BA762 report released (cowl doors openning)

[neila83]

Tired technicians' plane mixup led to inflight engine fire, inquiry finds | UK news | The Guardian (http://www.theguardian.com/uk-news/2015/jul/13/tired-technicians-plane-mixup-engine-fire-inquiry)

Can't find a link to the report itself, doesn't appear to be on the AAIB website as yet. Anyway this doesn't make good reading for BA, maintenance, flight, or cabin crew. A tad worrying after the Transasia incident that the pilot didn't follow procedure on engine shutdown...

[Airbanda]

Looks like a leak or breach of publication embargo.

[BARKINGMAD]

I suspected the original holes in the cheese were lurking VERY high up in management, hence the delay in the final release.

There will be a ground engineer with standard qualifications viz overworked, understaffed and commercialy pressured, a similar flight crew and weal marks on their backs from the lashing.

However, the bean counters will sleep easy knowing their names, job titles and positions will never be held up the same scrutiny as the coalface workers.

I still maintain the lessons from this accident have been hidden from the Professional Aviation community, until soon if this news report is to be believed, to the detriment of Flight Safety and thereby denying other organisations from learning and initiating their own preventative measures.:ugh:

[The late XV105]

Cached pages are available via Google (http://webcache.googleusercontent.com/search?q=cache:Ib5HbQe_j-YJ:www.theguardian.com/uk-news/2015/jul/13/tired-technicians-plane-mixup-engine-fire-inquiry+&cd=2&hl=en&ct=clnk&gl=uk)

[phantom menace]

Stable door and horse. This was a real wake up call.:=

[BARKINGMAD]

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

So that's all right then, all SLF and other airlines can sleep easy in their beds because the subject airline's engineers have been (so far exclusively) told what happened and how to prevent it??

I must contact AAIB and tell them there's no need to PUBLISH the full report, as required by legislation, thereby saving lotsa money and effort, as well as sparing the blushes of the subject airline's senior management.

So that's it folks, move along, nothing to see here...........:rolleyes:

[Super VC-10]

AAIB been merged with the NTSB?

Air Accident Investigation Bureau :rolleyes:

[tubby linton]

Send an email to :[email protected] and tell them how poor the aaib website is now it has been migrated to gov.uk. Try searching for an accident report and you will find that most have been deleted.

[Airbanda]

Send an email to :[email protected] and tell them how poor the aaib website is now it has been migrated to gov.uk. Try searching for an accident report and you will find that most have been deleted.

Contact the Cabinet Office too. The migration to .gov is their doing based on advice from their web 'guru' Martha Lane Fox of Last Minute.Com fame. Obviously she knows far more about technical websites than the punters who actually use the damn thing.

[DaveReidUK]

We can take some small comfort from the fact that there are a few dozen archived snapshots of the old AAIB site from Feb 2001 to Feb 2015 here: Internet Memory | UK Government Web Archive (http://webarchive.nationalarchives.gov.uk/*/http://www.aaib.gov.uk/)

[Airclues]

From the report;

No one was injured, although the report found one passenger dropped his wheelie suitcase from the top of the emergency chute, risking injuring rescue services who had rushed to the plane.

No comment!

[blind pew]

Long line of accidents and incidents - purely luck has averted major loss of life over more than a decade.....IMHO need to get rid of the old boys club from both the airline and authority - but that will never happen.
What happened to professionalism?

[Basil]

https://assets.digital.cabinet-office.gov.uk/media/55a4bdb940f0b61562000001/AAR_1-2015_G-EUOE.pdf

[Tiennetti]

The commander informed the AAIB that, excluding simulator training, he had last flown the A320-Series aircraft using manual thrust seven years before the accident

The co-pilot informed the AAIB that, apart from simulator training, he had never flown the A320-Series aircraft using manual thrust

Still looking through the report, but I am surprised to read this... how can it be possible?

[wiggy]

Because as I understand it ;) the company involved has an SOP that if "full time" auto thrust/autothrottle is available it must be used....the rule applies to almost all types, not just Airbus. That said you can despatch with autothrottle/auto thrust inop as per the DDG and the FCOM, you're obviously (?) trained and checked on in the sim on flying with manual thrust, but you can't opt to fly manual thrust on the line simply because you want to....

IMHO and that of many others for somewhat obvious reasons it's a somewhat a flawed SOP !!!!!! and has been the subject of much heated debate elsewhere, but ultimately management and the lawyers write the Ops manual. I wonder if it will now be amended.....

And if you must know I haven't operated my type on the line using manual thrust for well over five years...........

[cessnapete]

Amazed to read these BA pilots had never flown the aircraft using manual thrust!. Presumably the large heading changes mentioned in the report due to the yaw caused by manual thrust mismanagement.
I flew the BA 744 for a number of years and the SOP was, when manual handling, the auto throttle had to be disconnected when ever the autopilot not used. ie manual handling manual thrust control
Kept us in good handling practice in suitable conditions, why the difference on other types 777 etc.?
During my time with GSS on the B744F the SOP was even better, in that we did not use the Monitored Approach and were able to hand fly the aircraft at any time in suitable conditions. Its called Airmanship, and seems sadly lacking in these automated times.

In BA a retrograde step, in view of the ever increasing accidents happening due to poor manual handling.
I'm surprised British Airways subscribe to this procedure.

[Groucho]

A "comedy" of errors?

[wiggy]

cessnapete

I flew the BA 744 for a number of years and the SOP was, when manual handling, the auto throttle had to be disconnected when ever the autopilot not used.
ie manual handling manual thrust control.
Kept us in good handling practice in suitable conditions, why the difference on other types 777 etc.?

I'd agree, it's bizarre isn't it?

With the caveat that I'm not a trainer, but I went 744 - 777 a few years back I'll offer the following (IMHO very weak) explanation that I've heard:

AFAIK the 744 SOP remains as you remember it, the argument for manual flight=manual thrust being that if you do hand fly the 744 with autothrottle in the pitch/power couple could be destablising, ( theory being if you handfly with manual thrust you are knowingly making the thrust inputs and therefore supposedly are able to anticipate any pitch changes).

OTOH with the 777 operating in normal FBW mode the pitch power couple is automatically removed...so, in theory at least in normal circumstances regardless of thrust changes the aircraft shouldn't respond in pitch, therefore..... autothrottle isn't destablising when handflying...., therefore it can be used without detriment to manual flying...which BA management decided to convert to an SOP of autothrust must be used for manual flying...(because in their eyes it offers another level of protection to the flight envelope). I have to add that the 777 (in the sim at least) is a beaut to fly fully manually, however on the line at BA it's mandatory that the autothrottle is used if available.


During my time with GSS on the B744F

I suspect given the above if BA mainline ever had the 744F and the pitch/power couple has been engineered out (has it?) the SOP would have been autothrottle on at all times.

In BA a retrograde step, in view of the ever increasing accidents happening due to poor manual handling.

I can promise you that BA line pilots have been making this point for years, sadly we don't write the BA OM.....

[Landflap]

Thought you bus-drivers could not fly man/thrust (?). Aren't those armchair pilot 'Thrust Selectors' dummy Thrust Levers ? Couple of detents on the quadrant to be hit at the same time in order to satisfy the computers and "she does it for you"..................? Now, thrust levers like in my old Boeing had to be paddled, re-checked and targeted very carefully or you could blow things like EPR, EGT etc etc..................Gosh, these clever Frenchies ; They actually have convinced you lot that YOU are FLYING the aircraft !........................Ok, crash helmet on, heading for the bunker..............incoming !

[SMT Member]

Flew with a red-nosed carrier not long ago, on a cockpit fam flight. Beautiful visual approach into a fairly long and unobstructed runway, flown manually with manual thrust from around 9000ft. Aircraft was a strange mix of modern forward panel and jurassic overhead, jumpseat quite horrible but doable for a 45 min flight.

The take-off was manual flight and auto-throttle to around 15000ft.

Would rather, as in any day of the week and twice on Sundays, fly with a crew who are free to exercise judgement, and use automatics as and when it's the best option. Flying a short sector on a clear skies day, off a fairly quiet airport and into one that's even quieter, encountering almost no other traffic either enroute or in the terminal areas, is obviously a perfect opportunity to take the bull by the horns and do a spot of driving yourself. Any operation which has SOPs written specifically to prevent that, is run by a bunch of idiots. Probably the un-holy and culture destroying trinity of Lawyers, Accountants and Consultants.

[Global_Global]

First of all I would not want whatever I would do wrong in a similar situation been analysed in the court of Pprune but there is one thing that stood out for me as probably caused by stress hormones and a good learning moment of what not to do The commander, without confirmation from the co-pilot, quickly shut down the right engine and discharged the fire extinguisher bottle. Almost a Kegworth or another AirAsia due to too quick actions. Like my favourite TRE always used to say: have a coffee first, then shut the engine down...

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

[Volume]

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

[cessnapete]

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

[student88]

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


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

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

[cessnapete]

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

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

[blind pew]

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

[J.O.]

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

[smellster]

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

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

Wow......

[BARKINGMAD]

Oh dear oh dear oh dear!

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

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

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

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

Do we never learn from previous accidents???

[cessnapete]

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

[Super VC-10]

Comment:

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

1.6.16

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

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

[Amigo South]

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

[Flying Lawyer]

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

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

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

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

[Gordomac]

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

I left.

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

I left.

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

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

[overstress]

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


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

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

[neila83]

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

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

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

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

[Smudger]

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

[J.O.]

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

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

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

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

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

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

[Pinkman]

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

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

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

[JohnFTEng]

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

[hunterboy]

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

Nope, they will continue to sweat all the assets until the next incident.

[CISTRS]

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

Don't be daft. Are you comparing a commodity Airbus product to a finely engineered microwave oven?

[Discorde]

Human beings do not operate at their best during the night and early mornings since evolutionary developments have led to a natural inclination to inactivity and mental recovery during these periods.

The report mentions undetected aircraft swap error. Many years ago a large airline operated a fleet of freighters at Heathrow. Most of the duties were scheduled for night operation. One night the three pilots of one crew (including self as a junior copilot) wandered out to the apron and started our pre-flight checks. We noticed that an adjacent aircraft was being loaded in preference to ours and grumbled whoever made these decisions needed to get their priorities right. Then the light dawned - the loaders were indeed loading the correct aircraft and we were checking the wrong one. Three sheepish pilots trudged across to the adjacent stand and started again.

