BA Subsidiary - OpenSkies - Boeing 757 High Speed RTO -Wrong Flap Setting

[Niall Toibin II]

The B757 was operated by British Airways Open Sky subsidiery. Two management pilots, one a TRE, attempted take off with wrong flap setting - Only set Flap 1.

This is the company Statement:

Dear colleagues,

As many of you are already aware, one of our 757s experienced a high speed rejected takeoff on Monday 20th September at Orly airport.

There is much speculation, rumor and inaccuracies circulating regarding this event. There have been general and personal comments on external social media websites made by OpenSkies employees. Much of these comments are grossly inaccurate and may do immeasurable damage to the reputation and commercial viability of the company. It is important that we communicate to you by way of this memo as many of the facts of the incident.

The Facts:

• The flight was dispatched normally.
• During the takeoff roll the crew observed an inconsistency between what was seen on one of their instruments and what they expected to see.
• The crew decided that the safe course of action was to discontinue the takeoff. The crew performed a high speed rejected takeoff and taxied clear of the runway.
• There was no emergency evacuation and there were no injuries to the passengers or crew.
• Emergency services were advised of the RTO by ATC and they responded as a
precautionary measure.
• The aircraft suffered minor damage to tires and wheels consistent with a high speed RTO.
• Following an aircraft change, the flight was dispatched uneventfully to Newark.
OpenSkies is carrying out an investigation into this incident in accordance with company procedures to see what if any, Human Factors were involved and for us to make recommendations to prevent recurrence.

Thank you very much for your attention,

-----------------------------------


What the memo doesnt say is that the crew advised the pax and cabin crew that they had a minor problem on take off leading to the abort. It was only when ATC advised the crew of heavy smoke from gear while they waited to make a second take off that six tires deflated (fuse plugs) and the fire service poured water over the heavily smoking wheels.

The pilots are suspended and the cabin crew put on another aircraft and operated to Newark seven hours later (?)

It is incredable that only last week a post is on Terms and Endearment about the problems in Open Skies.. Coincidence !!

NT II

[Ak47d]

No experience with B757 but isn't there a Takeoff Config Warning upon advancing thrust lever? It need not be a high speed abort, wouldn't it?

Rgds

[protectthehornet]

I'm 99.99 percent sure that all transport planes have config warnings...but as long as SOME flap is down, even if not the RIGHT amount, no warning.

a reject is tough...wonder why they didn't put down more flap

AND WHY DIDN"T THEY CHECK as they took the runway. WE , on pprune, talked KILLER items to death...excuse the pun.

[Server too busy]

As long as the flaps are within limits the config warning won't go off. It doesn't account for an incorrect flap setting.

[misd-agin]

Noticed a difference between what they saw and what they expected to see....how quaint a description. :=

[sequ]

If indeed the flaps were selected at 1, there should have been a configuration warning. Flap 1 is not a takeoff flap setting in the 757.

Only if 5, 15, or 20 were selected and takeoff calculated with another setting, then there would be no warning, but as far as I know, Flap 1 is not on the 757.

If I recall, Flap 1 was only available for Takeoff on the 767-200.

Correct me if I´m wrong...

SEQU

[stilton]

Flaps one is available as a take off setting for the 757-200.



It is not (with our Airline) permitted on the -300 version.



In which case I do not see why they would receive a configuration warning.

[L337]

Looking at the "Facts" posted above, I see no mention of the word "Flaps."

We an speculate till the cows come home about what "Noticed a difference between what they saw and what they expected to see" means.

After an incident it is normal company policy to suspend the pilots. No assumption of guilt can be made from that suspension. To quote.

When an Accident or Incident is to be investigated the entire crew will be automatically
withdrawn from flying duty. This will ensure that all Crew Members are:

a. Rested from any operational pressures, particularly in the event
of any trauma, perceived or not, resulting from the accident.

b. Available for a medical examination, primarily for the benefit of
the Crew Member.

c. Able to complete the necessary reports and/or provide
statements regarding the accident or incident.

d. Available to assist the Investigation Teams.

