Incident at Heathrow

[Sunnyjohn]

Two things:

First, its good to see A and C looking at the view of the maintenance person. Having worked on the apron at turnarounds for BA (Then BEA - I'm old enough, too!), I can concur with the sometimes difficult conditions in wind and rain at three in the morning. That is no excuse for laxity but bear in mind that sometimes things are difficult to see in those conditions. Been there and dunnit!

Second, with regard the stuff from aircraft falling out of the sky in populated areas, it's worth noting that the greatest number of people killed in the UK by falling debris was over a relatively unpopulated area (Lockerbie, Scotland, eleven people killed).We live on a densely populated island and if stuff falls out of the sky it could land anywhere. Fortunately, for the most part, stuff doesn't.

[GreekIslandLover]

What a load of rubbish so any pilots flying on a shoestring budget.
can you tell us which airlines they are, would have gone straight in with out trying to save the aircraft, the mind boggles with some of the posts here

So saying that I thought the crew did a good job is wrong????? I really don't see what's wrong with that opinion. The point I was making is that not all airlines are equal, and BA do seem to have a better reputation than some with safety.

I don't think you read my post properly. My main purpose was in response to the poster who thought this looks bad for BA. I disagree, and think that the way they handled it in getting it down without loss of life and aircraft is a credit to them, and as SLF it is more likely to make me choose to fly BA than less likely. I'm sure with the benefit of hindsight lessons will be learned, but I do think it's a credit to the crew for bringing it down safely. Why people here are knocking this beats me. Surely as a fare paying passenger that's what you actually want to happen??

[BOAC]

No-one is 'knocking that' - it is "I dread to think what could have happened if it had been another airline run on a shoestring budget." which is wrong.

It is a common, possibly press-fed, perception that lo-cos are less 'safe' than mainline carriers.This is far from true and you might be surprised to compare the number of incidents per sector of many. ANY UK 'shoestring' carrier as you put it (whatever that means?) has to meet exactly the same minimum safety and training standards as BA, as laid down by the regulator.

You may well be correct in terms of foreign carriers, of course.

[GreekIslandLover]

I didn't say that there were any UK or European shoestring carriers. Many airlines fly in and out of Heathrow, and not all of them have a good safety record.

JACDEC SAFETY RANKING 2012 (http://www.jacdec.de/jacdec_safety_ranking_2012.htm)

If that had happened on take off to some of the carriers at the bottom of the list, I wonder if they would have handled it as well, and if the outcome would have been the same.

[BOAC]

I for one do not dispute that, but your post was less than clear on that. As long as we all agree that UK 'shoestring' carriers are safe, that is fine.

[Jazz Hands]

I'd be sceptical about that JACDEC ranking. I've known people try to make a living out of calculating "airline safety", and found it to be impossibly difficult to rationalise.

Having read the small print on the ranking, I'm not convinced that the factors considered are even relevant let alone a sensible method of benchmarking. :suspect:

[bullet190]

Greekislandlover,

I don't work for BA, I work for another UK airline. A couple of years ago I was presented with an A/C fit for service only to notice during the walk-round that all 3 cowling latches on the port engine were unlatched. Our cowling latches sound very similar to the ones on this incident.
Fortunately for me our 'holes in the cheese' didn't line up that day - it also means that I never got the chance to prove your theory wrong........and thats exactly the way I prefer it. :ok:

[Dimitris]

Have there been instances that a pilot has spoted an open or 'unlatched' cowl? What happens in that case? Ground crew is called to take care of it or the pilot actually closes the cowl/latch and up we go? (please tell me that ground crew is called in....)

Maybe instead of checking for a 'closed cowl' check for a 'latched cowl'. An unlatched cowl looks closed anyway. Maybe have pilots take a trip to the hangar during maintenance and have them open and close (latch) them. It would only take 5' of 'training'. Any sensible person will understand what they need to look and check once they know how the thing actually works.

I'm not saying pilots should be mechanics or vice versa, but if pilots are asked to check specific external features of the aircraft they should know how they actually work. A cowl that is not latched is not closed even if there is no gap.

As an SLF with technical background, I see how a cowl can be left unlatched once a year and I don't see any serious problem with that, sh*t happens! Were I see a problem is in people believing that ticking boxes and signing next to them if they don't know what they are actually looking for. That's not up to the pilots. What the pilot should say is: 'hey, you want me to check the cowl is latched? SHOW me how its latched by the people that actually latch it, so that I know when its not and I call you back to latch it'.

Do I make sense or should I delete this? Fly safe anyway!!

[wilnot]

Ok, I'm only an engineer, and a retired one at that, but the way it seems to me:

1. The cowls on both engines were closed but not latched.

2. It appears to be difficult by a visual check to establish whether they're latched. And without using some banned implement like a screwdriver a physical check may be next to impossible.

3. Result - a serious incident which could easily have resulted in a catastrophic accident.

Ergo, the manufacturers MUST design a mod which makes an unlatched cowl impossible to miss. Next time - and without some positive action there will be a next time - we could be looking at a hull loss with multiple fatalities.

[NigelOnDraft]

wilnot...

1: I would agree likely, we'll find out in due course
2: Agree again, a well made point by you and others against the "hang em out to dry" brigade
3: Not too sure about your conclusion, especially the "easily"?

Reading the 2009 TSB report - that was the 10th A320 series occurance. Not sure how many between 2009 and the BA one, but I would guess some more? It seems a fairly typical pattern that they break off with minimal serious corollary damage. The BA one may be unusual in that seemingly both came away, and something occurred, possibly sometime into flight, that did lead to a more serious engine problem.

It may be, hopefully, this occasion does get this issue solved in some way or other. Because history states if nothing significant is done, more A320 series engine cowls will come off.

[Agaricus bisporus]

banned implement like a screwdriver

A screwdriver is not a "banned implement". If it were how could engineers work? It should be carried if necessary and security told that it is a necessary tool of the trade.

Security regs quite specifically permit carrying "tools of the trade" and if a case can be made that a screwdriver needs to be carried by a pilot then security cannot stop you taking it through or they are preventing you from doing your job.

I only gave up carrying a Leatherman tool in about 2008 when we started doing an appreciable amount of positioning as pax but up until then had carried it every working day for 20 years. It had been spotted by sec search precisely twice since Sept 11 and on both occasions security (STN & GLA) agreed that it was permissable as a "tool of the trade".

Perhaps we are too quick be beaten by voluntarily succumbing to "rules" in our heads that don't exist/aren't valid in practice?

[DaveReidUK]

It seems a fairly typical pattern that they break off with minimal serious corollary damage.Apart from:

a) the America West A320 fan cowl door separation in June 2000 that caused substantial damage to the horizontal stabilizer

b) the Skyservice A320 FCD separation 3 months later that deformed the engine pylon resulting in the pins being pulled out from the EEC wiring harness connector (as well as slat and slat track damage)

Even without those precursors, a risk assessment concluding that nearly a quarter of a ton of aircraft structure in total suddenly breaking loose in flight doesn't present a potentially serious hazard would make interesting reading.

[NigelOnDraft]

Dave... It seems a fairly typical pattern that they break off with minimal serious corollary damageI would stand by that, but clarify my remarks by "serious" meaning in terms of flight safety / hazard. In neither case was any serious control / handling or management aspects apparent in the reports, indeed the AW report:The return for landing at the departure airport at 1331 was unremarkable.and the serious damage amounted to:and there were 3 holes in the lower surface of the left horizontal stabilizer, each approximately 2 inches wide and 8 inches long. The cowling door hold-open rod penetrated the lower skin and aft spar web of the horizontal stabilizerI am not suggesting this is "satisfactory", just there has not yet been sufficient impetus for the industry/regulators to fix this problem.

We shall see if Friday's events and pattern stand out enough to get this fixed?

[spannersatcx]

Spannersatcx, surely this rather depends on why the cowlings were opened in the first place. If it was for a maintenance task, I agree with what you say.

As a F/E I could enter a defect into the Aircraft Technical Log for anything about which I was unhappy e.g. No.1 engine cowlings open. It is then up to you, the licenced engineer to clear the defect.
You could do the same.

Many (minor) defects are cleared without reference to the AMM.

Yes it is horses for courses, however if you wrote in the log no1 eng cowl not secured/open, then it would be cleared by closed and secured. Simple, the responsibilty is now mine.
In days gone by manual references may not of been used, but under todays regulations you HAVE to do everything iaw....it takes 10 mins to do a job and 30 to find the manual reference. :ugh:
I only speak from my present environment, where it's me and 1 or 2 non certifying guys, so I sign and check everything, be it in the wind/rain/snow at 3am or on a bright sunny day on the ramp!

A lot will also depend on the culture within the establishment where you are.
Anyway I guess we are going off track slighly, so I'll leave it at that. :ok:

[ILS27LEFT]

Too many accidents despite multiple design changes and implementation of new maintenance procedures. The fact that only this specific engine type is regularly experiencing this type of incident indicates, very clearly, that this cowl latching design can be improved e.g. cowl clearly showing as opened when unlatched. It is clearly a design fault which must be fixed, sensors should also be added to warn flight deck if unlatched, very simple and not expensive at all. End of story. It is a serious design weakness and we cannot blame engineers and pilots (humans) for such a silly design mistake. No other engine has got this problem, I mean cowl showing closed, locked even if unlatched:D

[Sillert,V.I.]

Apologies if this link (http://www.aaib.gov.uk/cms_resources.cfm?file=/dft_avsafety_pdf_501061.pdf) to the 2000 Gatwick incident has been posted before (hard to tell now there are 26 pages of posts), but it seems to me to make interesting reading in the light of last Friday's incident.

[DaveReidUK]

it seems to me to make interesting reading in the light of last Friday's incidentIt has been referred to before, but I agree it's well worth reviewing.

The most important point to come out of that report, IMHO, is the recommendation that the AAIB didn't make (because it would have been aimed at individual LAEs rather than an organisation):

"Don't let yourself be distracted by anything during the act of closing the cowl doors. From the point at which you disconnect the door stays until you engage the 4th latch, nothing should be allowed to interrupt the process."

[lomapaseo]

Ergo, the manufacturers MUST design a mod which makes an unlatched cowl impossible to miss. Next time - and without some positive action there will be a next time - we could be looking at a hull loss with multiple fatalities.

Purely imaginary in all aspects.

Cowls have been unlatched and missed since the beginning of flight.
Anything in your own mind can lead to a hull loss and multiple fatalities (catastrophe by definition). The certification challenge seeks to minimize such occurrences by providing redundancies and multiple hoops (post work inspections) for such to happen. Just looking at the historical data since the beginning of the jet age confirms the inadequacies against such catastrophe.

However, such minimization by themselves need be tracked as this one has been. The rate of missed inspections was unacceptable, thus something needed to be done to minimize this rate. This investigation is a perfect vehicle to look at the post service bulletin inspection adequacy (nothing will ever be 100%)

[Pinkman]

Improve the latch design by all means. But to mandate, design, certify, manufacture, and retrofit could (will) take years. In the meantime would it be too much to ask to improve the human factors aspect by instituting a cross check system as is commonly done with other flight critical items. You know, "doors to automatic and cross check" that sort of thing. Banal? Maybe. But it is instructive to remember that the new pitots for F-GZCP (the aircraft operating AF 447) were sitting in the warehouse waiting to be fitted when the aircraft crashed. A known problem, awaiting an engineering fix (recommendation, not an AD). My observation - working in a safety critical industry - is that we tend to adopt a one-dimensional approach to fixing these issues, whereas in fact they are multi-dimensional and include human factors, training, engineering, operational excellence, culture... and a big dollop of common sense.

[hyatt_1_alpha]

To the author of post 451

I found your punchy and broad tirade amusing and rather sad.

Sad, that your belief in and respect for the corporate body in question is quite so strong, but I suppose like so much in life it all depends on personal experience and also what you witness happen to certain colleagues around you, those with whom you work with or have worked with, who have been very capable operators.

I will leave it at this if I may, your faith in that things are always done in a right and proper way is entirely misplaced. Sorry to disappoint.:eek:

[Dry wretched thunder]

So !!, based on the speculation, what was it like going into work the day after as A319 pilots, how is it referenced at team briefs ?, is it taboo untill the AAIB report or is talked about in a quiet room or are you sent on your way with a final shout from the room, "and remember and check those bloody latches".......point is though in the limbo stage between incident and report, how is it treated at the sharp end ??

[DaveReidUK]

in the limbo stage between incident and report, how is it treated at the sharp end ?? You need to ask?

I think it's safe to assume that BA co-pilots' dry-cleaning bills are about to shoot up as everyone gets down on their knees during the walkaround to check the security of the cowl doors.

what was it like going into work the day after as A319 pilotsNot just A319s, all BA's narrow-body Airbuses (apart from the LCY A318s) are V2500-powered. The entire Heathrow-based shorthaul fleet, in other words.

[frequentflyer2]

I think it's safe to assume that BA co-pilots' dry-cleaning bills are about to shoot up as everyone gets down on their knees during the walkaround to check the security of the cowl doors.

As slf I personally would pay £1 extra on every flight to meet these dry cleaning bills if that's what it takes to ensure no airliner is endangered in this way again.

[BOAC]

I think it's safe to assume that BA co-pilots' dry-cleaning bills are about to shoot up - why only co-pilots? It might not be raining.............

[jonseagull]

My other aircraft is a Twin Squirrel. Recently Eurocopter mandated a secondary latch system that was published as an AD. If you close the cowlings, the secondary system will latch in place. Even if the "primary " latches are not secured, the new "secondary" system will keep them attached to the airframe.

The bill was in excess of £10K and at the time, I thought it major overkill, especially as all the cowl latches are easily visible from the walk round. As in the Airbus, my other aircraft, 757/767, have latches at the six o'clock and I have never crawled under the engine to specifically physically check them as locked. I have always imagined the gap around the other sections of cowl would give away an unlocked cowl.

Perhaps Eurocopter have a neat idea?

[allosaurus]

You dont need a mod.Just another check box on current tech log page along the lines of:have the cowls been opened since last flight ? yes /no.if yes sign for cowl latch check (signed by maint staff). Or similar.I know this is probaly covered in current pre flight sheets but to highlight it on tech log page might focus maintenance/crew attention

[ASRAAM]

A long time ago someone invented the retractable undercarriage. Shortly afterwards pilots started landing wheels up, not often and usually when they were tired or distracted. At first managers said we must have " more rigour" and I'm sure that if Prune had been around there would have been pages of sanctimonious tosh. Sadly "rigour" failed to solve the problem and eventually the bean counters worked out that warning systems were cheaper than wheels up in the long run and the problem was solved.

Sadly aircraft kept flying into the ground, not often just when the pilots were tired or distracted, once more the managers called for "rigour" . Unfortunately aircraft continued to hit the ground so GPWS was invented and it hardly ever happened. When it did crews were accused of lack of "rigour". Fortunately along came EGPWS and the problem was largely solved.

I am sure the managers would like to keep Airbus cowlings closed by the application of more "rigour". Unfortunately I am equally sure that the problem will reoccur because at the end of the day most people involved in aviation are human.