It might be significant that the two worst accidents on Britain's railways (Quintinshill 1915 and Harrow 1952) occurred early in the morning after errors by operating staff (and failures to detect them by monitoring staff).

[Hansoff]

Why did the report not mention the Captain's signature on the Tech Log and the clear responsibility that is implied and enshrined in CS 25? IMHO most Captains do the first walk round of the day to help satisfy themselves that the aircraft is fit to fly, particularly after overnight engineering work. Is this not usually the case?
It seems harsh to bring the tug driver into this without bringing in the eye-witness reports of all the other aircraft taxiing out/in - some of whom may have noticed the cowls unlatched (and flapping?) state - and the ultimate responsibility of the aircraft commander.
The report looks at Human Factors but was limited to the technicians only - why?
The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity.
All the company issues mentioned on the engineering side need addressing - but also on the FC side as well. The report does not look at that. :confused:

[Hand Solo]

Is this not usually the case?

No.

some of whom may have noticed the cowls unlatched (and flapping?) state

Did any other aircraft notice the cowls unlatched or is this pure supposition on your part?

The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity.

And if the Tech Log entry had said "IDG oil replenished" would the Captain personally open the cowls and check the oil levels for himself? The Commander cannot personally check every aspect of the aircrafts airworthiness.

[Bronx]

JO

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

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


Which organization put pressure on the majority?

[NigelOnDraft]

The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity. Maybe try reading the report.

This occurred some 30+ times prior this accident. Since that accident, and despite more sticking plaster solutions by Airbus, Operators and Regulators, it has occurred another 3x.

Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.

Maybe such a comprehensive report might actually get Airbus to do something now? As noted, until this one all other occurrences have had little Safety implication.

As I read the report, I felt that if a Sim instructor had given me that series of warnings and indications, I might well have got up halfway through and walked out saying it was ridiculously busy and unrealistic :eek:

PS When I sign the Tech Log, I am not stating the aircraft is fit to fly AFAIK? I am accepting the aircraft as "offered for service".

[Mr Angry from Purley]

Amigo

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

Yes strange that they mentioned that CC1 was on day 3 etc but not the Flight Deck. That said their flying hours in the last 28 were not anywhere near high (41?) so I have to suggest it wasn't deemed relevant.
The Engineers hours were interesting however, same old issue - social, money v fatigue. Wonder if some of these strange fatiguing practices are ignored by the Pilots also to generate blocks of more time off or are we not allowed to mention this....

[Yaw String]

"On behalf of myself".. To quote many a recently heard PA,

"Captain, Sally here,,the pax seem a bit distraught, as they say they can see the inside of at least one engine"
" Bugger, seems at least one cowl is flapping around, I remember a fatal Danair incident where the stabiliser was hit by part of detached fuselage."

"MAYDAY MAYDAY MAYDAY" request vectors for immediate return and landing!"

Quoting myself back in May of 2013........

Didn't the definition of CRM change from cockpit to "Crew resource management", to address just this kind of incident..
Are we really to believe that strongly voiced passenger observations and concerns,were not successfully communicated to the pilots?..I find this highly unlikely........
In my current airline,the first question asked after the "CA1 report to the flight deck immediately please" announcement is made,is..."give me a cabin report"

[Super VC-10]

NigelonDraught said - Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.

What good reasons are there to not do maintenance of aircraft strictly by the book? :eek:

Frankly, I can't see any! :ugh:

[Groucho]

"I am not stating the aircraft is fit to fly"

Nigel - I understand you have a thing called the ANO - what does that say?

EDIT: Just found it

"that the aircraft is in every way fit for the intended flight"

Even if your airline tells you this 'responsibility' is delegated to others such as engineering, it isn't.

Bit of a dilemma for we 'responsible' people, isn't it?

[PT6Driver]

Picking up on the fact that the Captain did not receive the whole picture..

What is wrong with the SCCM taking a picture on his/her phone and showing it to the Captain?
This is an unusual situation and I am sure the cabin crew management would allow the phone to be turned on. Or maby not :ugh:

[neila83]

Maybe try reading the report.

This occurred some 30+ times prior this accident. Since that accident, and despite more sticking plaster solutions by Airbus, Operators and Regulators, it has occurred another 3x.

Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.

Maybe such a comprehensive report might actually get Airbus to do something now? As noted, until this one all other occurrences have had little Safety implication.

As I read the report, I felt that if a Sim instructor had given me that series of warnings and indications, I might well have got up halfway through and walked out saying it was ridiculously busy and unrealistic :eek:

PS When I sign the Tech Log, I am not stating the aircraft is fit to fly AFAIK? I am accepting the aircraft as "offered for service".

No finger pointing at any individuals, the numbers of holes that lined up here throughout the organisation suggest endemic problems across the board. Yes there is a design issue, but that is all the more reason everyone else has to do their job. And stop shirking responsibility.

BA maintenance is shown to be a complete shambles, god knows what else they are missing. I'd like my engineer to be as fit and fresh as my pilot, and a lot more equal in pay than currently. I'd like my pilot to follow procedure for shutting down engines, and to be able to fly a fully manual approach without someone else having to control thrust, because they've never done it before. Pilots of other reputable airlines are rightly incredulous at what went on here.

We're always told Asian airlines/AF won't admit they have a problem so won't fix it. It's beginning to look like BA are no different. So Airbus fix the cowling issue, great. Is this the only threat BA engineers and pilots have to deal with, and do you think maybe the report suggests the organisation has its own issues to address as well?

[TURIN]

What good reasons are there to not do maintenance of aircraft strictly by the book?

Frankly, I can't see any!

There aren't any 'good' reasons not to do anything by the book.



But there are still reasons it happens. Everyone knows what those reasons are.

[yotty]

If you mean carry out maintenance "strictly by the book" then you're into a situation which is pretty much unworkable, if, the company expects to get anywhere near it's dispatch reliability targets. If you would like me to check the revision status of all the manuals I'm required to work with, and to check the validity of any technical data that I normally store in my head, plus carrying out or checking for the latest risk assessments, any new health and safety legislation, any new information from the airfield operator,( I could go on ) prior to each Engineering operation I carry out, you wouldn't get an aircraft away on time ever! So how "strictly by the book" do you want me to be? :O

[Chesty Morgan]

But that's not your problem Yotty, it's the company's.

If flights start leaving late because people are doing their jobs properly all of a sudden you'll have more people to do the job.

[yotty]

Exactly Chesty, Any airline could ensure 100% reliability, it's "just" a matter of having enough Engineers, Aircraft spares, spare aircraft and crews and that would pretty much get that figure close to 100%. It's a conscious calculation by the operator to accept less performance for a lot less cost.

[Dimitrii]

If flights start leaving late because people are doing their jobs properly all of a sudden you'll have more people to do the job.

Or different people. . .

[TURIN]

If flights start leaving late because people are doing their jobs properly all of a sudden you'll have more people to do the job.

No offence, but that is a very naive statement. Airlines want 'on time every time' and anything less will not do.

[Chesty Morgan]

It's far from naive.

I know it'll never happen but if everyone did their jobs exactly by the book there would be delays and the airline would have to do something about it.

Trouble is not everybody is as bloody minded as me so here we are, under partly self induced time pressure, with bits falling off aeroplanes.

[slast]

if everyone did their jobs exactly by the book there would be delays and the airline would have to do something about it.
indeed, isn't that what is known as a "work to rule" industrial action?

[Redredrobin]

JohnFTEng asked yesterday -

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

The answer seems to be that fan cowls are not doors, but structure (according to EASA). As long as they do not break under 150% of expected flight loads (bending is acceptable), 'the theoretical probability of failure is zero and does not need to be considered further.' (Report 1.18.1, page 81).

So, as the fan cowl is not a door, it can never be ajar - as every schoolboy knows

[DaveReidUK]

The answer seems to be that fan cowls are not doors, but structureI don't see the relevance of that.

Even if they had been certificated as doors, the requirements only state that they should be designed so that unlatching during flight from the fully closed/latched/locked condition is extremely improbable.

But that's not what happened here, of course.

[cessnapete]

Ref the possible manual thrust issues in this incident.
According to a current Airbus pilot, BA requirement is 777/787/Airbus pilots to practice manual thrust management once every three years in the sim. Not approved on route flying.

[Redredrobin]

A little further on in the report (1.18.1, page 82) a definition of 'extremely improbable' is given as less than 1 in 1,000,000,000 per flight hour. This is the requirement for an aircraft 'system'. The experienced rate of fan cowl opening (Report 1.18.2, page 84) is 1 in 1.28 million flight cycles pre EASA AD F-2001-381 (hold open device) and 1 in 2.42 million after that AD. I don't know the average hours per A319/320/321 cycle but say it is about 2 hours, then the occurrence of fan cowls opening is about 200 times over the acceptable limit of a 'system' and it would be more of an issue.

In addition, if they were a system there would be a cockpit warning for unlatched cowls. However EASA reasoned that if you have a warning system you get false alarms

[neila83]

Ref the possible manual thrust issues in this incident.
According to a current Airbus pilot, BA requirement is 777/787/Airbus pilots to practice manual thrust management once every three years in the sim. Not approved on route flying.

Yes and that is slightly terrifying. At the end of the day, pilots are.needed when things go wrong with automation. If they only have to practice onnce every 3 years and never have done so in reality, how can we possibly rely on them when things go wrong? There is something deeply distrurving in the industry. I'm a Brit and i'd love BA to be the best but...

I've heard KLM and delta have started sending cadets up for acrobatics training. Seems a good idea

Virgin are apparently more flexible and allow airbus crews to use manual thrust at their discretion. It is increasingly worthwhile finding out an airlines SOPs before flying. Sad

[PAX_Britannica]

In addition, if they were a system there would be a cockpit warning for unlatched cowls. However EASA reasoned that if you have a warning system you get false alarms

Good point.
To avoid other false warnings, to facilitate keeping to schedule, and to save fuel, I'd like to suggest that TAWS/EGPWS, TCAS, and smoke detectors be removed from commercial transport aircraft.

As I've mentioned before, there is a tried and tested way of completely eliminating the risk of unlatched cowlings causing damage in flight.
Please compare the foreground and background aircraft in the image below. One of these aircraft will never suffer damage due to an improperly latched cowling.

http://www.trimotors.awiggins.com/images/Ford414Hand707atSFO.jpg

Depressing report. But maybe a useful reminder that fatigue is not only an issue for the folk in the front seats.

