to give the LAEs a name change to ..... wait for it....



Nothing original there then----delete Windscale / insert Sellafield:rolleyes:




SUPERVISOR!
Also, they think the best way to improve standards is to remove the supervisor from the hangar floor by giving him more clerical and administrative duties such as monitoring absence and carrying out disiplinary processes AND be responsible for investigating maint errors by his peers!
Self.

So if it's not a silly question, apart from the obvious refusal to understand and address the causal factors and heaven forbid, actually perceive that many problems emanate from the "management" culture of bullying and intimidation, who is actually going to be doing the hands on supervision now that the LAE's have been upgraded in nomenclature to Supervisor ?. I know it's a daft question and that I really should know better than to even think about asking it, but I do have this rather strange concern that possibly those who devised this solution are--in ( nept) (adequate ) (competent ) (different )---but I could be wrong of course.

One more silly question please. I always understood that BA already had this capacity in the form of the TMG grade ? If so, other than their attendance to achieve their KPI's ( Line maint excluded here please note as these guys are both productive and supervisory through necessity ) what exactly is their new function to be ?

[sdcycles]

Don't know if anyone has considered how many 'actual' LAME's there are back there residing in blighty. By that I mean B1/B2 certifiers. Since going expat I have found all the other nationalities have UK CAA LAME licenses in addition their own countries. Malaysian, Pakistani, Indian, Arab etc. For instance a Sudanese friend who is A+C also has full avionics including compass.So although I have previously seen how many LAMES have been issued by the CAA as far as I know it includes all the guy's from other countries and Airlines. Is the picture back in the UK distorted then? Anyone?

As I understand it flight deck and Cabin crew numbers/working hours are legislated by law and Insurance matters. I'm sure I can be corrected by someone with better intel. Engineers only enter the equation with airline insurance costs. That I do know for sure as a horses mouth inadvertantly told me a few years ago and it makes perfect sense.

Insurers require 'X' amount of UK CAA or other equivalents, (Aussies/New Zealanders, South Africans), for their insurance costs to be kept at a reasonable level.

I don't know how many guys are still in position in BA but I do know from personnal experience LGW BA ramp operation. And from people around me here, I have been told just how chaotic big checks can be at the worlds Worst Airline.

From reading this thread it is possible to make out people who do not really know what it is like trying to keep an airline safely to shedule in todays typically under resoursed world of aircraft maintenance. So I really did like the comment about the Smart German infiltrators with the WW2 GI's....Nice one matie!