The incident relates to an airline called "Open Skies" and not an airline called "British Airways."

[fueldump]

seqa

Correct me if I´m wrong...

You are duly corrected, you are wrong!!:ok:

Fueldump

[BOAC]

smoke from gear while they waited to make a second take off that six tires deflated (fuse plugs) :eek:

Any rumours on abort speed cf V1?

[Clandestino]

I'm glad we didn't see Spanair rerun and that peace of MGT communication made me laugh.

I wonder if 757 has brake temperature indicators or at least BRAKES HOT warning.

[hetfield]

Wasn't here a discussion lately about number of accidents/incidents with training/management pilots involved?

[SKS777FLYER]

No brake temperature indicators on the 757-200's I flew as equipped from Boeing.
Also, the 757-200 for Take Off use flaps 5-15 or 20
Flap 1 take off only on 767-200's.

For rejectd takeoffs; in the Boeing normal procedures section is a page with graphs based on weight, brake application speed, pressure altitude and OAT. Using the chart guides one to recommended action following rejected TO.
Generally for heavy (loaded to cross an ocean) ops an abort at more than 80 knots is gonna lead to some brake cooling time at least......and if enough energy has been absorbed by the brakes, fire fighting intervention may be necessary.
Who knows what they saw on the flap indicator panel or what their planned flap setting versus what they had was. I do know that having one Check Airman on the flight deck is cause for concern.... having TWO or sometimes more cause some concerns every now and then to FO's along for the ride.
I was a line type 757-767 Check Airman or LCKA for 15 years.

[keel beam]

Flap 1 is a misnomer. Only the Slats move at "Flap 1"

[underread east]

Not true, flaps do move:

(moving Flap lever to F1 detent)
• the slats extend to the midrange position
• the flaps extend to 1

Flaps 1, 5, 15, 20 are takeoff flap positions.

Finally, some 757-200s do have BTMS fitted.

Hold fire, who knows, we might all learn something from someone else's unfortunate mistake.

[big white bird]

Assuming the report is even half correct, what the hell were they doing attempting to conduct a second takeoff straight away?

[SKS777FLYER]

BWB.......The report on this thread was "while they waited"..... I didn't see any reference to a specific time frame. I can assume the crew was well aware of the need to comply to the advice of RTO procedures after an actual one. During my time on 757/767 I can recall many instances of especially 767-300 heavy RTO's that even initiated at 80knots (after which automatic RTO operates,if armed).... nearly every time a heavy 76-300 aborted with RTO armed, there was damage of some sort to the landing gear, thus putting the aircraft back in the barn B4 next flight.

I know...the airline in the thread operates only 757-200's.

[Lotpax]

I saw the aftermath of this, with the 757 on the apron and the fire service in attendance, one fireman with hose occasionally watering around the wheel aea. No smoke in sight, so presumably all over bar the shouting as the aircraft I was travelling in pulled on to stand.

Just a question from a curious pax, the main gear tyres appeared to be inflated (from about 50-60 metres away), if the plugs blow is it obvious?

[Birdy767]

Aero 11 - Erroneous Takeoff Reference Speeds (http://www.boeing.com/commercial/aeromagazine/aero_11/erroneous_story.html)

[GMS]

Flap 1 takeoffs are approved by Boeing. We use them at my company (TOM). Personally, I don't like this setting as it gives the least tail clearence on rotation.

GMS

[SKS777FLYER]

My bad, each operator just has to purchase the performance numbers from Boeing for the various TO flap settings.

[stilton]

All of our 757's and 767's have BTMS.

[TURIN]

many of which are from people castigating the pilots for "not doing the right thing".


Is MOL a Ppruner?


Back on thread, with an RTO above 80kts (I have no idea if this was above 80kts, but assume that 'high speed' would be) usually some kind of engineering inspection is required. I know zip about the above incident and even less about the 757. Just asking.

[The Ancient Geek]

Meanwhile, a Ryanair aircraft diverts due to a birdstrike on take-off, and a long and heated discussion follows about whether the pilots took the correct action. That thread gets 42 replies from fewer viewings, many of which are from people castigating the pilots for "not doing the right thing".