[DaveReidUK]

The experienced rate of fan cowl opening (Report 1.18.2, page 84) is 1 in 1.28 million flight cycles pre EASA AD F-2001-381 (hold open device) and 1 in 2.42 million after that AD. I don't know the average hours per A319/320/321 cycle but say it is about 2 hours, then the occurrence of fan cowls opening is about 200 times over the acceptable limit of a 'system' and it would be more of an issue.

Again, that's not what happened, nor is it what the AAIB said. The occurrence rates you quote are for loss in flight of cowl doors that are effectively already open, not the rate at which fully closed cowl doors open themselves in flight (which I suspect is zero).

The difference being that certification requirements can't possibly mitigate against the effects of departing with unsecured cowls any more than they could against, say, an unsecured cabin door (albeit that the latter, of course, have warning systems).

[gcal]

Porter (PD) #617 ? 06-Jul-2015 ? CYTZ - CYTS ? FlightAware (http://flightaware.com/live/flight/POE617/history/20150707/0130Z/CYTZ/CYTS)

It doesn't have to be an Airbus either..this Porter aircraft returned safely after losing a cowling according to AV Herald.

[Private jet]

I've heard KLM and delta have started sending cadets up for acrobatics training.

I think you meant aerobatics.
Acrobatics is stuff like juggling, tightrope walking and trapeze.
Although given this sorry situation it might be worth giving it a go!:sad:

[macdo]

What is annoying with airline management putting restrictions on manual thrust is that the first rule of Airbus is that if you don't like what the automatics are doing, revert to manual flight. Management see the recommendation to use Autothrust in most circumstances (which is entirely logical) but ignore the necessity to be fluent in manual thrust flying because of a perception of risk.:ugh:
The irony is, that the Airbus is very easy to fly in manual thrust/ap off, with all the protections there if you should be daft enough to cock it up.

[Heathrow Harry]

Last year at LHR I was on a 767 that had issues locking the cowling- they appeared to be trying to fix it with a hammer and swiss army knife

It did not look like a very robust or easy to use fitting TBH

[Private jet]

If you think an RB211 cowling is difficult to latch closed (and as I recall it usually wasn't) then you should have seen what the old JT9's were like! They never got left open or came open in flight though.

[GlobalNav]

JohnFTEng asked yesterday -

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

One more level of complication - well intended as it is = one or more failure modes that could affect propulsion.

[SET 18]

At the risk of starting another Boeing versus Airbus thread, I'd like to point out a pretty obvious design fault on the Airbus (though obv I stand to be corrected by engineers various)

The Airbus engines' doors just hang when unlatched. They fasten underneath and so it's very difficult to see when they're in that position.

Boeing's doors open differently and have to be fully in either position. They 'pop' semi-opened if not latched properly.

That's what I've been told anyway!

[DaveReidUK]

One more level of complication - well intended as it is = one or more failure modes that could affect propulsion.If, as the previous poster suggested, it's startup that's to be inhibited with the cowls unlocked, then you won't get as far as having any propulsion to affect.

And anyway the AAIB's recommendation isn't for that, it's for an unlatched condition warning system, not one that commands an engine to shut down.

[glorifiedtaxidriver]

let's say you run into a flock of birds, or encounter icing severe enough to give a spurious cowl open indication........

you now can't start your engine should the need arise :D

[RetiredBA/BY]

If BA flt ops management think there is a risk involved with pilots operating manual thrust, then it is they, the management who have created that risk by not allowing pilots to practice when circumstances allow. Do they not appreciate just how easy and pleasant to fly these modern aeroplanes are, and that hand flying is both enjoyable and professionally rewarding.

Perhaps they should ponder how we coped on VC10s, 707s and 737-200 etc, etc., with NO autothrottle, (or a Canberra with not even an autopilot !!) we just got on with it and flew the damned things, and on the 75/76 when hand flying we were required to disconnect the AT !!.

...........and am I to believe that BA allows dispatch with u/s autothrust yet the pilots may not have flown with manual thrust lever operation for 3 years, as CessnaPete reports ??

Worrying.

[wiggy]

...........am I to believe that BA allows dispatch with u/s autothrust yet the pilots may not have flown with manual thrust lever operation for 3 years ??


You are correct in your belief.


I will add that in the days when there was a usable in house BA intranet forum this whole topic was often the subject of lively debate (usually led by our Airbus colleagues). Management were consistent in voicing their belief that the current policy was a "good thing" :oh: :oh:

[Juan Tugoh]

Prior to the arrival of the A321, the use of manual thrust lever use on the Airbus Fleet was encouraged, when appropriate. There was a concern that with the longer body of the A321 a low speed event on approach would lead to a higher chance of a tail scrape on landing - a view borne out by the history of tail scrapes on the A321 of other operators. There was a heated debate with most of the trainers and line crew on one side and a few key managers on the other as to the future and how to should proceed with the introduction of the A321. The managers, with the typical "I've made my mind up now I will pretend to consult experts" approach decided they knew best, ignored all advice and went ahead with the ban on the use of A/T on the bus fleet.


A few years later the official line had changed and the management could now "prove" it was safer as they had had significantly fewer low speed events across the bus fleet since the introduction of this policy. It could be proven statistically. A poor argument at best as the stats will also conclusively prove that if you never fly there are zero low speed events and that is much safer. What the managers have actually done is mis-employ a little bit of NUTA; they noticed a problem, they understood the problem may lead to an increased likelihood of a tail scrape and they thought ahead and put in place a way to avoid the problem. All the time failing to understand that the use of manual thrust is not an inherently dangerous practice, but deliberately deskilling your pilot work force is.

Put another way, the managers identified a potential weakness in the skill set of their pilots and then decided to train IN that weakness. To deliberately re-enforce the potential failure, to strengthen the likelihood, following a failure of the system of a dangerously low speed event. A sim requirement for triennial currency? No substitute for daily competence. Surely by this flawed logic pilots should be banned from any form of manual flying.

[DaveReidUK]

If you think an RB211 cowling is difficult to latch closed (and as I recall it usually wasn't)

That post about issues locking a 767 cowl at LHR might well have been about a GE-powered (AA, AC, DL, J2, UN, UA) or PW-powered (AC, AM, DL, LY, UA) example.

[wiggy]

Juan

Thanks for the info.

FWIW if I recall the last missive on this from the Boeing side of the operation correctly the logic was, to paraphrase, that using A/T allowed us mere mortals to fly to touchdown more accurately, which led to fewer "long"/hot landings and therefore reduced achieved touchdown dispersion, all this being a good thing since it supposedly reduces the chance of a runway excursion.

As you say the consequences of de-skilling the workforce seem to have been ignored.

...I wonder what the chances are of this policy being "revisited" :yuk: in the light of this recent report?

[ASRAAM]

Wiggy,
The problem is that now the workforce have been well and truly deskilled any relaxation that allowed manual thrust handling would lead to an increase in the number of 'events', thus "proving" the management were correct all along!

I can almost see the logic of the original decision were it not for the fact that a U/S auto thrust remains a dispatchable snag

[wiggy]

ASRAAM

You're right..I suspect in the interests of not turning the supertanker around and/or causing red faces in the office the best we'll see is an increase in manual handling in the sim.

I suspect the lawyers are quite happy as long as we cover everything in the safety plan ("wagon wheel") in every brief, because then we're bound to have a safe flight - right :confused:

[offa]

The thread seems to be drifting away from the problem in discussing autoflight and tired flight engineers.
Being tired is fairly normal for many professions working long and difficult hours. You learn to live with it and recognise when you are vulnerable. Being fatigued is a different matter for discussion between pilot groups, management and authority. Too often we wave the tired / fatigue flag as soon as we make a mistake.
Standard procedures are your friend when you are tired and need to be adhered to even more vigorously. If the captain had ascertained that his aircraft really was safe to fly before scribbling his signature on the tech log and if the F/O had properly supported his captain by performing a proper pre-flight inspection then none of this would have happened.
Highly unprofessional.

[Centaurus]

BA requirement is 777/787/Airbus pilots to practice manual thrust management once every three years in the sim

Fat lot of good that will do in terms of currency. Like practicing a manually flown raw data visual approach once every three years and hey presto you are current and competent..

[cwatters]

In the shipping world it took a major disaster before they really sorted the doors open problem..

https://en.wikipedia.org/wiki/MS_Herald_of_Free_Enterprise

[wiggy]

If the captain had ascertained that his aircraft really was safe to fly before scribbling his signature on the tech log....

OK we're back to this one. I'm aware of the ANO so no verbatim quotes please, but may I ask the fellow captains here the following question? If you arrive at the aircraft, delegate the walkround, check that everything required has been signed off as complete by the engineers (for example but not exclusively Daily Inspections, Transit checks, ETOPS checks,) and have also satisfied yourself that the loaded fuel, oils etc, are sufficient for the flight then how much further into the maintenance process do you fellow professionals routinely "drill" down before accepting the aircraft ....err sorry, scribbling your name in the tech log?

[Hansoff]

I quote 'The formal pre-flight acceptance in the Aircraft Technical Log by the designated aircraft commander that both the aircraft and the Aircraft Technical Log have been inspected and found to be, respectively, fit for flight and in order.' from Captain's Aircraft Acceptance - SKYbrary Aviation Safety (http://www.skybrary.aero/index.php/Captain%27s_Aircraft_Acceptance).
As Groucho found these words are not written lightly. At the end of this definition are the words ' It is evident from the above that the first flight of the day and/or the first flight to be undertaken by a new aircraft commander are likely to require more activity prior to the acceptance signature.'.
That seems reasonable to me.
Wiggy's concern about the level of detailed inspection carried out before signing is belittling the role of the commander. Responsibility is about being sure, and not complacent. You do not depart before checking that the departure and route information is correctly entered and set up, for example, even though the company has provided the aircraft with that information. Why? Because mistakes can be made. On first issue or amendment of routing data, a new route, a new destination you will be particularly careful. Over the years how many static ports have been found to have masking tape over them during a walk-round? A walk round is a means of reasonably ascertaining that the aircraft is fit to do what is intended, opening and shutting some hatches may well be part of that task. If it all looks good, based on your experience and knowledge of the type, and knowledge of aviation and what can go wrong, then as a commander you have reasonably ascertained that the aircraft is fit ...etc. First flight, especially after someone has interfered with the aircraft's documented airworthiness, is a time to be especially vigilant. A walk round in these conditions, by the person with final responsibility to make sure that the holes are not lined up, may not be something to be done by others without that experience.

