G-VIIO Las Vegas

[BAengineer]

The NTSB report into the engine fire at Las Vegas in 2015 has now been released. The reasons for the fire are pretty routine and remedies have already been implemented.

However the report does go on to criticize the actions of the Captain during the evacuation, which doesn't make for good reading either for the Captain or BA's training system.

While the airplane was decelerating to a stop, the fire warning bell sounded. When the airplane came to stop, the captain called for the engine fire checklist. The third item on the checklist was to move the fuel control switch on the affected side (in this case, the left side) to the cutoff position, which shuts down the respective engine. The spar valve terminates fuel flow to an engine after it is shut down. Flight data recorder (FDR) data showed that about 28 seconds elapsed between the start of the engine failure and the time of the spar valve closure, and Boeing estimated that about 97 gallons of fuel had spilled onto the runway during this time. FDR data also showed that 22 seconds elapsed between the time that the captain initially called for the engine fire checklist and the time of the spar valve closure. (Thirteen seconds had elapsed between the time that the captain repeated his call for the engine fire checklist and the time of the spar valve closure.) If the left engine had been shut down sooner, there would have been less fuel on the runway to feed the fire.

The captain commanded the evacuation (step three in the evacuation checklist) before calling for the evacuation checklist and performing the first two steps in the checklist. Step two of the evacuation checklist instructs the captain to shut down both engines. The left engine was shut down as part of the engine fire checklist, but the right engine continued operating for about 43 seconds after the captain's evacuation command. The unusual attitude of two slides (the 3R and 4R slides) resulted from the jet blast coming from the right engine while it was operating.

The captain did not use the QRH to read and do his evacuation checklist items. The right engine was shut down after the relief pilot noticed EICAS indications showing that the engine was still running. Also, the captain's call for the evacuation checklist occurred after the relief pilot stated that the checklist needed to be performed. (The first officer had stated, just before the relief pilot, "we haven't done the engine checklist," but he most likely meant the evacuation checklist.) Because the captain did not follow standard procedures, his call for the evacuation checklist and the shutdown of the right engine were delayed.



Full report available at www.ntsb.gov

[Fly26]

Yes because we are all robots and absolutely perfect in every action we do during a non-normal highwork load events........

[FlightDetent]

Fly26 Evacuation is a mandatory check-ride item, reviewed to a pass standard by every ATPL captain at least once a year, more likely 4 times. Calling for EVAC with engine(s) running would be a fail on a licence re-validation day.

Understandably, in a real-life event, there are stressors not available in the SIM for training - such as fear for life - and the performance will be degraded. That is a physiological fact: https://en.wikipedia.org/wiki/Yerkes%E2%80%93Dodson_law

At the same time, the training AND checking are in place for the sole reason of preparing us for that real-life event. It's hard to comment beyond what's displayed in the first post already.

[DaveReidUK]

Link to Final Report (https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20150908X35241&AKey=1&RType=Final&IType=FA)

[AVR4000]

It would be good to have a camera view of the engines since my strong impression from different cases of "an engine was kept running when the evacuation commenced" is about the mindset beside actions related to the checklist.

Even if a bang is heard and the aircraft yaws slightly and the fire warning goes on - it doesn't mean "catastrophic fire" automatically so it is fully possible to stop with the idea of taxiing clear of the runway after shutting the engine down and use the fire suppression system. The lack of visibility from the flight deck and therefore inability to visually assess the engine condition could lead to the "taxi mindset". A camera showing the engines would tell a different story and the need for immediate evacuation and therefore immediate shutdown of both engines would be evident already during deceleration after the take-off was aborted.

It is also worth to mention that ATC didn't notify the pilots of fire on the left side of the aircraft. An appropriate conversation could have been:

"Speedbird 2276, stopping."
"Roger, Speedbird 2276, there are smoke and flames on your left side, smoke and flames on your left side, fire services are being dispatched."

Even after stopping with more serious fire, no radio call about this fact were transmitted to the crew, which could have assisted in their assessment of the situation.

I don't think the case is that easy that "blaming the captain" is the right course of action - there were several factors involved including a lack of information about the extent of the fire.

It was a bit different in Manchester 1985 since the tower immediately told the captain about the fire when he radioed "28 Mike, we are abandoning take-off... it looks as though we've got a fire on the number one" - ATC: "Right, there's a lot of fire, they are under way now" - this provided immediate cues about the situation and got them to alert the cabin crew during the roll about "evacuate on the starboard side, please" before the aircraft stopped.

The whole BA2276 story seems to revolve around a mindset that they had an engine failure, a serious one but nothing that would prevent them from taxi clear of the runway after assessing the situation. All videos of the aircraft when it comes to a stop before the doors open is a pretty good indication that the lack of information also meant that the sense of urgency weren't there.

If I hear an engine "go boom" I would like to be able to view it through a camera so I know what it is all about. Especially knowing that immediate evacuation and shutdown will be necessary after stopping (i.e. no "taxi clear of the runway" mindset).

[JammedStab]

If a situation had not reached the point of evacuating yet(which it seemd to be during the initial stages of the event), wouldn't one perform the memory items for an engine fire first which would hopefully get the fuel shut off fairly quickly and then call for the appropriate checklist(ie engine fire or evacuation checklist depending on which route one has decided to take). It can take a certain time period for one to get to the proper electronic checklist page or a paper one for that matter. Even when going directly to the Evacuation Checklist(back page of the QRH book and therefore very quickly accessed) takes a certain number of long seconds prior to getting the the point where one shuts down the engines as one is playing with outflow valves first.

[AVR4000]

Being able to see the engine would make a couple of important differences, especially when it comes to the assessment of the severity of the situation and the following execution of the engine fire checklist with the associated closure of the spar valve and activation of the suppression system would be more prompt. It would also be evident that evacuation were necessary immediately after stopping.

It seems like the whole "slowness" were caused by a lack of cues about the gravity of the situation, which slowed everything down.

[wiggy]

...the report does go on to criticize the actions of the Captain during the evacuation, which doesn't make for good reading either for the Captain or BA's training system.

I thought the report had been out for a while, today’s piece is an update on the final.

Anyhow my internet is playing up so the following comments are based on what I remember reading a few months back, plus some of the comments above.

Firstly and most importantly how often have we been told in the sim or read accident reports ourselves and thought :

“if only they had engaged their brains for a few seconds before moving controls”....

yet here we are in the cold light of day follow a nasty and the investigators and some commentators are running a stopwatch and commenting on timing....

As I recall it the abandon in question happened at fairly high speed. In the time between the fire bell sounding/fire eng EICAS message appearing and the fuel control switch being moved as the third action item of the “Fire Engine ....Checklist” the following had to be done:

The emergency had to be recognised and appropriate action recognised.
The abandon initiated and completed in an orderly manner,
The nature of the malfunction confirmed once stopped,
A decision made as to which checklist(s) to action, that command verbalised.....etc etc

I suspect you get my drift....quantifying the delay in terms of gallons of avtur spilt is interesting but as we know the process is a bit more involved than: fire bell/slam brakes on/ whack a fuel control switch to cutoff...

As has been said the flight crew got no info from ATC as to the seriousness of the fire. As I recall it and as I heard it elsewhere the captain only found out how bad things were when the relief First Officer went back into the cabin, saw the situation and either contacted the flight deck by inter phone or returned to the flight deck to pass the message directly. Can anyone confirm or correct that?

As for the evac checklist - it is a “fair cop” that for whatever reason it wasn’t actioned in a text book manner ( I think at the time of this accident it was a recall checklist, with a Boeing version on the yoke as a back up, and the BA version on the back of the paper QRH/in the ECL.)

Nevertheless the evac was successful....

The team here will however be pleased to know that the evac checklist BA use on it’s T7s have been completely rewritten as a result of this accident. It now it is very definitely a very prescriptive “read and do” involving both operating pilots..and because of that I suspect any stopwatch watchers still won’t be happy if we get around to forensic analysis of a future evacuation of a BA T7.

[lomapaseo]

BA engineer

The reasons for the fire are pretty routine and remedies have already been implemented.

I must have missed that. All my quick scan caught was possible causes, not specific remedies

[Airbubba]

Fly26 Evacuation is a mandatory check-ride item, reviewed to a pass standard by every ATPL captain at least once a year, more likely 4 times. Calling for EVAC with engine(s) running would be a fail on a licence re-validation day.

From the NTSB report:

The captain commanded the evacuation (step three in the evacuation checklist) before calling for the evacuation checklist and performing the first two steps in the checklist. Step two of the evacuation checklist instructs the captain to shut down both engines. The left engine was shut down as part of the engine fire checklist, but the right engine continued operating for about 43 seconds after the captain's evacuation command. The unusual attitude of two slides (the 3R and 4R slides) resulted from the jet blast coming from the right engine while it was operating.

The captain did not use the QRH to read and do his evacuation checklist items. The right engine was shut down after the relief pilot noticed EICAS indications showing that the engine was still running. Also, the captain's call for the evacuation checklist occurred after the relief pilot stated that the checklist needed to be performed. (The first officer had stated, just before the relief pilot, "we haven't done the engine checklist," but he most likely meant the evacuation checklist.) Because the captain did not follow standard procedures, his call for the evacuation checklist and the shutdown of the right engine were delayed.

Years ago evacuation was a many item memory drill checklist. Over time it morphed into a do-list with few or no memory items.

Some outfits took memory items to an extreme I'm told. A friend who upgraded to captain at Air Canada a couple of decades ago claims that he had to memorize all of the emergency checklists for the DC-9 even if the items weren't boldface or boxed for emphasis.

I've flown with folks who tried to impress me with their mental abilities by doing normal checklists from memory (and then sometimes messing them up :ugh:).

Here's the pertinent BA Evac checklist from the NTSB report:

Evacuation Checklist

The British Airways B777 FCOM QRH, dated June 2012, stated the following regarding an emergency evacuation: "The Captain will decide if an evacuation is necessary. Whenever an evacuation is required, the Evacuation Checklist must be used. The aircraft will be brought to a halt and the parking brake will be set." The QRH also stated, "all other checklists will be stopped. The Evacuation Checklist is independent of other non-normal checklists."

The evacuation checklist procedure, dated June 2013, was provided on the back cover of the QRH. The checklist detailed the responsibilities of each pilot if an evacuation was needed, which were as follows:

CAPTAIN

1. PARKING BRAKE.……………………………….……………………...…..Set

2. FUEL CONTROL SWITCHES (both).……………………………......CUTOFF

3. PA………………………………………………………. "This is an Emergency.

Evacuate, Evacuate (Hazard at ___)"

4. EVAC COMMAND switch……………………………….………….………ON

5. Notify ATC/Ground crew of evacuation.

FIRST OFFICER

1. OUTFLOW VALVE switches (both).…………………………………...…MAN

2. OUTFLOW VALVE MANUAL

switches (both) …………………………………………………...Hold in OPEN

until the outflow
valve indications show fully
open to depressurize the airplane

3. Engine fire switches (both)………….…………………………………..…PULL

Warning! Do not pull the ENGINE FIRE switches before the FUEL CONTROL switches are in the CUTOFF position.

4. APU fire switch…………………….……………………….…Override and Pull

5. If an engine or APU fire warning occurs:

Related fire switch………………………….……………Rotate to the stop

And hold for 1 second

[flyboyike]

If a situation had not reached the point of evacuating yet(which it seemd to be during the initial stages of the event), wouldn't one perform the memory items for an engine fire first which would hopefully get the fuel shut off fairly quickly and then call for the appropriate checklist(ie engine fire or evacuation checklist depending on which route one has decided to take).

You tell us, you're the 777 Captain around here.

[Father Dick Byrne]

Unusually commendable work by the NTSB. Too often, poor flight crew performance is omitted from ‘reports’, and previous BA events have lacked adequate exposition in this regard.

[BAengineer]

BA engineer



I must have missed that. All my quick scan caught was possible causes, not specific remedies

Well the remedy for the disk failure was increased inspection criteria for the web area of the disk. I would agree it doesn't 'fix' the basic cracking issue but it allows any defects to be caught before catastrophic failure of the disk.