Yea right.
Clueless people post to pprune. YAWN.

In this case someone screwed up, realised their mistake and rejected which was the RIGHT thing to do. Trying again before the tyres had cooled was not so clever. Nobody died.

In the Ryanair case the 737 is designed to fly on one engine so a birdstrike after V1 is no big deal. Fly the aircraft, do the engine out checklist, plan an appropriate diversion. They did the RIGHT thing.
Nobody died.

The difference is simple - the armchair wannabees travel low cost and have probably never heard of an obscure BA franchise operator who flies rich bankers between Paris and NY in opulant luxury at premium prices. Guess which grabs their attention ?.

[Over the lights]

Nobody stated that the crew were going to take-off again without consulting the brake cooling chart tables.

[sycamore]

Is water the standard agent for brake cooling/fire, or is it just convenient `pour les Pompiers`?

[GlueBall]

I've never heard of an airport fire drill where "fire service poured water over the heavily smoking wheels." Pouring water over hot magnesium wheels is not an approved method.

[Freeway]

Mistake made. Mistake recognised. Mistake resolved. Why all the fuss? That's after all why we have SOP's and the like.
Have you never made a mistake?
Time to move on me thinks. :ok:

[The Ancient Geek]

Mistake made. Mistake recognised. Mistake resolved. Why all the fuss? That's after all why we have SOP's and the like.
Have you never made a mistake?
Time to move on me thinks.


Amen brother.
The man who never made a mistrake never made anything.

Our job is to learn from both our own mistakes and those of others, SOPs are not just standard procedures, they are the checks and balances which should ensure that our mistakes are recognised and corrected before they become a problem.

[BOAC]

TAG - is there still not a question of the second attempt at take-off? Suppose the plugs had blown at 120kts on that. Surely either there was insufficient cooling time/too much taxying OR the tables may be wrong?

Yes, the fire service at CDG might benefit from a look too. I always understood the shock loading on the wheels from cold water could be catastrophic.

[TURIN]

From the OP.

It was only when ATC advised the crew of heavy smoke from gear while they waited to make a second take off that six tires deflated (fuse plugs) and the fire service poured water over the heavily smoking wheels.


No mention of actually attempting a TO.


Regarding water on hot wheels/brakes.

It seems that these days putting out a potential or actual brake/wheel fire on a loaded aircraft is more important than saving the wheels or anything in their way.

Personally witnessed a 777 brake fire extinguished with water. To be fair, the flames were licking the underside of the wing by the time the fire service got there so I can't say I blame em. :ok:

[BOAC]

Turin - I do not have access to a 757 QRH, but assuming it is SIMILAR to the 737,

When in caution zone, wheel fuse plugs may melt. Delay takeoff and inspect after one hour.

When in fuse plug melt zone, clear runway immediately. Unless required, do not set parking brake. Do not approach gear or attempt to taxi for one hour. Tire, wheel and brake replacement may be required

Of course you are correct in what the OP says, I am merely raising a metaphorical quizzical eyebrow due to the lack of information (hence my earlier question) since I would think it reasonable to assume they were in the 'caution' zone since 6 wheels blew? How would you have handled that?

The problem with water as I understand it is that the shock to the wheels can cause dramatic failure of the wheel assembly which with high pressure tyres can cause significant shrapnel as bits explode. I'm sure I saw a safety film once where bits went everywhere at very high speed. I'm sure a fireman will correct me.

[CorradoT]

BOAC

Video: this one? YouTube - Airbus A340-600 Rejected Take-Off test (subtitles) (http://www.youtube.com/watch?v=hRzWp67PIMw)

[TURIN]

BOAC

Quite right.

I'm just trying to give credit where due as perhaps the fuse plugs melted as they were waiting. IE IAW QRH drill.

Regarding the wheels/brakes.
The effect of exploding wheels due to shock cooling seems to be secondary to the effects of an actual fire.

