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Centaurus
21st Jun 2018, 14:21
British Airways Boeing 777 engine fire warning during takeoff followed by rejected take off and evacuation. . NTSB report just out should be vital reading by all Australian operators. Successful outcome of passenger evacuation but confusion in the flight deck with an engine on fire was potentially deadly.
https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20150908X35241&AKey=1&RType=HTML&IType=FA

Fluke
23rd Jun 2018, 11:41
NTSB report just out should be vital reading by all Australian operators

It is a detailed and interesting report but not sure if it qualifies as vital reading. Do you think Australian operators are prone to the same confusion ?

Augmented operations in a 2 Crew certified aircraft can throw up all sorts of negative distractions along with the “extra set of eyes” benefits. In the BA rejected T/O and evacuation, the observations and inputs from the Relief pilot certainly contributed to the successful evacuation. However less disciplined or sometimes mistaken, relief Crew present in the cockpit can interfere with decision making and checklist order. We train as 2 Crew in our renewals so we expect a certain flow and tempo while executing non normals. Too much or inappropriate feedback from extra crew can upset the running of a unannounced Electronic checklist ( Emergency Evacuation).

l am certain Australian operators with augmented crews are aware of these traps.

framer
23rd Jun 2018, 12:42
It is a detailed and interesting report but not sure if it qualifies as vital reading. Do you think Australian operators are prone to the same confusion ? Why would they not be?
l am certain Australian operators with augmented crews are aware of these traps.
As an Australian I find that an interesting opinion. I can’t imagine we have too much to teach the British about flying Airliners. If we are aware of the issues you raise then I’m pretty sure the Bristish will be too.
Have I misunderstood your point?

Capt Fathom
23rd Jun 2018, 12:57
I wouldn’t call it confusion.

Nothing like any scenario they’d trained for.

You make the most of your experience, training and what is going on around you and do your best to stick with the script.

It never goes by the script!

Fluke
23rd Jun 2018, 13:38
I wouldn’t call it confusion.

Nothing like any scenario they’d trained for.

Fair enough, confusion may not be the best description of cockpit situation but the cabin crew were confused with the way intelligence was gathered by the relief pilot and not though the inter phone as they may have expected.

My point is that we can’t train for all scenarios and the next evacuation will probably have different challenging circumstances. Therefore it is not vital that we specifically prepare for this scenario as I understood the initial post alluded to.
We should be prepared for any “script”.

Still as I said it was an interesting read.

parishiltons
23rd Jun 2018, 14:03
It is a detailed and interesting report but not sure if it qualifies as vital reading. Do you think Australian operators are prone to the same confusion ?

Augmented operations in a 2 Crew certified aircraft can throw up all sorts of negative distractions along with the “extra set of eyes” benefits. In the BA rejected T/O and evacuation, the observations and inputs from the Relief pilot certainly contributed to the successful evacuation. However less disciplined or sometimes mistaken, relief Crew present in the cockpit can interfere with decision making and checklist order. We train as 2 Crew in our renewals so we expect a certain flow and tempo while executing non normals. Too much or inappropriate feedback from extra crew can upset the running of a unannounced Electronic checklist ( Emergency Evacuation).

l am certain Australian operators with augmented crews are aware of these traps.


At least they promptly commanded an evacuation.

DirectAnywhere
23rd Jun 2018, 14:15
Couple of things I noticed.

1 Autothrottle wasn’t disconnected in the initial RTO actions. See this a lot in the sim, particularly with low speed RTOs.

2. Captain did their bit of the evac checklist from memory, which resulted in the aeroplane being evacuated with the number 2 engine running for 45 seconds or so after the evacuation was ordered. While Boeing gives some flexibility to Captains to manage checklists by memory if they see fit, this doesn’t seem like the ideal time to implement this policy and could have resulted in a very serious outcome for passengers adjacent to the number two engine.

3. The FO tried to open the outflow valves in accordance with the checklist but appears to have left the switches in AUTO, meaning no manual control. The valves would have been open anyway on the ground so no biggy, but interesting to see how the FO thought he had done the checklist but appears to have missed a step.