[lomapaseo]

Well the remedy for the disk failure was increased inspection criteria for the web area of the disk. I would agree it doesn't 'fix' the basic cracking issue but it allows any defects to be caught before catastrophic failure of the disk.

Unless they can attached this to a lifing issue (wear out mode) simply saying look at it some more, may not address causes associated with maintenance or abnormal operation which are not covered in repetitive inspections..

[DCThumb]

Why do checklists always put the WARNING after the item on the list they are warning you about?
Surely better to put it first? We have a number like this on our aircraft!

[wiggy]

Fair point, FWIW on actual 777 documentation any Warnings are highlighted much more clearly than in the pure text version pasted above, and I’ll reiterate my earlier comment that the current BA 777 evacuation checklist is structured completely differently from the one pasted above/current at the time of the LAS accident.

[His dudeness]

Unusually commendable work by the NTSB. Too often, poor flight crew performance is omitted from ‘reports’, and previous BA events have lacked adequate exposition in this regard.

Not my impression. Which accidents/incidents you took this conclusion from ?

[SLF3]

One can't help but suspect that if this had been an Emirati or Chinese crew some of the posters on here would be adopting a slightly more critical stance........

[nomorecatering]

I noticed on the Checklist it says shutdown the engines with the fuel cutoff switches & only then the firewall cutoff switches. Do not shut down the engine with the firewall shutoff valves. Why is that.

[ShotOne]

"Fuel control switch, spar valves, fuel cutoff switch, firewall cutoff switch, firewall shutoff valves..." For those of us on other types trying to follow, could we stick to some sort of standard terminology please.?

[wiggy]

OK.......since you ask....the below is taken from the current Boeing 777 FCOM, if you disagree with the terminology that follows I suggest you take it up with the likes of tdracer.

”Fuel Control Switch”- (situated just aft and below of the thrust levers)

When placed to “CUTOFF “

closes the fuel valves
removes ignitor power
unlocks the engine fire switch.
”Engine Fire Switch” (situated on centre pedestal aft of Fuel Control Switches)

When pulled:

arms both engine fire extinguishers


closes the associated engine and spar fuel valves


closes the associated engine bleed air valves


trips the associated engine generators off


shuts off hydraulic fluid to the associated engine–driven hydraulic pump


depressurises the associated engine–driven hydraulic pump


removes power to the thrust reverser isolation valve.


Rotate to position 1 or 2 – discharges the selected fire extinguisher into the engine.

If I recall the techy stuff correctly the reason for the emphasis in the evacuation checklist on operating the Fuel Control switches before operating the fire switches harks back to the Hatton Cross accident where it was discovered that on some aircraft in some mod states in some circumstances (!!) the spar valves would fail to close if the fire switches were pulled before the fuel control switches were placed to cutoff. I think at Hatton X they ended up with fuel p***** out all over the place until spar valves were manually closed by some brave souls in the emergency services or some brave engineers.


As an aside I note that it seems some think not enough opprobrium is being heaped on the LAS Crew....I haven’t seen anyone here being uncritical of at least some of the crew actions in the LAS case, so I have to ask is there a standard amount of ***** we are required to chuck at crews post accident, or is it a sliding scale dependent on airline?

[Centaurus]

Having observed the laborious and time consuming delays by some crews in the simulator finding the right page in the QRH for Evacuation. Then reading going through each item step by step before finally reaching the part where the captain says "EVACUATE", I really get concerned that time is running out and the passengers are still strapped into their seats. With no shortage of real life examples of fire breeching the cabin and associated toxic heat and smoke overcoming those trying to get out, I firmly believe the former Recall or Memory Evacuation checklist was safer overall. We know that deadly mistakes were made in some accidents where the Memory items were inadvertently omitted and that was the rationale for Boeing and other manufacturers to conduct a Read and Do checklist policy. BUT as a captive audience member jammed in my window seat and the smoke rolling towards me while on the flight deck someone flipping the pages of a QRH that tell the crew what to do next, I would prefer they take the risk of a missed Memory item but just get me out of there fast.
I am aware that research has shown the Read and Do Evacuation checklist is the safest option, but I still prefer to have my crew whipping through a Memory checklist and giving passengers a better chance of survival. Illogical maybe, but a gut feeling nevertheless.

[JammedStab]

I think there was a 707 engine fire years back at the same company that was not completed. Fatal results.

[AVR4000]

Some information would help the crew:

1. A report from ATC that flames and smoke are visible when the "stopping" call were made or independent from it (this would help a crew to understand the gravity of the situation where they are unable to see it for themselves).

2. The ability to view the engines from the flight deck (camera surveillance) in order to understand the situation immediately after the bang and engine failure.

The decision to evacuate must be based on information about the conditions outside (and inside) the aircraft and I don't think a fire warning is enough to reach such a conclusion (what happens if said warning goes out because the fire suppression system did its thing and the fire was extinguished?).

Making an automatic connection between a fire warning AND evacuation, i.e. that the latter is the default action simply because of the former doesn't feel like an optimum solution.

I understand the captain and his surprise that ATC didn't tell him about the fire (which is common during other fire events such as American 383) when they reported "stopping". It would be pretty logical to assume some attention from that direction when an aircraft report "stopping" shortly after commencing take-off.

The mindset of this crew seem to be "engine failure with fire warning" rather than "catastrophic engine fire" with the associated need for prompt evacuation after coming to a complete stop. Keeping the other engine running indicate a mindset about vacating the runway and that the issue were more of a technical "glitch" rather than a potential disaster.

It looks like this event were linked to a lack of appropriate information, which slowed the whole decision process followed by a rush to get things done (thus the start of evacuation with the no 2 still running).

A simple "Speedbird 2276, you have fire on your left side, repeat fire on your left side, fire crews are being dispatched" from ATC would have assisted the decision making here. It is actually pretty surprised that no call to that effect were being made (compare it with the American 383 and British Airtours 28M).

[Meikleour]

JammedStab: I think you are referring to the BOAC B707 which dropped an engine into the Staines reservoir and made a successful landing back at LHR on the then runway 05. Showing my age here! The 707 in those days had separate LP and HP fuel valves, the former on the engineer's panel - and yes, that item was missed but resulted in valve position lights being retrofitted to the aircraft to obviate a recurrence. More modern types combine the two valves functions.

[BitMoreRightRudder]

As an aside I note that it seems some think not enough opprobrium is being heaped on the LAS Crew....I haven’t seen anyone here being uncritical of at least some of the crew actions in the LAS case, so I have to ask is there a standard amount of ***** we are required to chuck at crews post accident, or is it a sliding scale dependent on airline?

Well it is Pprune Wiggy, the arm chair squadron chief training standard Air Marshall Commodores are always poised ready to educate us all. And it is entirely airline dependant. If a BA crew stuff up the green eyes brigade are always out in force with their armchair dwelling brothers.

This incident wasn’t an optimal crew performance, but when such s**t happens in real life, I can’t imagine much is all that optimal to our colleagues who end up having to deal with it. A lot of people analyse events from the comfort of their keyboard and think back to their last sim - “well I dealt with it much better”.

Yeah. In a simulator.

[DaveReidUK]

JammedStab: I think you are referring to the BOAC B707 which dropped an engine into the Staines reservoir and made a successful landing back at LHR on the then runway 05.

50 years ago ...

[sudden twang]

Wiggy are you a TC? Very good posts.
Lets not lose sight of the proximate cause of this incident,the engine failed. I’m not entirely sure where the blame if any lies for that but it certainly wasn’t with the captain. He just happened to be in the wrong place at the wrong time.
The fact that everyone survived is testament to a job done well enough.
Some of the cabin crew btw were faced with a v difficult situation. It was perplexing, time critical and dangerous. They paused considered risk v benefit then actioned their tasks effectively. Very impressive.

[sudden twang]

and previous BA events have lacked adequate exposition in this regard.
Not sure what incidents you are referring to but there have been a number of events where BA flight crew have saved the day in complicated scenarios:
747 double eng fail
747 volcanic ash
747 slats retracting from JNB
737 rudder hard over
777 loss of thrust ( capt BA38 saved that one)
747 en rte NBO ROD 29,000fpm recovered single pilot at night didn’t pop a rivet
A320 loss of all airspeed indications
i could go on.

[wiggy]

Wiggy are you a TC?

I’ve been a ‘Trainer”, but not with my current outfit..

Don’t think I’ve ever read an accident report ever, regardless of Airline/operator were there has been nil criticism /observations of the crew actions...and I include some of the high profile “hero status” accidents...

In the LAS case I don’t think anyone (inside or outside BA) has ever claimed the evacuation checklist was actioned in an optimal manner....

Comparing incidents on the line with sim performance and timings - Sim performance is the “ ideal”, and it darn ought to be good, after all you know it’s coming somewhere during the recurrent..... in the real world plug into the mix startle factor, touch of fatigue/midnight on the body clock, less than forthcoming comms from external observer (cf. AVR4000’s excellent post about the crews mindset initially and the subsequent need to change it.) there’s scope for erosion..there’s something about plans of campaign not surviving first contact with the enemy that might be appropriate...

[groundbum]

the middle part of the SULLY movie spent all its time with the NTSB and others wondering why he didn't just land at any of the nearby airfields...

Maybe they should change sim sessions so you're in there for 2000+ hours then suddenly pull a scenario. Then see how perfect the drill is..

G

[AVR4000]

I’ve been a ‘Trainer”, but not with my current outfit..

Don’t think I’ve ever read an accident report ever, regardless of Airline/operator were there has been nil criticism /observations of the crew actions...and I include some of the high profile “hero status” accidents...

In the LAS case I don’t think anyone (inside or outside BA) has ever claimed the evacuation checklist was actioned in an optimal manner....

Comparing incidents on the line with sim performance and timings - Sim performance is the “ ideal”, and it darn ought to be good, after all you know it’s coming somewhere during the recurrent..... in the real world plug into the mix startle factor, touch of fatigue/midnight on the body clock, less than forthcoming comms from external observer (cf. AVR4000’s excellent post about the crews mindset initially and the subsequent need to change it.) there’s scope for erosion..there’s something about plans of campaign not surviving first contact with the enemy that might be appropriate...



I think all videos of this event including the in-cabin ones where the "All passengers, please remain seated" shows a crew that try to assess the situation. They knew they had an engine failure and yes, a fire warning came on after a few seconds but they had no idea due to a lack of information that there were a fuel leak and severe fire between the fuselage and engine 1.

The lack of ATC information also made it "less urgent". My own mindset would be like:

"OK, we have an engine failure, fire warning came on but we did the suppression already and NO INFORMATION from ATC when we stopped either so it's a failure and we will taxi clear of the runway in a few minutes so engine 2 can be kept running."

The lack of an ATC call would certainly give the impression that NO FIRE could be seen. It is reasonable for a crew to expect a call about visible flames if there are any, either from ATC as a reply to their "stopping" message or by other aircraft in the vicinity or a combination. This crew acted pretty much the way it could be expected from a lack of appropriate information, i.e. "keep the engine running for taxi, assess the situation and taxi clear of the runway when things are checked".

It could even have been that way that the crew did decided to taxi clear of the runway before stopping due to their mindset under the circumstances (lack of radio calls about fire could very well produced a mindset of getting clear, especially if a taxiway were in a convenient location as they slowed down).

The focus should be on providing pilots with tools for situational assessment, i.e. the ability to know the environment outside the aircraft and make appropriate decisions based on such knowledge. It is pretty natural to consider "taxi clear" or even "taxi to gate" after an engine failure, both due to the risks of evacuation but also for passenger comfort.

Evacuation can't be the "supposed default action" just because of an engine failure, i.e. that the absolute first thing that should be done is the evacuation checklist immediately after stopping on the runway without any other information than "engine failure, fire warning came on a few seconds later".

