BA762 report released (cowl doors openning)

[Global_Global]

First of all I would not want whatever I would do wrong in a similar situation been analysed in the court of Pprune but there is one thing that stood out for me as probably caused by stress hormones and a good learning moment of what not to do

The commander, without confirmation from the co-pilot, quickly shut down the right engine and discharged the fire extinguisher bottle.

Almost a Kegworth or another AirAsia due to too quick actions. Like my favourite TRE always used to say: have a coffee first, then shut the engine down...

So, to be clear: this is no judgement as it can happen to all of us and the ones claiming that it will not happen to them should mail their licences back to the Beehive!

[Volume]

Crew apparently failed to understand fully what passengers who witnessed the incident were telling them and an initial attempt by a senior cabin crew member to reach the captain was unsuccessful. Investigators found that “information regarding the fuel leak was not assimilated by the cabin crew and not passed to the flight crew as required”.

Another victim of the secure (not safe) cockpit door?

[cessnapete]

Virgin Atlantic more enlightened in this area, allowing manual thrust practice at the crews discretion. (A330)

[student88]

Another victim of the secure (not safe) cockpit door?

Although a physical barrier, I'm not too sure the flight deck door can be blamed these days for a break down in communication.

Personally if I had the CC calling in the climb out, the auto pilot would go in, PF takes the radio and the PM investigates. Cabin crew don't normally call so urgently so it's pretty obvious that something serious has happened.

[cessnapete]

Wiggy

No, the 744F identical automatics to pax version. (Didn't fly the -800 version)
At the start of operations the GSS Ops manager ( ex BA Short Haul) wanted the BA split approach SOP but was outvoted by Training and crew opinion.
IMO we therefore had a more relaxed operating environment where manual handling was at the Capt/ crews discretion at all stages of the sector, and gave us much more freedom to hand fly, and maintain our skills on a long haul operation.

Even then the BA SOP was becoming comical in some respects. I remember on a severe CAVOK arr into LHR on a Route Check, I took over the handling from the co-pilot on a split approach, passing approx WOD, <10000ft., no Holding and landing westerly.
On the debrief the RTC criticised me , in that I should not have resumed control until on final, as I did not have the runway continuously in sight, ie when past downwind to base leg. A requirement of the split approach philosophy apparently.

[blind pew]

Back to Victorian working practices?
82 shift working hours in 7 days...absolute disgrace - where is health and safety or for that matter having a life when BA condone and probably expect this sort of "loyalty".

[J.O.]

I know something of the genesis of the PMA / split approach philosophy and of how it got into the ALAR document in the first place. Let's just say that politics and influence won the day, rather than good sense. In my personal opinion, it remains one of the strangest notions I've ever seen in aviation, especially in a highly automated flight deck.

[smellster]

I find the most eye opening part of the report so far on page 101, 2.6.6:

' the commander then quickly selected the right thrust lever to idle, the No 2 (right) engine master to off and pushed the No 2 fire switch. Contrary to SOPs and training, he did not confirm with the co-pilot his identification of which engine to shut down, nor was the co-pilot given the opportunity to confirm the commander’s individual switch selections. "

Wow......

[BARKINGMAD]

Oh dear oh dear oh dear!

If the first morsels of feedback are correct, though I have not yet read the full report, then I am not surprised this one was sat on for so long.

How embarrassing for the affected company, both the reports thrust and the scathing comments and opinion it will attract.

Someone high up in the company's food chain needs to grasp this problem, own it and flush out the dinosaurs who encouraged the Swiss cheese holes to line up.

For those who have read it in full, have a look at the accident to G-OBMM and then compare how similar they are, right down to the CC v Flight Deck communications breakdown.

Do we never learn from previous accidents???

[cessnapete]

Unfortunately for the safety case, since the long ago CC unrest in BA, a large minority of the senior cabin crew still treat the F/C with disrespect and hardly communicate in normal situations. They still blame the pilots for the failure of their industrial action.
I presume Flight Ops Management accept the situation so as not to annoy the Unions.

[Super VC-10]

Comment:

There seems to be a lot of corner-cutting going on by Maintenance.

1.6.16

Neither technician had placed warning notices in the cockpit prior to opening the fan cowls, as prescribed in the applicableAMM 71-13-00-010-010-A procedure

Also, they are reported to have opened the fan cowls on another aircraft (G-EUXI), again without placing warning notices, and also without recording the fact - is this latter action legal?

[Amigo South]

Interesting that the report talks about duty hours for engineers but flying hours for the pilots. It is well known that BA SH Pilots spend lots of time on duty but not flying. Maybe the AAIB should report the crews duty hours up to the incident?

[Flying Lawyer]

J. O.

I know something of the genesis of the PMA / split approach philosophy and of how it got into the ALAR document in the first place. Let's just say that politics and influence won the day, rather than good sense. In my personal opinion, it remains one of the strangest notions I've ever seen in aviation, especially in a highly automated flight deck.

When did it first appear in the ALAR document?