Easy to discuss it from here while not sitting in a burning aeroplane, but it appears slowing things down just a little and reading and actioning the checklist carefully in a high workload/ stress environment with a considerable startle factor in play, may have led to a better outcome. No one died and they all walked away but there are definitely learnings to be taken away from this. I know I’ve taken something out of reading it.

Oilhead
23rd Jun 2018, 14:20
I wouldn’t call it confusion.

Nothing like any scenario they’d trained for.

You make the most of your experience, training and what is going on around you and do your best to stick with the script.

It never goes by the script!

Why wouldn't crews be being trained for high speed and low speed regime engine fires/failure? My airline most certainly trains for an event just like this. Startle factor always tests our true abilities and preparation.

Capn Bloggs
23rd Jun 2018, 16:07
Fathom, it was a classic bang just before V1 with a fire. A standard sim exercise that is practised regularly by every jet operator in the world.

Jenna Talia
23rd Jun 2018, 17:11
Easy to discuss it from here while not sitting in a burning aeroplane, but it appears slowing things down just a little and reading and actioning the checklist carefully in a high workload/ stress environment with a considerable startle factor in play, may have led to a better outcome. No one died and they all walked away but there are definitely learnings to be taken away from this. I know I’ve taken something out of reading it.

Best comment I have read in a long time :ok:

parabellum
23rd Jun 2018, 17:25
The report also mentioned that due to the delay in shutting down #2 only two exits could be used and these became “choked” by passengers trying to evacuate, a CC nightmare I imagine, pax
evacuating with their hand baggage trolleys won’t have helped either.

aviation_enthus
23rd Jun 2018, 18:59
I think this accident is a perfect example of how startle factor can ruin the flow of what is otherwise a ‘standard’ sim failure. A friend of mine described a similar effect with an EFATO which resulted in smoke in the flightdeck/cabin and flames visible from the engine. He said the shock made the whole scenario completely different to sim training.

Two youtube clips worth sharing:

https://youtu.be/tfeKuX0CtXA
BA 777 at Las Vegas. Around the 3:00 mark you can see the slides come out but the smoke on the far side is still being blown away from the jet blast off the RH engine. You can just see the R4/3 slides appear as well but they’re clearly being blown around until the engine is shutdown.

https://youtu.be/9K3HDfhgdXo
Dynamic Airways 767. As soon as the first rear slide appears you can see it being blown away by the jet blast from the RH engine. Makes it quite difficult for the pax to use.

Capt Fathom
24th Jun 2018, 01:05
classic bang just before V1 with a fire. A standard sim exercise

That’s my point. A Sim exercise. You know it’s coming and you’ve gone through it the night before, verbatim.

Pull up to a stop and halfway through the drills the instructor says ‘Yep that’s great, let’s move on to the next lesson’.

Nothing like a real fire to ramp it up to the next level.

Capn Bloggs
24th Jun 2018, 02:37
I hope you're not making excuses. That performance was pretty ordinary by any benchmark.

I hope Aussie ATC would have been more helpful...

greenfields
24th Jun 2018, 02:51
That’s my point. A Sim exercise. You know it’s coming and you’ve gone through it the night before, verbatim.

Pull up to a stop and halfway through the drills the instructor says ‘Yep that’s great, let’s move on to the next lesson’.

Nothing like a real fire to ramp it up to the next level.



And one of the biggest problems with a Sim Exercise is the matrix, thanks CASA...... :rolleyes: The sim is always trained to do an Evacuation, and never is a scenario given where a thought process developed of whether an evacuation should be done, or would it be better to keep the pax in their seats? The scenario is always created where the pilots MUST do an evacuation to tick the box in the matrix. So when it happens for real, and the crew have to actually consider what they are going to do, they haven't trained for any form of decision making during such an event where the adrenaline will be high. The sim events are just a case of playing it by numbers. Fire before V1, stop, Evacuate. So they are trained to be robots, which as this event has shown, may not result in the best handling of such an occurrence.