A camera located in front of the nose gear (showing the landing gear and engines) and another one on the tail (showing the engines, wings and top of the fuselage) would provide all information needed, right away. The most appropriate course of action would be:

1. Engine failure or fire - throttle to idle, fuel cutoff, ignition off, fire handle pull
2. Assess situation (using the camera system and other sources such as ATC)
3. If serious fire: Evacuation checklist, shut down remaining engines
4. If minor failure: Keep other engine running, taxi clear of the runway when appropriate

If step 1 and 2 happens at the same time (i.e. the crew knows about the fire already while they are braking) - evacuation checklist immediately when the aircraft comes to a complete stop.

I can't blame the BA2276 crew for their attempts to assess the situation rather than just ordering evacuation when they had no idea about the conditions (it is pretty evident that their first clue were the visible smoke rising above the fuselage and it took a while before it happened since the plume was dynamic during braking and the major development started after they had stopped, this is also visible on the in-cabin video). It shows the aircraft accelerating normally, suddenly it shudders heavily but nothing particular is seen first, they stop and after a couple of seconds black smoke rises in front of the wing and the callout "Ladies and gentlemen, please remain seated" can be heard.

The crew couldn't see anything particularly amiss until the smoke become visible and the lack of ATC information certainly did slow them down.

Even the American 383 did show a bit of the mindset issue when the number 1 was running when the doors opened (seems like the pilots also thought about taxiing clear of the runway). It is very audible that the engine is idling when the first passengers went out of the L1 door before it spools down and stops.

It is appropriate to arrange ways for a crew to get the information needed to do a prompt evacuation decision when needed.

There is another video of BA2276 commencing take-off where the engine failure can be seen and it doesn't look dramatic at first; it is possible to see smoke being emitted but the aircraft slows down and stops without something that would indicate the need for immediate evacuation. The fierce fire became visible after stopping when the plume became static and the fuel started to flow onto the runway.

Edit: It is pretty interesting to notice that even when they called "Speedbird 2276, mayday, mayday, request fire services" - there was still no information from the ATC regarding fire despite the smoke now being way more serious. When they made their mayday call a decent exchange of information would have been: "Speedbird 2276, fire services are on their way, there's a lot of smoke on the left side of your aircraft".

If I would see an aircraft on fire like that I would certainly call the crew and report it, especially when it is pretty evident from the lack of evacuation AND one engine still running that they don't really understand the situation.

It is almost painful to hear the lack of fire communication from ATC in this case, it is like crew were "expected" to figure everything out on their own. It is pretty clear that ATC saw what's happened since they started to issue go-around commands and closed the runway but not a single word about the fire being serious.

Since the fire was located between the engine and fuselage, such information is important since looking out of the flight deck windows would produce a "normal" view of the wing, without anything amiss.

[Father Dick Byrne]

A weakness of the DODAR structure favoured, I understand, by BA, is that ‘diagnose’ must follow the absent ‘gather’...

Regarding ATC: Controllers are warned not to interrupt flight crew who may be busy, but always stand ready to answer an enquiry. If the commander needs information about the state of his aircraft it is entirely his responsibility to seek it, whether that means opening the window and looking out, asking the cabin crew, or asking ATC.

This is not the only recent high-profile BA event in which the commander has not sought the necessary information as diligently as he should have done, in my opinion, and it’s one of the reasons why I favour other operators when travelling.

[wiggy]

Father D B

T-DODAR is a favoured structure by some in BA for some non-normals, in some circumstances..pattern matching and rule based decision structures are allowed, as is Airmanship/common sense.... ..

If the commander needs information about the state of his aircraft it is entirely his responsibility to seek it, whether that means opening the window and looking out, asking the cabin crew, or asking ATC.

This is not the only recent high-profile BA event in which the commander has not sought the necessary information as diligently as he should have done, in my opinion, .

I take it in gathering information to form that opinion you read the full NTSB report on the accident in which it states that after the aircraft stopped the Relief F/O looked through a flight deck side window, saw a shadow of what he thought might be that of smoke, reported that fact and the basis of that information the same First Officer was dispatched aft by the captain to gather information on what was visible from the cabin?

[Father Dick Byrne]

wiggy,

I’m assuming you read the words ‘Regarding ATC...’ in my post immediately above..?

You may rest assured I’m acutely aware of the NTSB’s report.

[suninmyeyes]

I do not know if Father Dick Byrne is a troll or whether he just has a very poor grasp of flight deck procedures, air traffic procedures and what actually happened on that day in LAS.

DODAR would not have been an appropriate tool for that situation and was not used.

As for “Controllers are warned not to interrupt flight crew who may be busy,” I think any controller reading this would tell a pilot that they could see flames if they thought the pilot was unaware, even if they knew they would be busy.

As for the safety record of the airline concerned. If I am correct their last long haul fatal accident was as mentioned a Boeing 707 almost 50 years ago where 4 passengers died. A brave stewardess who went back into the smoke to try to rescue them also died. I wonder if all of the other long haul operators Father Dick Byrne apparently favours have been operating since that time without any fatal accidents too.

[wiggy]

F D B

:=

I read what you wrote about ATC..I also read what you wrote about information gathering from other sources.

So at LAS - “Mayday” declared, including the fire word, all called on R/T. You are right, he didn’t specifically ask ATC if they could see flames but Lord, it’s hard to be perfect sometimes..

After the call the Captain isn’t sat on his backside doing nothing, he attempts to gather information by dispatching the relief F/O into the cabin, who sees what is going on and reports back .. on the basis of that information decision is made to evacuate.

Despite or due to all the above you effectively give the entire Airline a “fail” on the basis that according to you there is a pattern of information not being diligently gathered..quite how you know about all the times there are non-normal events on BA flights where information is diligently gathered I don’t know.

Ultimately of course it is your opinion, however I think it is only fair to ask which perfect airline(s) you are prepared to fly on, so in future we can all carry out forensic analysis on their incident/accident reports.

[Emma Royds]

A weakness of the DODAR structure favoured, I understand, by BA, is that ‘diagnose’ must follow the absent ‘gather’...

Regarding ATC: Controllers are warned not to interrupt flight crew who may be busy, but always stand ready to answer an enquiry. If the commander needs information about the state of his aircraft it is entirely his responsibility to seek it, whether that means opening the window and looking out, asking the cabin crew, or asking ATC.

This is not the only recent high-profile BA event in which the commander has not sought the necessary information as diligently as he should have done, in my opinion, and it’s one of the reasons why I favour other operators when travelling.

Give me prior warning to duck before the handbag goes flying over my head! :E

[Banana4321]

I would have thought that it is both possible and useful for a single "EVAC" button to perform the required cutoffs and fire extinguishers and therefore eliminate the need for (most of) the Evacuation Checklist (or a significant part thereof). We live in an age of technology. Non?

[Geragau]

To think that initially the nigels came in droves to praise their crew sky high to the stratosphere. They must be cringing now. Well, their saving grace...the limelight is not on the incident anymore, everyone has forgotten.




The NTSB report into the engine fire at Las Vegas in 2015 has now been released. The reasons for the fire are pretty routine and remedies have already been implemented.

However the report does go on to criticize the actions of the Captain during the evacuation, which doesn't make for good reading either for the Captain or BA's training system.



Full report available at www.ntsb.gov

[Father Dick Byrne]

I do not know if Father Dick Byrne is a troll or whether he just has a very poor grasp of flight deck procedures, air traffic procedures and what actually happened on that day...

You have no idea how far wrong you are, in those words and the rest of your post.

Because this has gone from professional to personal, I’ll take no further part.

[tdracer]

I would have thought that it is both possible and useful for a single "EVAC" button to perform the required cutoffs and fire extinguishers and therefore eliminate the need for (most of) the Evacuation Checklist (or a significant part thereof). We live in an age of technology. Non?

Are you seriously advocating a single button that would shutdown all the engines? You don't see a problem with that?

[Capn Bloggs]

It is almost painful to hear the lack of fire communication from ATC in this case, it is like crew were "expected" to figure everything out on their own. It is pretty clear that ATC saw what's happened since they started to issue go-around commands and closed the runway but not a single word about the fire being serious.
I agree. I'm sitting there trying to work out what is going on. What do you guys want, everybody to be polite and stay quiet until I ask? The aeroplane's majorly on fire, FFS ATC should keep calling me until I respond! "BA, there's a large fire underneath your centre fuselage!". "Tell ATC to be quiet, I'm busy", while I continue to "Diagnose?". I don't think so.

Are you seriously advocating a single button that would shutdown all the engines? You don't see a problem with that?
Put it on a squat switch. What could possibly go wrong? :{

The relief pilot told a cabin crewmember to get ready to evacuate and, after returning to the flight deck, stated (at 1615:50), "doesn't look good to me." Also at that time, the CVR recorded a sound similar to the interphone (a call from the cabin to the flight deck), which was not answered.
Methinks that should be 1613:50.

Video again, for a refresh...
https://youtu.be/tfeKuX0CtXA

[RatherBeFlying]

The cabin crew and passengers were very much aware, but it took a long time for the flight crew to receive the information.

The announcement "Remain seated" while a fire is obviously increasing by leaps and bounds only communicates that the flight crew is unaware of the fire. Had they been aware, the announcement would have been "Evacuate".

[pax britanica]

Isnt it about time that airliners were fitted with video cams that focussed on key areas of the aircraft . Aviation seems to prefer indicators over reality as this technology ha been around for a few years, I know that anything fitted to an airliner cost 20 times as muchas the same thing fitted toa car and understand why but in the circumstances and many others where there is airframe damage out of sight from the flight deck is it too much to spend ratehr than relying on EGT indications and fire 'sensors'

if you spent $!00m plus ona building you would surely have some cctv in there but not it seems on a plane.

As to this incident , from a pax POV then I think the crew did pretty well, they functioned as a crew for a start despite the captain fast tracking a checklist item and as has been often said its all very well having procedures and following them but when the sh-t really hits the fan right in front of you then you may decide to act ina slightly different but still logical way and the key thing is the aircraft stopped quickly and safely , fuel was contained-not ideally but contained and the everyone got out quickly and safely. It struck me in the Sully film how much time the feds spent trying to prove that eh could have landed , well maybe he could if he had headed for Teterboro the same second the first goose struck -ignoring shut down and restart processes of course and . A lot of Monday morning quarterbacking on these issues -whats next VAR for the flight deck LoL

[mickjoebill]

At the pull and twist of a handle, the worlds most tested computers can’t be trusted to “make safe” an aircraft for evacuation, once it’s come to a stop?

mjb

[AVR4000]

The lack of ATC information can be summarized using a couple of screenshots from the airport security camera and should make it pretty evident why they should have updated the crew.

https://cimg2.ibsrv.net/gimg/www.gmforum.com-vbulletin/846x437/6xpefxb_7b2f689fecdc7ed22372890a20117055bc5a8b0e.png

This is the point of engine failure and the beginning of the event.

https://cimg0.ibsrv.net/gimg/www.gmforum.com-vbulletin/845x434/djf7ouo_24ddd97bf579b8010e2550226c2133661534f72c.png

The fuel ignites a few seconds later, take-off is now aborted and the aircraft starts to slow down.

https://cimg2.ibsrv.net/gimg/www.gmforum.com-vbulletin/845x436/og88lbt_5036072c5491bfc723152ab6f60a5cd0736ecba1.png
The fire is now more intense and things start to get serious. No ATC calls has been made yet since it is just a few seconds after the initial event.

https://cimg6.ibsrv.net/gimg/www.gmforum.com-vbulletin/321x157/gtmezmf_5a80a978930771310afe0a2a1c888604efaeb73c.png

This is the situation when the crew transmit "Speedbird 2276, stopping". This is the first time where an ATC reply would be expected AND to those who make the argument about "ATC shouldn't disturb the crew" - this is when the latter *is* contacting them reporting that they abort take-off. The situation is pretty evidently bad AND the lack of any more comment from the pilot such as "Speedbird 2276, stopping... (pause) we have an engine fire" is a clear indication that they are unaware of the serious fire.