[GlobalNav]

@DavidReidUK

I think the AAIB recommendation has merit.

The notion of a Start-up lockout could work, but my point is that it further complicates the engine system, leaving an opening for unintended consequences, perhaps imperfect statement of requirements and all that. If done perfectly, of course, it's fine. But if we proliferate "fixes" like this we can add all sorts of new failure modes, and the eventual need to "fix" those too.

Just my philosophy, your mileage may vary.

[Nige321]

Surely the simple answer is a latch which can only be opened or locked with a tool that has 6' of 'COWL IS UNLATCHED' red tape on it, and can only be removed if the cowl is locked??

Let's call it a 'key'...

Even my automatic car has an interlock on the ignition key, it won't come out the lock unless the handbrake is on and the gear selector in 'Park'...:ugh:

[wiggy]

Wiggy's concern about the level of detailed inspection carried out before signing is belittling the role of the commander.

I'm not quite sure why you choose to read my question that way, or why you seem to think I'm against the idea of an external check but so be it...

[Hansoff]

Yours was a valid question and I am interested in the responses. However, it seemed to me that you were almost advocating signing for the aircraft as long as everyone else has done what they signed for....
Also, you say that you are happy to arrive at the aircraft and delegate the walk round - and that is what concerns me with the actions taken in this case and the AAIB report. Do BA (or other operator's) Captains routinely delegate first flight walk rounds? Why? The AAIB report did not consider the pros and cons of those actions (preferring to concentrate on shortcomings in engineering management, which do need addressing) - I think they should have. My opinion - I am interested in what others think about it.

[flite idol]

The First Officer is as qualified as me to an external inspection of the ship. In some respects more so as he does more of them than me. When I was an FO I had a few skippers shadow me on walk arounds mumbling about how an FO got them in trouble by missing something 10 years ago blah blah blah. I understand that the Captain signs the log and its legal ramifications but we also have a reasonable expectation that others employed by the airline, either directly or by contract to perform their duties are trained a qualified to do so. So where do we draw the line? If I inspected everyone else's tasks to my total and verifiable satisfaction the jet would never move. When dispatched under a DDG, I read the specific deferral, confirm it is the appropriate deferral for the issue ( caught a few of them over the years) and if FD CB's should be pulled and collared the I verify they were done. I don't climb into the E and E compartment or open the APU cowl to inspect engineering tasks performed there. RESONABLE EXPECTATION.

[JW411]

Interestingly enough, I flew for my last company for 19 very successful years. The SOP was that the captain ALWAYS did the external and there was many a night that I froze my balls off doing walk rounds whilst the F/O was nicely tucked up in a warm cockpit.

Funnily enough, for the previous 25 years I had had the benefit of a stalwart flight engineer who normally looked after this inspection for me but now that he wasn't there any more, it seemed reasonable to adopt this responsibility and to do it myself. Most of the time I found very little wrong but on occasion, I found cowlings not done up properly.

Certainly, if I had been flying an aircraft that already had 34 reported occasions of getting airborne with unlocked cowlings then I can absolutely assure you that this item would have been very high in my hit list - EVEN IF IT MEANT GETTING MY KNEES WET IN THE PROCESS.

This whole episode smacks of complacency.

Who comes out of it well?

I simply cannot believe that pilots on a multi-crew flight deck are still shutting engines down without involving the other pilot. It is simply incredible.

As to not having been allowed to use manual thrust for years and years. That is a fantastic concept to me.

The whole thing was a bloody shambles.

They were very lucky.

From an operational point of view they managed to close both runways at Heathrow and that must have impressed the rest of the aviation world who were trying to land at the time including their own brethern.

In fact, it makes me wonder about the BA habit of "committing" to Heathrow on the basis that it has two runways when one of their own tribe can shut the whole place down in minutes.

Am I alone or can someone out there tell me that they actually did well?

[Hansoff]

JW - you aren't alone!
As for the fact that the FO knows most about the walk round because s/he does more of them - that is worrying. But so is shadowing FOs (or engineers, or cabin crew), except when brand new and under training, or suspicious.

[cessnapete]

It does seem incredible that in spite of the spate of accidents worldwide caused by pilot mishandling, that BA Training Management promote this practice of de-skilling their pilots.
It seems the only pilots in BA allowed to maintain their manual flying practice en route, where it matters, are on the B744.

[ASRAAM]

Ok, for those of you who think the Capt should ALWAYS do the walk round, here's a question.

The jetty has been the removed and you are about to push back when the purser tells you the toilet tank is full. You contact the handlers on the radio to arrange for it to be emptied.
When the task has been completed do you ask for the jetty to be re-attached so you can go down and personally make sure the flap has been closed or do you take it on trust even though no signatures are involved.
As many have said, you have to trust the rest of the operation to achieve its tasks. I do find it interesting though that there are those here who were prepared to trust a Flight Engineer to do the walk round but not the First Officer

[ASRAAM]

The point I am attempting to make is that it is not possible or realistic for the Captain to check all work carried out on the aircraft. It is also reasonable to delegate jobs to the F/O, especially since the F/O holds a P1 rating on the aircraft. I used the toilet servicing as a practical and reasonable example, it could have been all manner of other tasks

[Hansoff]

ASRAAM, noone expects the Captain to be single pilot on a multi-crew aircraft. Delegation is part of the Captain's remit - when safe. Arguably there are times, like first flight, flight after maintenance (in this case BOTH of these), or even inexperienced FO when it could be prudent and responsible for the Captain to ensure that he does the walk round. Experience levels may even be similar but ultimately the Captain carries the can, not the FO. If the Captain does not have the combination of knowledge, experience and ability s/he should not be signing for the aircraft. Blaming engineers, engineering, management or FOs is passing the buck and not what the Captain is paid for.
However, you are right - the deicing process is one example where there are opportunities for aircraft to attempt to get airborne without the crew, let alone the Captain, being able to verify, if they wanted to, that what is supposed to have been done has in fact been done.
Another post mentions contractors - this is relevant to deicing. A contractor owes allegiance to a different company and will be under different pressures. The contractor does not fly on the aircraft .....
There are many opportunities for serious problems that are only fully recognised after serious incidents - my argument is that it is the Captain who can and should do his best to stop the holes lining up as s/he is the last link. Delegation may be the way to do this - but surely not when on the ground, with no emergencies unfolding, with no alarms going off...

[Denti]

Working currently for a non british oneworld airline it is clearly defined in the SOPs who does the walkaround. It is the duty of the PM of the sector to do the exterior inspection and he signs for that in the tech log, even if it is the FO. However, it is a signature only for the exterior inspection, the captain has to sign the tech log in any case as well.

The FO is as qualified to do the walkaround as is the captain, but i guess that is mainly a training thing, some airlines chose to train their FOs, some don't.

[Lordflasheart]

Interesting story - both on the ground and in the air.

Did anyone get 'disciplined' in any way, for any aspect of this (mis)adventure ?

[Chu Chu]

I don't suppose anything would have stopped the captain from saying to the FO "The aircraft is fresh out of maintenance, so be sure to get a good look at the cowl doors."

[gcal]

Or even...dip the tanks as the aircraft has just come out of maintenance.
I was on a BA flight not that long ago and the captain explained exactly what they were doing.
BA to my mind still has that level of communication with the pax.

[JW411]

ASRAAM:

I suspect that you are a First Officer?

Nowhere did I ever suggest that F/Os were not to be trusted with doing the pre-flight walkaround. If you read my original post it quite clearly states that the Company SOP stated that the Captain carried out this duty. As I said, there was many a dark and stormy night when I would cheerfully have stayed in the warmth of the cockpit.

I also suspect that you are too young to have flown with a Flight Engineer?

You express surprise that I would trust a Flight Engineer to carry out the pre flight inspection. Please understand that this very important task was always done by the Flight Engineer for that was one of the many reasons that he was there. You need to realise that the Flight Engineer sat about two feet behind the two horses arses in front and he got to the scene of the accident about 1 nanosecond after they did. Therefore, he had a great interest in protecting his own future. We trusted them to do their job and I was never ever let down.

Finally, I was quite interested in your statement that checking the bog flap would involve re-connecting the jetway. It is highly unlikely that any of us would even consider doing this but my worry is that you would consider having to re-connect a jetway a problem. Are you worried about what the management might say?

As someone who flew successfully for 50 years or so without breaking anything, do not ever let the fact that you have asked for a jetway to be re-connected affect your decision. If you consider that safety is involved, go for it every time. You would be amazed at how quickly the so-called management melts into the background when you go into print!

[Managed Descent]

JW 411. I am a retired FE and in a former life the captain did a walk around as well. That was 3 inspections on a turnaround or preflight. On only a couple of occasions the captain discovered something I had missed. That is why we did proper inspections. Sure, I was embarrassed but we looked after each other and worked as a team. It is very easy to be distracted and miss something. They must be really talented these young fellows to be able to do it all in 25 minutes.

[Brakes...beer]

JW411

I suspect you are retired. Whatever your particular company SOP specified, nowadays, every walkround is conducted by the PF. For the captain to double-check it would be ludicrous. The bottom line is the bloke/lady missed something, as we all do. He will spend the rest of his life kicking himself for that, but he will be a better pilot for it. If you are retired you will have the satisfaction of saying, "I would never have done that," but the rest of us will think, "I could make any mistake like that tomorrow."

[framer]

I suspect you are retired. Whatever your particular company SOP specified, nowadays, every walkround is conducted by the PF. that must be an Airline specific SOP. If I want to do the walk around then I will, regardless of who will be PF.

[Groucho]

framer - I believe from previous posts that b...b is with BA and has limited exposure to the airline world. I know from chats with BA guys down route that that indeed is their SOP, based on the F/O being 'P1 qualified' by BA during training.

As you say, his comment is only BA specific and there is no general airline-wide 'SOP' for the conduct of walk-rounds.

For me, I interpret 'the rules' to be that I have to be 'confident' that my F/O is capable of correctly conducting a walk-round and that is the basis on which I sign the tech log as 'fit for flight' in that respect. If I had doubts, I would do it, yes, rain or no rain.....

[FullWings]

Our SOPs are for the guy whose sector it is to do the walk round when two-crew and for one of the heavies to do it when there are extra bods available. This can be varied according to personal preference but most people do it this way.