I have no idea if the correct engineering procedures were followed in this case, nor do I know how easy it would have been to spot on the walk round. I am pretty sure however that if there had been an ECAM or a large flag hanging off the engine the aircraft would not have got airborne.

[Flap 80]

Allosaurus...totally agree...this is the simplest way to prevent a recurrence..current pre UOE incident policy required a tech log entry when cowls were opened but apparently rarely done..already post UOE a duplicate sign off in AML needed when cowls have been opened.....totally impracticable on a walkround for flight crew to lie under the engine to confirm latch closure especially if cowling weight gives impression of totally closed and if latches have been secured closed when cowling was open...fault lies with poor design feature and also with authorities for failing to act on many previous events...VS A320 LGW Incident in 2000? raised all these concerns.

[DaveReidUK]

VS A320 LGW Incident in 2000?Airtours.

Among the AAIB's recommendations in the investigation report:

"It is recommended that the DGAC mandate aircraft modification aimed at appreciably reducing the likelihood of A320 fan cowl doors inadvertently remaining unlatched after maintenance. It is considered that, while measures to exhort maintenance personnel to ensure the doors are latched and to improve the conspicuity of unfastened latches may assist, they are unlikely to be fully effective and modification aimed at providing obvious indication of unlatched doors is required."

"It is recommended that the DGAC and Airbus Industrie consider the incorporation of a system to provide flight deck warning of unlatched fan cowl doors on the A319, A320, A321 and A330 aircraft types."

Enough said.

[procede]

Indicators in the flight deck might require extra cables. Maybe they could simply have a system that disables the starters or works through the FADEC?

[Lord Spandex Masher]

Allosaurus, you don't even need a new box. Just write it in like, for instance, "gear pins fitted" and then "gear pins unfitted!" Trouble is people forget to do that and they'll forget to tick the box as well. Even then it doesn't mean they've physically done anything except ink some paper.

[allosaurus]

Spandex Masher

Yes i take your point that it could be written on tech log page,but that could be forgotten.If theres a check box it brings it to your attention.
Also I think you might have impuned the integrity of many LAME.s by suggesting that its just ink on paper.,that LAME,s dont do their job correctly and sign for things in the tech log that they havent done?

[Agaricus bisporus]

gear pins unfitted fnaaar!

Steady, you'll be upsetting engineers with implications of illiteracy...

[Heathrow Harry]

it's Ok - they can't read his post to start with..........

[Sillert,V.I.]

.....totally impracticable on a walkround for flight crew to lie under the engine to confirm latch closure especially if cowling weight gives impression of totally closed and if latches have been secured closed when cowling was open...

So it's entirely possible, probable even, the pilot performing the walkround checked the cowl doors & believed them to be properly latched.

Would it be worth pilots feeling the difference between a secure and insecure cowl door side-by-side? Not my aircraft, but I'd have thought there'd be some telltale sign that could be easily verified on walkround, even without that banned screwdriver, providing you knew exactly what to look for.

[Lord Spandex Masher]

fnaaar!

Steady, you'll be upsetting engineers with implications of illiteracy...

You there! Dismantle that, take it over there and mantle it up again. :}

Allosaurus,
Also I think you might have impuned the integrity of many LAME.s by suggesting that its just ink on paper.,that LAME,s dont do their job correctly and sign for things in the tech log that they havent done?

Definitely not my intention to question anyone's integrity. More a case of forgetting to do something but remembering to sign for it. I've signed for a PDI before having forgotten to do it so even the best make mistakes. ;)

[NigelOnDraft]

There have been ~5500 A320 series delivered. They do, say 3 sectors per day, and 1 "daily service" opening the cowls. An engineering team might meet say 20 (?) aircraft on an evening shift to service overnight.

There have been ~15 "loss of cowl(s)" incidents, nil accidents AFAIK (although that would require a close look at the definition - NB damage to engines and cowlings is not counted).

Is a repetitive paperwork, or rigour, exercise going to solve the issue? In times of cost/manning pressures? Or are these very rare "slips" better solved by trying to easily highlight the problem prior dispatch as previous recommendations have stated (and been ignored)?

[cwatters]

How much does a door sensor cost? My car, microwave oven, the washing machine and even my fridge all have one.

[oxenos]

It would, of course, be a requirement to open the cowls every day to check the "cowl door open" warning system was working.

[RadioSaigon]

Maybe a silly suggestion, coming from the "cheap seats" GA... but all this talk of dry cleaning bills, AD's, sensors, EICAM etc., worries me a little. Can't help but wonder, would a little lo-tech help with confirming the cowl latch position, without all this hassle, heartache, expense and drama? Something like, maybe, a mirror on a stick?

Just a thought...

[screwdriver]

Or a flight engineer prepared to get his knees wet.
I await the incoming!

[Tinribs]

Some time in the fifties car makers discovered that if the bonnet opens while you are mobile bad things can happen.

They decided to have two latches one holds the bonnet closed good and proper the other just holds it more or less down but stops it coming any further up. It also allows it to project a bit so you notice the upsticking and vibrate a bit so you wonder what the noise is

They did this because they knew every so ofter one latch just isn't enough

Maybe there is a mesage, one latch holds the cover downish the other holds it nice and snug. You could even put a little contact to say first latch only engaged gov do something

When a problem has happened several times on similar types we ought to do something

[kenjaDROP]

I am not an airline pilot or ground crew member, but am an aerospace engineer of some 35 years standing, having worked on mainly military stuff.
Forgive me if someone else has previously raised this point, but I think not. It seems to me that, having read all the preceding posts and watched intently the video Airbus A320 (V2500) Opening & Closing of Engine Cowl Doors - YouTube ( - particularly at 8.45mins in!) there may be a 'bum trick' been missed by other posters concerning the cowl latching on the V2500.
If this video illustrates the current latching system, and I'll be the first to admit that it's now some 3 years old, so may not, it appears nevertheless that each cowl latch may be able to be pushed home/flush WITHOUT THE HOOK OF THE LATCH ENGAGED on its corresponding pin/toggle and the LATCH HELD FLUSH by it's trigger/button! The cowls seem to fall closed or near to closed in this situation.
I cannot therefore see any way in which, given this scenario, :-
A) the latches could be easily observed to be unlatched, on a walk-round or by ground crew observation or the like
B) any painting of the latches in fluorescent colours or likewise would aid the identification of an unlatched latch
C) the cowls could be easily seen to be gaping/unlatched with the aircraft at rest.
Having looked at the latch design (from H******l, I assume) it seems not beyond the wit of man to engineer a latch that CANNOT be closed unless it is fully hooked onto its mating pin/toggle, such that unlatched latches would definitely hang down from the nacelle. Paint 'em fluorescent then, if you like, and they would almost definitely be noticed!

[kenjaDROP]

Wilnot

re. post #509

apologies, just read yours in more detail....seems like we are thinking along the same lines!

[doubtfire]

Was pleased to note in the tech log on the A319 I flew today.
...after overnight maintenance. " engine cowls closed and checked" and then another entry, "double independent inspection of engine cowls"
This is also true of oil filler caps after replenishment and has been for a long time at Ezy. (well at my base anyway)

[Swedish Steve]

They do, say 3 sectors per day, and 1 "daily service"
On the BA A319s the fan cowls are not routinely opened until the weekly check. The engine oil is checked every night, but there is a good access panel for that. There is rarely any reason to open the fan cowls, except for the weekly check of the IDG oil levels.
On most engines, there is an access panel for the IDG oil check, but not on the V2500. I wonder if a modification to fit an IDG service panel would be justifyed because it might stop the next cowl loss?

[yotty]

Swedish Steve. Good point, the fan cowls also need opening to carry out Bearing 1 2 3 MCD chk.

[J-Class]

There are two interesting regulatory issues arising from this incident:

1. AAIB/FAA etc. recommendations versus ADs. This seems to be an instance where, in retrospect, one would wish that an AD had been issued following previous similar incidents. One wonders why this didn't happen, given that a double cowl separation could easily arise from a single maintenance/inspection SNAFU and could fatally compromise twin-engine redundancy.

2. What actions operators should take in the time lag between the AAIB starting its investigation and publication of its report. To give one example (which sadly involved friends of mine): in July 2009 a four year old girl fell through the railings at the top of the integral airstairs of a RYR 737-800 at STN. There was an AAIB investigation leading to a report (http://www.aaib.gov.uk/cms_resources.cfm?file=/Boeing%20737-800,%20EI-DLJ%2008-10.pdf) which was published just over a year later in August 2010. This time lag was unfortunately too great to prevent a recurrence of exactly the same incident to another little girl at Girona in June 2010 (http://www.fomento.gob.es/NR/rdonlyres/074D6DB8-E3D0-47D7-B60F-6758694160B4/112677/2010_017_A_ENG.pdf).

There is anecdotal evidence on this board of operators taking immediate action to tighten their procedures - and their engine cowls. And there is a wide spectrum between incidents which require a whole fleet to be grounded immediately (e.g. 787 batteries) and stuff which can be kicked into next year. But the two Ryanair incidents show that operators can't be relied upon to get things right prior to the regulator's report and recommendation - so perhaps more is required from the regulators in the interim?

(Finally - please don't jump on the fact that I've mentioned two RYR incidents. I'm sure there are similar 'regulatory lag' examples out there involving other operators.)

[xcitation]

I'm [sure] there are similar 'regulatory lag' examples out there involving other operators.


You mean like a voluntary recall due to pitot tube icing.

[vctenderness]

Thankfully BA have announced they are not going to dish out sack loads of compo to SLF delayed by this incident.

Bad s***t happens folks so get over it!

[DaveReidUK]

[quote DaveReidUK]I'm [sure] there are similar 'regulatory lag' examples out there involving other operators.Xcitation, if you're going to use quotes, please attribute them accurately.Those are not my words, in fact I have no idea what you are talking about.

Your quote comes from the post immediately preceding yours, from J-Class, who I'm sure will be happy to address whatever point you were trying to make.

[mercurydancer]

What I cannot understand is the posts about unlatched cowlings, but both engines on the BA aircraft showed problems. I can believe that one cowling was undone and blew off, but two? I'd appreciate an explanation, theory, conjecture or even gossip.

[J-Class]

The theory/conjecture is easy enough - presumably both engines were serviced prior to the flight, cowls on both not properly secured, the fact they were both open not noticed / not obvious to crew.

[Agaricus bisporus]

With regard to the manufacturer making a mod or having it imposed on them this industry surely does not have a glorious history of doing this, indeed it has in the past given us reason to believe it does all it can to avoid such a solution.
Just look how long it took the well documented and repeatedly reported pitot head problems. It required a three figure body count to prompt action on that one, it's an aspect of our manufacturers and regulators that gives us nothing to be proud of.

[Leftofcentre2009]

"Some time in the fifties car makers discovered that if the bonnet opens while you are mobile bad things can happen.

They decided to have two latches one holds the bonnet closed good and proper the other just holds it more or less down but stops it coming any further up. It also allows it to project a bit so you notice the upsticking and vibrate a bit so you wonder what the noise is

They did this because they knew every so ofter one latch just isn't enough"

We call this method of working a FAIL SAFE do we not?

[Alwaysairbus]

Unfortunately, if as on first hand, it is confirmed that the cowls were not latched and secured correctly, this is a classic Human Factors incident.

A very poor design by Airbus which has been notified to them on numerous occasions since entry into service of the V2500.

A modification to keep the cowls 'unfaired' until mechanically closed is also of poor design.

Even with safeguards like duplicate inspections to ensure correct latching, depending on time of day/weather conditions this could still be missed in the current era of limited engineering resources to carry out maintenance at most airlines, exasperated by the poor design.

All this could be remedied by either a better mechanical indication system or modification to latches of a similar design to other types such as on the RB211-535/524. Whether it's Airbus's or the Airlines reluctance to this due to costs is up for debate.

[JW411]

As already stated, BA have announced that they will pay no compensation to those affected by the 190 flights cancelled because of this incident.

I am mildly surprised at this decision for I would have thought that a smart lawyer would have little difficulty in proving that BA probably caused the chaos in the first place.

[E_S_P]

Flaphoot surely in this day and age of technology there should be proximity switches on the cowl doors ? All other doors whether they be passenger, service, type 3, freight or avionics bay doors have proximity switches.

I am not splitting hairs, but the 'quick fix' of fitting proximity switches are of little use - they will only tell you once the cowl had been blown open. At rest with the cowl latches unlocked, they would still appear to being 'locked' as gravity forces them together. Another type of switch mechanism to register the positive latch engagement would be required. :ok:

[WHBM]

..... and that delay arises from causes within the carrier's control ....

BA are somewhat fortunate that the general media, until the event fell from their attention, consistently reported the issue just as a "fire in an engine", rather than picking up on the cowl doors not being secured.

Maybe not as many journalists go through our Site as we sometimes think ......

[gcal]

@555

Yes they put devices on cars to prevent bonnets opening in motion but this did not prevent it happening to Renault Clio cars, and not rarely either. I witnessed this on a busy road and it was an extremely dodgy moment as the driver would have had no view forward.
At no time were these vehicles recalled to fix this potentially dangerous fault (In fact I do not believe a car has ever been recalled by the UK authorities for any reason, and I can only speak in this for the UK) and the matter was passed off as a maintenance problem or lack of maintenance/user problem.
A new more robust latch was fitted through the good will of dealers and on request; hushed up if you will.
In short the regulatory authorities were slow to act and their response was about as good as a chocolate tea pot.

Perhaps we are in a similar position here and in an industry which has a history of disasters caused by bits falling off despite some of them being deemed 'fail safe' a term which should be an oxymoron.
Was it not widely mooted that the Aer Lingus Viscount that crashed back in the 60s in the Irish Channel could have been a victim of a catering door or hatch coming loose and destroying part of the empanage?
I believe the HS748 had similar problems and we are all aware of the DC10 debacle.
Somewhere I have photo of a BCAL 707 on which a nose wheel door detached. The door hit the leading edge of the wing then made a deep crease upwards and along the main body, then on up the fin (due to one of the tyres having been inflated with air and being damaged on the take off run, so perhaps and exception but one that could have been avoided).

Bits falling off aircraft that could/should have been properly secured and by the present stage of aviation (Murphy factor excluded) should pretty much have been eliminated.

Perhaps we should be thankful that due to the diligence of those involved these things happen as seldom as they do.

My thoughts for what they are worth and Murphy never seems to go away and rest in peace.

[A and C]

Screwdrivers !

I am very buch in disagreement with you about the screwdriver, I have not a chance of getting mine on to LGW or any other UK airport, as fight crew it would seem that those in security cant or wont except that on occations I need to check the fuel sticks or check a cowling is locked.

You are correct as to the airside "tools of the trade" rules but getting any logical or sensable answers form those involved with security as to what a pilot can carry on duty is next to imposable as they all spend most of the time gold plating the rules just to cover their own six.

The other problem is that what is good for one UK airport is not good at another when it comes to what a crewmember may take airside.

The bottom line is that flight crew are now so distrusted by security that they cant carry tools that in the past have been used to check things that might not strictly be part of their job discription but were worth a quick look at on a walk around inspection and by doing so the security system has removed the last back stop in a flight safety system.