ATC should have replied "there's a lot of smoke and visible flames on the left side of your aircraft" at this time and it is pretty evident just by looking at the picture.

https://cimg8.ibsrv.net/gimg/www.gmforum.com-vbulletin/843x435/b16qrwy_e5d985c05b2bb2bce94d319fab9a1f11a2db6652.png
This is the situation when the crew transmit "Speedbird 2276, mayday, mayday, request fire services". This is the second occasion when ATC should have told them that they have a serious fire on their left side and a lot of smoke.

https://cimg2.ibsrv.net/gimg/www.gmforum.com-vbulletin/843x420/eaauxrs_de7cb0a885624a6be02d96924aaad75c3177cbd6.png
This picture is from the point in time when ATC reply "fire services on their way" and that they didn't add any information about the fire and smoke is pretty baffling indeed.

An appropriate ATC exchange between Speedbird 2276 and themselves would have been something along the lines:

BA2276: "Speedbird 2276, stopping."
ATC: "Roger, Speedbird 2276, there's smoke and flames on the left side of your aircraft."
BA2276: "OK, standby" (from Speedbird 2276)
BA2276: "Speedbird 2276, mayday, mayday, request fire services!"
ATC: "Fire services are on their way, there's still a lot of smoke and fire on your left side."

The other version would be:

BA2276: "Speedbird 2276, stopping."
BA 2276: "Speedbird 2276, mayday, mayday, request fire services!"
ATC: "Roger, Speedbird 2276, fire services are on their way, there's a lot of smoke and flames on the left side of your aircraft, they are on their way now."
BA2276: "OK, standby"

We can compare it with the 1985 accident in Manchester and the ATC exchange. This image says it all:

https://cimg3.ibsrv.net/gimg/www.gmforum.com-vbulletin/500x336/qgluzem_9550736da067e5b28efd121daec38d656667ab71.jpg
This is British Airtours flight 28M during their abandoned take-off and the picture was taken at approximately the same time as their information exchange with ATC:

KT28M: "28 Mike, we're abandoning take-off.... (pause, fire warning comes on) it looks as though we've got a fire on the number one."
ATC: "Right, there's a lot of fire, they are on their way now."

This information enabled the captain to tell the cabin "Evacuate on the right side please" and also placed him and his F/O in the appropriate mindset regarding shutting down the remaining engine and get going with evacuation immediately after stopping.

So yes, ATC should convey information to a burning aircraft when the crew contact them. Kindly notice this - "when the crew contact them". It is appropriate to report visible smoke and flames when the aborted take-off is reported (it means that the crew is in the "communicate" stage of aviate, navigate, communicate) so replying with information about the situation is appropriate.

I am pretty sure that the situation in Manchester would have been even worse than it became *if* ATC hadn't told the crew about the fire. It is probable that they would have stopped with the number 2 still running, trying to assess the situation before finally ordering evacuation (or that the cabin crew had initiated it before the engine had been shut down due to the rapidly deteriorating conditions in the cabin).

So a combination of improved possibilities for the crew to assess the situation (cameras) and relevant ATC information during the "communicate" stage is the best course of action.

[AVR4000]

At the pull and twist of a handle, the worlds most tested computers can’t be trusted to “make safe” an aircraft for evacuation, once it’s come to a stop?

mjb

It doesn't work that way since such a system would have to perform a couple of things:

1. Set parking brake.
2. Shut down the remaining engine(s).
3. Close the fuel supply to the engines.
4. Operate the fire suppression system if needed (such as when fire warning is still on after the first shot have been fired into the engine).
5. Depressurize the cabin.

The next question is when this system should kick into action? Is it when an engine failure is detected (a failure would be defined as sudden rpm drop, loss of thrust, reduced burner pressure, overheating, fire indication etc)? It must be able to distinguish between an "engine failure" and a "catastrophic fuel-fed fire" since the need to evacuate arise in the latter case but not the former.

The question is how the system can determine a fuel leak and a fire caused by it unless a sophisticated set of sensors paired with a computer system can figure out that "X amount of fuel is flowing but the engine is shut down" or "the amount of fuel pumped out of the tank is higher than the amount of fuel received on the engine end". I.e. the fuel is flowing at a normal rate from the tank but the engine failure caused the line to separate so it is flowing out on the tarmac rather than into the right place.

An over-automated aircraft relying on artificial intelligence (i.e. the decision-making is now transferred to the machine itself and different systems operate in specific ways on different events) would be less safe since the automation would require very exact, reliable input from multiple sources in order to make appropriate decisions such as shutting down engines immediately when the speed hits 0 after an abandoned take-off.

Even a manual "evacuation switch" that shuts down the engines, close the fuel-supply, depressurizes the cabin and everything would require pretty complex co-operation across different systems without adding any particular benefit but rather increase risks if something doesn't work in the process.

The normal evacuation checklists are OK, the thing is to convey information to the crew so they can make a quick, informed decision whether an evacuation is necessary or not.

[BAengineer]

At the pull and twist of a handle, the worlds most tested computers can’t be trusted to “make safe” an aircraft for evacuation, once it’s come to a stop?

mjb

Well the only real thing you have to make safe is to stop both engines - on the 777 that is a matter of flicking 2 switches. I dont see that adding yet another way of shutting down is really needed.

[tdracer]

At the pull and twist of a handle, the worlds most tested computers can’t be trusted to “make safe” an aircraft for evacuation, once it’s come to a stop?

mjb


Any switch that has the capability to shut down both (or all) engines has a failure mode that will do exactly that when it shouldn't. As I wrote before, do you really thinks its a good idea to design in a failure mode that will cause the loss of all engines?
It would also violate a several FAR/CSs...
Heck, even with the action of two, independent switches required to shut down both engines, there have been at least two cases when the pilots shut down both engines in-flight when they meant to do something else...

[back to Boeing]

Any switch that has the capability to shut down both (or all) engines has a failure mode that will do exactly that when it shouldn't. As I wrote before, do you really thinks its a good idea to design in a failure mode that will cause the loss of all engines?
It would also violate a several FAR/CSs...
Heck, even with the action of two, independent switches required to shut down both engines, there have been at least two cases when the pilots shut down both engines in-flight when they meant to do something else...

adding to that. One of the basic tenants of aviation safety is redundancy. Where is the redundancy in one switch killing off everything

[Cloudtopper]

Where are the initial posters , back in 2015 , saying this was well handled .....

[ROKNA]

The ATC tape clearly show both ATC and 777 getting stepped on while trying to each tell the other there was a problem

The tower was getting a Delta to go around having seen the smoke from the 777, the Delta really dragged out the RT

Plenty of youtube clips capture it
https://www.youtube.com/watch?v=XiNwbTsOpPg

[Yaw String]

Lots of discussion on whether the crew received information on the true nature of their dilemma.
I think one of the most difficult decisions can often be,"do we need to evacuate",however...once the decision has been made,it is a " read and do" procedure. I believe this to be the case in most airlines in the World.
The boss didn't "read and do"..
shouldn't this be the crux of the discussion!
Maybe he didn't have quick access to the Evacuation Checklist ...either electronic or paper...

[wiggy]

..once the decision has been made,it is a " read and do" procedure. I believe this to be the case in most airlines in the World.
The boss didn't "read and do"..
shouldn't this be the crux of the discussion!
Maybe he didn't have quick access to the Evacuation Checklist ...either electronic or paper...







FYI and for obvious reasons procedures have changed but as vaguely recall it at the time of the accident at BA the evacuation checklist was not a mandatory “read and do”, it was done from memory but it was available on the back cover of the QRH and on the yoke clip (though that version did not contain the warning about Fuel Control switch operation).

The Electronic Checklist occults once the Fire Switches are pulled so is not used for that checklist.

[sudden twang]

Wiggy,
i think the read and do came in way before this event. The checklist was amended at some point to make the yoke checklist non SOP. I agree with everything else’s that you’ve said. 👍
And as for the CRUX of the matter surely it’s why the capt had to reject the take off in the first place. It was a latent system failure that made it necessary to initiate the evacuation
Whichever way you look at it everyone got off safely. Good maybe, good enough definitely.
Gone are the days when an evacuation was as easy as ABCDE. A aircraft stop B brakes set C cut off fuel to engines and APU D depressurise E evacuate.
Its likely that had the crew gone against SOPs and moved the fuel control switch to cut off during the deceleration then this event would have had a better outcome. However I very much doubt any airline would advise this for v g reasons.

[wiggy]

Sudden Twang

i think the read and do came in way before this event. The checklist was amended at some point to make the yoke checklist non SOP.

Fair enough... for a long time it was supposedly a checklist done from memory and then if possible the actions checked using the paper QRH...I’ll admit I thought we formally transitioned to “read and do” very shortly after this accident, but that was umpteen iterations of QRH and IPad etc ago so if I haven’t got the timing of the change of procedure correct blame my fading memory.

Yaw String

Wiggy, I agree that the initial crux of the matter was why the event occured.
However,after the final report has been released,I think it is reasonable to be discussing how to,or not to,evacuate successfully.

?? TBH you lost me with that comment, I’m not aware I’m on record as saying we shouldn’t be discussing the evacuation....

[sudden twang]

Nobody was injured in the Singapore inferno,therefore a successful outcome,However,would you have reacted the way they did!

An interesting comparison. Whilst both crews were in the wrong place at the wrong time and the failures were not down to them, nothing the BA Flt crew did exacerbated the fire. The same cannot be said of the SIN crew. Both incidents resulted in all occupants surviving so again good enough.
Train in the Sim to be as perfect as possible then when there is real shock, surprise, Adrenalin etc humans won’t Perform as well but will hopefully be good enough to allow to all to survive.

[42go]

To me, all this kerfuffle about whether ATC told the crew about the fire, how long it took to call an evac, etc etc, are ALL overshadowed by the fact that the Captain initiated the evac without doing the most important action - shutting down the running engine. It was lucky no-one got sucked into the motor. That should be the focus of any criticism here.

[sewushr]

Am I the only one that thinks it odd that BA no longer insist on 'window blinds open' as part of their pre-departure and pre-landing safety announcement (unless they have re-instated it very recently).

It isn't mandatory to include this as part of the briefing, but it is considered by most Safety Regulators to be good practice, and most other airlines I've flown on recently still include it, and are quite insistent that all window blinds are fully open for take off and landing. As an airline that has had more than one incident involving a cabin evacuation with a fire outside the aircraft, I'd have thought it would be prudent to re-instate it.

Apologies if they have done so. I haven't flown with BA for quite a few months, but took several flights with them after the Las Vegas incident and was struck by the fact that it no longer formed part of the safety briefing.

[wiggy]

Sewushr

There’s been a change since you flew - Blinds are required to be up, the cabin crew make an announcement to that effect pre takeoff and pre landing.

To me, all this kerfuffle about whether ATC told the crew about the fire, how long it took to call an evac, etc etc, are ALL overshadowed by the fact that the Captain initiated the evac without doing the most important action -........That should be the focus of any criticism here.

I’d agree that’s tempting but I’m not sure you can do that in isolation...without wishing to sounds uncharacteristically “new age” about this you have to be a bit holistic about this and look at why the checklist wasn’t actioned correctly, not just focus “ criticism” on that fact. Yelling “yah boo, I’m criticising him/the entire Fleet/entire Airline because an evac checklist wasn’t done properly” doesn’t improve flight safety one iota.

There’s been a quite grown up debate about this accident elsewhere on Pprune..interesting observations there: possibly disruptive effect of the “heavy” (verses the sanitised two crew environment that is emulated in the sim), the checklist sequence, and the WTF /almost dislocation/disbelief factor individuals can experience when faced with a really serious emergency, something that is an emotion that you certainly will never get in the sim.

Not saying any of the above “excuses” the checklist being handled the way it was, but I can see why it happened and why similar will happen again. I’ve flown for over forty years, never had a perfect day at work, never flown with a perfect colleague.

[tdracer]

Wiggy, trying not to be critical (and since you appear to be knowledgeable about such things), why isn't the evac check list a memory recall item? An evacuation is almost by definition an emergency, I'd think taking the time to look it up could be critical to the success (or lack there of).
Sure, it wouldn't prevent a startled crew from getting in wrong (although that's what sim training is for - to make it second nature), but the seconds it would save could well save lives.

[svhar]

I’ve flown for over forty years, never had a perfect day at work, never flown with a perfect colleague.

