Vulcan incident Doncaster 28th May
SFCC, I take you belong to the old guard of the blame culture that has been endemic within the miltary until recently, have you not heard of Human Factors and a just culture, do you really believe what you posted and that basically the person/person responsible did this deliberately or through negligence. The guys on the project will be gutted but thankfull that it did not have a worse outcome and will work hard to rectify and try and get through this.
If the investigation is done properly it will show the contributory factors and allow lessons to be learned and implement changes to make sure nothing like this can happens again and the culpabilty chart should be used to place the incident in the context required and then and only then will someone get blamed if it is proven someone was negligent.
If the engineers in the last few places I have worked had you as a boss they would probably be on the dole now and nothing would be learned as people will hide lesser errors and then what happens when a worse incident occurs from removing an open and honest reporting Safety Management System.
If the investigation is done properly it will show the contributory factors and allow lessons to be learned and implement changes to make sure nothing like this can happens again and the culpabilty chart should be used to place the incident in the context required and then and only then will someone get blamed if it is proven someone was negligent.
If the engineers in the last few places I have worked had you as a boss they would probably be on the dole now and nothing would be learned as people will hide lesser errors and then what happens when a worse incident occurs from removing an open and honest reporting Safety Management System.
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All very very British
Muck around and hope everything will be ok on the day. If Adolf were alive he would still be wondering how the Brits didn't get invaded.
Last edited by oldchina; 30th May 2012 at 19:52.
Silica gel dessicant bags in the intakes? Never came across these during my time on Vulcan's, maybe that is due to old age (on my part - memory or lack off!)) or did we just fly the aircraft to often to require these items to be deemed necessary? Glad all are OK.
If they carry out the correct investigation and that is the proven case then so be it, but until then no.
There could be any number of reasons for missing it of which negligence could be one, I prefer to wait for the investigation report and not predict or apportion blame without its findings, apparently that is what a lot of people within Pprune military are always requesting after an accident/incident i.e leave it to the investigators/BoI
There could be any number of reasons for missing it of which negligence could be one, I prefer to wait for the investigation report and not predict or apportion blame without its findings, apparently that is what a lot of people within Pprune military are always requesting after an accident/incident i.e leave it to the investigators/BoI
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Exrigger
This latest incident is without doubt extremely serious in every respect not only for the loss of the two engines but for the future of the project as a whole and if you can suggest any cause at all, OTHER than negligence, then I would ask you get in touch with the CAA because I'm sure they would be interested to hear it. Frankly, the only other remote possibility is incompetence.
I'm not suggesting either, that the aircrew were not at fault for not checking, but I would certainly have hoped and expected the groundcrew to have had a good look down the intakes, especially as they sit so high off the ground to see without the use of steps. I mean, bags of silica gel? come on.
What you need to look at closely is that, had this happened a very short time later, the outcome would almost certainly have been much much worse. The loss of two engines after V2 or rotate simply doesn't bear thinking about.
FOD ingestion, of this type, IS preventable and IS detectable. The fact that it wasn't detected and/or prevented speaks volumes about the working practices of TVOC or maybe lack of and I fear it may spell the end for the project.
Winco
This latest incident is without doubt extremely serious in every respect not only for the loss of the two engines but for the future of the project as a whole and if you can suggest any cause at all, OTHER than negligence, then I would ask you get in touch with the CAA because I'm sure they would be interested to hear it. Frankly, the only other remote possibility is incompetence.
I'm not suggesting either, that the aircrew were not at fault for not checking, but I would certainly have hoped and expected the groundcrew to have had a good look down the intakes, especially as they sit so high off the ground to see without the use of steps. I mean, bags of silica gel? come on.
What you need to look at closely is that, had this happened a very short time later, the outcome would almost certainly have been much much worse. The loss of two engines after V2 or rotate simply doesn't bear thinking about.
FOD ingestion, of this type, IS preventable and IS detectable. The fact that it wasn't detected and/or prevented speaks volumes about the working practices of TVOC or maybe lack of and I fear it may spell the end for the project.
Winco
Winco, thank you for your response. I am only pointing out that in this day and age within the aircraft industry/miltary there is a system that is called the Safety Management System which includes Human Factors and is what the MAA & CAA are supposed to instruct is integral to the industry to find out what went wrong and put it right, if that turns out to be negligence/incompetance then this will be addressed in the appropriate way and you are right the CAA will be very interested and will more than likely be closely involved in their process for the investigation, also you are correct it could have had an absolutely catastrophic outcome and I have written nothing to play it down or make light of the issue (as I don't where I work).