Capn Bloggs
24th Jun 2018, 03:19
and never is a scenario given where a thought process developed of whether an evacuation should be done, or would it be better to keep the pax in their seats?
Some of my sim Fire RTOs have resulted in keeping the pax on board after assessing the situation. Hopefully, this will prompt some thinking if indeed some sims are "just playing it by the numbers".

The sim events are just a case of playing it by numbers. Fire before V1, stop, Evacuate. So they are trained to be robots, which as this event has shown, may not result in the best handling of such an occurrence.
Had the BA crew been robots, I suggest that the whole event would have gone much more smoothly than it did.

willadvise
24th Jun 2018, 04:16
I hope Aussie ATC would have been more helpful...

Curious about this CB. What aspect of LAS ATC are you critical of? If you are referring to the YouTube video, be aware the ATC audio is not in synch with the video. ATC had already activated the fire services before the aircraft asked for them.

greenfields
24th Jun 2018, 05:28
Had the BA crew been robots, I suggest that the whole event would have gone much more smoothly than it did.

Correct, which is why training them to be robots is an abject failure.

Ollie Onion
24th Jun 2018, 07:52
A bit harsh to say that there as confusion, when you watch it in real time the stop to evacuation seems entirely reasonable to me. Sure it could of been done ‘better’ but I just hope that given a similar set of circumstances I can be in the pub later on reflecting on the successful evacuation of all on board with no serious injuries. I thought the report showed a crew who worked particularly well together to ‘trap’ each other’s lapses and generate a successful outcome, that is why there is two or three of us. Well done to the cabin crew as well who seem to have made excellent assessments of their respective doors and if they should be used.

Capn Bloggs
24th Jun 2018, 08:14
What aspect of LAS ATC are you critical of?
On the evidence presented, there was no help from ATC regarding what was actually going on. She told BA that fire services were on the way (only when they declared the Mayday-double transmission, then she repeated herself) but I would have loved to have heard "major flames and smoke on the port side and underneath". "Fire services are on their way". What can she see? Should we evacuate based on that call? As it was, BA said, as they announced the evacuation to ATC, "we have a fire", possibly indicating that the real situation outside had only just dawned on them. 60 seconds from the Mayday (and the tower saying services are on the way) before a door opened. Fair enough stopped on a Lo Vis takeoff where no-one can see you, but in broad daylight?

It is obvious there was "procrastination" in the cockpit and in fact, the Evacuate command only came after the jumpseater came back from the cabin. I can't help but think that if ATC has said "you're ablaze", the evacuation would have come much earlier.

Liked the yank who said it looked like a brake fire... and Ground One asking to close the runway.

framer
24th Jun 2018, 10:41
It is obvious there was "procrastination" in the cockpit
Bloggs,
I just timed myself setting an imaginary park brake, making an imaginary PA, asking my FO to identify and then running memory items, then having a very brief imaginary chat with ATC before asking for the Evac checklist. I stopped the iPad timer when the Evac command came. It was 12 seconds slower than what the BA crew did.
I would recommend anyone reading this to do the same in the calm quiet environment of their lounge room, without additional cargo fire alerts, startle effect etc.
For me it was an eye opener because I know from experience that I would have been graded nicely in the sim yet 12 seconds is a long time to be sitting in 25a looking at ( and probably feeling) a large fire three feet away.
Regardless of how contributors to this thread view the BA crews actions I suggest you run this little exercise and see if it changes/ tempers/ reaffirms your current assessment.
I am certainly throwing no stones in their direction.

Slezy9
24th Jun 2018, 11:34
That’s my point. A Sim exercise. You know it’s coming and you’ve gone through it the night before, verbatim.

Pull up to a stop and halfway through the drills the instructor says ‘Yep that’s great, let’s move on to the next lesson’.

Nothing like a real fire to ramp it up to the next level.

Exactly, the sim is the sim... It's not real, there is no fear (except maybe loss of licence), the instructor is telling you what you can see.

I hope people who throw stones from the comfy 1 G armchair get it perfect every time.