I have flown for over thirty years. Most of my days at work were perfect and most of my colleagues were perfect. I would say well over 90%. Never had to evacuate though. Maybe our thresholds are different.

[RatherBeFlying]

This should be the first checklist item after a reject or landing with engine problems once the aircraft has come to a stop.

Assessing fire status should of course include checking with cabin crew eg. "Flight attendants report airframe condition"

[double_barrel]

I am surprised that there is no comment on the evidence that the cabin crew were trying to contact the cockpit but were ignored as the flight crew focussed on apparently more urgent things. It seems to me that was an opportunity to learn something important that was lost. Perhaps it would help if the cabin crew had a means of indicating a fire with a simple button that would show an indicator somewhere on the instrumentation, that might be more easily integrated into the thinking process while the flight crew is trying to understand a situation.

[Capn Bloggs]

Assess Fire Status...This should be the first checklist item after a reject or landing with engine problems once the aircraft has come to a stop.
Too much potential for dithering, to and fro, "what did he say?" "could you confirm that?" etc etc. Shut it down immediately, fire BOTH bottles, then ask questions.

[wiggy]

I am surprised that there is no comment on the evidence that the cabin crew were trying to contact the cockpit but were ignored as the flight crew focussed on apparently more urgent things..

As I read it (both the narrative and the CVR transcript) the cabin crew made one single attempt at interphone contact at about much the same time as there was a discussion going between the captain and the relief F/O about the gathering of information (;)..) The indication on the Flight deck of an incoming call would have been a short chime...”bing”....(and the first one of our sensory systems that degrades under highworkload/stress is.......) and a latched “ ....call” message on the EICAS, which given the circumstances would perhaps have been one of several messages displayed, some of a more eye catching nature than others ...I can only guess the...”...call” got missed with everything else that was going on....

[framer]

the cabin crew were trying to contact the cockpit but were ignored as the flight crew focussed on apparently more urgent things. I’d bet my bottom dollar the call wasn’t ‘ignored’ , just simply not processed as wiggy alluded to above.

[Jwscud]

Wiggy, trying not to be critical (and since you appear to be knowledgeable about such things), why isn't the evac check list a memory recall item? An evacuation is almost by definition an emergency, I'd think taking the time to look it up could be critical to the success (or lack there of).
Sure, it wouldn't prevent a startled crew from getting in wrong (although that's what sim training is for - to make it second nature), but the seconds it would save could well save lives.

My understanding is it isn’t a Boeing memory item? On the 737 and 777 at 2 different airlines we now work to the Boeing checklist which is as posted up, solely with differences for types. BA used to have it on the yoke of the 777 with separate actions for Captain and FO, but the AAIB highlighted problems with that in the G-YMMM accident. They were then operating using Captain and FO actions from the back of the QRH, and finally after this accident they have gone for the Boeing version as above.

The decision to evacuate is a big one, and one advantage of using the QRH is it is considered and done correctly, rather than the rush that left an engine running in this case. Our training department’s view is that 5 seconds to get the QRH and start reading is preferable to launching passengers into a still turning and burning GE90.

I was trained elsewhere where that simply reading the condition statement on the Evacuation checklist gives you a chance to assess and confirm that you are making the correct decision (that airline had had some over-punchy initiations or needless evacuations).

[JammedStab]

Guys......

According to the report, "While the airplane was decelerating to a stop, the fire warning bell sounded. When the airplane came to stop, the captain called for the engine fire checklist. The third item on the checklist was to move the fuel control switch on the affected side (in this case, the left side) to the cutoff position, which shuts down the respective engine."

Where I work, on this type, there are memory items for this situation which will quickly shut down the engine, cut off fuel and discharge fire bottles. Is it different at BA with only a checklist which can take significantly more seconds to perform?

[back to Boeing]

It is called the fire engine checklist. Which is a full checklist. However the first couple of items are memory items. However to initiate the memory items the PF calls for the appropriate checklist. But that doesn't mean physically grabbing it to perform the memory items.

[JammedStab]

It is called the fire engine checklist. Which is a full checklist. However the first couple of items are memory items. However to initiate the memory items the PF calls for the appropriate checklist. But that doesn't mean physically grabbing it to perform the memory items.

Just to be clear, for this situation at BA one does not call for Memory Items(and then the checklist once the Memory Items are said to be complete) but instead calls for the Engine Fire checklist at which point, the first two items are performed by memory(different to what I am used to).

[Capn Bloggs]

Could someone please post the current 777 Engine Fire QRH procedure?

[haughtney1]

Could someone please post the current 777 Engine Fire QRH procedure?


777 QRH

FIRE ENG L, R

Condition: Fire is detected in the engine

1 A/T ARM switch (affected side) . . . . . . Confirm. . . . . . . . . . OFF

2 Thrust lever (affected side) . . . . . . Confirm. . . . . . . . . . Idle

3 FUEL CONTROL switch (affected side) . . . . . . Confirm. . . . . . . CUTOFF

4 Engine fire switch (affected side) . . . . . . Confirm. . . . . . . . . . Pull

5 If the FIRE ENG message stays shown:

Engine fire switch (affected side) . . . . . . . . . . Rotate to the stop and hold for 1 second

If after 30 seconds, the FIRE ENG message stays shown:

Engine fire switch (affected side) . . . . . . . . . .Rotate to the other stop and hold for 1 second

6 APU selector (if APU available) . . . . . . . . . . . . START, then ON

7 Transponder mode selector . . . . . . . . . . TA ONLY

8 Plan to land at the nearest suitable airport.

 Continued on next page 

Etc etc etc.

Obviously, this checklist assumes amongst other things that the fire is occurring whilst in flight, but the basic tenant of the memory items for an engine fire on the ground are indentical e.g. items 1 through 5.

[back to Boeing]

Just to be clear, for this situation at BA one does not call for Memory Items(and then the checklist once the Memory Items are said to be complete) but instead calls for the Engine Fire checklist at which point, the first two items are performed by memory(different to what I am used to).

not sure how you do it. But having flown several different Boeing types for several different operators. The checklists are exactly the same done in exactly the same order. Just the mouth music is slightly different.

[wiggy]

Blimey reading some of the above this is in danger of getting confusing..I began to wonder if I’d missed something whilst I’ve been on leave.

I don’t know what other Boeing operators do but if you want to know what the BA T7 procedure is IMHO it is the version haughtney1 has posted, and I agree with his/her comment that items 1 to 5 are done from memory.

[Volume]

As you can see in bullet 8, this procedure is for an engine fire in flight. Hence it is not optimized for an engine fire on ground (when fuel can collect and burn close to the fuselage, while in flight it will only affect a part of the wing and the according trailing edge devices) and not optimized to prepare for an evacuation.
Normally there should be two procedures (air/ground). And there should be an engine fire procedure (fire warning while the engine performs normally) and an "catastrophic engine failure procedure" when a bunch of warnings go off at the sime time, the engine stops producing thrust and a loud bang supplements the cockpit indications. But that would of course increase the number of procedures to an unacceplable level...
Having a 30 second wait in the procedure makes it quite unsuitable for a situation like this, when prompt decisions about an evacuation have to be taken, and preparation takes time (spool down of the other engine).

For the concorde crash the engine fire procedure was also not the best one to perform with priority... Although formally there was an engine fire warning, so formally it was the right procedure. Hard to blame the crew.

[haughtney1]

Just to add to what Volume is saying, the point is made by Boeing in the Checklist instructions..e.g. how to use the checklists.

Non–Normal Checklist Operation

Non–normal checklists start with steps to correct the situation. If needed, information for planning the rest of the flight is included. In the printed non-normal checklists, when special items are needed to configure the airplane for landing, the items are included in the Deferred Items section of the checklist. In the electronic checklists, deferred items are automatically added to the end of the applicable normal checklist. Flight patterns for some engine out situations are located in the Maneuvers chapter and show the sequence of configuration changes.

While every attempt is made to supply needed non–normal checklists, it is not possible to develop checklists for all conceivable situations. In some smoke, fire, or fumes situations, the flight crew may need to move between the Smoke, Fire or Fumes checklist and the Smoke or Fumes Removal checklist. In some multiple failure situations, the flight crew may need to combine the elements of more than one checklist. In all situations, the captain must assess the situation and use good judgment to determine the safest course of action.

So in summary, do what you need to do as even Boeing are happy to go into print to say that all things are not black or white.

[M.Mouse]

As you can see in bullet 8, this procedure is for an engine fire in flight. Hence it is not optimized for an engine fire on ground (when fuel can collect and burn close to the fuselage, while in flight it will only affect a part of the wing and the according trailing edge devices) and not optimized to prepare for an evacuation. Normally there should be two procedures (air/ground).

So what would be different in an Engine Fire Checklist (Ground) and an Engine Fire Checklist (Air)? As far as I am aware Boeing do not differentiate.


And there should be an engine fire procedure (fire warning while the engine performs normally) and an "catastrophic engine failure procedure" when a bunch of warnings go off at the sime time, the engine stops producing thrust and a loud bang supplements the cockpit indications. But that would of course increase the number of procedures to an unacceplable(sic) level...

There is. It is called the 'Engine Severe Damage/Separation' checklist.

Essentially the initial actions are the same leading to the Fire Switch being pulled. In the Engine Severe Damage/Separation case the memory items stop at that point. i.e. the fire bottles do not get discharged.

It may have changed since I was with BA but I recall that on the ground the Engine Fire checklist is accomplished for Engine Severe Damage/Separation.

[wiggy]

Open to correction as usual but the teaching now is to do the specific checklist appropriate to the specific malfunction.

[Capn Bloggs]

So what would be different in an Engine Fire Checklist (Ground) and an Engine Fire Checklist (Air)?
On the ground, you get the thing shut down and both bottles into it immediately. No 30".

Boeing doesn't differentiate, yet. The NTSB, in this and another report, recommends a ground fire procedure be developed by the manufacturers and operators.

[JammedStab]

It doesn't matter whether you are in flight or on the ground. Common sense dictates that you do the memory items portion of the engine fire checklist which will do what was required, shut down the engine and cutoff the fuel. Is there any good reason to delay cutting off the fire because item 8 on the most appropriate checklist happens to say land at the nearest suitable airport?

One needs to use some logic. Stop the aircraft, set the park brake, (possibly make some sort of remain seated PA, if that is the company procedure and appropriate for the situation), then the PIC can do the appropriate Memory Items. Once again, use logic as you don't need to select the autothrottle arm switch off, just quickly do the appropriate memory items. All this can be completed in less than 10 seconds from the parking brake being set. Then if evacuation is required, follow that checklist(which can be accessed quickly because Boeing made it on the back page of the paper QRH(in addition to the e-checklist).

Not sure why the engine fire checklist was called for initially. That can lead to delays in the critical first items, especially with some new guy trying to sort through the electronic checklist and making wrong inputs due to rushing/lack of familiarity, etc.

[wiggy]

Not sure why the engine fire checklist was called for.

If we are still discussing the Vegas accident then that was because during the deceleration the crew got an Engine Fire warning (Bell and EICAS message), it's in the narrative section of the report but not mentioned in the CVR transcript.

[Car RAMROD]

On the ground, you get the thing shut down and both bottles into it immediately. No 30".

Boeing doesn't differentiate, yet. The NTSB, in this and another report, recommends a ground fire procedure be developed by the manufacturers and operators.

The only potential issue here (depending on a/c type though, I'm not familiar with all Boeings) is if you have fired both bottles into one engine, then get into the evac checklist and the other engine has caught fire too in the mean time. You've now got no bottle for that one. Incredibly remote possibility, yes, but if the other eng hasn't caught fire at this point you'd be firing the 2nd bottle into the one that was originally on fire anyway, presuming it still had the fire warning.

[Chu Chu]

Wouldn't firing the second bottle immediately just displace the extinguishing agent from the first one (rather than restoring the levels after the first shot has begun to dissipate)?

[Locked door]

Ramrod, each engine has two bottles.

The SOP is to wait 30secs between bottles both on the ground and airbourne, firing them both at the same time is outside of SOP and of questionable benefit.