Unless we’ve landed somewhere off-schedule, we always have engineering cover, so I use the walk round to concentrate on the stuff that’s most likely to cause trouble, e.g. is the gear pinned down? Tyres and brakes. Engines. Puddles of fluid underneath. Has someone made a dent/hole and not owned up to it? That kind of thing. Does it “look right” or are you getting a nagging feeling?

Most carriers run to a schedule which leaves only a certain amount of time for pre-fight preparation. You could spend a disproportionate amount of that peering into nooks and crannies and be none the wiser, then have to cut corners elsewhere. There has to be a balance. You’re not doing a D-check...

It does surprise me that there aren’t proximity sensors fitted to engine cowlings, considering the risk involved. Most of the other doors and hatches do have them but the consequences of going flying with them not quite right are often minimal.

[Basil]

Managed Descent,
I am a retired FE and in a former life the captain did a walk around as well.
CX perchance?

[ASRAAM]

JW
I suspect that you are a First Officer?

No.

I am also fully aware of the role of the Flight Engineer. As you say it was his job to do the walk round. Just as it is now the job ( for the majority of airlines I suspect) for the pilots to take turns to complete the walk round.

The days of the co-pilot being told to sit there, shut up and only touch the controls if I tell you to are long gone.

The point I had been attempting to make,and which I suspect you are being deliberately obtuse about is that there are many tasks around the dispatch and minor maintenance of aircraft that we TRUST other individuals to complete.

Unfortunately, in this case the individual missed something. That is no reason to suggest First Officers should never do the walk round. You might as well say the engineers missed something, don't let them fix aircraft!

The fact is that in this event a significant number of mistakes were made by various people.

Despite the recommendation of the investigation Airbus seem likely to wriggle out of fitting any warning system that gives cockpit notification of unlatched cowl flaps.

I'm willing to bet that there will be further human failings and that it will happen again.

Finally I wonder if it was the Capt or First Officer who completed the walk round the other 36 times this problem occurred?

[DaveReidUK]

Interesting to note that the cowl door hold-open device (which was engaged) failed in its stated purpose ("to make it more obvious that the fan cowl doors are unlatched").

The AAIB seem in two minds about the effectiveness of said device:

"This accident, and numerous other fan cowl door loss events on A320 family aircraft, show that the gap is not sufficiently obvious to be detected reliably. The gap is obvious when pointed out, but not so in the absence of prior knowledge."

"[The co-pilot] stated that he was unaware of the fact that there is a visible gap between the fan cowl door and the nacelle when the fan cowl doors are unlatched and held open by the hold-open device. He stated, in hindsight, that if he had known this, he would have stood quarter-on to the engine to look at the fan cowl door shut lines and it would have been obvious to him on his external walk-around that the fan cowl doors were unlatched. However, he believed that this information had never been highlighted to him previously."

[Groucho]

If, as 'Nigel' posted, there were "30+" incidents of unlocked cowlings on Airbus, it seems that BA (and a significant number of the previous operators) failed remarkably to take the necessary steps to warn their staff.

As someone else had posted, it would seem that 'first flight' walk-rounds specifically SHOULD call for a thorough check of cowlings - or did the F/O fail to do what was called for?

How many events does it take?

[Managed Descent]

Yes Basil and a very good idea it was. The chances of the Swiss cheese holes are considerably improved with more than one look. I have boarded aircraft in modern times where nobody did any external inspection. Reputable carriers as well. Flew in, it will fly out.

[MrSnuggles]

I know this is an unrealistic scenario, because of the Money and Savings attitude that rules everything.

However, knowing that humans detect change and movement very well, if I was the manager of an airline I would try and make it so one person makes a brief walkaround before entering the airplane and then another more thorough walkaround when it is appropriate before starting to taxi.

In my imaginary airline there would also be a Flight Engineer, btw.

[Uplinker]

In my first airline - which operated four different types of aircraft - every time we did a new type rating; at some point during the ground-school the instructor would take us to the hangar or the ramp and deploy the flaps and open all the maintenance doors etc. and show us around the aircraft, pointing out all the parts of the aircraft we had been studying and what to look for on a walk around.

In my second airline, (which flies Airbus FBW), this was NEVER done, and continues NOT to be done, despite my pointing it out. They just rely on the written explanation in the manuals as to what to look for on a walk around. No pictures or diagrams mind you - just the written word. After this BA incident, we had a flurry of aircrew notices with - wonder of wonders - a photograph of the cowl locks !! Hallelujah !

Amazing. Have they all forgotten the Potomac river crash, where a walk around was not done because the pilots didn't want to get cold in the snow, (poor lambs) so they didn't know that their P1 probes were blocked with snow, which resulted in too little power from the engines on take-off and the subsequent horrific crash into the ice covered Potomac river?

It is a very simple matter when looking at an Airbus engine, to crouch down, put one hand on the ground to look underneath at the cowl locks. Yes, if it is raining, you will get a wet, and possibly cold hand, but is that really such a problem in the grand scheme of things?

I had to wave at and stop a Cessna 172 taxying at an airfield many years ago - it was taxying with the wing tie down weights STILL TIED TO THE WINGS AND DRAGGING ALONG THE GROUND. I kid you not.

Walk arounds are important folks. Once airborne, you can't pull into a layby and get out to sort the problem.



PS: Airbus state that PM does the walkaround.

[glorifiedtaxidriver]

Uplinker (sorry for thread drift)

you may wish to read the NTSB report before being un necessarily disrespectful to the crew of this aircraft who paid the price for their error.

1. The aircraft was de iced

2. The aircraft had a prolonged taxi in precipitation before takeoff allowing a build up of contamination

3. The crew were well aware of the contamination hazard (they held during taxi, close behind a DC9 hoping the jet efflux would prevent further build up of contamination)

4. In all probability(according to the NTSB) the Pt2 probes were contaminated by the jet exhaust from the DC9 in front, blowing surface contaminant into the B737 nacelles.

5. The crew omitted to select the engine anti-ice to "on" after starting the engines.

6. The captain failed to reject the takeoff despite the FO's concern over the engine indications.

they made several errors mainly due to inexperience of winter ops, but the walkround was irrelevant as the contamination occurred after engine start.

[woptb]

There have been a number of accidents where the AAIB has highlighted engineer fatigue as a contributing factor.
The AAIB report into the 2010 Olympic DHC8, which suffered engine oil loss, necessitating a shutdown and precautionary diversion (this following a maintenance input at FlyBe). The report highlighted fatigue amongst maintenance staff. One engineer had worked an average of 15.7 hrs a day over a ten day period!!
In 2011 they (the AAIB) recommended that EASA expand guidance/advisory material in EASA Part 145 regulation, “on how approved maintenance organisations should manage and monitor the risk of maintenance engineer fatigue as part of their requirement to take human performance limitations into account.”
Pretty weak & the EASA response, even weaker! The elephant in the room is that ‘effectively’ maintenance engineer’s hours are uncontrolled. The reason is cost, EASA don’t have the balls to grasp the nettle of regulating engineer duty hours/fatigue.

[TURIN]

For what its worth my particular area of BA is taking duty hours very seriously. In fact O/T is not being worked as a result of a very careful attitude by the man in charge.

I cannot speak of other areas of BA or other airlines.

:ok:

[Helen49]

I have often sat in terminal buildings watching pilots do the walk round inspection and often thought it a complete waste of time. Heads down, avoiding the rain or looking at other things. Seemed it was just a case of being able to tick the box rather than a proper inspection. Once timed a skipper inspecting a 737, 45 seconds from start to finish. Seemed far too quick to detect problems.

Familiarity and contempt come to mind. I am not intending to be particularly critical; I have seen the same attitude to the inspection regime in many areas of aviation. Very easy to see what we expect to see rather than what is actually in front of us. I suggest that thorough inspections in most areas of life demand more attention than we give them.

[Krystal n chips]

" The elephant in the room is that ‘effectively’ maintenance engineer’s hours are uncontrolled. The reason is cost, EASA don’t have the balls to grasp the nettle of regulating engineer duty hours/fatigue " .

The issue of engineers working hours / fatigue is not entirely due to the points you raise, albeit I totally agree they have a distinct relevance.

Ground engineers are their own worst enemy, and always have been, in respect of working hours given the lure of, and for some, essential, overtime payments. I met many who would do as much as they could irrespective of the hours involved.

This also suits management as it's clearly considerably more cost effective to pay for overtime when required, rather than employ more engineers on a full time basis.

The issue of the walk round however is one that should be of greater concern.

We have all seen, and please, don't say it never happened, the fabled "aircrew walk round" as in " x wings / x wheels / x engines....all there, done" at some point. That's not a criticism by the way.

Ground engineers can be just as fallible at times.

Interesting though the read the comments on here as to whom the task is delegated to and, from a different era, the role of the F/E.

Certainly, from personal experience, with Qantas / SAA it was invariably the F/E who would also insist on seeing the evidence of a water drain check for example, and certainly, on one "well known Middle East airline", the F/E always did the walk round along with a G/E, such as myself.

That's not a wallow in nostalgia, but frankly, the more trained eyes that do an external inspection, the better.

[woptb]

Agree with much of what you have to say,but essentially the lack of an effective walkround was a contributing factor rather than root cause.

Improvements in barrier defences help,but unless the roots of the issue are 'fixed' it will reoccurr and another aircraft will get airborne with an insecure fan cowl. Relying on human behaviour,in the case of the engineers & flight crew,is weak,the problem needs to be 'engineered out',as has already been aluded to.

The issue of engineers fatigue is a long standing one and i agree ,engineers can make a rod for their own back,by being OT grabbers! Unless their hours are regulated, in many companies they will continue to work excessive hours.

SMS for 145 maintenenace organisations may have an impact (if it is ever implemented) on FRM,but unless implicitly regulated fatigue will continue to have a major impact.

[flydive1]

Once timed a skipper inspecting a 737, 45 seconds from start to finish. Seemed far too quick to detect problems.

Was it "first flight of the day", first flight of his rotation, a turn around?

[fatboy slim]

Disagree I'm afraid.

When I heard about this issue several years ago I ALWAYS got down one one knee to check on both engines on every walk round whatever the weather. I also asked my colleagues if they had checked when they got back in, and sometimes they would go back out to confirm. This is an avoidable mistake. Don't assume, don't rely on anyone else etc. etc.