Capn Bloggs
24th Jun 2018, 13:35
Framer, I just did it as Captain Armchair. I was comfortably inside the 2min 6 seconds it took for the Captain to call for the evacuation checklist. Look, please don't get me wrong. I'm not saying I'll get it right, and would expect to get hammered on Prune when I don't, but the fact is, that whole sequence was pretty ordinary, as pointed out by Centaurus. I can't see how anybody could say otherwise.

Throw in almost zero help from ATC, the crew doing an inflight engine fire drill on the ground (FO using the MFD timer for the 30"??; I'm not familiar with the 777 but wouldn't you just use the (if fitted) stopwatch?) and precious seconds go wasted.

Pull up to a stop and halfway through the drills the instructor says ‘Yep that’s great, let’s move on to the next lesson’.
Maybe in your outfit; not mine.

framer
24th Jun 2018, 13:50
Good stuff Blogs, glad you did that.
Lots of different ways of looking at it I guess. I measured from when the aircraft came to a stop until the Evacuation command was given, BA did it in 1 min 16 sec. I took longer in my armchair with some pre-planning. ( I understand that a mistake was made re the running engine).

Snakecharma
25th Jun 2018, 00:24
It was a bit untidy BUT it worked at the end of the day.

The MFD timer is neither here or there, it comes up as part of the checklist, so no biggie, though in this instance the 30 seconds is irrelevant.

Bear in mind though that from the 777 flight deck you cannot see the wing at all, let alone the engines, you cannot hear the engines, except maybe at takeoff thrust, the wind is probably blowing the smoke away from you and you are relying on external cues, so from that perspective prob not much different to your 717 Bloggs.

In real terms the difference between a false fire indication and a real fire is, I suspect as I have never had one, difficult to determine, because of the things I listed above, so chuck everyone out down the slides and injure someone and it is a false indication and someone will have a go at you, don't throw them down the slides immediately without confirmation that it is a real fire and someone will have a go at you - so in reality you are between the devil and the deep blue sea.

DirectAnywhere
25th Jun 2018, 05:09
Sorry Snakecharma but no-one is suggesting there were any issues with the decision to evacuate.

There was no question there was a fire - the relief pilot confirmed that to the Captain almost immediately via visual inspection from the cabin - and that the decision to evacuate was correct. No-one is criticising that decision The devil and the deep blue sea were in the same place. There was no middle ground. They were in the poo, no doubt about it.

The issues from this evac relate primarily to the Captain’s decision to run the evac checklist from memory and subsequent failure to shutdown the operating #2 engine. Exits 2L, 3L, 2R and, after 5 pax evac’d, 1L were rendered unusable by fire. The Captain’s decision to run the checklist from memory and failure to shutdown the #2 engine rendered 3R and 4R unusable as a result of jet blast. Therefore, of the 8 exits, 4 were unusable due fire, 2 were effectively rendered unusable by the Captain and only 2 were available for evac, being 1R and 4L, at extreme ends and sides of the aircraft.

They were somewhat fortunate the aircraft was only half full as they only had 1/4 of the exits available, broadly in line with certification requirements of half the exits for a full pax load.

I would respectfully suggest you need to read the report carefully, rather than make vague statements about demons and oceans.

As I said earlier, there are clear learnings in this accident. I look at recent sims I’ve done, and this report, and take those learnings gladly on board. I’m not sure I could have done better but I hope I can take something from this and maybe learn from it if, heaven forbid, I’m confronted with something similar while in the LHS one day.

Snakecharma
25th Jun 2018, 07:04
Direct - the joys of (me) jumping into the middle of a thread :) you are correct the captains’ decision to ‘sort of’ do the checklist was not a brilliant one, I was commenting (albeit obliquely) more generally on the various thoughts about how the checklist procedures were intended to be done in a 2 crew environment and how having extra people on the flight deck both helps and hinders the workflow on the flight deck and a few other things.

I can understand (I don’t and didn’t say I agree with) why things played out as they did - he couldn’t see anything of any note from the flight deck, as Capn Bloggs suggested there wasn’t a huge amount of support/info from ATC, so he sent the relief pilot into the cabin to have a look.