[F900 Ex]

A and C
Screwdrivers !


I dont see why not, we do - plus we even keep a small toolkit onboard for exactly the reasons mentioned during pre-flight inspections. As for security not allowing it in certain airports see how long it lasts when flights start getting canx because of safety they cannot argue that one.

[greenspinner]

As far as I remember on the DC-10 there was a pop up indicator (on the engine two at least) to show you from the ground that the fan was not properly closed. It was a simple mechanical mechanism with a red index which was visible from the ground during WAC.
It's seems that current technologies could not duplicate it !!!:confused:

[3holelover]

Greenspinner...

The Dear Old Diesel Dixie (with CF6-50's) did indeed have pop-out indicators, but they were for the latch handle of the reverser cowl closing mechanism. They were both sides of all three... if the handle wasn't closed properly, or not rigged properly, it's end would hit the trigger for the spring-loaded pop-out (you'd see a red dowel sticking out of the fan cowl about 2 inches.).

The V2500 cowl issue could easily be fixed by a spring device that held the cowls open a bit until and unless they were latched closed. ....and I agree, since it almost requires getting on your knees to verify the latches are all closed, some simple pop-out device (popped if any latch not latched) is a great idea.

As has been said, It happens to them more often simply because they sit naturally fully closed (without being latched). The KISS principle ought to be considered in any response.

[mono]

Just to show no-one is immune. In the video posted earlier, The maintenance crew have clearly latched the fan cowl closed without correctly latching the forward C-Duct latch. At around 8.50 the red flag is clearly visible!

Airbus A320 (V2500) Opening & Closing of Engine Cowl Doors - YouTube (http://www.youtube.com/embed/FcScjE_QDTM?feature=player_embedded)

To add to other comments, There is a mod (mandatory via EASA and FAA AD's) which puts a spring loaded block in the front of the nacelle which stops the doors from being fully down until the block is moved out of the way. So if the doors are just dropped then they don't appear latched. Once the block has been moved and the doors ready for the latching It is recommended in the AMM that the process should be completed.

Somehow it seems this was allowed to happen prior to this flight.

[silverstrata]

>>>You can't just drop into an unfamiliar base without
>>>getting charts, plates, performance and briefings.

>>Yes you can. You press the PTT and say "what's your ILS
>>frequency and inbound course?"


Nice reply Mr Spandex. And quite correct too.

But you forgot to add that the modern f/o would be heads-down reprogramming the FMC for most of the approach, and would only finish setting it up as you taxied in on stand at Stansted.

So much for modern training methods...... :ugh:

.

[bookworm]

Or a flight engineer prepared to get his knees wet.

You're not seriously suggesting that the BA "Look the Part" behaviour (http://www.britishairways.com/careers/ourhistoryandculture.shtml) be superseded by a "See the Component" behaviour during walk-arounds, are you? ;)

[screwdriver]

Semi tongue in cheek. Although the next line in the document you refer to states "do things properly":ok:

[BOAC]

So much for modern training methods...... - was that actually an original quote about needing all that guff? I don't have time to 'search'. What have pilots become? Mantra-driven book followers? Was it by one of those 'modern f/o s', in which case there may be hope.

Scenario. Let's be totally over-dramatic (just for fun). Bits are actually dropping off my machine. I have had a structural failure - let's say an oxy bottle explodes, blowing bits into an engine and damaging the pylon.

Me to 'modern f/o': "Look, there's Stansted down there, I'm going in on R05. Tell London ATC I'm going visual on a Mayday".

'Modern f/o to me: "...but we don't have charts or a company frequency and I need to put the approach in the FMC - and we haven't briefed - you know, minima, autobrake, reverse.... ".

Me to modern f/o: "Gear down, landing checks to flaps"

Didn't we always say that the Swissair cockpit fire gave us some important lessons (yes, I know it would not have mattered, but we should learn)?

[JW411]

Isn't that just the truth. In my last job we flew mostly in the middle of the night and traffic was light. Assuming that the weather was reasonably benign most airfields in Europe would offer us a straight-in visual to the opposite end of the runway given on the ATIS.

This used to cause great panic to a lot of the youngsters that I was trying to teach. As you say, their first reaction was to start trying to punch rubbish into the automatics.

I used to stop them very, very firmly and make them look out of the window and land the bloody aeroplane.

What would cause even more panic was if ATC invited them to fly a visual approach from downwind.

How can these people call themselves professional PILOTS?

[wannabe024]

The older I get the better I was...:rolleyes:

[Lord Spandex Masher]

BOAC, as I responded to the original I went and found it for you.

Why not choose STN? You've got problems with potentially both engines and you're downwind at your familiar homebase. You can't just drop into an unfamiliar base without getting charts, plates, performance and briefings. On the other hand, an approach into LHR is a non-event for BA airbus pilots.

But you forgot to add that the modern f/o would be heads-down reprogramming the FMC for most of the approach, and would only finish setting it up as you taxied in on stand at Stansted.

That's fine with me. He may be too busy and may or may not have heard the autopilot come out, the gear go down etc.. But as long as he isn't hindering then no snags.

[BOAC]

But as long as he isn't hindering then no snags. - aye, but I know you would REALLY prefer him 'head-up' and actually helping.:p

[blind pew]

BOAC if you want how it should be done look up the newish Swissair MD 80 with a fire in the overhead panel...
Smoke appeared around 10 mins out of Munich...did a 180 and landed downwind within 10 mins..stand to be corrected on the time.
No forward viz and co pilot was fanning the skippers ASI to read the airspeed.
Everything covered in ash.
Skipper (mate of mine) was walking around with hand in bandages for a month or so from being burnt.
Fire from battery emergency bus...circuit breaker underfloor.

Another but more resent was an airbus airborne LHR with several hydraulic failure warnings - pages said off load all systems..did a quick circuit -Apparently computor failure.
So there are some pilots still who can fly but they wouldn't be 150hr pay to fly ones.

[One Outsider]

The older I get the better I was...:rolleyes:Quite. It really is tiresome how every thread have to become a venue for every old fogey to diminish younger generations. They become even worse when retired.

Bit of a shame that one's job was the sole source of identity and self-esteem.

[tubby linton]

From the usual excellent reliable news source (AvHerald):

On May 29th the NTSB reported quoting the AAIB, that both engine cowl doors separated during takeoff and fell onto the runway, one engine was leaking fuel and had been shut down, they were returning to Heathrow. Later the crew reported the other (still running) engine was on fire, the aircraft continued for a safe landing, was shut down and evacuated. The NTSB assigned an accredited representative into the investigation led by the AAIB.

[BOAC]

to diminish younger generations - you may not have noticed, but they seem to be managing that pretty well themselves without the OF's help.

[Lord Spandex Masher]

- aye, but I know you would REALLY prefer him 'head-up' and actually helping.:p

Absolutely but if he can't help because his brain has gone pop...

[s e t h]

seems like only a matter of time before there is a pile of bodies to deal with if this isn't fixed.
didn't airbus swop out the pitot tubes after the last gigantic pile of bodies?shoudn't they be proactive here rather than dodging the issue till it bites a boatload of people at once :suspect:
can there really be any viable excuse when they have 75 bodies lined up under wraps? :confused:

[Jet II]

Would it be worth pilots feeling the difference between a secure and insecure cowl door side-by-side? Not my aircraft, but I'd have thought there'd be some telltale sign that could be easily verified on walkround, even without that banned screwdriver, providing you knew exactly what to look for.

Flight crew know exactly what to look for and they dont need a screwdriver to do it. Forgive me if this has been posted before, but Airbus widely publicise exactly what the problem is - whether there should be a problem in the first place is another matter.

Saftey First - July 2012 (http://www.ukfsc.co.uk/files/Safety%20Briefings%20_%20Presentations/Airbus%20Safety%20First%20Mag%20-%20July%202012.pdf)

[wannabe024]

I wonder when the last death directly attributable to UK commercial aviation occured?

[DaveReidUK]

From the usual excellent reliable news source (AvHerald):

On May 29th the NTSB reported quoting the AAIB, that both engine cowl doors separated during takeoff and fell onto the runway, one engine was leaking fuel and had been shut down, they were returning to Heathrow. Later the crew reported the other (still running) engine was on fire, the aircraft continued for a safe landing, was shut down and evacuated. The NTSB assigned an accredited representative into the investigation led by the AAIB.Several aspects of that report sound highly dubious.

Firstly, it would be a very unusual breach of etiquette for the NTSB, in assisting an AAIB investigation, to release information that AFAIK the AAIB itself has not yet placed in the public domain.

Secondly, we know from the video showing the thrust reverser deployment that the aircraft landed with No1 engine operating. If it, too, was on fire then it's strange that none of the video or eyewitness evidence supports this claim. In fact, AvHerald also quotes a passenger on board as saying:

"I was a passenger on the flight sitting next to engine that caught fire. Facts are that covers (cowls?) on both engines fell off at take off and hit the airplane. Liquid started leaking as we climbed further. Took 10-15 minutes before the captain announced return. As descending the fire broke out in the right engine - quite a blaze at first - burned maybe 30 sec to 1 minute - then it died down as the right engine got cut off. Aircraft swayed a bit before it continued in a stable descent. Worried about the left engine as it was fully exposed as well. Landed maybe 5 minutes+ later pretty normal with 1 engine running"

[Finn47]

NTSB statement here:

An Airbus A319-131, registration number G-EUOE, during departure from London-Heathrow International Airport, had the engine cowls from both International Aero Engines V2500 engines separate and fall on to the runway. The pilots reported that they shut down one engine, there was a fuel leak, and that they were returning. The pilots subsequently reported that one engine was shut down and the other engine was on fire. The airplane landed, was shut down, and the passengers were evacuated via the emergency slides.ENG13WA029 (http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20130524X30219&key=1)

[flydive1]

Me to 'modern f/o': ............
'Modern f/o to me: .................

How can these people call themselves professional PILOTS?

Yes, I remember your captains saying the same thing.....
My captains too........
You just cannot trust those youngsters
;);)

When was that famous crash with the captain joking about ducks and copilots?

[wannabe024]

Warning about what exactly?

This thread is about the possibility of engine cowels being unsecured? Have you been warning about that for a long time?

When was the last death directly attributable to UK commercial aviation? Whose generation was it?

If CVRs and FDRs had been available for the last 50 years would the current generations be able to sit here and pick apart the flying skills and decision making of previous generations? Would they discover some howling errors? Would they be amazed with what older generations have gotten away with? Have the sands of time covered over these errors to the extent that they will never be on public record, unlike current incidents/accidents?

I'm very sure that most pilots on here, of all generations, can uncomfortably point to errors over their careers that may possible have led to something a lot more serious had other variables lined up. They/we got away with them due to luck and good fortune. Nothing else!

The older I get the better I was...!

[DaveReidUK]

When was the last death directly attributable to UK commercial aviation?

Four years ago.

[Sir George Cayley]

Dave R

My answer would have been the BY 757 in Spain where a passenger died very shortly after the crash and before that Kegworth.

It comes down to the definition maybe so I wonder which fatality you are pointing towards?

[wannabe024]

2009? Nothing immediately springs to mind.

How many passengers died?

ETA: Me too SGC

[Idle Thrust]

Didn't we always say that the Swissair cockpit fire gave us some important lessons (yes, I know it would not have mattered, but we should learn)?

Actually BOAC, while the Canadian TSB stated that it would not have mattered, it has been demonstrated that they could have landed at Halifax if a timely decision to do so had been taken.

[DaveReidUK]

How many passengers died?All on board - 14 passengers, 2 crew.

Air Accidents Investigation: 2/2011 G-REDL (http://www.aaib.gov.uk/publications/formal_reports/2_2011_g_redl.cfm)

[wannabe024]

Fair enough.

Whilst factually correct, I'm sure you'll agree that a catastrophic Main Rotor Gearbox failure would have challenged a crew of any generation, whether you pointed the aircraft at the runway and commanded gear and flaps or not.

I hope the gist of my post was still understood? :ok:

[DaveReidUK]

I'm sure you'll agree that a catastrophic Main Rotor Gearbox failure would have challenged a crew of any generation, whether you pointed the aircraft at the runway and commanded gear and flaps or not.OK, if you would care to ask a more specific question, I'll do my best to answer. As it is, I haven't a clue what your parameters are.

[wannabe024]

My parameters lie within the topic of the thread. That's why I posted. Tangential discussions based on dissecting minute detail hold no interest to me I'm afraid.

I believe that my point was clear. :)

[DaveReidUK]

I believe that my point was clear.Then I'll defer to others to whom it was, to try to help you out.

I wonder when the last death directly attributable to UK commercial aviation occured? When was the last death directly attributable to UK commercial aviation? Whose generation was it?

[off watch]

Wouldn't you think someone who can log into PPRuNe would know how to use Google ? Don't feed the trolls Dave ! :hmm:

[4468]

"The older I get, the better I was!"

Absolutely priceless. Thanks for sharing!:):)

Yes, I remember your captains saying the same thing.....
My captains too........
You just cannot trust those youngsters

And just when you thought things couldn't get more cringeworthy along comes Lord Spandex! Exactly the kind of person you NEVER want to share a flight deck with!

Us old duffers really should learn to accept that it doesn't matter how many hours you have in your logbook. The junior guy in the other seat can often be the only person who can save you from your own ego!!

The question about ducks and co pilots is a perfect example. Google it if you're not familiar! Add 'Staines Trident' or 'Papa India' if necessary.

It may not be a democracy, but to be anything less than a team is frequently a bad result!!

No suggestion WHATSOEVER of that in the case we are discussing. Such is now the BA way, and LONG may it continue!!!! Maybe I've just been spoiled!:)

[HeathrowAirport]

A lot of the A319s that BA own are going around with white engine cowlings on the right hand side. Anyone know anything about this? As it's only been this week that many have them now.

[Lord Spandex Masher]

Yes, I remember your captains saying the same thing.....
My captains too........
You just cannot trust those youngsters

And just when you thought things couldn't get more cringeworthy along comes Lord Spandex! Exactly the kind of person you NEVER want to share a flight deck with!


If you're attributing what you quoted to me then you've got it completely wrong. If you're not would you mind explaining your outburst?

[blind pew]

Idle thrust
Have you got a reference or link to that?
Had two mates on the enquiry who were adamant that they didn't have time.

[Skipness One Echo]

A lot of the A319s that BA own are going around with white engine cowlings on the right hand side. Anyone know anything about this? As it's only been this week that many have them now.
The Dove aircraft were painted with white engines and now they've all been mixed in together during routine maintenance. The Doves now have blue bits and the rest of the fleet have random white panels.

[Pinkman]

I was browsing through the Hobbs report (An Overview of Human Factors in Aviation Maintenance - 2008)

http://www.atsb.gov.au/media/27818/ar2008055.pdf

... and was interested to see the section on Page 25 that clearly identifies accessibility and visibility as key issues in aviation maintenance

Its a good overview and most of the case studies are well known to PPrune readers

[quentinc]

Quentic - can you explain, exactly, how you avoid populated areas in the south of England in a jet flying at several miles a minute... perhaps you could give us definition of "least populated" - last question - do you have a CPL?