[Tinribs]

I understand Heln49's perspective on the walkround but she might not be grasping the many functions being attempted
On a walkround we are checking the aircraft of course but also what progress is being made with baggage loading. where are empty carts being left. has the fuel truck gone or is it waiting for another job. is catering complete and is surplus engineering equipment from another aircraft being left behind mine. Is the area I am about to push back into safe for the aircraft and the tires. is there a big queue at the marshalling point is the normal route for take off available or is there a mix up with other aircraft or a a stuck one. on pushback can I safely start engines.how far is it to the grass behind me.

So if the pilot looks to be gazing about there is good reason

[Mac the Knife]

If I were to design a new big widebody I'd bring back the F/E.

Screw the bean-counters and screw my extra $20 or $50.

I'd feel a lot easier and so would everybody (including maybe the insurance companies).

And I bet it would cost less than a Robot for a Pilot.

Mac

:\

[boeing_eng]

Engineers have always been their own worst enemy's when it comes to working hours and O/T...

Most have opted out of the European working time directive to allow virtually unlimited O/T in some cases. As previously mentioned, this totally suits employers who can run operations with a reduced number of engineers. This often puts pressure on engineers working normal rosters when for whatever reason there are not sufficient volunteers for O/T. The token measures that are currently in place regarding fatigue are really only aimed at working long continuous periods in the case of AOG's etc (and even these are based on self-assessments!)

Although this incident should be a big wake up call, nothing will seriously change! HF courses will naturally pay lip service to this report (just like the 1-11 windscreen incident before) However, I don't expect to see any serious attempt to regulate the hours of certifying engineers before I retire!:=

[M.Mouse]

If I were to design a new big widebody I'd bring back the F/E.

In the early 1990s I positioned somewhere in Australia on an Australian Airlines B767. I visited the flight deck to say hello as a fellow pilot and was surprised to find three crew!

The aircraft had been modified to accomodate him with part of the overhead panel relocated to an engineer's panel on the right of the flight deck and also a small screen of some kind (I forget what it was precisely). I stayed for landing and apart from reading the checklists he did little else.

To design an aeroplane for a flight engineer and make it meaningful would be to reduce automatic monitoring and switching, effectively creating work where previously there was none.

I have little doubt in the cowling incident a flight engineer would probably have picked up the omission but I do not think this (preventable) incident warrants bringing back the flight engineer.

[boeing_eng]

The first batch of Ansett 767-200's were operated for a period after delivery with an F/E (more like an observer!) due to Union pressure but eventually reverted to two crew . I also agree an F/E is not something relevant to preventing this accident....

[PAXboy]

So, let me get this right, a Citroen or Renault hatch back has a catch on the bonnet lid so that - if it is not correctly locked closed - it will be obvious to even a layman passing by that the bonnet is open. But the Airbus does not have this?

[M.Mouse]

So, let me get this right, a Citroen or Renault hatch back has a catch on the bonnet lid so that - if it is not correctly locked closed - it will be obvious to even a layman passing by that the bonnet is open. But the Airbus does not have this?

A brilliant piece of deduction.

[gcal]

@PAXboy

Not always:

Clio bonnet catch failure again - PistonHeads (http://www.pistonheads.com/gassing/topic.asp?t=1136342)

Latches/doors and any flappy bits are a perennial problem on any sort of transport.

[Hansoff]

TINRIBS - sorry, but I think Helen49, and everyone else here has a good grasp of what is required. And, while interesting, most of what you are looking at when you are walking round will have changed by the time the doors are closed - so not very useful, IMHO. Information for the management of time but not for safety. The airport authorities have spent a great deal of time and money making sure your stand is suitable for your aircraft and the operations that go on around it. But, no harm in being aware as longs as it does not detract from the purpose of the walkround - making sure the aircraft is fit to go flying.

It would seem there is a consensus that the walkround is very important and that the most responsible manager around, the Captain, who signs a document to say that all is ship-shape can delegate happily as the other crew member is fully qualified and that we trust each other. We do, but the responsible manager is most aware of where the holes are (and one of these is as a result of overstretched engineering), or should always try to be, and must not forget that fact, particularly when there is a risk of holes lining up.

So, regardless of who the SOP says should do the walkround it might be prudent that the Captain do the walkround on the first flight of the day, of the duty, after any engineering work or even just when s/he feels like it. Not double-checking but exercising the right to deviate from SOP when needed. Feelings in bones are important too, which is one way humans score over robots.

And also, complacency needs to be confronted continuously. The 'office' is not an office - but can get so familiar and so warm, with superb views, that after many years it is understandable that this term is used.

The AAIB did not confront this but has, in its omission, left it to those who can and are best placed to do it, to do so. I think this is possibly another one of the holes in the cheese - and this discussion could help by encouraging analysis of other reports rather than complete acceptance.

[TheChitterneFlyer]

[QUOTE]Would rather, as in any day of the week and twice on Sundays, fly with a crew who are free to exercise judgement, and use automatics as and when it's the best option. Flying a short sector on a clear skies day, off a fairly quiet airport and into one that's even quieter, encountering almost no other traffic either enroute or in the terminal areas, is obviously a perfect opportunity to take the bull by the horns and do a spot of driving yourself. Any operation which has SOPs written specifically to prevent that, is run by a bunch of idiots. Probably the un-holy and culture destroying trinity of Lawyers, Accountants and Consultants.[QUOTE]


As a three crew operator of the BA TriStar it was routine to be able to manually handle the aircraft as required. The additional pair of eyes monitoring the flight progress made it a safe procedure. However, most crew would only hand fly the aeroplane if the circumstances were suitable to do so, i.e. not a busy ATC environment or bad weather. Given that there are now only two crew on the flight deck it wouldn't be prudent to have to expect the other pilot to have to closely monitor the handling pilots performance whilst also carrying out his other normal duties. However, if company rules allow hand flying to take place I wouldn't expect a professional crew to do so during anything but good flying conditions and quiet airspace. Just my two-penneth.


TCF

[Old Fella]

Hi TCF, hope all is well with you. As a fellow former three man crew member, often the oldest as the F/E, I would be very pleased to see the re-introduction of the F/E. Most of the modern-day pilots would not have any understanding of what professional flight engineers contributed to the operation. We certainly, in most cases, added to the environment within the cockpit. The MEL was much thicker, not because we were smarter than the computers which monitor and/or control the various systems, but because we had more options open to us. As well, we were a third set of eyes able to contribute in the busy ATC environments. No realistic person could claim to be able to monitor systems more ably than computers do, because computers don't suffer fatigue as humans do. For many reasons I can think of I wish F/E's were still part of the crew, as I do believe we were a worthwhile element in the overall operation. Obviously the airline I worked for did, they paid us the same pay scale as the F/O.

[SLF3]

If the walkaround is so important would it not merit more than a 20 minute video as part of conversion training?

[blind pew]

Thechitternflyer
Would disagree ...in my last company we flew manually in bad weather where there wasn't the risk of meeting VFR traffic and because it needed higher skill levels hence better training.
It was also the captain who did the outside check unless we carried a FE...and nothing stopped the FO from doing his own walk around.
We spent an evening in the hanger with the engineers going around the airframe during transition course and we were checked on our annual route check.
Sadly BA has continued some of the practices from the 70s and downgraded others.
One of those is the non flying pilot operating the throttles...what the report says about heading loss poses the questions whether they would have passed an. IR renewal and whether the apparent yaw angles could have overstressed the fin?
As a crew they would have failed a sim check wrt the fuel leak and shutting the engine down.
Sadly it isn't an isolated incident by far...their other latest misdemeanour at Joburg where the other two monitored Junior writing off a 747 is another example of a lack of training and following SOP.
Someone needs to look at their overall operation before their luck runs out.

[blind pew]

That's part of the problem Chitterne...my first company had some absolutely stupid SOPs...the chief trainer on my first fleet did most of his conversion course on a wide body on autopilot....rumour has it 'twas that he couldn't fly instruments.
My last company was run by interceptor/ground attack militia pilots who could really fly....
Comes out to the lowest common denominator - whatever that means :)

[M.Mouse]

The MEL was much thicker, not because we were smarter than the computers which monitor and/or control the various systems, but because we had more options open to us.

I have the utmost respect for the skills and abilities of most flight engineers but I have to disagree with that statement.

There were not 'more options' but there were far less sophisticated systems which needed more human input to deal with than current systems. Design and development has led us to a point where engineers are not needed to handle systems and system malfunctions and all the arguments being espoused here are actually for a third pair of trained eyes. That is neither practical nor affordable.

[TheChitterneFlyer]

M.Mouse, I don't disagree. However, was it really necessary to develop what have now become very expensive and complex aeroplanes? If the development had been confined to pilot displays/navigation systems and less automation we wouldn't be in the pickle that we find ourselves in today. That third pair of eyes would still be there and not leaving one crewmember on their own on the flight deck. The diagnostic process of managing system failures would have been simplified.


It then raises the question of whether or not more recent incidents and disasters might have been avoidable. IMHO many lives and millions of dollars have been lost by the advent of making airborne systems over-complex. The bean counters have, most certainly, made a significant contribution towards taking a backward step with air safety.


TCF

[M.Mouse]

I have to respectfully disagree. Air travel is statistically safer than ever before and catastrophic failures rarer than ever before.

When I first flew the B747-400 I recall flying with a senior captain who had previously flown the B747 Classic right from its introduction into British Airways. He had suffered 13 engine failures on early aircraft. He had a flight engineer and each event was handled safely.

I flew the '400 for 10 years and suffered 1 engine failure which was a failure of the FADEC we handled it safely. I think I prefer more complex but ultimately more reliable modern engineering.

There will always be human error no matter how we strive for an accident free environment. I cannot agree that less sophisticated engineering warranting a third crew member would ultimately improve safety.

[J.O.]

Transplant the accident rate from the days of older technology aircraft on to today's utilization rate and there'd be a large airliner at the bottom of a smoking hole every three days. That would be unsustainable with the paying customer.

[Basil]

gcal, Latches/doors and any flappy bits are a perennial problem on any sort of transport.

and the solution is:

http://bringatrailer.com/wp-content/uploads/2013/05/1967_Morgan_4-4_front_quarter_resize.jpg

High speed straps anyone? :E

[WillowRun 6-3]

At hopefully only a bit of risk toward thread creep . . . and looking only at the lack of hand-flying skills and/or proficiency as a factor in the incident, a question, particularly directed at those who are a bit (or quite) incredulous at SOPs in question (or at the larger trend of over-reliance on automation): suppose that international standards magically were to be changed so that hand-flying proficiency became a requirement for CAAs to issue licenses for pilots. Would the standard be essentially a reiteration of the skills and proficiency required before automation became both so sophisticated and widespread? Or would your formulation of what constitutes sufficient airmanship with respect to flying the aeroplane without automation represent some later-day definition? (Of course, I did say "magically" . . . so I'm not planning on needing to deflect any broadsides about how unrealistic the premise of my question is.)