This interrupted the normal (sim like) flow of events in the flight deck, he shut down the engine with the fire, and then they half did the rest of the checklists. As I said untidy.

i would hope I would do things differently, but until it happens to me (touch wood it won’t) I can’t really comment, but I can understand how things planned out as they did.

Potsie Weber
25th Jun 2018, 08:42
At our yearly CRM session, the following video was talked about regarding pointing and calling. I believe its a good methodology to employ in briefings/self briefings etc for RTO's to help minimise the possibility of missing steps of memory items.

https://youtu.be/9LmdUz3rOQU

Capn Bloggs
26th Jun 2018, 05:43
What's the point of that? :}

Ascend Charlie
26th Jun 2018, 06:45
I've seen pilots point at an engine oil pressure gauge (for which I had quietly pulled the C/B) and say "Ts and Ps normal".

framer
26th Jun 2018, 07:29
I’ve seen a pilot point at a woman in the front seat of a convertible Mercedes and say “ sh1t, that’s my wife!”

Buckshot
26th Jun 2018, 11:12
Good CRM example of a V1 cut from VA

https://www.youtube.com/watch?v=8gIwZiEnULQ

Capn Bloggs
26th Jun 2018, 12:21
2:26 parked until pilots out. Plus probably another 60 to get the pax off. A good example of the ridiculousness of the 30" wait.

Stopwatch! :ok:

framer
26th Jun 2018, 14:43
In that video it takes exactly two minutes from when the aircraft comes to a stop until the evacuation command is given.
Forty four seconds longer than the BA crew. The BA f/o reduced the 30 Second wait to 15 seconds.
It sure is a fine line between rushing and cocking it up v’s taking longer than necessary. The one thing that is obvious is that the fire crews arriving on scene quickly made things much safer so the timing of the call for services is critical.

Ollie Onion
27th Jun 2018, 04:49
Sorry but that video is totally unrealistic to how the situation would develop in real life, that crew clearly is rehearsed and knows exactly what is coming. Having conducted several investigations into engine failures and RTO’s you can’t underestimate just how much of a factor the ‘startle effect’ is. The best instructor I ever had in the sim once told me that you should be deliberately slow in the Sim as when it happens in real life you will go twice as fast with the adrenaline, from all the crew I have interviewed that does seem to be the case. I have seen some amazing lapses, mistakes made in the heat of the moment when under pressure from an unexpected situation, best thing you can do is ‘review’ over and over which is what the BA crew did, things were done wrong but thankfully it was mopped up by each other to a good outcome.

haughtney1
27th Jun 2018, 05:31
Sorry but that video is totally unrealistic to how the situation would develop in real life, that crew clearly is rehearsed and knows exactly what is coming. Having conducted several investigations into engine failures and RTO’s you can’t underestimate just how much of a factor the ‘startle effect’ is. The best instructor I ever had in the sim once told me that you should be deliberately slow in the Sim as when it happens in real life you will go twice as fast with the adrenaline, from all the crew I have interviewed that does seem to be the case. I have seen some amazing lapses, mistakes made in the heat of the moment when under pressure from an unexpected situation, best thing you can do is ‘review’ over and over which is what the BA crew did, things were done wrong but thankfully it was mopped up by each other to a good outcome.

Totally agree Ollie, lots of Monday morning quarter backing going on, with a significant whiff of arrogance attached as well.
First of all, yes it could have been done better, but errors were trapped or mitigated and most importantly EVERYONE lived to tell the tail.
Having been through a highspeed (144kts according to the QAR) RTO back in my 757 days I can tell you it isn’t as black and white as the report will relate nor is the sim a particularly realistic representation.
This reminds me of the witch hunt and whispering campaign that went on after the 777 at LHR as well as when the crew BA9
did such a fantastic job...but were initially vilified.
The key thing here is to add knowledge, to be critical if necessary but most importantly be better prepared to deal with a problem as it arises.
For me this report merely reinforces my experience of the RTO I went through and the ensuing intital confusion and relative chaos.