FWIW
Least populated: I can't imagine an approach to an airport in the UK, that would pass over more people than that to 27L/R at Heathrow.
CPL: No. PPL(A) expired

[Case One]

I stopped flying 320 family aeroplanes nine years ago (V2500 and CFM). Back then this was a very well known problem. Obviously it's still ongoing and a better solution needs to be found.

However I was trained to always squat down to visually check the latches and check for a gap. Contrary to what some have written here it's hardly onerous and you don't get your knees dirty (if that's a worry change jobs). I'm sure thousands of 320 drivers do it every day. A nameless BA mate told me that until this incident he never checked the latches - he does now. I suspect the same may be true at other operators.

I'm sorry, but is a decent walk round too much to hope for? Isn't it part of our job to compensate for known issues with the machines we operate (for none are or ever will be perfect).

[SLFandProud]

"Some time in the fifties car makers discovered that if the bonnet opens while you are mobile bad things can happen.

They decided to have two latches one holds the bonnet closed good and proper the other just holds it more or less down but stops it coming any further up. It also allows it to project a bit so you notice the upsticking and vibrate a bit so you wonder what the noise is

They did this because they knew every so ofter one latch just isn't enough"

We call this method of working a FAIL SAFE do we not?
Just as a point of order, no that is not 'fail safe'. It is belt and braces, which is no bad thing.

A 'fail safe' is a situation whereby the failure of the mechanism 'naturally' fails in a safe way. An example would be (if you'll excuse the mention of railways) electro-pneumatic braking system on trains, whereby the natural state of the individual brakes on the wheels is that they are held on using jolly big springs, and the action of the train's braking system is to pull the brakes off using pneumatics. If any part of the train's system fails (for example the train splits, causing the brake-line to separate, releasing the pressure from the braking system) basic laws of physics (Newton & Hooke) cause the brakes to revert to the applied state rather than any backup mechanism* per se.


A fail safe cowl latching mechanism would be one whereby if the latch fails, the cowl nevertheless remains in the safest position while in flight (which is to say, closed.) You can envisage designing the cowls such that while in flight the flow of air passing the cowl naturally tends to push the cowl closed rather than tearing it off. (Simplistically, arranging the cowls such that their hinges were at the front and opened like the petals of a flower, would seem to be a 'fail safe' design in respect to the latches.)

(Note I'm not recommending that design - I'm sure there are plenty of reasons they're not designed like that and plenty of reasons why they are designed as they are, but that would be a design whereby the cowls would seem to fail safe in the event of latches not working.)





* some smartarse (me!) is going to say, 'what happens if the springs don't work'. Well, that's a different failure than the train braking system failing, so doesn't affect whether or not the design of the braking system is fail safe. I suppose one could start to worry about whether or not springs need their own fail safe, but to a certain extent worrying about whether or not springs are going to spontaneously stop being springy is a bit like worrying about whether or not gravity is going to stop working mid-flight. Possibly worth worrying about if you worry about the Bermuda Triangle, but otherwise you have to draw a line somewhere...

[JW411]

Case One:

"A nameless BA mate told me that until this incident he never checked the latches."

If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?

Breathtaking.

[IFixPlanes]

Even when the maintenance forgot to lock the latches, it is part of flight crew "Exterior Walk-Around" acc FCOM PRO-NOR-SOP-05:
...
Fan cowl doors...................................................CLOS ED/LATCHED
...

[Case One]

Originally posted by JW411:
If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?

His words not mine, I have no reason to doubt him. I've known him for many years and always considered him to be professional. He seemed unaware and genuinely shocked. I consider it highly unlikely that he is an exceptional case.

It's not however the first time I tripped over an inexplicable yawning gap in an experienced pilot's aeronautical knowledge. No doubt I have some myself. I place some of the blame on the curious emphasis of modern training systems. Certainly, to my eyes they don't seem to place "Rule 1 - don't crash" in it's rightful place. Still, I'm becoming a grumpy old fart.

[pontifex]

Case One,

Snap!

[Super VC-10]

Allow me to put Wannabe024's question more specifically -

When was the last death attributed to the operation of a scheduled commercial passenger flight operated by a UK-based airline on a (a) scheduled, or (b) charter, flight?

[Wirbelsturm]

A nameless BA mate told me that until this incident he never checked the latches

I always checked the cowl latches in my time on the 'Bus'. At the time the walk round mandated that they were checked, either from the front (crouch down) or from the side by the wing tip whilst checking the nav lights.

Then 'someone' mandated that checking the cowl latches was a maintenance procedure and 'not required' by the flight crew.

AFAIK 'most' crews still check the latches.

Not proportioning 'blame' in any way, just stating how the responsibilities changed with the reduced turnaround times.

[Super VC-10]

BBC News - Engine problems sparked Heathrow emergency (http://www.bbc.co.uk/news/uk-england-london-22717943)

[DaveReidUK]

When was the last death attributed to the operation of a scheduled commercial passenger flight operated by a UK-based airline on a (a) scheduled, or (b) charter, flight?

Thanks goodness for someone who can phrase a question unambiguously. :O

May 1995.

[daikilo]

From what I am aware of, the manufacturer recommends that crew-memebers be required to check cowl latches during walk-around. If this was not the rule at BAW then God help them.

[Richard J.]

BBC News - Engine problems sparked Heathrow emergency (http://www.bbc.co.uk/news/uk-england-london-22717943)

That's the BBC report based on the statement from NTSB that AAIB has now said is wrong. The NTSB statement includes this: "The pilots subsequently reported that one engine was shut down and the other engine was on fire." According to the Guardian and others, AAIB say this is not true. Apparently we are to get an interim report/bulletin from AAIB later today (Fri 31 May).

For some reason, the BBC have not quoted AAIB, but are carrying links to eminent news organisations that have, such as the Huddersfield Daily Examiner and the Ellesmere Port Pioneer.

[lomapaseo]

Richard J

That's the BBC report based on the statement from NTSB that AAIB has now said is wrong. The NTSB statement includes this: "The pilots subsequently reported that one engine was shut down and the other engine was on fire." According to the Guardian and others, AAIB say this is not true. Apparently we are to get an interim report/bulletin from AAIB later today (Fri 31 May).


I getting more and more confused about these so called news stories and who they are quoting.

No where in your BBC link did I see anything that quoted an NTSB source saying that there was a fire in one engine. Yet you seem to mention that the AAIB disavowed this statement from the NTSB :confused:

I think I will have to wait for an official link to an NTSB site as well as an AAIB issued interim report and forget about BBC etc. releases of rumours.

[wiggy]

I getting more and more confused about these so called news stories and who they are quoting.

FWIW "they" are quoting this:

ENG13WA029 (http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20130524X30219&key=1)


I think I will have to wait for an official link to an NTSB site

It is from the official NTSB site.

[justanotherflyer]

For some reason, the BBC have not quoted AAIB, but are carrying links to eminent news organisations that have, such as the Huddersfield Daily Examiner and the Ellesmere Port Pioneer.

Chuckle. :D

[A and C]

There was nothing wrong with this aircraft, the fault was the faiure to lock the cowling latches, those who seek to fit a " Fool proof system" are the types who would fit enough systems to ensure that there could be no human error and end up with a totaly safe aircraft because it is to heavy to fly.

No one deliberatly released this aircraft to service, it slipped though the inspection net for reasons that we dont yet understand, but some above have shown a total lack of understanding of the pressues put on line maintenance personel and flight crews. These presures have slowiy been built up one small step at a time, minor increases in inappropriate H & S and Security measures may not seem to be a burden by those in walm offices who mandate these regulations but the cumulative effect of the mountain of non aviation regulation on those who have to work in a cold, wet and noisy ramp enviroment is a major distraction to the primery task in hand.

For instance I as a pilot cant get a security pass for a major UK airport because my one of my employers who was based abroad went bust and cant verify that I was contracted to a UK airline that also went bust. The fact that during this whole period I held a security pass and was based at the very UK airport that now wont issue me a pass is irritating to say the least. the problem is that without the pass for that airport I cant park in the staff car park, some idiot has closed the road that gives me easy access to the office for no apparent reason and I cant get out onto the ramp to do my walk around inspection without having someone let me in and out of the door on the jet way. All of this is individualy trivial but it makes for a longer working day and so the picture of the errosion of flight saftey by a thousand small cuts is clear.

The flight safety people like to go on about all the airport staff being part of the flight safety system, this is very good in theory but those in managment who impose more and more small reguations have yet to get the message that all this regulation is distracting people from the task of keeping aircraft safe.

The question both the airline and airport managers should be asking themselfs is "did the small bit of nifnaf & trivia regulation I put in place to cover my own six destract a guy from his flight safety task ?".

Individualy it is unlikely that one regulation will do this but collectively the answer is a very big YES you are building an accident one reguation at a time.

[hunterboy]

Without wishing to second guess the outcome of this particular incident, I think it is generally recognised that BA engineering is having a few problems with overstretch at the moment. The 777 diversion due to a lack of engineering checks springs to mind.....

[Sunnyjohn]

Pinkman - thanks for the link to the Hobbs Report on Maintenance staff work issues. As an ex-maintenance person, I'm pleased to see this issue being taken seriously. Good for the Aussies!

[spooky3]

Just as a point of order, no that is not 'fail safe'. It is belt and braces, which is no bad thing.

A 'fail safe' is a situation whereby the failure of the mechanism 'naturally' fails in a safe way. An example would be (if you'll excuse the mention of railways) electro-pneumatic braking system on trains, whereby the natural state of the individual brakes on the wheels is that they are held on using jolly big springs, and the action of the train's braking system is to pull the brakes off using pneumatics. If any part of the train's system fails (for example the train splits, causing the brake-line to separate, releasing the pressure from the braking system) basic laws of physics (Newton & Hooke) cause the brakes to revert to the applied state rather than any backup mechanism* per se.


A fail safe cowl latching mechanism would be one whereby if the latch fails, the cowl nevertheless remains in the safest position while in flight (which is to say, closed.) You can envisage designing the cowls such that while in flight the flow of air passing the cowl naturally tends to push the cowl closed rather than tearing it off. (Simplistically, arranging the cowls such that their hinges were at the front and opened like the petals of a flower, would seem to be a 'fail safe' design in respect to the latches.)

(Note I'm not recommending that design - I'm sure there are plenty of reasons they're not designed like that and plenty of reasons why they are designed as they are, but that would be a design whereby the cowls would seem to fail safe in the event of latches not working.)





* some smartarse (me!) is going to say, 'what happens if the springs don't work'. Well, that's a different failure than the train braking system failing, so doesn't affect whether or not the design of the braking system is fail safe. I suppose one could start to worry about whether or not springs need their own fail safe, but to a certain extent worrying about whether or not springs are going to spontaneously stop being springy is a bit like worrying about whether or not gravity is going to stop working mid-flight. Possibly worth worrying about if you worry about the Bermuda Triangle, but otherwise you have to draw a line somewhere...


Air brakes on a truck work just the same ie if the system fails the brakes are automatically applied....

[Safety Concerns]

what about just employing cost effective "professionalism" endorsed by management and regulators in real terms rather than just hollow words or reports which paint a nice picture but don't relate to the reality.

[phil gollin]

I do find the disagreement between AAIB and NTSB rather odd ( see posts from Richard J, lomapaseo and Wiggy above ) rather disturbing.

Surely they should be VERY clear on the facts before publishing ?

( See Guardian story here ;

Air safety officials deny claim that BA jet was close to catastrophe | World news | The Guardian (http://www.guardian.co.uk/world/2013/may/30/air-safety-officials-ba-jet)

[NigelOnDraft]

To be technically correct, the NTSB dod not say "one shutdown, other on fire." They said:The pilots reported that they shut down one engine, there was a fuel leak, and that they were returning. The pilots subsequently reported that one engine was shut down and the other engine was on fireSo they quote what (they understand) the pilots reported. There are quite a few links in the chain between the NTSB narrative and what actually happened, especially if you interpret "reported" as what was understood by somone on the other end of the radio, rather than, say an interview.

Pretty academic, wait until this afternoon ;)

[Smellybeard]

I wonder does the dark blue colour of the cowl hide shadows of what might be going on in hard to see places? Will we see a change in livery?

[Sillert,V.I.]

Case One:

"A nameless BA mate told me that until this incident he never checked the latches."

If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?

Breathtaking.

In the real world, folks sometimes take shortcuts.

IMO there is a world of difference between not checking the cowl latches thoroughly on a quick turnaround, and not doing the same checks on the first flight of the day. Especially on an aircraft that has just come out of maintenance.

[Safety Concerns]

IMO there is a world of difference between not checking the cowl latches thoroughly on a quick turnaround, and not doing the same checks on the first flight of the day. Especially on an aircraft that has just come out of maintenance.

Is there a clue there?

Are we heading for yet another AAIB report focusing on maintenance?

Time will tell.

From the Hobbs report:

‘technical/maintenance failure’ emerged as the leading cause of airline accidents and fatalities, surpassing controlled flight into terrain, which had previously been the predominant cause of airline accidents.

According to former NTSB Board member John Goglia, deficient maintenance has been implicated in 7 of 14 recent airline accidents.

So is maintenance getting the same level of attention as CFIT did?

If cutting budget, manpower, spares, tools, inspectors, targetting occurrence reporters qualifies then I suppose yes.

But wouldn't crews prefer to be handed over a plane that is going to work?

[musicrab]

Ok, I'm a lurker here (amongst many I guess) and after I post this I will probably return to being a lurker but...
1. the NTSB appears to be a bit of an ass (to use a US phrase)
2. the AAIB needs to kick some ass in its final report
3. Not sure what to say about BA. I don't know if coming back to base was the best option. But, again, I'll see what the AAIB says.
Looking forward to an authoritative update from the AAIB today.

[quentinc]

http://www.aaib.gov.uk/cms_resources.cfm?file=/AAIB%20S3-2013%20G-EUOE.pdf

[RomeoTangoFoxtrotMike]

The initial report is out...

Air Accidents Investigation: S3/2013 - Airbus A319-131, G-EUOE (http://www.aaib.gov.uk/publications/special_bulletins/s3_2013___airbus_a319_131__g_euoe.cfm)

[musicrab]

"The flight crew elected to return to Heathrow." before the engine fire, so I guess the return to home base was understandable.

[cldrvr]

Key finding?





Subsequent investigation revealed that the fan cowl doors on both engines
were left unlatched during maintenance and this was not identified prior to
aircraft departure

[BOAC]

As they say on the trains - "Mind the gap"? A hard lesson learnt, I trust.

[pudoc]

Who takes responsibility for making sure the cowlings are latched? The last engineer working on the engines or the pilot doing the walk around?

[LeadSled]

Folks,
Just listening to Sky News, BA CEO says (I kid you not)

" the cowls are like the bonnet on your car ------ they have no structural strength ------ they should be able to fall off without doing too much damage".

Oh! Well!, that's all right Nigel, back to sleep. And we whinge about the reptiles of the press getting aviation stories wrong!!

And, of course, all car bonnets have a double latch, part of the design standard.