Too many recorded cases of casualties due to fire, not many due to shock cooled exploding tyres.

[Lotpax]

May I ask again (as a pax who saw this aircraft from only about 50m away), when the plugs blow is it obvious?

I witnessed a fireman intermittently spraying a liquid over the wheels and all the tyres looked normally round. 3 fire engines were in attendance.

I'm perfectly prepared to accept that the tyres can appear inflated when they are not, but am just interested.

[hollingworthp]

Yes, the fire service at CDG might benefit from a look too.

And even better than that - the rouge chaps at Orly could look into it also ;-)

[SKS777FLYER]

In my 30 years of airline flying, I never saw jetliner wheels with known fuse plug deflations, so I have no direct sightings. On a multi wheel bogie, with just one deflation, I would think a cursory look might appear that all tires properly inflated. If all, or most plugs let go, the wheel rims are gonna drop right down to the tarmac on the deflated ones.

Did blow fuse plugs on an F4 Phantom once after taxi in. The rims settled onto the flightline, very noticable.:uhoh:

[Lotpax]

SKS777Flyer

Thanks for the info, much appreciated.

[Prober]

On a 767 with Brake Temp indicators and carbon brakes, the temperature warning showed shortly after T/O (up to 6 IIRC). It cooled during the short flight, but was obviously going to cause problems at the other end, so necessary precautions were taken. After landing the temperature increased to max (9) but gradually cooled. When it got down to 3 and was approaching the “normal” range, the engineer and I went to stand down the fire cover. We were discussing the options and the engineer leant over to feel the wheel – but before his hand got there, the fusible plug blew and we both nearly shot through the wing tank with shock.

There was no expectation of another T/O until our problem (a sticky brake) had been solved, but what it did show was that a plug can blow even when the temperature is back in the acceptable range. (Are we ready for another try?:*) Now, back to topic…

[Feathers McGraw]

In the event that the flaps were set incorrectly, if this had been noticed early enough in the take-off roll is it permissible to move the flap lever to the correct setting and carry on?

Or does that lead to confusion about V speeds etc?

[Knackered Nigel]

Feathers,

If there is a noticed discrepancy, the best course of action during the t/o roll is to do what the crew did - RTO.

The flaps and slats take time to run to position, so they may not get there, apart from the fact that if you have noticed such an error whilst hurtling along, you may not have time to agree what the setting should be.

Also, this is outside SOPs!

[Feathers McGraw]

OK, thanks for that.

I had thought of those things, but I was trying to get an idea of how dodgy making a flap selection under pressure would be in contrast with ending up with wheel, tyre and brake entertainment after a high energy RTO,

As a matter of interest, about how long would you say it takes for the flaps to run out to the maximum T/O position? On a 752.

And yes, I'd thought about SOPs and the chance of making things even worse by mistake.

[Knackered Nigel]

Aircraft are obviously certified to be able to carry out and RTO at just before V1. If you get a wheel fire - you are in a position to evacuate if necessary before it becomes more serious.

If you try to take off with the wrong/no flap setting - you could end up in a smoking heap.

Don't operate the 757, and haven't timed the flaps on my type. It isn't just a matter of the time taken to reach the correct setting, it is the fact that the wrong setting is there and there may not be time to discuss/sort it - you can always stop. You can get airborne on 1 engine (type dependant), but you may not get airborne with no/incorrect flap on modern airliners due to the wing design

[punkalouver]

In the event that the flaps were set incorrectly, if this had been noticed early enough in the take-off roll is it permissible to move the flap lever to the correct setting and carry on?

Or does that lead to confusion about V speeds etc?

The was a now defunct 767 carrier in Canada where this happened. Warning horn I believe at the start of the roll, takeoff flap then set. I believe the flaps were still moving to the selected position at rotation. FDM picked it up and eventually the crew was identified. I heard that it cost the captain a future job at another carrier as they knew all about it.

First part is 99% accurate, latter part just rumour. Then again, there were lots of good stories from that carrier.

Discovering a misset flap at high speed is a different story of course.