I ask because the split approach (Monitored Approach) was SOP in BEA when relying on instruments after passing the holding or main approach beacon by the mid 1960s.

The BA decision to adopt and adapt the BEA procedure following the merger wasn't universally popular, to say the least, according to Capt Hugh Dibley who BOAC/BA pilots of a certain age here will know. He told me the story (many years later) in characteristically strong, and amusing, terms.

Please excuse a question which is not directly on topic, and from someone who isn't a professional pilot.

[Gordomac]

Oooooooh I love the ever so but tempting thread creep. Alluded to in a minority of my posts, but ,I am moved to say that all of this started in 1973 ! Cheese holes lining up, bean counters etc , etc,. Here's the thing (for you yankeeddoodles), When Northeast & Cambrian were integrated into BARD (British Airways Regional Division), we lonely FO's lost everything. The Monitored Approach procedure loved by those who got the Cat111 stuff approved but was not THE most desirable in conditions other than blinding fog, became STANDARD. So, Capt was always Capt. Well, he always was. I was not allowed to do ANY R/T , not allowed to taxi and P1/s, clearly out of the window, endangered my hours build up to the ATPL. BUT, BEA guys logging Panel Operator time as P2 got away with it.

I left.

We do talk about Management buy outs. I loved my Trident 1e- check with the UK CAA present. Checker stated that this was my CONTINUED opportunity to " demonstrate my continued ability to operate as pilot in command of a multi-engined aircraft in controlled airspace ". With the Flight Engineer's foot on my leg, I remonstrated that I would not be able to do that under current BEA SOP procedures because I was NEVER the Pilot in Command in regular practice because of the appalling Monitored Approach SOPS adopted by BEA. I got my way, passed, but my future was severely compromised.

I left.

The dumbing down of the industry with high levels of reliance on automated flight not really understood by those who operate it will lead to more of this.

Click..................click.............................off to the bar thanks !

[overstress]

The dumbing down of the industry with high levels of reliance on automated flight not really understood by those who operate it will lead to more of this.

Unfastened cowlings have nothing to do with reliance on automated flight...

It's good practice to use a level of automation appropriate to the workload, and it's very unfortunate if the situation/snag/defect/occurrence has led to the absence of said automation.. just when you could do with it.

[neila83]

Unfastened cowlings have nothing to do with reliance on automated flight...

It's good practice to use a level of automation appropriate to the workload, and it's very unfortunate if the situation/snag/defect/occurrence has led to the absence of said automation.. just when you could do with it.

But is it not a concern that the pilots seem to have struggled to manually fly a one engine out approach, which should be a very well trained procedure, to the point of splitting handling/thrust duties, which doesn't seem ideal. And a captain panicking and shutting down the engine without following procedure, there's a very good reason for that procedure and a lot of pointed remarks were made about the ability of the transasia captain who did the same.

I hope a humble approach will be taken in the organisation, there are issues raised all the way through in this report, and the fact they occur at every level from management to maintenance to crew suggests they are not one-offs...

[Smudger]

Automation or not... regardless of aircraft manufacturer.. if you can't fly the aeroplane purely manually without automatic assistance and flight directors then you should not be sitting in that seat... you MUST be able to fly the aeroplane yourself .. that's why you are called A PILOT... it ain't rocket science for heaven's sake .... Off thread sorry

[J.O.]

Originally Posted by Flying Lawyer

J. O.When did it first appear in the ALAR document?

I ask because the split approach (Monitored Approach) was SOP in BEA when relying on instruments after passing the holding or main approach beacon by the mid 1960s.

The BA decision to adopt and adapt the BEA procedure following the merger wasn't universally popular, to say the least, according to Capt Hugh Dibley who BOAC/BA pilots of a certain age here will know. He told me the story (many years later) in characteristically strong, and amusing, terms.

Please excuse a question which is not directly on topic, and from someone who isn't a professional pilot.

Sorry FL, poor choice of words on my part. PMA was indeed around prior to the ALAR project.

The ALAR project was established by FSF with support from CAAs and major airlines around the world. The project committee was all set to publish the final document which didn't include PMA. Pressure was brought to bear by a certain organization who had supported and participated in the project. That organization was also the only proponent of PMA on the team. The ALAR tool kit was subsequently amended to add PMA as a possible tool for reducing accidents, even though the majority of the project team felt it was a step in the wrong direction.

[Pinkman]

Working hours

Agree totally with Blind Pew - those working hours by maintenance staff are incredible - any human factors professional would raise one if not two eyebrows.

I can categorically state that all BA Engineers have been fully briefed on exactly what happened, the reasons why it happened and the measures put in place to prevent it happening it again."

If that is the case, and given that the maintenance error (classic fatigue mistake) was the initiating hole in the cheese, are BA going to cap hours and overtime?

[JohnFTEng]

Fan Cowl Interlocks

On most consumer appliances there is an interlock that prevents operation when casing is open. On a highly automated machine like an Airbus why is there nothing similar - Fan cowl unlocked > start-up inhibited?