I hope this interview goes viral on the net, so you can all benefit from these pearls of wisdom.


The last engineer working on the engines or the pilot doing the walk around? In short, both!!

[fincastle84]

Fortunately they got away with it this time. Let's all be thankful for that, it could have been a whole lot worse.

[quentinc]

In short, both!!

and whoever at the AAIB has chosen the photo to use in Figure 1, I would suggest, is conveying to the reader that this wouldn't have been too hard to spot.

[sailor]

First fault - the engineer's (s' perhaps)

Ultimate responsibility, particularly after maintenance - flight crew exterior walkround inspection error/omission.

[Wander00]

Just a thought - according to the AAIB report a photo taken before pushback showed the doors unlatched - who took the piccie - was it someone who might have understood what he/she was looking at?

[ILS27LEFT]

The fact remains that the V2500 engines have experienced 32 events of unlatched cowlings falling off of which 80% during take off, this means 32 cases of multiple failures by engineers and pilots, I am therefore not inclined to blame both on this occasion, in my opinion the design must be improved and cockpit warning sensors added to this engine or it will happen again. The pilots could have died too so negligence in my opinion would be an inappropriate excuse to cover Airbus responsibility: misleading, inappropriate design is responsible for these 32 events.

[kenjaDROP]

To quote AAIB Bulletin S3/2013 SPECIAL:

Safety Recommendation 2013-011
It is recommended that Airbus formally notifies operators
of A320-family aircraft of the fan cowl door loss event
on A319 G-EUOE on 24 May 2013, and reiterates the
importance of verifying that the fan cowl doors are
latched prior to flight by visually checking the position
of the latches.

- to refer to my earlier post, what bl**dy good does it do in "visually checking the position of the latches.". I remain pretty damn sure that the latches can be closed/stowed/pushed home/flush, not hooked on, with the cowls still 'dangling'!
The only tell-tale then is the gap around the actual cowls. Am I right?
If so, why the AAIB recommendation to look for latch positions?!!!

[4468]

Many people in many jobs have the luxury when they make an error/omission, of simply screwing it up, tossing it in the bin and starting again. It happens all the time.

Pilots OTOH have to pick up the pieces, not just from their own human fallibilities, but those from every other individual along the way. From designer, to manufacturer, to politician, to manager, to trainer, to maintainer, to ATC et al!

Yes they may be paid the 'big bucks', but that alone serves as no protection from their own 'human condition'!

I would expect harsh criticism from only those who are perfect. But I fear I may be disappointed. For such is the nature of some who are attracted to this occupation. I realised that long, long before PPRUNE!

Lessons to (re)learn from this incident as always, but much to admire too!

People (quentinc) should be very careful of assuming that what is shown in the AAIB 'generic' pictures, is what would have been apparent on this specific a/c, at this specific time?

[Dimitris]

Just a thought - according to the AAIB report a photo taken before pushback showed the doors unlatched - who took the piccie - was it someone who might have understood what he/she was looking at?

Maybe CCTV?

[jackharr]

Low tech.....Something like, maybe, a mirror on a stick?Here you are from Amazon with free delivery all for £2.99

http://www.amazon.co.uk/Stainless-Steel-Dental-Inspection-Mirror/dp/B004E4DVT0


:)Jack

[Beanbag]

The photo in the AAIB report is of the cowls with the hold-open device still in place (according to the text of the report). As I understand it - from the report and the previous 33 pages of this thread - once that device is deactivated the cowls drop to the fully closed position and the only way to tell they're not latched is to look at the latch position.

[Henryknup]

Having opened and closed more fan cowls on various different engines than I care to remember I have to say in IAE ,s defence there is no difference whatsoever in the basic design or method of latching the cowls compared to RR GE CFM or PW engines .
In fact the V2500 engine is the only one I have come across which is available with a secondary cowl lock mod available

[BOAC]

People (quentinc) should be very careful of assuming that what is shown in the AAIB 'generic' pictures, is what would have been apparent on this specific a/c, at this specific time? - page 4 para 1? I would have thought if it were visible in a 'photo' 'prior to pushback'?? Mind you, we don't know how 'prior'!and the only way to tell they're not latched is to look at the latch position. - not my reading of Fig1, page 3? Are you saying the 'gap' shown will NOT be visible?

[glad rag]

Has this happened before?

[BOAC]

Has this happened before?- paras 3,4,5 page 4?

Edit: - or do you mean to this Captain - one hopes not........................

[wilnot]

Whilst of course the AAIB report is only interim (and the full, final report will no doubt go into much more depth and detail), it seems to me shocking that their only recommendation do far is to reiterate the need to check the cowl latches on walk-around.

There's clearly something fundamentally wrong with maintenance procedures if mechanics can simply forget to latch the cowls, and presumably with no supervisory check on this.

This is going to happen again, quite possibly with dire results.

[pax2908]

I wonder if some bright (and in contrast with the outside colour) paint could be used over the full length/circumference, on the "edge" of the cowl which would not be normally visible when properly closed and latched...?

[BOAC]

Seriously, folks - is it beyond Airbus to design a working latch that will hang down if it is not latched?:ugh:

[Smellybeard]

Seriously, folks - is it beyond Airbus to design a working latch that will hang down if it is not latched?
No, it's not and that's what they do; hang down if they are not latched.

I wonder if some bright (and in contrast with the outside colour) paint could be used over the full length/circumference, on the "edge" of the cowl which would not be normally visible when properly closed and latched...?
What time was the pilot's walkaround conducted at? Would they have been relying on artificial light? Sodium, perhaps. Ever look at dark blue in yellow light? I no longer fly but speaking as an industrial designer with a background in usability and human factors, the colour of the nacelles will be an issue that needs to be examined.

[kenjaDROP]

BOAC, I've taken this incident so to heart (see my posts #543 and 641) that I've actually designed one, albeit on my simple CAD program here - a latch that can't be closed unless it is hooked over it's mating eye-bolt/toggle! Therefore it will hang down if unlatched. This is based on the existing V2500 latch design but modified.
I'm not publishing it here in case someone in Placentia, CA pinches it without royalties!! I'm off to the patents office on Monday! Just joking!!

[kenjaDROP]

No, it's not and that's what they do; hang down if they are not latched.

Is that fact?

[BOAC]

No, it's not and that's what they do; hang down if they are not latched. - I'm sure some here have claimed they can be 'flush' when not latched? I mean, you are saying eng and pilot missed 4 latches 'hanging down'..........................?

Post #59 "the training captain said to me on the walk around, 'always bend down and check the fan cowl latches are actually secured, they can easily be left unlatched and not noticed'"

From the Canadian report
"The fan cowling has four latches that connect at the bottom of the engine. The fan cowling doors are heavy and designed such that, when hanging unsupported, they fair flush, giving the appearance of being locked, even if they are not latched. Normally, the latches can be in three possible conditions (see Appendix A (http://www.bst.gc.ca/eng/rapports-reports/aviation/2000/a00o0199/a00o0199.asp#Appendix_A)):

latches fully locked and will appear flush with the cowling;
latches closed, but cowling not locked. In this condition, they will protrude about one inch underneath the cowling. This is the normal condition of the latches after maintenance opens the cowling, until the latches are re-locked; and
latches fully open and cowling unlocked. This is considered a temporary condition after unlocking the cowls. According to industry standard, the latches are immediately closed because the fully unlocked latch presents a personal injury risk to maintenance engineers. Fully unlocked latches protrude down about four inches from the bottom of the cowling."

It would seem that no 2 is NOT a good idea?

[Alber Ratman]

Design fault maybe, but the latches on a 73 or 75 are not much different. One Engineer forgot to latch them, could have been a mechanic and the stamper hasn't checked the work, a CAT A who forgot. However if it was a service check, the cowls should have been on that task card for the check. I can remember anywhere I have worked where dupes on cowls happens, oil tank caps, yes, but not cowls. The last resort was on the walkround, and that was missed too, but nobody has mentioned any possible reasons for all these cheese holes lined up.. MEDA will be interesting.

As for latch condition, if you try and close the doors to latch them, with the latches in the open position (handle unlocked from the lug), the lug floats about and can trap between the cowls, making it impossible to reposition them on the correct location. I was shown and did carry out the closing operation with the latches shut, close the doors, unlock the latches, locate the lugs on the hooks then lock them. However once closed, I would lock them shut and never walk away until I did..

[BOAC]

Design fault maybe - leaving aside the 'human failings, AR, more a procedural fault? Why not leave the damn things hanging down in everyone's way until you are ready to close them? Having them almost flush to 'get them out of peoples 'way' seems crazy.

[Safety Concerns]

but nobody has mentioned any possible reasons for all these cheese holes lined up.. MEDA will be interesting.

That Alber as I suspect you already know is the bit nobody wants you to mention. I suspect the final report will be very interesting.

[lomapaseo]

Let's look at the success rate (no cowls unlatched in-flight) between the various airlines operating this type design (multiple aircraft types?) since the latest SB was issued.

Now if this was so difficult to comply with I'm quite sure all the airlines would be proposing their own work-around to Airbus without any help from this forum.

The question is did they?

or did they just accept that the devil they know is better than a new Airbus invention?

If the last statement is true then the issue lies more with the operator than the engineering folk at Airbus especially if the operator convinced their regulator that they could/would easily comply with the Service bulletin.

Now I don't know the answers to the questions I raise but I certainly don't trust the viability of the solutions I've seen posted on this thread.

[Irish Steve]

From the AAIB report on THIS incident

The fan cowl doors can be propped open by two stays
mounted on the inside of each door, to allow access
for servicing. When the doors are lowered from the
propped‑open position, a ‘hold open’ device on the bottom
of the fixed engine inlet cowl prevents the fan cowl doors
from closing fully under gravity. In this condition the fan
cowl doors stand slightly proud of the nacelle (Figure 1),
to provide a visual cue that the doors are not latched

So, they do not hang flush when unlatched, and given it's getting light before 0500, and departure was after 08, the walk round should have been in broad daylight. The doors stuck out a little, and the latches were hanging down, but for whatever reason, it was missed.

Not practical to make 2 engineers sign off closing the cowls, there are not always 2 engineers at outstations or at overnight stops.

Painting the edge a good bright reflective colour, or a length of reflective tape on the inside might make the gap stand out more.

Switches that tie in to the ECAS in the same way as cabin, cargo and emergency doors might be a way to go.

This is the first time an in flight fire has happened as a result of cowls departing, but there have been over 30 previous incidents, so this is not as rare as some might think, and needs a proper fix, not just a gentle reminder to do the pre flight properly, as that clearly doesn't work all the time.

As with the 777, this could have been a LOT worse than it eventually was. For that we should all be very thankful.

[Alber Ratman]

If it was a service check or daily, Big Airways must use a task sheet for it and if the doors must be opened, then the paperwork should state it and the closing of as well, with stamper requirement to sign. I would be surprised if it wasn't. I cannot remember if having fan cowls open affects operation of the slats (doubt it). There is an AMM reference for the closing/opening the things..

I doubt another BA engineer looked at them (CAT A will have approvals for that task) and the final cheese hole was a flight crew member propably with his mind on another facet of the sector..

[angels]

the final cheese hole

I realise what you are saying but I think we're incredibly lucky that in fact the cheese holes did NOT all line up. Some of them did and we ended up with no-one hurt either on the plane or on the ground -- and hopefully lessons learned.

It all could have been far, far worse.

[RTM Boy]

Given the extensive damage to the aircraft caused by the cowls detaching, as reported in the AAIB bulletin, it was nothing short of a miracle that G-EUOE made it back to LHR.

The only way to look at this is as a fundamental failure of processes and procedures of both BA maintenance and crew walkaround. Yes, the latches are badly placed. Yes, they may be diffucult to see. But the consequences of not checking that they are properly fastened could easily have been of the most serious kind with serious loss of life to PAX, aircrew and on the ground. Imagine the consequences of an A319 landing on central London?

Every time I hear the phrase "lessons will be learned" I wince. This type of incident had happened no less than 32 times up to July last year and Airbus made it clear then that latches should be checked carefully. How often does it have to happen for appropriate steps to be taken to prevent it?

[20milesout]

BOAC wrote:
"...latches closed, but cowling not locked. In this condition, they will protrude about one inch underneath the cowling. This is the normal condition of the latches after maintenance opens the cowling, until the latches are re-locked...
...It would seem that no 2 is NOT a good idea?..."

That´s exactly how it is done and that´s the crux. Health and Safety , you know

[racerboy]

Just to clarify a few things on the fan cowls.

They are not opened on a daily check at all. Only on a weekly for the IDG oil level check and also on service checks.

The fan cowls can be unlatched and look like the photo from the report with a large gap between the cowls and engine OR they can be unlatched and be perfectly flush and without bending down can appear to be closed and latched.

The fan cowl closure is subject to a Verification check by 2 separate engineers at all times.

[FullWings]

Another interesting point is that the cowlings were in a symmetrical unsafe position, both on either side of the engines and either side of the aeroplane. I've always thought it much more difficult to pick up multiple anomalies that were balanced in some way, as opposed to single defects that stuck out as not being ''right'' even though they were quite subtle.

[roving]

1min 50 secs in on this video.

Airbus A320 exterior inspection.Exterior walk around - YouTube

[NigelOnDraft]

Given the extensive damage to the aircraft caused by the cowls detaching, as reported in the AAIB bulletin, it was nothing short of a miracle that G-EUOE made it back to LHR.could easily have been of the most serious kind with serious loss of life to PAX, aircrew and on the groundSorry - disagree. In flying / structural terms none of the damage seems relevant apart from the RH engine issue(s).

The only way to look at this is as a fundamental failure of processes and procedures of both BA maintenance and crew walkaroundMaybe, but equally a failing in the 31 other airlines / crews / training this has occured to/in.

Every time I hear the phrase "lessons will be learned" I wince. This type of incident had happened no less than 32 times up to July last year and Airbus made it clear then that latches should be checked carefully. How often does it have to happen for appropriate steps to be taken to prevent it?Ahh, we agree. I suspect it has just been demonstrated yet again that HF is not going to solve this problem. At best it will reduce the probability of occurance, maybe only temporarily. I suspect, and hope, and get the feeling the AAIB are tending towards, this needs to be the "wake up" call for a design change/tweak to reinforce the HF side.

[quentinc]

People (quentinc) should be very careful of assuming that what is shown in the AAIB 'generic' pictures, is what would have been apparent on this specific a/c, at this specific time?

You are correct. FWIW I haven't assumed anything, however poor my choice of words... I just think the author's use of a somewhat distant shot, at an acute angle, is intended to show that it should be noticeable. Whatever the situation is in this case.

[NigelOnDraft]

1min 50 secs in on this video.Yes interesting. Except that is a CFM and the pilot's eye never went below the bottom of the engine. On a 319/320 V2500 the latches are approx 6" long right underneath. You almost need your head on the ground to see them.