Fore those that don’t realise, the fire extinguishers only discharge between the engine structure and cowling displacing air, they don’t go into the engine core. One squib theoretically can displace all the air in that space (assuming the cowling isn’t damaged), firing both has negligible extra effect. The 30 sec pause is to allow the first extinguishant to take effect, when air (O2) starts to leak back in the second squib forces it back out again giving 60 secs of full retardant.

[lomapaseo]

The crux of the problem with on-ground fire is the pooling under the aircraft in the presence of winds (not just extinguishers or shutoff valves). In that case you want to get out early. How and when the decision is made is a communication issue. It would seem that eyes outside the cockpit would be a benefit but the decision making then bears looking onto.

[Car RAMROD]

Ramrod, each engine has two bottles.


The T7 has 2 bottles per engine? That'd be nice!
I'm only used to two bottles total- one for each or two can be discharged into one eng if required.

Like I said initially- "depending on a/c type though, I'm not familiar with all Boeings" :)

[JammedStab]

The only potential issue here (depending on a/c type though, I'm not familiar with all Boeings) is if you have fired both bottles into one engine, then get into the evac checklist and the other engine has caught fire too in the mean time. You've now got no bottle for that one. Incredibly remote possibility, yes, but if the other eng hasn't caught fire at this point you'd be firing the 2nd bottle into the one that was originally on fire anyway, presuming it still had the fire warning.


Two bottles total. One would use both bottles and not consider saving one for the other engine in a case like this.

[wiggy]

The T7 has 2 bottles per engine? That'd be nice!
I'm only used to two bottles total- one for each or two can be discharged into one eng if required.

Like I said initially- "depending on a/c type though, I'm not familiar with all Boeings" :)




There is some misleading info creeping into the thread.... - J S is absolutely correct in stating that the T7 (well the one’s In the BA fit) have two engine fire bottles total...sounds like the same set-up/you use the same logic as what you are used to on whatever you fly.

Eeeeh, Mind you, we are lucky these days when I were a lad I flew a twin jet that had no fire extinguishers......:uhoh:

[Volume]

The big question is: Do the bottles do any good if the actual fire is on the tarmac below the engine where the fuel pools...
For me the bottles are totally useless on the ground, and you should concentrate on other things (stearing the aircraft out of the wind so that fire/smoke spreads away from the fuselage, prepare evacuation, instruct cabin crew, instruct rescue services).

If the engine nacelle is breached, the bottles do almost nothing. Just polute the environment...

[wiggy]

Boeing 777/787 FCTM advice on the matter:

Discharging Fire Bottles during an Evacuation

The evacuation NNC specifies discharge of the engine or APU fire bottles if an engine or APU fire warning light is illuminated. However, evacuation situations can present possibilities regarding the potential for fire that are beyond the scope of the NNC and may not activate an engine or APU fire warning. The crew should consider the following when deciding whether to discharge one or more fire bottles into the engines and/or APU:


if an engine fire warning light is not illuminated, but a fire indication exists or a fire is reported in or near an engine, discharge both available fire bottles into the affected engine

if the APU fire warning light is not illuminated, but a fire indication exists or a fire is reported in or near the APU, discharge the APU bottle

the discharged halon agent is designed to extinguish a fire and has very little or no fire prevention capability in the engine nacelles. Halon dissipates quickly into the atmosphere

[AVR4000]

I have a feeling that a couple of posters in this thread miss the point about information. A fire indication doesn't mean "evacuate immediately" so everything starts with appropriate INFORMATION. Shutting down engines and so on are directly related to this very important piece of the puzzle.

Introducing checklists with different ideas such as "always evacuate when a fire indication is present" or "always evacuate after engine failure" or "always shut down all engines if one of them fail/is on fire" and varieties thereof wouldn't produce appropriate results and would lead to unnecessary evacuations based on indications only.

A proper decision to evacuate the aircraft after an engine failure with fire must be based on proper information relayed through a couple of channels:

Cameras
Cabin crew
ATC
Other channels

This means the ability for the crew to quickly learn what is going on and make the decision to evacuate based on this information. It is also a way to avoid this "engine running" issue. The cause of the engine no 2 running here are a couple of factors:

1. Lack of information about the fire - the pilots stopped the aircraft with the mindset of it being an engine failure and fire, NOT a pooled fuel fire. Keeping the engine running for taxiing clear of the runway was logical based on what they knew when they stopped.
2. The lack of information was further enhanced by the ATC silence, thus giving the impression that the situation wasn't that serious.
3. The result was a rushed decision to evacuate since the fire had been ongoing for a while already and that led to a chaotic execution of the checklists and the still running no 2 kept going for about 44 seconds before they shut it down.

So yes, the lack of appropriate information did delay the evacuation and caused a rushed decision when it came eventually, thus leading to the no 2 engine still running when the doors opened.

The whole case is a clear demonstration that INFORMATION must be available to the flight crew at an early stage so the appropriate decisions can be taken and the "taxi clear of the runway" mindset can be avoided in cases where the aircraft must be abandoned immediately.

Arguments along the lines of: "the crew should have evacuated immediately since they had fire warning" and similar makes no sense. Yes, they did have a fire warning but it still doesn't mean "evacuate" and it would be highly inappropriate to connect it with that course of action.

Delayed and rushed decisions to evacuate is an information problem and it is an obvious issue in this case, especially the lack of external (ATC) sources. The cabin call system could also be scrutinized - i.e. a more obvious indication of incoming high priority emergency calls from the cabin and perhaps fire warning buttons located at the flight attendant stations (i.e. the ability for CC to relay such information to the flight deck if flames are visible outside of the aircraft).

Edit: It is pretty logical and normal to leave an engine running after a failure on the other one when on the runway since shutting down everything without such a need would cause more disruptions to the airport. Taxi clear of the runway after the situation has been assessed is appropriate.

Stopping on the runway is for serious emergencies; moving the aircraft to a different location under power of the remaining engine is logical when the circumstances are such that the passengers should remain on board until appropriate means of exiting the aircraft are ready (airstairs or returning to a gate).

The "shutdown all engines because of a fire indication" item isn't a logical thing to add to the checklists.

And yes, ATC SHOULD SPEAK UP when a crew report that they are aborting take-off if there are visible smoke and flames from the aircraft since such information is extremely important to get to the crew as quick as possible.

"If you see something, say something" is an appropriate principle and a burning aircraft is a good case for it.

It is also more urgent to convey such information to a crew that *doesn't* report a fire when they report "stopping" or "abandoning take-off".

[hans brinker]

A long time ago I flew the DHC8. It was a new type for the company, before there was only the "little f#kker". Our technical department didn't like the bombardier ECKL, and rewrote the whole thing. While I didn't like everything about it, it was an enormous improvement over the factory one. One thing they added was an "On Ground emergency". For everything fire or smoke related the procedure was the same (going from memory here):
- bring aircraft to a stop
- set parking brake
- mayday call to atc
- pa call to alert flight attendant
- both fuel levers cut-off
- Apu off
- both fire handles pull
- push Apu fire bottle
- push number one bottle for both engines
- asses situation to see if evacuation is required
+ If evacuation required, pa call for evacuation , atc call we are evacuating, batteries off
+ If not pa call remain seated, atc call we need tow truck.

The main idea was, this is not a time to second guessing, we need one thing that covers all. I asked during my PC wouldn't it be better to keep both bottles for the engine that is on fire and the answer was no for three reasons. One, no need to confirm what is on fire, two, no need to wait for 30seconds to fire bottle, you are on the ground, don't fight fire, evacuate, three, no change of forgetting to shut the working engine.
Like i said, didn't agree with necessnecessarily everything, but it would have worked here.

[wiggy]

I have a feeling that a couple of posters in this thread miss the point about information. A fire indication doesn't mean "evacuate immediately" so everything starts with appropriate INFORMATION.

:ok:


The stop in this case was called for an engine failure.

During the decel there was then a fire warning (bell + EICAS message) on the same engine.

AFAIK the teaching has never been that in the event of a rejected take-off with an associated fire warning one should default to automatically throwing everybody down the slides, though I’d accept that there might be circumstances so dire (e.g. flames actually around the flight deck windows) that you might do that. Maybe trainers such as M. Mouse have an opinion on this issue, or have taught, or have seen it taught differently.

[BAengineer]

The big question is: Do the bottles do any good if the actual fire is on the tarmac below the engine where the fuel pools...
For me the bottles are totally useless on the ground, and you should concentrate on other things (stearing the aircraft out of the wind so that fire/smoke spreads away from the fuselage, prepare evacuation, instruct cabin crew, instruct rescue services).


You would have thought that we would have learned the lesson about that from the 1985 Manchester BA disaster...

[Volume]

I have a feeling that a couple of posters in this thread miss the point about information. A fire indication doesn't mean "evacuate immediately"
I think the point is: a fire indication does not neccesarily mean an engine fire. (in the sense of "usual engine fire within the engine fire zone for which the aircraft is designed")
A fire indication should not trigger anything automatic immediately. No standard engine fire procedure, no evacuation.
An engine fire warning should trigger a (very quick) investigation into the situation, followed by appropriate action. It is an anachronistic situation, that in many aircraft the passengers can see the fire situation clearly on their IFE (in colour and HD...), but neither the cockpit nor the cabin crew has a clue.

It would be interesting to see a statistic: How many engine fire indication do indeed indicate that there is a fire the aircraft and the fire warning/extinguishing system, the fire containment and the procedure is designed for? How many are false warnings? How many are a totally different situation (like a catastrophic engine failure, a fire originating outside the designated fire zone the extinguishing system can handle, a fire already spreading beyond the fire zone)?

No matter whether you finally will evacuate, it is always a good idea to prepare for an evacuation as early as possible, as typically time is a critical factor.
As we have seen in singapore, the decision to leave evyone on board and let the fire brigade do their job fast and without disturbancy may be the more clever action. Anyway you should as soon as possible think through the different alternatives and prepare as fast as possible. Whether you actually will evacuate may be decided later, but no time should be lost prior to that decision. You can not revover time lost. Turning the aircraft into a favourable position with respect to the wind or to improve access for the fire services will never hurt.

Firing both bottles following the SOP may save your a**** because nobody can accuse you of doing something wrong, Sometimes it is more important to save everybody on board.

You would have thought that we would have learned the lesson
"we" may have learned the lesson, but do we teach it to new pilots?

[sudden twang]

You would have thought that we would have learned the lesson about that from the 1985 Manchester BA disaster...

How many times have you had an assymetric RTO on a 777?
How many crews have you observed in a777 simulator attempting to turn as they slow from an RTO?
Yes we have learned the lesson from Pete’s event in MAN and VOLUME we do teach it to all new and old but it’s quite difficult to do sometimes with RTO braking. What can be more important is stopping on the tarmac quickly and completing the process efficiently ( as opposed to quickly).
a turn during an RTO is often prebriefed eg turn into any fire works for a headwind but is the reverse for a tailwind, would not be required with a Xwind for one engine but critical for the other etc.
My experience?
Number of RTOs in the a/c single figures
number of RTOs in a Sim 3 figures
number of RTOs observed in a Sim 4 figures. BWDIK

[Dairyground]

For everything fire or smoke related the procedure was the same (going from memory here):
- bring aircraft to a stop
- set parking brake
- mayday call to atc
- pa call to alert flight attendant
- both fuel levers cut-off
- Apu off
- both fire handles pull
- push Apu fire bottle
- push number one bottle for both engines
- asses situation to see if evacuation is required
+ If evacuation required, pa call for evacuation , atc call we are evacuating, batteries off
+ If not pa call remain seated, atc call we need tow truck.
As someone with past involvement in procedure design and risk management, though not in aviation, I am surprised at the order of the early items in this list. I would expect fuel cut off to appear early, certainly before setting the parking brake. In the G-VIIO case the residual momentum and the dying thrust from the operating engine could probably have moved the aircraft clear of the pool of burning fuel.

[lomapaseo]

As someone with past involvement in procedure design and risk management, though not in aviation, I am surprised at the order of the early items in this list. I would expect fuel cut off to appear early, certainly before setting the parking brake. In the G-VIIO case the residual momentum and the dying thrust from the operating engine could probably have moved the aircraft clear of the pool of burning fuel.