[TheChitterneFlyer]

Well, all I can say about older technology and 13,000 flying hours is that I only experienced four emergency engine shut-downs. Two (singular) on a C-130K, one on a B747-100 and one on a B747-300. The B747-200 was extremely reliable; as was the TriStar -200 and -500. The two engine shutdowns on the C-130K were both due to a hydraulic pump break-up. As for the engine failures on the B747 - one was loss of oil and the other was a turbine failure.

[Discorde]

Until about 20 years ago the UK CAA requirement for IR renewal in the sim was: no autopilot, no autothrottle, nav by ADF/ VOR/ ILS. Use of the flight director was allowed. As a TIRE I would brief crews that although there was little relevance to everyday flight ops the exercise kept handling skills and instrument scan to a high level of competence. A by-product was maintaining pilots' confidence in their abilities. Training captains were required to fly the exercise with one engine shut down. Perhaps airline accountants and managers could be persuaded to include a similar exercise in recurrent sim checks.

[superq7]

Airbus considering redesign.

Airbus examining open-cowl cockpit warning for A320neo - 7/27/2015 - Flight Global (http://www.flightglobal.com/news/articles/airbus-examining-open-cowl-cockpit-warning-for-a320neo-415047/)

[MrSnuggles]

Strapping the hood to the car is all fun and dainty, but what about my earlier suggestion to use the human cognitive skills of detecting change and movement?

This way we don't try to exclude the human - rather keep the human skills very much in the loop. Isn't that what this is all about, really? Hand flying skills are also about working with the human cognitive skills of detecting change and movement. Computerising everything works against this excellent capability our ancestors evolved for us.

[Epsomdog]

Can't help thinking everyone is missing the point!

This incident happened because two experienced and qualified engineers, made an aircraft, unserviceable/unfit for flight and failed to record the fact in the tech log!

That's a pretty basic error that needs to be addressed!

[TURIN]

Actually they did record it in the tech log. After they had gone to the wrong aircraft to complete the job.

[DaveReidUK]

Can't help thinking everyone is missing the point!

This incident happened because two experienced and qualified engineers, made an aircraft, unserviceable/unfit for flight and failed to record the fact in the tech log!

That's a pretty basic error that needs to be addressed!

You might want to read the investigation report, if you think that's what happened.

Or are you saying that the AAIB got it wrong ?

[KTF]

From the report it says that the latches are painted an orange colour in an attempt to make them visible when unlocked.

Would it not also be a good idea to paint the edges of the cowls that are visible when they are not fully closed in the same orange colour rather than blue to make them more visible as well?

[akaSylvia]

I suspect that Epsomdog (http://www.pprune.org/members/403195-epsomdog) is referring to the initial error in this cascade: leaving the aircraft with the cowling doors not propped up. The report is clear that the technicians shouldn't have left them unlatched without propping them up and they should not have left the aircraft without putting a warning note on the flight deck. Either of these would have been a red flag to the flight crew the following morning.

[TURIN]

Fair point. However, the AMM requirement is either cowls latched or open and held open on the stays. Either way, a log entry to say the IDGs required servicing would have saved the day. I'm not going to get all holier than thou over this because I dare-say, most if not all line-maintenance personnel are guilty of a similar offence on a day to day basis. Time being the driver usually.

[Epsomdog]

You might want to read the investigation report, if you think that's what happened.

Or are you saying that the AAIB got it wrong ?

I have read the report! And that is exactly what happened. The cowls were opened and then left in an unlatched condition. No log entry was made and they left to attend another aircraft.

Sorry but that is a pretty basic error to make!

[Avionker]

I have read the report! And that is exactly what happened. The cowls were opened and then left in an unlatched condition. No log entry was made and they left to attend another aircraft.

Sorry but that is a pretty basic error to make!

Epsomdog

It certainly is.

I think we can all agree that it should not have been done. I also think we can all agree that it should have been caught prior to the aircraft departing.

There were numerous contributing factors to the incident, and appearing to single out the initial error whilst ignoring everything else in the report is disappointing, especially for someone who has 45 years in the industry as you do.

For me the 2 most interesting points of the report are the Maintenance Supervisor felt that the allocated manpower for the shift was insufficient, and that this was regarded as normal.

The fact the company subsequently employed no fewer than 26 additional staff is very revealing.

[Epsomdog]

Epsomdog

It certainly is.

I think we can all agree that it should not have been done. I also think we can all agree that it should have been caught prior to the aircraft departing.

There were numerous contributing factors to the incident, and appearing to single out the initial error whilst ignoring everything else in the report is disappointing, especially for someone who has 45 years in the industry as you do.

For me the 2 most interesting points of the report are the Maintenance Supervisor felt that the allocated manpower for the shift was insufficient, and that this was regarded as normal.

The fact the company subsequently employed no fewer than 26 additional staff is very revealing.

I agree, there were numerous oppertunities to spot the original error. You're right, these issues should not be ignored. However the debate seemed to be focusing on these failures, rather than the original mistake. I was attempting to re-focus the discussion on the real problem.

How or why did the guys make the initial mistake?

Lack of training? Lack of manpower? Workload pressure?

[DaveReidUK]

This incident happened because two experienced and qualified engineers, made an aircraft, unserviceable/unfit for flight and failed to record the fact in the tech log!

You might want to read the investigation report, if you think that's what happened.

Or are you saying that the AAIB got it wrong ?
I have read the report! And that is exactly what happened. The cowls were opened and then left in an unlatched condition. No log entry was made and they left to attend another aircraft.

The AAIB report states (P32) that after the cowl doors were opened an open Tech Log entry was made in respect of the Weekly Check (entry left open because at that stage the low IDG oil levels hadn't been actioned).

The log entry was later closed (P34) when the technicians wrongly concluded that the cowl doors had been subsequently closed by a third party and that the IDG oils were in fact OK.

So it's not a case of doing something and failing to record it in the Tech Log, quite the opposite.

[akaSylvia]

I've just finished a post summarising the incident. I wanted to put in so much more but I was already pushing 6,000 words. This thread got me thinking about who all could have done something differently:


shift managers using overtime
engineers
mates who said "huh, weird" in staff room
staff trainers
painters
first officer
flight crew trainers
tug driver
(can we list the ground staff photographer? probably pushing it)
captain
cabin crew
fire captain (actually no, he wasn't supposed to make the call but holding back would have been worse)
aircraft designers

Who'd I miss?

[DaveReidUK]

Who'd I miss?

Regulators?

[Chris Scott]

This event in May 2013 turns out to be a great deal more serious than many remote observers like me had realised, and the comprehensive report will merit further reading. For most of us pilots – retired or otherwise – it’s an eye-opener to the problems faced by our hard-pressed line-maintenance colleagues on a routine night shift. That a bespoke system such as presumably created for T5 should turn out to be so dysfunctional is disappointing.

The in-flight conduct of the flight crew is another matter, but I agree with the poster who points out that anyone who had previously suggested this scenario as a LOFT exercise for a recurrent sim check would probably have found the idea dismissed as improbable and over-complex.

As a retired A320 pilot, my main historic interest here has been the failure of the pilot’s external check to flag-up the unlatched cowlings. A bit more unexpected are the problems the pilots experienced in use of manual thrust after the #2 engine had been shut down. In the hope that the Moderators will permit it, these are the two aspects I’m going to discuss at some length in this post.

MANUAL THRUST

From the AAIB Report (pages 14 & 15):
“The commander informed the AAIB that, excluding simulator training, he had last flown the A320-series aircraft using manual thrust seven years before the accident.”
“The co-pilot informed the AAIB that, apart from simulator training, he had never flown the A320-series aircraft using manual thrust.”

The co-pilot had joined the fleet at the end of 2006. The BA policy for single-engine flying on the A320-series when the AP is not available may have changed since I left the fleet at the end of 2001. I’m not privy to a current FCOM, or to the one pertaining at the time of the accident (May 2013). Generally speaking, as PF, it’s easier to use manual thrust in single-engine flight because the rudder requirement can be anticipated and co-ordinated as you move the throttle/thrust-lever; provided, of course, you are the one handling it!

I gather that, since my retirement, BA has more or less banned the use of manual thrust in normal (twin-engined) ops when A/THR is available. I flew the A320 as a line captain from March 1988 (just after the A320 had received its type-certification) until the end of 2001. At Toulouse, Airbus trainers had encouraged the use of manual thrust for “manual” flying. For a manual landing in good visibility, I invariably disconnected A/THR, usually just before the AP, at least a minute before touchdown. The GS-MINI system is brilliant, provided you use the constantly-varying “managed” speed as a target, rather than a minimum speed. It greatly reduces the number of thrust adjustments required. The manual throttle/thrust-levers are, however, a delight: easily the best of the six jet types I flew.

If manual thrust is no longer permitted as an option in normal ops, it would explain the lack of recent experience of both pilots. They would be less well equipped in any A/THR failure. The essential learning experience would not be easy if the crew was simultaneously dealing with other failures, as in this case. If an engine is shutdown when A/THR is available, one of the essential actions is to increase the thrust limit on the remaining engine to MCT. On the A320-series, this is achieved by advancing its thrust lever from the CLB detent to the MCT/FLEX detent. Unless that much thrust is required immediately, it would be quite inappropriate to do that in the manual-thrust case. In the absence of an IAS trace in the Report, this is one possible explanation for the co-pilot advancing the #1 engine thrust lever well beyond the CLB gate after the #2 engine had been shut down (see next paragraph). Is manual thrust practised in the simulator for the single-engine case?


The other surprise for me, sitting in my peaceful retirement, was the captain’s decision, as PM (PNF), to take over the thrust management on the approach (see page 9) after completing the #2 (right) engine fire-drill/shut-down. This may have been in reaction to the co-pilot’s initial over-increase of thrust on the #1 engine to more than CLB thrust (see previous paragraph). The latter had led to a big yaw, and his corrective use of more than 10 degrees’ left rudder had disconnected the AP. But the co-pilot’s continuing difficulty in maintaining heading in manual handling may have been all the greater for not initiating his own thrust changes. In the following 2 minutes, the thrust-lever angle peaks 3 times, and varies between the CLB detent and idle (see Fig 16, page 41). That represents a lot of leg work and rudder re-trimming, which should not have been necessary. In any case, could an AP have been re-engaged?