Try an A319 when loading and you have to squeeze between the (operating) loading belt and the front on the engine - or sometimes you cannot. The refuelling pipe, ground air or other equipment under the engine. Or the day when the engineers are still working cowls open when the walkround is done. It's a "best as possible" but I would never suggest perfect everytime ;)

[Safety Concerns]

http://www.youtube.com/watch?v=FcScjE_QDTM

Try this then around 08:50

[NigelOnDraft]

Try this then around 08:50Illustrates the issues well doesn't it? Chap lying on his back on the ground to confirm the latching is correct. On a nice dry clean hangar floor with no eqpt around.

[Safety Concerns]

A Licensed Engineers view from the Independent

This is the second incident of this type I am aware of the first was with another operators aircraft on a flight within UK.

Reason everyone wants to fly for peanuts hence the European Aviation Safety Authority was set up and have taken control of maintenance from CAA.These people are accountants, lawyers and politicians hence they do the bidding of the highest payer IE Airlines and European aircraft manufacturers .

Maintenance standards have been totally eroded at the bequest of board rooms and the UK CAA has became a "paper tiger" .

This incident will be ignored and we will keep going in the same direction until such times as we kill people and not necessarily the first time we kill them either, it will have to wait until its spectacular over London or another major city then "lessons will have to be learned".

The lessons were learned on the railways in the 1890's and the 1920's learned again in 1912 on the Titanic learned through the 60's 70s,80s 90's in aviation with the American industry controlling its regulators and again in the UK with privatization of rail.

If you put profit and Ego before proper and correct maintenance in a business in which you carry passengers eventually you will kill people.

I am a Licensed aircraft Engineer for a UK Airline (not BA)and I fight this battle every day ensuring crew and passengers fly safely, I constantly battle against a board room who wish me to do it for less and with less people and they have the support of regulators NOT me.

By the way most probable reason for incident some over worked engineer left the latches securing the cowls open because he was rushed to go and do something else due to lack of staff.Reason for lack of staff to save money to pay professional gamblers in city dividends.

[1979 Engineer]

You can trace the root cause of this incident back to at least 1987.
When I was working as a PDI engineer at LHR Terminal 1 'the management' decided that there would no longer be an engineer attending departing a/c and that the only PDI would be done by the flight crew as they did at the outstations.

As an engineer I was equipped with a suitable pair of overalls, and a 'GS' screwdriver to insert in the gap between fan cowls etc and try to lever them apart. I was also given the time (while the fuel went on) to have a proper look around. We even had a tumble dryer in the crew room to dry the knees of our overalls, which was used frequently.

So 'the management' decided that the best 'bloke' (as it was in those days!) to kneel on the wet tarmac and check the low hanging cowls was a chap in a suit with no tools or protective clothing. This chap would then have to sit in the flight deck for the next few hours in a damp suit...

When I joined the Aircraft Maintenance Industry in 1979 I was taught about Murphy's law that states 'if it can go wrong it will go wrong'. This is why a/c and maintenance system are designed to make sure it doesn't go wrong.

If one of my colleagues on a long wet night shift didn't close the cowls etc there would be a good chance I would catch it on my walk around, and then there was still the flight crew walk around. Plus any previous comments in the Tech log, which would be be a good indication of possible problem areas.

It doesn't take a rocket scientist to work out what removing the PDI engineer might lead too.

So BA, I know you monitor this forum closely, before you hang an engineer or pilot out to dry (excuse the pun!) just remember the management decisions back in the 1987, and all the money you saved!

I was that angry young man in 1987 telling you what a bad decision it was.

You know who you are...

[BARKINGMAD]

Seeing as "CHIRP" has been highlighting the overstretch suffered by ALL those on the flightline over the last few years, can we picture the poor hassled, distracted and under-resourced engineer who makes the original error in not securing the aircraft?

The backstop is provided by a line pilot, possibly operating under the much publicised inadequate report times, who's fought his way through the security nightmare provided at most airports and who may be conscious of the approaching ATC slot and pressured by the "on-time" fanaticism practised by management who seem to have lost the picture BIG TIME since few of them have ever practised "on the line"!

If this working environment, as portrayed in "CHIRP" but ignored by CAA SRG in their mealy-mouthed responses to such alerts, is not drastically changed in favour of MANAGING the task safely, as opposed to cutting costs at all costs, then we will continue to see such holes in the cheese lining up again and again, until the "Tombstone Imperative" kicks in, together with the litigation in retrospect.

Please let's back off the troops at line level and direct our fire at those further up the food chain who are ultimately responsible for imposing the working practices and pressures which allow errors like this to slip through!

A well publicised attempted manslaughter trial of the smooth suits responsible would send a timely and strong message to those whose profession is paring the twig down so far that it breaks, but alas by that time they have moved on to cause chaos elsewhere! :ugh:

[SLF3]

Agree with the previous poster that the key to this is the photo in the AAIB report (clearly not chosen at random) and the statement that they have photographic evidence to show the cowls were not closed. Further, the recommendation is aimed at Operators, not Airbus, suggesting the AAIB have a view as to who needs to raise their game.

If the picture is representative, all the stuff about the need to crouch or lie down to see the latches is not germane to this incident.

I am sure many on this forum will suggest this was not a particularly serious incident - to humble SLF a fractured fuel line and a fire external to the engine that could only be extinguished on the ground is to close for comfort.

[Safety Concerns]

Further, the recommendation is aimed at Operators, not Airbus, suggesting the AAIB have a view as to who needs to raise their game

Can't read anything into such a report yet far too early. I suspect however that Aviation House and Waterside will be on edge until the AAIB finish their work.

The following may be of interest to some:

G-CPER
G-YMME
G-VIIA

[JennyB]

Nice to see BALPA showing solidarity with engineering in this case:

David Reynolds, the head of safety at the British Airline Pilots Association said: “It is very unfortunate that the cowls were not locked. It is something the engineers to check.
“It is their job to make sure they are closed.
“A pilot’s role is to look out for anything obvious, but the only way in which they could have done this by lying on their back underneath the engines, which is not practical.”

[Alexander de Meerkat]

Jenny B - a voice of common sense at last. I am not sure this was easily spotted, and I have no doubt that changes to walk around procedures will be made. The fact that both engines were in the same state made it doubly difficult. I have great sympathy with the pilot who did the walk around, and I hope that the people who make the key decisions think likewise - past experience would suggest that they might not.

[Shaman]

Dave Reynolds is a former engineer so his remarks have some credence.

[Alwaysairbus]

I'm just wondering whether in BA the flight crew still carryout the pre flight or just a walkround and sign acceptance.

EU-OPS1 AND Part M clearly states what the pre flight should include. For whatever the reason, undoubted multiple human factor induced errors ensured in this case it wasn't it wasn't.

Maybe BALPA should actually consider the maintenance aspects and pressures engineers are under and provide more thoughtful statements rather than unhelpful statements that they have put out.

Still it was a miraculous landing considering it's practiced every 6 months in a sim. Maybe some more practical on the line should be included with weather thrown in.

[EGT Redline]

Agree with the previous poster that the key to this is the photo in the AAIB report (clearly not chosen at random) and the statement that they have photographic evidence to show the cowls were not closed. Further, the recommendation is aimed at Operators, not Airbus, suggesting the AAIB have a view as to who needs to raise their game.

If the picture is representative, all the stuff about the need to crouch or lie down to see the latches is not germane to this incident.

The AAIB photograph is purely representative. As a multi licensed and type rated aircraft engineer who has opened and closed the cowlings on this particular engine type more times than I care to remember, I can tell you categorically that the fan cowls can be in one of two positions when closed but unlatched.

The first instance is as shown in the AAIB photograph. This picture clearly shows the cowlings proud of the inlet cowl and thrust reverser translating cowl. There is a noticeable gap which is clearly visible when you are standing close to the engine and I find it very hard to believe that the flight crew would have missed it during their PFI that particular morning. However, if the 'hold open' device attached to the bottom of the inlet cowl at the 6 o'clock position has been depressed as the cowls are closed, they will sit flush under the weight of gravity and appear secure. There will be no visible gap and unless the crew physically stoop down and look at the underside of the engine, they will have no way of identifying the 4 latches hanging in the breeze.

There is no design fault with these cowlings. When correctly closed and latched they will not come undone. The final report will no doubt reveal a multitude of circumstances and failings that led to this incident. I'm almost certain a lack of qualified manpower and excessive workload within the engineering department will be at the top of the list.

[2dPilot]

On the face of it it seems odd that a detaching cowl can a) Sever a fuel pipe, b) damage the airframe, and, c) damage other aircraft systems (which would be?). I wonder if the primary design criteria were "the cowl will never detach" or "damage would not be expected" if it did? Remember the light-weight foam insulation on the space-suttle fuel-tanks. Detaching foam lumps were tolerated until the Challenger disaster.

On a second point, someone mentioned the safety catch system on car bonnets, in relation to belt-and-brace systems. It's worth remembering that car bonnets also have a spring on the main lock, that holds the bonnet well out-of-line with other body work making it clear at a glance if the main lock us not engaged. One would think either a spring or just gravity could be used to hold such panels open or part-open until properly locked.

[hambleoldboy]

Idle Thrust (and Blind Pew):Re Swissair 111

Wrong.

Read the TSB Canada report Refs 2.20.3. and 2.20.4

Nothing the pilots could have done would have saved the aircraft.

Slandering deceased colleagues is frankly despicable.

Ex BOAC, BAOD, Swissair

[xyzzy]

"Detaching foam lumps were tolerated until the Challenger disaster."

Columbia, not Challenger.

Space Shuttle Columbia disaster - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster)

[Rulebreaker]

Well said Jenny B we even had mr learmount on tv suggesting a re design of the nacelle cause it was a bit difficult for the pilot to complete his pre flight check!

I wonder if anyone has heard of that wonder devise called a telescopic mirror should allow the pilot to just crouch a little without getting his knees wet.

[Dengue_Dude]

Having a pin that protrudes when the cowling is LOCKED rather than devices that are flush when locked would undoubtedly help in situations like this.

2d worth.

[Bmi-fan]

So, presumably BA are liable for compensation then to anyone who was delayed last Friday?

[BARKINGMAD]

"I wonder if anyone has heard of that wonder devise called a telescopic mirror should allow the pilot to just crouch a little without getting his knees wet".

Assuming Transec or DaFT can be persuaded we won't use the stick to beat the flight crew during hijack attempt or break the glass of the mirror and cut our own throats with the shards.

Ah I forgot, we're driving the plane but can't take nose-hair tweezers longer than 2" airside, in case.........?!

Interesting to see if the average UK or O'seas airport Stasi would permit a PILOT to take such an item through the obstacle course, without causing delay, leading to rushed external checks..............:rolleyes:

[slip and turn]

So, in 2013, pilots just don't take the walk round checks seriously enough ?

I too couldn't believe the bird-strike suggestion and concluded the engine covers must have been left undone on at least the left engine, but resisted the temptation to post as I am no longer a regular and it may have been a bit presumptious of me :O But today I couldn't resist popping in to see the inevitable thread and how Pprune posters had developed it from the outset, and what the reaction was to the interim report. I then saw David Learmount answer Yes to BBC's Chris Ekin's suggestion as to who was ultimately responsible and then to proceed to dilute his answer with allusions to design flaws and other stuff ... So I am only posting because I fear lessons are not much learned yet, particularly by pilots who seem to think there are more important things to worry about and it is a design problem or an engineer problem.

The importance of walkround checks is drummed into all student PPLs and walkround inspection quizzes are still to be found at air cadet events, flying club events and airshows, right? But move on up into the commercial world and due to over-confidence and over-work the walkround so often becomes more and more of a chore it seems, and it can so easily become a subconscious going through the motions exercise - one rarely rewarded by the identification of any significant anomaly during the inspection and conversely even when inspection is inferior, rarely resulting in memorable frights through incidents like this.

Part of this tendency is perhaps due to the fantastic current day reliability of airframes and engines and yes well honed engineering procedures, and yet part is still due perhaps to a misplaced blind faith and political or marketing 'spin' in the consistent quality of the "brand" and its processes and procedures. There's a disconnect there somewhere.

These both give everyone an over-optimistic take on aviation risks generally and do nothing to help keep in mind the risks posed every day by simple human error. That's why we still have checklists, isn't it?

Every pilot's walk round check has an official checklist associated with the type does it not? How many commercial pilots do you see with a checklist in their hand outside the airframe? More often one or both hands are in pockets and the boys and girls are hardly dressed for getting down and dirty as has been said. Maybe on this type a kind of prayer mat should be standard equipment, or would that cause further delays at security?

Lessons to be learned? Simulator training obviously helped overcome the walk round failings and thank goodness for that, but now how about introducing mandatory attendance to regular walk round quizzes in the hangar ? Or is that suggestion beneath contempt ? ;)

I do however now know this much: engine cover latches on this one are beneath most things, and whilst I don't think anything can be achieved by seeing heads roll or even seeing any extra persons put on their back, I do think this incident has been a great leveler for some pilots who need revision training of a most basic kind, engineering cost managers who needed a wake up call, and all those who might otherwise equate "leading brand" with a tendency to infallibility.

... just my two-pennorth if regulars will allow :\

[Ye Olde Pilot]

Surely it is not rocket science to have a microswitch to engage when locked.
My old Range Rover tells me if my tailgate/bonnet or sunroof is not locked.

Failing that a basic check can be carried out with the mirror and stick devices used in Northern Ireland decades ago to check under vehicles.

Of course today new pilots come straight from the sim/computer game and have little or no mechanical knowledge. It's not on to have to bend down and get the
trousers dirty. That a job for the oilys:ok:

[wiggy]

Slip and turn
I'm not excusing poor walk rounds but I feel you underestimate commercial demands . Given that our every minute is a cost on somebody's budget I reckon your chances of getting the pilots in to do some walk round training or quizzes is about nil. Similarly nobody is going to produce a checklist you can walk round with - though I guess a copy of the FCOM on a IPad might do the trick.

That said we could all do with spending less time in security and more time at the aircraft, but that's one for the politicians....

[hunterboy]

Unless the pilot does the walk around at Dep-10 mins or so, then they are likely to see all sorts of ground equipment attached and engineering still crawling over the aircraft. Half the time I do the walk arounds the engineers are topping up the oils. I believe BA is one of the few airlines where the same engineer can work on both engines...I know it has been brought to mgmt attention before . Who will take the fall? Some poor overworked line engineer being ordered and timed from aircraft to aircraft, or the designer of a time management system that allows this?

[FREDA]

An engineering oversight left the cowls unsecured and we're still trying to blame this on pilot error? A flight crews skills brought the bloody thing back in one piece and the cabin crews skills got everyone out of a burning aeroplane alive.
In most incidents crew get the blame as they're usually already dead. This isn't one of those. Take it on the chin, learn from it, and stop blaming the usual scapegoats.

[steveg872]

There really isn't any need for crew to kneel or crawl on the ground to inspect the catches. Phones with cameras are now almost universal. Surely quickly holding the phone at or near ground level and a quick 'snap' up at the engine would allow easy inspection of the photo?

This has the added advantage their check would be documented!

While I'm sure it would be even better to get hands on the catches, this would be a lot better than not checking.