Valid considerations, but one must consider the cause effect of specific annunciations in order to design for a desired response.. What you assume is correct but statistical experience must be also considered "Pool" fires are thankfully rarities as a cause for the initial annunciations to the crew. Thus the expected response from the crew is reflected in the current procedures.

The issue in my mind is how to annunciate to the crew in a timely fashion that a pool fire has occurred and that appropriate reaction is expected.

[sudden twang]

Dairyground,
the list that you quoted from another poster is not the same sequence as would have been taught to the crew of IO.
SOPs evolve in the light of experience but cannot cater for every eventuality. Statistically speaking it’s best to stop the aircraft apply the park brake make a PA ( I know I know but it’s the BA way) then diagnose the malfunction and call for the memory drill or ECL. The reason is that this “cages the chimp” and manages workload effectively.
IOs problem was the fuel leak unfortunately there isn’t an easy way to diagnose this event from the flight deck except by external observer or as in this case the ensuing fire caused by the leaked fuel. HTH

[RatherBeFlying]

IOs problem was the fuel leak unfortunately there isn’t an easy way to diagnose this event from the flight deck except by external observer or as in this case the ensuing fire caused by the leaked fuel. HTH

The pax and cabin crew were very much aware immediately.

The problem is that their information did not get through to the cockpit until much later in the proceedings.

"Remain seated" while a fire is raging nearby reminds me of the advice given to Grenfell residents to remain in their units

[Capn Bloggs]

"Remain seated" while a fire is raging nearby reminds me of the advice given to Grenfell residents to remain in their units
Would you rather everybody try to bail out immediately, to be blasted by the engines which probably have disabled the O/W and rear slides (as happened to the starboard slides in this case)?

[JammedStab]

Would you rather everybody try to bail out immediately, to be blasted by the engines which probably have disabled the O/W and rear slides (as happened to the starboard slides in this case)?

Or sucked into an engine if they go off the leading edge of some of the smaller aircraft without slides. Like these guys here who could have been sucked in if there was a delay. Evacuated due to a bomb joke...

https://www.express.co.uk/travel/articles/966637/plane-passengers-injured-following-bomb-haux-lion-air-flight

[RatherBeFlying]

I'd rather see an immediate assessment of the fire situation after stopping which includes checking with cabin crew who are far better placed to see any developing fire.

While certification tests have demonstrated the airframe will tolerate brake and tire fires after a reject for three minutes before ARFF intervention, all bets are off for any other fire situation.

The very first PA should be "Cabin crew report airframe condition"

Failure to respond to the interphone delayed this evacuation. Some day a fire will develop more quickly and a similar delay in assessing for fire will cost lives.

[The Blu Riband]

"Cabin crew report airframe condition"


Yep.. That'll work...

[double_barrel]

.......
- both fire handles pull
- push Apu fire bottle
- push number one bottle for both engines
......


As a matter of interest, does firing the extinguisher damage the engine? I assume at the least it prevents it from restarting until some fairly major clean-up has been performed? Is this a factor in the decision-making on the ground ? I guess the owners would not be happy to see their expensive aeroplane with 2 f'd-up engines plus a f'd-up APU without very good reason. Or is it just an inert gas that disappears? In the air can you ever re-start an engine after firing its extinguisher?


So many questions......

[lomapaseo]

As a matter of interest, does firing the extinguisher damage the engine? I assume at the least it prevents it from restarting until some fairly major clean-up has been performed? Is this a factor in the decision-making on the ground ? I guess the owners would not be happy to see their expensive aeroplane with 2 f'd-up engines plus a f'd-up APU without very good reason. Or is it just an inert gas that disappears? In the air can you ever re-start an engine after firing its extinguisher?


So many questions......

What if questions get a little technical in this forum.

Engine extinguishers are external to the spinning bits inside the engine. They are designed to work between the outside of the engine and inside the cowling around the engine. Restart afterwards is a function of getting air pressure to the spinning bits in the engine and the time it takes to do this vs where the aircraft is on-the-ground or in-flight. In a high workload environment you manage the aircraft first

[tdracer]

To elaborate a bit one what Loma posted, the fire extinguishers are intended to put out a fire in the engine nacelle - external to the actual engine - and do not have any effect on the engine itself. Most aircraft use Halon gas as the agent (some new installations use a more environmentally friendly powder similar to baking soda). Firing the extinguisher doesn't damage anything (although the powder based systems require some cleanup afterward).
Pulling the fire handle isolates the engine - fuel, electrical, hydraulic, and pneumatic. If the fire handle is restored to the normal position, the engine can be re-started although there are no procedures to ever do so (and if there really was a fire, you'd have to be either really desperate or daft to re-introduce fuel to the scene of the fire).

[BAengineer]

As a matter of interest, does firing the extinguisher damage the engine? I assume at the least it prevents it from restarting until some fairly major clean-up has been performed?

Depends on the type of fire extingiushant. If it is Halon or Foam the engine needs washing or steam cleaning, if it is CO2 or Dry powder it is an engine removal.

[procede]

Depends on the type of fire extingiushant. If it is Halon or Foam the engine needs washing or steam cleaning, if it is CO2 or Dry powder it is an engine removal.
This surprises me. I'd expect foam and especially powder to require a removal. With Halon or CO2, being almost inert gasses, I would not expect much cleaning to be needed at all.

Note that Halon does damage to the ozone layer.

[double_barrel]

Thanks all. Interesting

This surprises me. I'd expect foam and especially powder to require a removal. With Halon or CO2, being almost inert gasses, I would not expect much cleaning to be needed at all.

I imagine that CO2 could create some thermal stress that would be worthy of checkup.

[RatherBeFlying]

Currently cabin crew are trained to handle fires inside the cabin. This training should be expanded to cover checking for airframe and engine fires after a reject or landing with engine problems - along with proactive communication of fire status with the flight crew.

They need to be able to distinguish between tire/wheel/brake fires where three minutes is allowed before ARFF arrives - and uncontrolled fuel fed fires demanding immediate evacuation.

Given that interphone calls may not be answered in a high cockpit workload situation, cabin crew need to be able to actuate an "EVACUATE" alarm that would annunciate in the cockpit and display prominently on the EFIS.

It may also be useful to have a "Fire / Smoke Visible" annunciation so that the cockpit crew will be prepared in the case that the cabin crew determines evacuation is necessary.

Underlying these suggestions is considerable history of cockpit crews running checklists while unaware of a serious fire behind.

[OvertHawk]

Why are we discussing the cabin crew needing to advise the cockpit about fires?

I've got a twenty grand car with more exterior camera coverage than Donald Trump. C'mon folks - it's not rocket science to provide external cameras.

[lomapaseo]

Why are we discussing the cabin crew needing to advise the cockpit about fires?

I've got a twenty grand car with more exterior camera coverage than Donald Trump. C'mon folks - it's not rocket science to provide external cameras.

Cameras, don't assess they only deliver current outside events covered in smoke. I would trust the trained FA's for more comprehensive assessments while the pilots are working their check lists

[Capn Bloggs]

All well and good and theoretical, but there were ATCs with a clear view of the large fire and smoke who said nothing apart from "Fire services are on the way".

[wiggy]

RBF

Currently cabin crew are trained to handle fires inside the cabin. This training should be expanded to cover checking for airframe and engine fires after a reject or landing with engine problems - along with proactive communication of fire status with the flight crew.

They need to be able to distinguish between tire/wheel/brake fires where three minutes is allowed before ARFF arrives - and uncontrolled fuel fed fires demanding immediate evacuation.

Not sure what sort of aircraft you are working on or thinking of but a couple of points if I may:

1. From inside an airframe such as a 777 there is very restricted external visibilty. There is Zero/nil/nada visibility of the landing gear from within the fuselage - so absolutely no possibility of cabin crew looking at tire/wheel/brakes etc... and as far as engines are concerned it is only possible to see a portion of the front of the engine nacelles, and if you want a cabin crew member to check engines out they might have to leave their seat, which brings me to :.

2. If you are going to start asking CC to carry out an external check through the cabin windows in the event of an RTO they will have to leave their seats, possibly leaving their door unguarded ( it is often minimum crew these days so often just one crewmember at most if not all doors, even on the wide bodies)... if an EVAC is then signalled from the Flight Deck when the Cabin crew are not at their doors you really are in for a world of hurt or much much worse......

Given that interphone calls may not be answered in a high cockpit workload situation, cabin crew need to be able to actuate an "EVACUATE" alarm that would annunciate in the cockpit and display prominently on the EFIS.

You've effectively got that on the 777 already ( and no doubt on other types) ...the EVAC alarm can be triggered in the Cabin and it gets very noisy on the Flight deck and a big red light flashes...and FWIW at some airlines if not all Cabin crew are briefed that in the event of a clearly catastophic situation they can self intiate evacuation...

[de fumo in flammam]

Not sure about the 777, but on some types, opening the window and sticking your head/body well outside gives a good view of wing and engines, and to some extent, the gear. In the event of a suspected external fire, I would generally do that.

[wiggy]

It's an information gathering option on the T7 as far as wings and engnes......but obviously (??) not for the Cabin crew...:\

[M.Mouse]

Cabin crew are not selected for their analytical skills. Having seen cabin crew describe to pilots via the interphone the state of a cabin fire during a joint training exercise the last people I would choose to make an assessment of external issues with an aeroplane are cabin crew!

Why is everybody trying to re-invent the wheel? The Las Vegas incident was unusual but nobody died or was seriously hurt. Admittedly the flight crew's handling of the event was not exemplary but bringing in ever more complex procedures and rules to attempt to legislate for every conceivable set of circumstances is utter madness.

[42go]

Why is everyone trying to HIDE the wheel? All this faffing about with did ATC tell the pilots/should the cabin crew tell the pilots/should there be camera coverage of the engines belies the point that the actual evacuation was rushed by the Captain and dangerous with an engine still running. The focus should be on what have BA done to sort this out.

The dual fire bottle firing, by-the-way, is to ensure there are no highly charged explosive bottles left around for the fire crew.

[wiggy]

Why is everyone trying to HIDE the wheel?

In what way is anything being hidden?

All this faffing about with did ATC tell the pilots/should the cabin crew tell the pilots/should there be camera coverage of the engines

Others here have criticised the captain for not gathering information promptly enough, seems he can't win.

the point that the actual evacuation was rushed by the Captain and dangerous with an engine still running.

Nobody is ignoring that/has ignored that, nobody has claimed it was a well handled evacuation.

The focus should be on what have BA done to sort this out.

That was "sorted out" - well over twelve months ago. BA have completely rewritten their version of the T7 evacuation checklist and have changed the emphasis/manner of it's handling.

[sudden twang]

The “ wheel” of this incident is why the engine suffered a catastrophic failure. The captains out of sequence actions resulted in some slides being unusable. That made the situation complicated for the cabin crew ( v well handled by them ) but it had no effect on the outcome in terms of passenger survival or aircraft damage.
We can all learn from this to be methodical in our actions and cage the chimp but it’s not easy.
Decision making after an RTO is v difficult for any captain especially in LVOs.
Id be reluctant to initiate an evac with just a fire warning and would seek information from ATC,fellow pilots taxiing, cabin crew ,cameras if fitted ,DV window or sending the heavy. back.
But pilots know this should we give up Wiggy?

[wiggy]

We can all learn from this to be methodical in our actions and cage the chimp but it’s not easy.

Agreed.

I'm not sure how much more blood can be extracted from this particluar stone but some people seem to keep trying,.. I can't imagine why..:oh:

Aircraft suffered catastrophic engine failure.
Aircraft stopped.
Evacuation - sub-optimal - AFAIK nobody has denied that..nevertheless...
Nobody killed, everybody gets off.
NTSB carry investigation and publish full report, warts and all.
BA carry out own analysis and changes their own procedures as a result in order to encourage people to methodical and help them cage the chimp..