Later, when the captain took control at about 500 ft agl for the landing, he delegated thrust control to the co-pilot. We are all prone to atypical mental processes under high pressure. I’m wondering if this may have been a case of reversion to the SOP of some previous type. The report (page 67) quotes the manufacturer’s SOP that the thrust levers are operated by the PF in abnormal and emergency conditions, and I assume BA still subscribes to that policy in the air, though not for the selection of reverse thrust on landing.



PILOT’S EXTERNAL CHECK

From the AAIB report, para 2.5.4, pages 97-98:
“The co-pilot had not been tested in his conduct of the walk-around and the operator did not carry out periodic checks of how flight crews were performing the external walk-around (nor was there any requirement for them to do so). Thus it was not possible to ensure that flight crews were consistently performing [it] to the standard shown in the operator’s training video and as set out in the FCOM procedure.”

Throughout my 14 years on the BA A320 fleet (referred to as the Airbus fleet), all pilots were assessed annually on the external check as part of what BA described as the route check (line check). Route checks were normally conducted by a specialist Route-Check Captain (RCC). When possible, the RCC checked the two pilots as a crew on a two-sector rotation, occupying the P3 seat as a supernumerary crew member. This enabled the RCC to evaluate both pilots in their P1 and P2 roles. Being free of any duties other than observation, the RCC could assess the whole operation dispassionately; including CRM within the cockpit, and the crew’s interaction with cabin crew and ground staff. The P3 seat affords a view of either pilot’s actions that the opposite seat cannot.

On arrival at the aircraft for the first sector, the RCC would observe the captain and co-pilot meeting the cabin crew, reading the technical log, and doing the safety checks. Then it was normal practice to observe most of the external check (on our fleet conducted by the pilot doing the P1 duties, which was typically the captain on the first sector). That gave the RCC the chance to verify that at least all the items on one side of the a/c had been checked properly, as well as the nose and the tail, before hurrying back to the cockpit. (Meanwhile, the pilot doing the P2 duties had covered a lot of ground. But no system checks are required on the A320-series, and his/her preparations would become clear during the pilots’ pre-departure briefing.)

When a line check or line training is conducted from a pilot’s seat, the check pilot or trainer is unlikely to have the time or capacity to accompany the candidate on the walk-around. The role of specialist RCC was discontinued by BA soon after I retired, and this may have coincided with a change of policy on the conduct of the line check.

Again, from the AAIB report (page 97):
“The co-pilot had watched the operator’s training video on the A320-series external walk-around when he undertook the type conversion course several years previously.
“When interviewed, he was unaware of the need to specifically check the fan cowl door for a visible gap between the doors and the nose cowl. His described method of how he checked the latches did not enable him to identify that the fan cowl doors were unlatched. This suggests that either the operator’s training video was ineffective, or that he had been aware of this at some point but had forgotten it with the passage of time.”

As someone has already pointed out on this thread, one is actually looking for the absence of a visible gap: i.e., that the L/Es of the fan-cowling doors are absolutely flush with the nose cowl. This applies to both makes of engine. When left hanging down and unlatched, both types hang much closer to the line of the engine nacelle than one might expect. The gap obviously increases from top to bottom. The CFM fan cowlings are a notoriously bad fit when closed, but from memory the latch mechanism is perhaps more intuitive (less complex) than the IAE. The latches are at the bottom of the cowlings in both types, very close to the ground (slightly less so on the IAE).

It’s essential to stoop and bend one’s head down quite close to the ground to ascertain that both doors are flush and the latches are secured. This can be done from the front of the engine, or from the sides.

During many years as a RCC, the bottom line for me was that, if the pilot didn’t lower his/her head sufficiently, the check could not have been performed properly. This was only too common, and became a standard bleat during de-briefs, not to mention my periodic route-check summaries. At the end of 1996, after nearly nine years of A320 ops, I estimated that between 5% and 10% of captains were omitting the check, and nearly 5% of co-pilots. That represented an improvement on our small, close-knit fleet. In those days, we still had only ten A320s, all CFM-powered. By the time I left at the end of 2001, we had added about eight IAE-powered A319s. The rate of pilots omitting the check remained similar, as I recall, despite the expansion of the pilot force.

I’m disappointed that the level of priority given to the training and checking of walk-around checks has apparently fallen. Pilots are the last line in the defence against serious defects on despatch. If the standard of routine walk-arounds has fallen accordingly, it would also represent a gap in an important aspect of the technical knowledge of the current generation of junior line pilots. This may imply a lack of motivation in some cases, but the main reason would be the ratchet of reductions of time available for pre-flight preparation, and never-ending demands for cost-savings in initial and recurrent training. Apart from the adverse effects on pilots’ broad understanding of aircraft systems and maintenance, a further side effect would be to hinder the development of the valuable rapport between them and line engineers.

[slast]

Good post Chris. I was only on the fleet for 3 years until 91 (?) so won't comment other than to say that I didn't know BA had cut out the dedicated Route Check Captain position. That was really the Chief Pilot's independent "quality control" over both his Technical and Training subordinates. I am pretty unhappy with the idea that manual thrust is only done in the sim., since for exactly the handling issues you mention the occasions when it may be necessary are already generating high workload/stress levels.

[Chris Scott]

Thanks, Steve,

Great to hear from you after all these years! They were exciting times, even allowing for your missing that first summer at Gatwick, with night charters and the brand new North Terminal. In those early years we were all true volunteers, were we not? We joined the fleet from many others because we wanted to fly cutting-edge technology. I only ever heard of one pilot who was disappointed with his choice.

Re your comments: yes, that was precisely my understanding, and what Pete Looker told me when hiring me for the job as RCC. For about eight months of each year, apart from the occasional contingency, we were ordinary line pilots; the remaining months were spent doing route checks (line checks). Whenever possible, each check was of a pair of pilots, and done from the P3 seat.

The fact that the pilot’s walk-around is no longer part of the line check leads me to conclude that the line-checking pilot, as well as being a trainer, must also be operating in a pilot seat – either as captain or co-pilot. In most cases, (s)he would be unable to observe the candidate’s walk-around. Being able to evaluate the external check is not the only advantage of line checking from the jump seat, as pointed out in my previous post.

For other readers: RCCs were employed in much smaller numbers than the trainers, and were regarded as something of an anomaly. (In BCAL, where I came from, the role hadn’t existed.) The fact that we evaluated pilots only on everyday line operations – every pilot’s bread-and-butter task – inevitably led to resentment in some quarters. It’s a bit like a workmate criticising your driving when you’re giving him a lift! And it wasn’t only line pilots that occasionally objected.

As you know only too well as a trainer, although training captains also had to conduct route checks from time to time on an ad-hoc basis if no RCC was available, it represented only a small part of their relationship with the line pilots. When it happened, the training captain usually did the check from a pilot’s seat. That made for a bond with the candidate, which has its pros and cons. You cannot scrutinise all aspects of a pilot’s performance when you have your own workload.

Mostly, trainers’ work is in conversion training (on the sim and the aircraft) and recurrent simulator checks. No one expects – or is expected – to perform completely flawless sorties in those situations. Most of us are only too ready to accept criticisms and help from trainers, provided they sign us up for another six months! But, on the line, more pride is at stake.

So, to put it bluntly, as I think you’ll agree, trainers were generally more popular than RCCs. That sentiment probably extended to management pilots, whom we also had to evaluate annually. A manager, who might only get one or two flights a month, may not take kindly to receiving banal debrief items they’ve seen RCCs list in fleet summaries. My feeling was that, despite their desk-bound lack of practice on the line, treating management candidates differently would be misleading to the manager and might lead to a decline in fleet standards, as well as being unfair and dishonest.

The demise of the role of the specialist RCC in BA may have been encouraged by the above, but another factor is likely to have been decisive, as always: costs. Checking one pilot at a time means twice the number of line checks. But, if in each case the crew is limited to the minimum crew complement of two, the check costs nothing. The line checks may not be as wide-ranging or objective as a RCC was able to do from the jump seat, but at least the training captains get to fly more often.

[Bergerie1]

I have read the AAIB's report with great interest and clearly it raises a considerable number of issues that are of concern. I last flew a commercial flight in 1995 and have never flown an Airbus type other than their simulators in Toulouse, so for both reasons I will not comment here on the rights and wrongs of the conduct of the flight.

However, I am astounded to read in Chris Scott's posts above that BA do not permit pilots to fly using manual thrust during normal operations. In my view, it is essential that pilots should be encouraged to fly the aircraft manually whenever workload and weather conditions permit. A few practice sessions on the simulator is totally inadequate.

I know I am an old fossil but, after reading some of the accounts here on PPRuNe and in official accident reports, I cannot understand how or why BA pilot management have allowed this to happen. Pilots are there, not only to conduct normal flights, but, far more importantly, to act as long stop when things go wrong - including the automatics.

[majora]

Agree, I have hand flown jet transports for 9 hours straight many times. It is a very necessary skill if you had to drive thru a serious squall line or make up for a loss of most of the automatics. Mr Murphy will rear his ugly head at the most inconvenient times. Everything works fine until you really need it.

[wiggy]

Bergerie

I cannot understand how or why BA pilot management have allowed this to happen.

J T provided a pretty good explanation of management's reasoning for full time use of autothrottle on the Airbus in post #80 on this very thread. Management on other fleets subject to the same rules, such as the 777 claim (amongst other things) that use of Autothrottle reduces touchdown point dispersion and therefore reduces the risk of a runway excursion.

Please don't shoot the messenger, I am not saying I agree with the policy.

[Bergerie1]

wiggy,

I wouldn't dream of shooting the messenger, I agree with too many of your posts.

I've re-read post No. 80 and am still appalled. I'm just glad I'm not flying any more.

[Juan Tugoh]

I've re-read post No. 80 and am still appalled.

Nearly all the pilots on the fleet were appalled too. Luckily we had/have a management that listen to the opinions of trainers and line pilots - oh no wait a minute, we don't.

This is a classic case of misuse of SESMA. The argument that banning the use of automatics leads to less low speed events is akin to arguing that if we don't fly at all we get no low speed events.