[slip and turn]

An engineering oversight left the cowls unsecured and we're still trying to blame this on pilot error?Not just trying to blame this on pilot error, FREDA. The pilot error was in failing to spot the unlatched covers before committing aviation ! No pilot doubts that today, do they ?
A flight crews skills brought the bloody thing back in one piece and the cabin crews skills got everyone out of a burning aeroplane alive.Yep but is the flight crew mentally still in one piece? They are surely deeply embarrassed even if it is one of the there but for the grace go I type unfortunate incidents, and of course the engineers will also be embarrassed for having handed over a loaded gun - but they didn't pull the trigger - pilots did that!

Take it on the chin, learn from it, and stop blaming the usual scapegoats.Yes, pilots should do that and I am sure most would take it on the chin. To be clear, just like David Learmount when he said Yes to BBC's Chris Ekin, Yes I ultimately blame the pilot responsible for the walk round check on this one. Since 1903 he or she has been ultimately responsible for the team effort that puts each piece of tin safely into the sky as well as gets it down again safely but especially when something that should be picked up by the Mark I eyeball during the customary walk round is missed. So in analysing what went wrong here it would be preferable, would it not, if ideas of simple prevention next time rather than skilled cure again in future were the ones that were applauded?

Let's not forget too quickly that an incomplete undisciplined (unscripted/unprompted?) walk round inspection, depending on how diligently it is done of course, may be tantamount to Russian Roulette. Now unless we put money on it, and beancounters do of course, the rest of us have never applauded the Christopher Walkens of this world for surviving Russian Roulette now have we?

Unlike David Learmount I do not think it is right to dilute my "Yes" vote with phrases like 'design fault' or 'engineer error' to the extent we have incorrectly spun headlines in tomorrow's newspapers. Those responsible for those other errors are in play but they are not ultimately accountable for this incident.

[Fargoo]

True and the crew did a great job, I'm sure the AAIB will be looking into why one of the links in the chain (crew pre-flight check) didn't spot this known problem.

I'm sure any footage that is available from the stand cameras at Heathrow will show whether this check was sufficient or needs further amendment.

I'm sure any conscientious F/O doing the pre-flight would bend down and glance at the cowls but it's clear that this isn't always enough to spot a problem.

I hope that this re-focuses attention on the problems with this cowl rather than a quick hatchet job on the individuals involved and forget about it.

[screwdriver]

"I wonder if anyone has heard of that wonder devise called a telescopic mirror should allow the pilot to just crouch a little without getting his knees wet."

That level of technology? Not in our lifetime!

[Ian W]

@1979Engineer

So BA, I know you monitor this forum closely, before you hang an engineer or pilot out to dry (excuse the pun!) just remember the management decisions back in the 1987, and all the money you saved!

I was that angry young man in 1987 telling you what a bad decision it was.

You know who you are...

Well 1979 - an accountant will do just that. 26 years the cost of employing 7 or 8 engineers (full benefits etc which is around 3 times basic salary) - vs cost of this incident. The decision to stop engineers doing PDI was correct from their purely financial point of view.

Experts here - there are several saying that this was a 'minor' event will be the ones listened to by the suited accountant.

I have had just this type of argument in the past - the only time you will win is if you tell them to take responsibility as despite their name accountants never want to be accountable

[ericferret]

Not that many years ago a colleague was called to head office to attend a disciplinary hearing in respect of a missing elevator closure panel that was spotted on a flight crew walk round.

He signed the last daily inspection the night before in the dark and failed to notice it was missing.

The panels location could be seen clearly from the ground as the green primer paint contrasted strongly with the aircrafts silver paint finish.

He listened to the charge against him then asked a simple question. Where is everybody else? He went on to point out that the aircraft had had several inspections conducted prior to his by pilots and engineers. Nobody had noticed this panel missing in a weeks flying.
The panel was found in a bucket on the tail dock in heavy maintenance.

A good question might be how many microswitches do you want given the large number of access doors and panels on a modern aircraft and how many duplicate inspections. The truth is you have to rely on human beings who are fallible.

Normally I make a point of not lowering the cowlings until I am ready to latch them.
On lowering them I latch them straight away and normally if possible have a second engineer confirm the latching.
However a leak check post a ground run on stand may well require the cowlings to be reopened.

As other posters have pointed out the pressure on line maintenance to reduce costs is immense with major airlines leading the charge. Anyone with an interest in this should get access to the information distributed by the Association of Licensed Aircraft Engineers. Many senior engineers (agewise) including myself are struggling to continue in the current climate and retirement can't come soon enough.

One thing I will guarantee is that the maintenance staff involved will be distraught and this will never be forgotten for as long as they work on aircraft.

Maybe flight crew should have access to a "prayer mat" to allow them to look under the cowling without getting their knees wet, though quite what the pax will make of the crew praying to the engine prior to flight is anybodies guess!!!!!!!!!

[Case One]

I cannot believe that people are still suggesting that you cannot check the latches without getting on your back under the pod. Nonsense, you squat down, place one hand on the ground and lean over, it's not hard, just do it. It's well worth 10 seconds per engine to save your butt - regardless of what rules your company makes. You need to lie under the pod to open or close the latches, not check them.

As for doing walk-rounds whilst the aeroplane is still being worked on, that's another issue. Personally, that's the point I have to trust the re-fuelers, engineers etc to do their jobs, I simply don't have time to go out again.

[Dan Winterland]

Airbus think you can. Here's the reference from PRO-NOR-SOP05 (Exterior Inspection).

http://i210.photobucket.com/albums/bb73/dbchippy/wac_zps90770978.png

And what's more, I can confidently state this accident wouldn't have happened if I had done the walkaround check - as I check the catches!

[Catastrophic_Failure]

I still would like to know where and how they got the all important snaps from pushback...

And why, assuming these weren't from CCTV, no one thought to bring this to someone's, anyone's, attention at the time?

[PAXboy]

This is a dumb question from a PAX.

Attach one of those long orange "Remove before flight"tags to the latch itself? It would trail on the ground and, if the a/c got to the stand, blow clearly in the wind.

[framer]

Every year the pilots get a few more tasks to complete between sign on and push back, every year it takes a fraction longer to get through security and to the aircraft, every year the pilots face gets a little more somber.
The same is true for the Engineers and the gate staff, the folk at the Operations desk and the refuellers and caterers. Every year there is slightly less time for a chat and a " how do you do" as the aircraft is signed over from Engineer to Pilot. Every year information flows less and less.
Peak human performance occurs with moderate external stress, we are beyond the apex of the curve and moving steadily down the other side. If we add another task to the duty ( " here....carry this telescoping mirror" " Sir where is your IPhone for the latch inspection? ...what do you mean you have an old Nokia?" ) without extending sign on times or allocating more staff to Engineering duties, we will push ourselves even further down the steep side of the performance/ stress curve.
The answer is sufficient numbers of well trained crew with enough time to do a professional job. Anything else is more of the same.

[CISTRS]

From London Evening Standard:
As the report reveals maintenance shortcomings at BA, lawyers may argue that the airline is liable. The total exposure to BA of compensation claims could total £10m.


That could buy a lot of flight crew walkaround overalls, inspection mirrors, screwdrivers and torches. Surely this sort of kit should be stowed on board?

[smith747]

Yes ... communication and team-work is the key. Many years ago, my copilot found a bent compressor blade on the walk-round. He told me, the Captain, and I asked for an immediate engineering assessment which led to a decision for an aircraft change.

Here is a line of communication that that is essential. It is the Captain's responsibility to initiate the correct actions from any adverse report from any information received.

This Captain, although unaware of the initial error, ensured that he brought the flight to a safe conclusion. He is to be congratulated for a job well done and saving the lives of all concerned.

Blame is an emotive word that the legal profession thrives on. All concerned must be thankful for a safe conclusion and I trust that we have all learned from this by improving procedures and inspections ... the best outcome!

Retired after 31 years

[Dan Winterland]

Quote PAXboy ''This is a dumb question from a PAX.

Attach one of those long orange "Remove before flight"tags to the latch itself? It would trail on the ground and, if the a/c got to the stand, blow clearly in the wind.''

Like this?

http://i210.photobucket.com/albums/bb73/dbchippy/pin_zps671374fd.png

Not such a dumb idea. This is the Airbus modification for IAE engines introduced last year. It's fitted to the lated A320 series and it holds the doors open slightly to make it obvious they aren't latched and the red flag dangles out of the cowling as well. Of course, it requires the engineer to engage and stow the pin the flag is attached to, but it's a major improvement

[Blondie2005]

Slip and turn: great post. I'm work in a responsible job in another sector where I have to do the equivalent of "getting my knees dirty" every single damn day. I work on the basis of assuming that other people haven't done what they are supposed to have done, and about 1% of the time I'm right. Sure, in situations like this problems often have organisational causes as much as individual ones but checks and double checks are built into systems for a reason. Complacency can quite literally be a killer.

[Phil.Capron]

Post 710 just about sorts it for me.Little bit surprised this hasn't been done already considering the number of incidents with these cowlings.There needs to be a hardware change e.g. as above.
Don't forget the outcome to this event.....Congratulations to the crew(s) for a job well done.

[Super VC-10]

Why is it that accountants think that their job is to decide how a company's money is spent. :ugh:

Surely their job is to account for all money coming in, and all money going out. How it is spent should be left to others. :ok:

[NigelOnDraft]

I work on the basis of assuming that other people haven't done what they are supposed to have done, and about 1% of the time I'm right.I would say finding snags on a walkround is probably higher than 1% - trouble is it very rarely is the Eng Cowlings.

So the walkround needs to "target" the frequently found problems (lights cracked, birdstrike, brake wear, tyres etc.) and the "high danger" points. Also, as engineers have been withdrawn / servicing less frequent, the walkround has altered from "second checking the engineer" (cowls) to an actual turnround - what has fallen off / got damaged / worn out? Bear in mid the cowl check is just one, not emphasised / highlighted line, in the checklist.

It's academic now for most A320 operators, especially BA - people will check cowls closely for a year or 2. But we must make sure we don't enhance that to the loss of something else (the brigade of lights, knee pads, mirrors miss the point the cowl is but one of many elements), and the "solution" outlasts the awareness period.

NoD

[Blondie2005]

NoD - agreed, but it seems to me as a complete outsider that there's a big list of things which need to be checked, all of which are mission critical, and so they all need to be checked, not just some of them. I take the point that is coming across loud and clear on here from industry professionals that pressure is applied by the "beancounters" to do ever more with decreasing resources and not a lot of time to do them but surely the choice is this: be safe, or be on time. Again in my own work (an entirely different field but there are some comparable aspects) I have faced equivalent situations and firmly said "no - we are doing this the right way not the quick way". Or am I wide of the mark with this comparison?

[framer]

"framer" - yes you are right we get more tasks, and with 25 minutes turn-around we learn to be more efficient, but no way will I avoid spending 20 seconds on checking this or other things that is of importance, to cut corners, simply because what we think we are saving in time, is of no insignificant.
That's great, I hope you are the pilot when I am paxing. I take a similar attitude to my duties but do you want all of your flights to be safe or all flights to be safe? You go on to say:
I have seen it with few commanders etc., where they love to play a game to see how close to the edge they can fly, perform with regards to descent, configuring to get established by 1000 ft. Sure when it works it is sweet, however one day "Murphy's law will hit them" and they will run out of options and time, as they leave themselves no margin for the unexpected!
Fortunately this is the minority, but still one incident is one to much!
That makes the point quite clearly, a system has to be tolerant of behaviours other than just the most exemplorary. The same commanders you speak of cannot be trusted to be as diligent as yourself with checking the latches etc, and they will always be there, in every company to a greater or lesser extent.
So if you are tasked with ensuring that this never happens again you have to go deeper than " it wouldn't happen if I was flying" if you wish to be successful.
The trick is know that these errors will occur, and to design systems that are tolerant of those errors. Ensuring that the accountants that run the airlines don't reduce time available to operational staff to a degree that encourages rushing is key. It is the make-up of the system itself.

[Le Pen]

This may be of interest from 2002.... Same old story :(

http://www.pprune.org/rumours-news/71919-maintenance-standards.html

LP

[BARKINGMAD]

Bending down by the # 2 engine with an active mobile phone adjacent to the refuelling operation seems designed to excite those ramp jobsworths who go apoplectic on seeing anything not conforming to their obsessions.

I also recall various airlines' ops manuals forbidding/discouraging the use of mobile phones ANYWHERE in the fuselage environment during refuelling...............

Any chance we can depart from the redesign/tools-to-overcome passion and get back to allocating to engineers and flight crew SUFFICIENT TIME to perform and complete their essential pre and post flight tasks? :=

[Heathrow Harry]

there is no risk of a mobile phone setting off an explosion - this urban myth was killed years ago by EXXON and the Institute of Petroleum but by then everyone "knew" it was dangerous and so it has lived on

[BARKINGMAD]

Thanks "Harry", I always thought there was something dodgy about that theory, but I maintain that until ALL the books have been rewritten, then "Jobsworth" will come screaming across the tarmac to vent his fury and distract us from spotting the not-so-obvious! :hmm:

[Pinkman]

Heathrow Harry: that is not so. The risk is small (actually vanishingly small) but it is there. There have been ignitions on retail forecourts. Commercially available Mobile phones are not intrinsically safe and non "Ex" devices are banned in refineries and terminal process areas.

Yes, you have to try really hard to ignite fuel in a vehicle tank (and it usually happens from static from the phone across the filler neck rather than RF into vapour) but as an ex-oil company HSE person who investigated several retail site fires I assure you the risk is always there.

UKPIA - Refining Britain's Fuels - Mobile Phones on Filling Station Forecourts (http://www.ukpia.com/industry_issues/health-and-safety/mobile-phones-on-forecourts.aspx) sums it up (the Energy Institute is the former Institute of Petroleum).

Rob (Member: Energy Institute)

[Bond'll Do]

PLS refocus here as this (after AAIB interim) is about the 'walkaround'.

As commander/PIC, I was trained aka my early trainee days by a very grey-haired chappie who took great 'glee' in 'sabotaging' certain pre-flight 'things' to see how vigilant I was.

I felt a bit like 'Inspector Clouseau' in a Peter Sellars movie sometimes....wondering what 'Cato' had been up to...

That eventually transposed in my long airline career into the following fundamentals as follows;

1) If I was taking out a directly inbound flight after turnaround with no defects, I always did the walkaround myself...irrespective of skills of my F/O man/woman...unless I could remember specifically doing a full walkaround with them (and with intensity/focus) before.

2) If I was taking out a flight that had some ground time before departure and I was in the remotest unsure about my co-pilot (as, in not having done a walkaround/preflight with me before)...I insisted that he/she do the preflight walkaround with me. I would then make my own decision and discuss after in the FD. This often was a sharing to the F/O....however...in all bias....it was feedback based and I claim a few minor but significant misses myself. Fuel leaks were missed, Hyd fluid 'misses', Landing light whole sides missing (aka bulbs smashed/inop...kinda easy to do with boarding steps sometimes hiding wing-root obscuring lights there. Any ambiguous answers to the walkaround meant me or ground engineer asked to inspect. Despite any delay incurred.
Any 'newbie' got a 'bond'...de facto walkaround.