[40KTSOFFOG]

Re-selecting a flap position on the take-off role? Never!!

The full accident report into the Northwest DC-9-82 accident at Detroit on 18th Aug 1987 makes very interesting reading. The crew were distracted following engine start and a lot of the post-start actions had been missed. This included setting flap and arming the autothrottle (TLC). Due to numerous subtle distractions they had also failed to complete the relevant checklist.

On the take-off role they recognised that the autothrottle had not been engaged but continued with the take-off. This was the final clue that they were given that something was not right.

They crashed shortly after rotation with the loss of 153 lives!

[Niall Toibin II]

Open Skies completed the RTO investigation.

The crew rejected the take off at 21 kts below Vee one due to incorrect setting of flap one instead of flap 5. The F/O set flap 1 in the after start set up and this was not discovered by the Captain during the before taxi checklist, and again both pilots missed it during the before takeoff checklist. The error was only discovered during take-off. Then, the crew did not properly check brake cooling times and were preparing for another take off when they were advised of smoke from gear. The crew only became aware of the problem when the aircraft behind in the taxi queue for the second take off attempt called that he could see smoke from the gear. They cleared the taxiway and then 6 wheels deflated so the crew decided not to try another take off!

The crew were questioned for poor use of two checklists, crosschecks and the decisions for preparing to make another take off inside the brakes cool down time. Open Skies management was questioned about the poor introduction of a new SOP and for then issuing a 150 page amendment a month after bringing the new Ryanair style procedures into use. It was questioned if the new procedures may have given the crew confusion from the old procedures but the Flaps checking procedure was considered clear.

After completion of the investigation Open Skies chiefs decided the Captain of the RTO aircraft would keep his job as a Captain and stay as Deputy Head of Training. The F/O will also kept his job as Deputy Director of Flight Operations. The F/O involved also passed his command assessment with the same Captain the week before the RTO (he was one of only 2 of 14 F/O’s that pass the assessment). He will still be promoted in January. Both pilots received additional simulator training in the use of the flap lever and checklist, but no other action was taken against the crew.

The RTO happened at a time of much discontent over pay, contracts, procedures and allegations of heavy handed tactics by the (ex Ryanair) DFO, big issues and big distractions for the pilots. The RTO, all the distractions and the survival of the DFO’s two most senior manager’s has raised big credibility issues for the flight operations department both inside the company. Only last week managers were called into question again after an unsecured cart ran out of control along the complete length of a B757 cabin smashing into an open flight deck door during landing. This will be a separate topic.

battered BA subsidiary’s problems. The CEO recently sent an internal memo about direct entry captains joining from BA next month. It stated Open Skies was not making a profit. After almost 3 years, how much longer can the subsidiary survive?

[IcePack]

If the report is true. Streuth! & the controling authority where are they in this?
Wonder how they look any of their staff in the eye? Guess they don't.

[BOAC]

It appears to amplify the old CFS adage

"If you cannot do it, teach it, and if you cannot do that, become a manager!":)

[Hotel Tango]

DEPUTY HEAD OF TRAINING & DEPUTY HEAD OF OPERATIONS! One cowboy outfit to avoid then by the looks of it! Truly amazing.

[chris weston]

With gain up to full BOAC we have:

"If you can't do it, teach.
If you can't teach, teach teachers.
If you can't teach teachers, go into educational administration."

CW

[STBYRUD]

Sounds like they handled it better than a well known middle european flag carrier some years back - 747, Hong Kong. Rushed pushback, taxi and lineup - no one set takeoff flaps. Captain sets takeoff thrust, hits TO/GA, config warning, chooses to continue and instead sets the flap lever to 20. Only 10 knots before Vr (according to the post-incident analysis) were the flaps in the correct position for takeoff. Sound judgement....:ugh:

[exeng]

Same thing happened in BA (real BA, not Open Skies) out of BHX some number of years ago. 737, no flaps at start of roll - take-off config warning so the Capt selected flap 5 which was achieved by rotate - the Capt found himself in the RH seat in double quick time.


Regards
Exeng