TBH I'm not sure what else it is people re looking for here - maybe the captain ( long since retired BTW) tied to a post somewhere and pelted with rotten fruit for perpetuity? BA boycotted because alledgedly they are not as rigorous in some areas other carrers ( never ever got that list of ideal airlines did we??)????
.

[42go]

Fact: Engines fail
Fact: Humans screw up

This person actually knows that, but would like to know, for the interest of other pilots, "what have BA done to sort this out.".

I am not sure what "in order to encourage people to methodical and help them cage the chimp.." means in BA. Tell me more, twang

[lomapaseo]

This person actually knows that, but would like to know, for the interest of other pilots, "what have BA done to sort this out.".

To assign this corrective action to only BA is of little value. The issue of "why" is more global than that and properly a learning for all pilots.

Personally I will await the recommendations form the NTSB to examine any unique deficiencies on BA's part or to instead make a more global recommendation

[42go]

Loma - "To assign this corrective action to only BA is of little value. The issue of "why" is more global than that and properly a learning for all pilots." - hence my use of the words "other pilots" and why we need to hear?

I think you have a wait on your hands if it the NTSB you are waiting for. They published their 'Final Report' at https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20150908X35241&AKey=1&RType=Final&IType=FA which makes no recommendations - nor real comment - on the evacuation procedure.

The whole evacuation event was, to put it bluntly, a shambles. Heaven only knows what the crew were doing in the cockpit - 43 seconds from calling the evac to shutting down the right-hand engine, giving 25 seconds for passengers using 1R to be ingested into the engine.

That is where the problems lay. It may well be a company-wide training issue. I hope we will hear from the Nigels what has changed.

[DaveReidUK]

I think you have a wait on your hands if it the NTSB you are waiting for. They published their 'Final Report' at https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20150908X35241&AKey=1&RType=Final&IType=FA (https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20150908X35241&AKey=1&RType =Final&IType=FA) which makes no recommendations - nor real comment - on the evacuation procedure.

NTSB investigation reports, unlike those from some other AIBs, do not contain safety recommendations.

Any that are made as a result of an investigation are published separately, and often some time after the final report is published.

So don't jump to conclusions.

https://www.ntsb.gov/safety/safety-recs/_layouts/ntsb.recsearch/RecTabs.aspx

[sudden twang]

[QUOTE=42go;10190

I am not sure what "in order to encourage people to methodical and help them cage the chimp.." means in BA. Tell me more, twang[/QUOTE]
At least quote me accurately.
Google it.

[IcePack]

Hopefully this incident inc this thread will prompt pilots into fully understanding what they are trying to achieve prior to & during an evac. I was no ace, but was always astounded at the “flaffing” about on the simulator when similar scenarios were presented.
Granted real life is somewhat different (I did have several incidents in my career). Understanding what you need to do as second nature & communicating that to your colleague is all that is required. Communication with the cabin is part of what you are trying to achieve. (Stop check list/continue checklist (ecam) at appropriate moment gives time for cabin communication)

[suninmyeyes]

Not sure about the 777, but on some types, opening the window and sticking your head/body well outside gives a good view of wing and engines, and to some extent, the gear. In the event of a suspected external fire, I would generally do that.

On the 777 with the flight deck window closed you cannot see even a wingtip from the front seats even if you stick your head hard up against the side window and squash your nose. If you open the window and stick your body out as far as you dare you can just see a bit of outboard engine cowling but no gear. If you ever board the aircraft via steps at door 2 left wait until you are level with the left engine and then look forward to the flight deck, you cannot see any flight deck windows, you only see fuselage due to the curve at the front of the fuselage.

So for all those who felt the crew should have been more aware of the fire, it 's a great theoretical idea but not feasible. The crew can be alerted to a fire in the engine by a fire warning but a fire from spilt fuel underneath the engine is something that cannot be seen from the flight deck. They would need information from an external source like ATC or from someone in the cabin which is what happened.

As in most emergencies things do not always go perfectly. However this thread has tended to focus exclusively on the areas that could have been done better and ignored the bits that were done well and some people have therefore tried to infer it was all done badly. For those who have come out of their sim check and had the training Captain say "Well done, that was perfect, no debrief required " I salute you. I tend to live in the real world where with hindsight things could always be done a bit a better.

[wiggy]

Fact: Engines fail

I am not sure what "in order to encourage people to methodical and help them cage the chimp.." means in BA. Tell me more, twang

Look up Prof Steve Peters and The Chimp Paradox...it's not just a BA "thing".

[ManaAdaSystem]

Not sure about the 777, but on some types, opening the window and sticking your head/body well outside gives a good view of wing and engines, and to some extent, the gear. In the event of a suspected external fire, I would generally do that.

Amazing! We got to post 120 before somebody made this suggestion! Cameras, cabin crew, ATC. Just open the window and look outside! Even if you can’t see the whole engine, you would see the smoke.
I leave it to the investigators to count seconds. They are good at that. How long did it take to get to the numbers they found?

The main error in this case was the captains evacuation order before the engines were shut down. The read and do procedure should have prevented this. He was very lucky nobody got killed because of this error.

[JammedStab]

Amazing! We got to post 120 before somebody made this suggestion! Cameras, cabin crew, ATC. Just open the window and look outside! Even if you can’t see the whole engine, you would see the smoke.


I agree with the take a look through the open window idea. But, if only part of the engine is in view, I wouldn't want to make a big bet that not seeing any smoke guaranteed that there actually was no smoke depending on the wind conditions. And the wind is more often than not, blowing toward the tail and away from view when on the runway.

[RexBanner]

Look up Prof Steve Peters and The Chimp Paradox...it's not just a BA "thing".

Not just a BA thing but my God do we bang on about it ad infinitum every single CRM and LFS course.

[Fortissimo]

At face value, there was an engine failure and fire leading to an RTO and evacuation, and nobody died. "Nothing to see here..." However, if you follow the ARMS methodology, this could easily have escalated into a catastrophic outcome (major loss of life and/or hull loss).

Several slides were rendered useless by crew actions or the effects of fire, but there was sufficient redundancy for a successful evac, aided by a 55% load factor. All good news, but there is no doubt that the barriers had been eroded. What might have been the result for a full pax load? Or a bigger fire?

For me, this opens the debate again on having initial evacuation actions as a memory item. There are arguments to be had for and against, and it might not be appropriate for all types, but it does need a reasoned discussion rather than the usual PPrune/Donald Trump game of playing the man rather than the ball. And if, say, slotting the engines and fuel masters as an immediate action causes other problems on a particular type (depressurisation etc), then those are the issues that need feeding into future design considerations and certification standards.

The second issue that is worth further thought is that, at least in in lighter winds, a 5-7kt crosswind appears to be the perfect scenario for directing upwind engine-associated fires against the hull (as with the Manchester accident). So is the 'stop in a straight line' SOP for some wide-body operators sensible or is it worth revisiting in light of the G-VIIO experience?

NB, these are questions, not answers!

[CharlesLindbergh]

They need to be able to distinguish between tire/wheel/brake fires where three minutes is allowed before ARFF arrives - and uncontrolled fuel fed fires demanding immediate evacuation.


The idea that ARFF is required to be at the scene of an emergency within three minutes is one of the most commonly held incorrect beliefs among people who are familiar with aviation. A three minute response time must be demonstrated (under rather ideal conditions) as a part of airport certification.

All that ARFF has to do is respond to emergencies in a fire truck. Three minutes is generally viewed as a target response maximum but there is nothing requiring it.

14 CFR §139.319(H):

H. Response requirements.

(1) With the aircraft rescue and firefighting equipment required under this part and the number of trained personnel that will assure an effective operation, each certificate holder must -

(i) Respond to each emergency during periods of air carrier operations; and

(ii) When requested by the Administrator, demonstrate compliance with the response requirements specified in this section.

(2) The response required by paragraph (h)(1)(ii) of this section must achieve the following performance criteria [emphasis added]:

(i) Within 3 minutes from the time of the alarm, at least one required aircraft rescue and firefighting vehicle must reach the midpoint of the farthest runway serving air carrier aircraft from its assigned post or reach any other specified point of comparable distance on the movement area that is available to air carriers, and begin application of extinguishing agent.

(ii) Within 4 minutes from the time of alarm, all other required vehicles must reach the point specified in paragraph (h)(2)(i) of this section from their assigned posts and begin application of an extinguishing agent.

~~~~~~~~~

The requirement is that ARFF must respond to each emergency during periods of air carrier operations. There is no time requirement for those responses.

I bolded the part of the regulation which states the other part of the regulation that the time requirements apply to. The time requirements do not apply to (H)(1)(i), and it would be absurd if they did. (What if it's snowing? Are you going to fine or jail the fire crew?)

[Airbubba]

After milking some money with settlements in U.S. courts the 'victims' seek further justice in the UK.

From The Evening Standard:

Three flight attendants sue BA for £110,000 over runway fire ordeal

Tristan Kirk (https://www.standard.co.uk/author/tristan-kirk)
15 hours ago

Three British Airways (https://www.standard.co.uk/topic/british-airways) flight attendants who helped passengers escape a plane on fire are suing the airline for £110,000.

Marie Dyos, Lynette Robinson and Suely Goncalves-McLoughlin helped to evacuate 170 people from a Boeing 777 when an engine burst into flames at McCarran airport in Las Vegas.

The drama unfolded as the Gatwick-bound plane accelerated along the runway for take-off, forcing the pilot to brake and order an evacuation.
The three cabin crew members say they have been left mentally scarred by the incident, being the last to exit the jet after helping passengers escape.
https://static.standard.co.uk/s3fs-public/thumbnails/image/2020/02/03/10/mariedyoslnetterobinsonBA03-02-2020.jpgMarie Dyos and Lynette Robinson (Champion News) The Mayor’s and City of London court heard the three women have been left with post-traumatic stress disorder while Miss Goncalves-McLoughlin also claims her vision was damaged in the September 2015 incident.

They are now suing British Airways for damages, with Ms Robinson and Miss Goncalves-McLoughlin claiming £40,000 and Mrs Dyos seeking £30,000.

They have accused fellow crew members of being negligent by “failing to follow the engine fire checklist”, allowing 97 gallons of fuel to spill onto the runway and allegedly feed the fire.

The captain is also accused of delaying shutting down the other engine, prolonging the evacuation as two escape slides could not be used.

British Airways denies all blame, disputing that the air crew had failed to follow procedure and defending the actions of the captain.

The court heard Ms Robinson, from East Sussex, opened a door on the right of the plane but the escape chute was unusable due to the blast from the still-running right engine. She is now plagued by flashbacks and remains “anxious and hyper vigilant”, said the women’s barrister Martin Haukeland.

He said Miss Goncalves-McLoughlin, from East Sussex, suffered damage to her cornea when she also opened a door on the right of the plane. “Her eyes were exposed to high velocity particles thrown up by the still running right-hand engine,” said Mr Haukeland.

Mrs Dyos, of Horley, Surrey, has returned to work but is undergoing treatment for anxiety and struggles with PTSD (https://www.standard.co.uk/topic/ptsd) symptoms, the court heard.

She claims to suffer from lasting shoulder pain due to holding closed a cupboard door to create a gangway for the passengers.

At a preliminary hearing, Lucy Wyles, for BA, pointed out that the women have already settled US lawsuits brought against the Boeing Company and GE Aviation Systems LLC in 2016 and said they should not be entitled to further compensation over the same incident.

[ZFT]

I wonder what Barbara Harrison would make of these 3?

[DaveReidUK]

It's interesting that, according to the Evening Standard, BA deny that the crew failed to follow procedure (commanding the evacuation before shutting down the live engine), despite that being one of the NTSB's findings.

Three flight attendants sue BA for £110,000 over runway fire ordeal (https://www.standard.co.uk/news/uk/three-flight-attendants-sue-ba-for-110000-over-runway-fire-ordeal-a4351861.html)

Presumably BA are relying on an investigation report being inadmissible in court ?

[Bergerie1]

Well said ZFT.

[ATC Watcher]

Regardless of who is right or wrong here , seen the low amount claimed I wonder why BA did not settled a compromise out of court, This might drag on in the media and cannot be good publicity for BA whatever the result of the court ..