3) Any aircraft having had maintenance overnight or longer had the engineers log/worksheets poured over by me. Perhaps sad to say but my career will show that I had various serious snags coming out of engineering /maintenance checks....that is the plain truth and in my long experience. Any a/c coming from the various degrees of maintenance for me to operate quite often did not leave on time as I would find significant 'snags' (or would be found by my known/trusted F/O).

No particular 'dissing' with engineering...rather, as I saw it engineers fix what they're told to. My job is to double-check that what it says has been done.

So Golden rule of a long no-incident/accident career was the paramount first check(s) as above.

Second backup after walkaround...I asked :[A]Is the aircraft 'flyable'Will any deferred defects stop/hinder me to where I'm flying via/to to get their safely?(WX/Airport/ATC issues etc and et al.,).

So, data calculations [B]beginfrom there with fuel and pax/cargo load.

Never ever will be any rush or time-slot factors. Company delivers us to aircraft to do our checks. Those checks save lives, full stop. They end when all has been done exactly to the book...no more...no less.

No lazy practices...no reliance on somebody you do not trust in all the human chain. As Commander/PIC...that 'trust' was only ever delegated to someone I had personally shown how to do a 'proper' walkaround/preflight external checks. After pre-flight confirmation, I asked pertinent questions to those I trusted. To make extra-sure, I often was at the a/c while the F/O was checking wx and gathering the paperwork. So, I used to do a good pre-flight before they got there and noted any discrepancies. (A bit like my early training-as above). If the F/O's walkabout (used to be F/E) didn't match mine...then we'd have a CRM chat and then go look at the issue.

example:
9 times out of 10 any discrepancy was possibly minor like 2 landing light bulbs out on one wing....however....on a NBO-LHR sector, for example, the best lighting focussed 'ON' the runway was IMPO the safest....as various 'beasts' are well known to sit (to get warmth) on the tarmac. For those that knew me on the 747-1 and 2 hundreds takeoff full loads were 'critical' on some days. Every beam of light was crucial....as any 'beasts' eyes shone back clearly. So, full takeoff lighting usually helped to see 'eye twinkles' and get the NBO runway team to go scare them off....as they were very likely to just run in any direction....incl. right 'at' an aircraft on takeoff.

I can only hope that the above is helpful to any current aviators. I haven't saved the world in my flying career....I just possibly may have added a few mins of delay (not a minute of which I regret) to make sure that the above had been completed properly....whatever it took....good weather or bad...made no difference.

The proper pre-flight cannot be circumvented and is always fun (come hail/snow/whatever) as it makes sure...as far as humanly possible...that all that is needed to get the aircraft safely airborne is in place! Get 'intimate' with your aircraft and know its faults and foibles. If in an iota of doubt....get it checked out...re-check in any hindrance of doubt.

That is what a 40-year+ flying career is all about and despite what anyone says...whatever their name badge says.....the PIC/Captain is responsible for the safe conduct of any flight. No go anywhere if you aren't satisfied. EVER!

The 'pre-flight' stage is right up until decision to take-off. Icing etc...long taxis can denigrate safe flight possibilities, too.

[ericferret]

A couple of years ago a company aircraft suffered substantial damage following a cowling being left open during a ground run. This resulted in the aircraft being off line for over a month.

The pilot who started the engine and the engineers present were held to blame. There were human factors issues involved in why the engineers did not close or notice the cowling open and it was a large cowling clearly visible as open. The pilot was sat in the cockpit and unable to see the cowling but as commander had a resposibility.

What was interesting was that the manufacturer had identified this potential hazard and a modification which involved a warning light in the cockpit had been developed.
This clearly would have indicated to the pilot that an unsafe condition existed.

I questioned why the mod had not been embodied. The answer was that the risk of spurious indications outweighed the benefit. One wonders if half a million pounds later that cost /risk analysis was still valid.

At least I was able to give copies of the modification to the staff involved which enabled them to demonstrate that the company also had to take a share of the blame.

In reality situations such as this where maintenance is ongoing are non standard and carry a higher risk than a normal operation. We all need to be vigilant and sometimes that second look around can be the saving.

I was employed on hangar maintenance with the aircraft leaving the hangar around 5 am. I made a habit of walking round the aircraft as I went out of the door on my way home after all maintenance was complete and certified. Panels found open, ground lock still fitted, empty hydraulic oil can in the wheel well, reel of locking wire in the wheel well. Worth that extra couple of minutes to save the embarrasment of the crew pointing out the above.

[FlightCosting]

Super VC-10 said
Why do accountants think it is their job to decide how money is spent.

The answer, in the case of BA, is when the lunatics started running the Asylum. The most important department became not Ops but the Treasury AKA finance or accounts. The bean counters nowadays think that if they say multitasking and cost cutting will not impinge on safety then the peasants flying and maintaining those long pointy things that the SLF pay the accountants loadsofmoney to sit in, will just abide by their rules.

When I started in the business, airlines were run by people who had been at the sharp end and could talk to crew and engineers in the same language. The guys who had cut their teeth flying by the seat of their pants in the Berlin airlift. The new breed of bean counters can just about find their assigned seats.

[BARKINGMAD]

Bond'll Do, I totally agree with such a meticulous attitude towards the inspection by flight crew.

However, I still think that in 2013 with the beancounters insisting on 25 minute T/Rs, this sort of careful preparation is being discouraged by THEM, the faceless ones who are stretching and sweating the assets so much.

Until they are hung out to dry for fostering an unsafe working environment, despite the "CHIRP" and others warnings, we are all at serious risk of similar accidents/incidents.

It might even be CHEAPER to change their operating philosophy than to expect Mr Toulouse Hi-Teq to redesign the cowlings and we all know that money talks.......................?

However, as all Corporations have been classified as psychotic in their behaviour if analysed as if they were human, I don't hold any hope that such a behaviour change will happen til more metal is bent and blood spilt.

[212man]

Heathrow Harry: that is not so. The risk is small (actually vanishingly small) but it is there. There have been ignitions on retail forecourts. Commercially available Mobile phones are not intrinsically safe and non "Ex" devices are banned in refineries and terminal process areas.

Those (real) explosions have been with PETROL - not Jet-A1 (or diesel.) Igniting ambient temperature Jet A-1 is actually very difficult, as anyone who has done the triennial fire fighting drills will know (as you will too, I assume.)

[Fargoo]

Quote PAXboy ''This is a dumb question from a PAX.

Attach one of those long orange "Remove before flight"tags to the latch itself? It would trail on the ground and, if the a/c got to the stand, blow clearly in the wind.''

Like this?

http://i210.photobucket.com/albums/bb73/dbchippy/pin_zps671374fd.png

Not such a dumb idea. This is the Airbus modification for IAE engines introduced last year. It's fitted to the lated A320 series and it holds the doors open slightly to make it obvious they aren't latched and the red flag dangles out of the cowling as well. Of course, it requires the engineer to engage and stow the pin the flag is attached to, but it's a major improvement

Do BA have this mod? I know they have the hold open device but I believe the flag and pin is a separate mod that many operators have not put on yet.

Regardless of this , it doesn't stop the cowls being left unlatched. The mechanic can still remove the pin and close the cowls without latching them.

[Filler Dent]

@ 1979Engineer
You know who you are...

I wrote this back in 2006 about a certain director leaving.
Not much has changed has it?

http://www.pprune.org/rumours-news/237556-bas-engineering-director-retires.html#post2758321

Engineering has become a byword for expense and poor performance since he became Director. Too much control has been given to the accountants that have cut the wrong costs, management whose sole intention is to bully and intimidate the workforce and a total disregard for the professional recognition of Licensed Engineers within the organisation.

The recent proposal for the "Aircraft Maintenance Supervisor" is a prime example of management who either do not care and think they are beyond the realms of the usual processes of negotiating - probably both.

As many people here will probably be familiar with the AAIB reports regarding missing bits of airplanes and the recommendations there in, one of the main shortfalls highlighted was the lack of supervision about the aircraft under maintenance. Combined with the recent events at Glasgow, where a manager "lent" his approval stamp to an unqualified Technician, there is now a sudden urgency to introduce this supervisory grade, especially since BA had told the AAIB last autumn that it had acted on these recommendations.

Firstly, BA just tells its existing LAEs (Licensed Aircraft Engineers) of which there is around 500, "we want you to all be Supervisors, and here is your new powers". Rightly so, the question was asked "where's the money?" for the new responsibilities. There is none - so the proposal stalls in a tirade of negative feedback.

It goes quiet for a few weeks when management comes up with the next proposal. This time the Supervisor grade is now deemed to be management itself. All LAEs can apply for it and anyone else who meets the criteria. Very good, BUT there is a huge sting in the tail and issues which compromise the integrity and independence of the Certifying Engineer.

The LAEs which neither wish to become management or fail in their application will have an immediate pay cut of £3000. That’s going to do wonders for morale and productivity then - especially over the summer schedule.

Most worrying of all however is the conditions of TMG (Management Grade) in relation to Certifying Engineers and the pressures which surely will be put upon them, since a proportion of their salary(bonuses and pay rises) will be performance related. Forgive me, BUT can you see a conflict of interests here? I’m sure the AAIB will be impressed by this after the next incident report.

I've seen many young, good licensed engineers, leave BA as a direct result of the companies disdain for this group of individuals. These are exactly the people BA should be retaining for the future. I fear however it isn't going to get much better, but Big Mac leaving can only be good news.

[Joetom]

Multi Eng Maint, worth a read me thinks.

AERO : Controlling Nuisance Moisture (http://www.boeing.com/commercial/aeromagazine/aero_05/m/m01/index.html)

Just click on second line down when on the link, Multi Eng Maint.

[blimey]

No lazy practices...no reliance on somebody you do not trust in all the human chain. As Commander/PIC...that 'trust' was only ever delegated to someone I had personally shown how to do a 'proper' walkaround/preflight external checks. After pre-flight confirmation, I asked pertinent questions to those I trusted. To make extra-sure, I often was at the a/c while the F/O was checking wx and gathering the paperwork. So, I used to do a good pre-flight before they got there and noted any discrepancies. (A bit like my early training-as above). If the F/O's walkabout (used to be F/E) didn't match mine...then we'd have a CRM chat and then go look at the issue.

Your CRM, did it stand for Captain's Right Mate? :rolleyes:

[vulcanised]

Wonder if anyone has considered sabotage?

[wdowell]

When though ? After the walk-about ?

[Flap 5]

Just as an observation this was the first flight of the day. Normally I have found that this would mean the Captain flying as he would like to be the first to control the aircraft on the first flight of the day. This would mean the First Officer would do the walkaround check. The Captain signs for the aircraft on the say so of the Engineer and the exterior check done by the First Officer. These are highly reliable aircraft and the F/O may well not be as vigilant as he might be first thing in the morning. Just a thought.

[BOAC]

Normally I have found that this would mean the Captain flying as he would like to be the first to control the aircraft on the first flight of the day. This would mean the First Officer would do the walkaround check. - not as I remember it - has it changed?

[Flap 5]

- not as I remember it - has it changed?

No change. Generally the Captain takes the first sector, especially if he is with a junior F/O. In fact in the distant past the Flight Engineer would do the walk around check. Unfortunately they are virtually extinct now.

[HEATHROW DIRECTOR]

<<F/O may well not be as vigilant as he might be first thing in the morning>>

Let's hope you never get taken to hospital in the early hours where you might need life-saving treatment from a doctor who has been working for 24 hours.

As someone who has worked in aviation all my life I find some points on here beyond belief. If the latches cannot be checked standing up why not provide overalls for the pilot so he could lay down?

[BOAC]

No change. Generally the Captain takes the first sector, - not what I asked!

[Flap 5]

<<F/O may well not be as vigilant as he might be first thing in the morning>>

Let's hope you never get taken to hospital in the early hours where you might need life-saving treatment from a doctor who has been working for 24 hours.



No need to get offended.

To use your analogy: A few years ago I had a hospital operation which required me to stay in hospital for nearly three weeks. It was obvious that medical cover was poorer at weekends with more junior staff than weekdays when more senior staff were on duty. In fact this problem is all over the news now.

The same applies to operating aircraft.

[Flap 5]

- not what I asked!

In that case I think you are implying that the Captain could do both the walk around and fly the first sector? The aircraft is not sitting on the tarmac just outside of flight planning. All the crew go together though security and passport control. The pilot flying has to do the cockpit checks and set up the FMGC for the sector. There really isn't time for him to the walk around as well while the F/O twiddles his thumbs.

[BOAC]

The pilot flying has to do the cockpit checks and set up the FMGC for the sector. There really isn't time for him to the walk around as well while the F/O twiddles his thumbs. An interesting view of SOPs and quite unreal in most airlines - I obviously did it all wrong for the 20+years - and I never sat there as Captain 'twiddling my thumbs' while the F/O did HIS walk-round:confused:. Are you really an ATPL/737?

Edit: Do you mean FMCG?

[fireflybob]

My experience of newer FOs is that they were far better at spotting anomalies on the walk-round that an old fogie like myself!

[dixi188]

Flap 5.

Ease up.

I'm not extinct, just redundant. :)

[OBK!]

Might be that way in flight sim flaps 5 but not in reality.

PF does walk around in BA (pilot flying...as in if the captain is flying, he also does walkaround). And the comment about captain wanting first sector is comedy.

[Airclues]

No change. Generally the Captain takes the first sector,

Flap 5

I don't believe that was what BOAC was referring to? I believe (I'm sure that he can confirm) that he was referring to who did the walkround. When I flew for BA the pilot flying the sector did the walkround.

Has this changed?

[screwdriver]

Depends on the fleet.

[BOAC]

Screw - I think what has us all ROFL 'ing is the F/O 'twiddling his thumbs' and the revelation that "The aircraft is not sitting on the tarmac just outside of flight planning." - no wonder I used to have trouble finding the damn thing.....................

Love to know which 'airline' this comes from.....

[Permafrost_ATPL]

Thoroughly enjoying Flap 5 explaining to BOAC how commercial aviation works :}

Out of sheer curiosity, what do FOs do on the ground at BA when PNF? Does the captain take care of walk-around, tech log, cockpit checks, FMS setup and pax PA? I suppose the turnaround times allow it if that's the case. I wouldn't want to include the walk-around with the 25 min turnaround at my outfit...

[BizJetJock]

Who does what is extremely variable from company to company, and country to country. For instance, there are parts of the world where the F/O is not allowed to do the external check!

[Airclues]

On the BA Airbus the flying pilot does the walkround while the non-flying pilot does the FMS (or whatever it's called nowadays) setup. As far as I'm aware, this is common to all BA fleets. Perhaps screwdriver could tell us which fleet differs?

[OBK!]

Who does what is extremely variable from company to company, and country to country. For instance, there are parts of the world where the F/O is not allowed to do the external check!

...or start the engines, or taxi, or tech log, or reject/call stop! The previous airline I worked for didn't even have tillers on the RHS.

[Permafrost_ATPL]

Airclues
On the BA Airbus the flying pilot does the walkround while the non-flying pilot does the FMS

Interesting, I suppose it's a similar philosophy to the monitored approach.