I am sure the investigation will ask and answer that and other questions raised here and elsewhere and even if someone is culpable at the end of it all, if these safety gates are not already in place they soon will be, even if it turns out that 558 won't require them, but somewhere else might learn something from the final outcome.
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Exrigger
I hope you don't think I was gloating at all about this because I am not at all. Despite my concerns over Pleming's ability to run this show, it is truly great to see a Vulcan back in the skies.
I don't however, think the incident can be played down in any way, shape or form. This was a very serious incident indeed and the CAA will look long and hard at the practices of TVOC or at least I hope they will.
It could so easily have ended in disaster, not only for the crew but for many others and that is my concern. There are very strict rules, regulations and procedures in place to prevent this very type of thing happening, and it does smack of negligence and/or incompetence that:
a) Something found its way into the intake in the first place and was left there.
b) As bns points out, there was NO open entry left in the F700 or whatever
c) The groundcrew who did the BF and the Aircrew who did the walk round both failed miserably to detect the bags of silica gel
My question for the team is, who is putting the aircraft to bed and leaving FOD down the intakes of all places? Do they know what they are doing and are they 'qualified' in any way?
I have been flying jet-engined aircraft for more years than I care to remember and I don't ever remember someone purposely leaving something in the engine intakes, it is crass stupidity.
I hope you don't think I was gloating at all about this because I am not at all. Despite my concerns over Pleming's ability to run this show, it is truly great to see a Vulcan back in the skies.
I don't however, think the incident can be played down in any way, shape or form. This was a very serious incident indeed and the CAA will look long and hard at the practices of TVOC or at least I hope they will.
It could so easily have ended in disaster, not only for the crew but for many others and that is my concern. There are very strict rules, regulations and procedures in place to prevent this very type of thing happening, and it does smack of negligence and/or incompetence that:
a) Something found its way into the intake in the first place and was left there.
b) As bns points out, there was NO open entry left in the F700 or whatever
c) The groundcrew who did the BF and the Aircrew who did the walk round both failed miserably to detect the bags of silica gel
My question for the team is, who is putting the aircraft to bed and leaving FOD down the intakes of all places? Do they know what they are doing and are they 'qualified' in any way?
I have been flying jet-engined aircraft for more years than I care to remember and I don't ever remember someone purposely leaving something in the engine intakes, it is crass stupidity.
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Not often that I agree entirely with Winco, but on this occasion I absolutely do.
Firstly, those silica bags were, and always have been an accident waiting to happen. Silica bags are used with good reason in engine storage, however, they are placed inside a sealed engine WVR bag within minutes of being removed from an oven, to ensure that they are free from moisture and able to soak up any errant humidity. The bags are fitted with moisture indicators to then show when they have served their purpose.
The bags in 558's intakes were not in a sealed environment at all, and consequently were most likely of little use within hours of their fitment. Were they controlled? Had they been oven dried and were moisture indicators fitted?
A good idea in basic principle, but in reality, little more than FOD after a day or two.
This was waiting to happen in my view, and the fact that they have been missed is scandalous. Anyone who has worked with and around aircraft constantly has the impact of FOD impressed upon them, and the steps taken to minimise any risks. This in my view is, as has been stated before, either incompetence in that a known and obvious FOD hazard was missed, or negligence in that the intakes were never checked in the first place, either way, it does nothing for my already low confidence in this outfit to maintain an aircraft in a safe and serviceable state...
Firstly, those silica bags were, and always have been an accident waiting to happen. Silica bags are used with good reason in engine storage, however, they are placed inside a sealed engine WVR bag within minutes of being removed from an oven, to ensure that they are free from moisture and able to soak up any errant humidity. The bags are fitted with moisture indicators to then show when they have served their purpose.
The bags in 558's intakes were not in a sealed environment at all, and consequently were most likely of little use within hours of their fitment. Were they controlled? Had they been oven dried and were moisture indicators fitted?
A good idea in basic principle, but in reality, little more than FOD after a day or two.
This was waiting to happen in my view, and the fact that they have been missed is scandalous. Anyone who has worked with and around aircraft constantly has the impact of FOD impressed upon them, and the steps taken to minimise any risks. This in my view is, as has been stated before, either incompetence in that a known and obvious FOD hazard was missed, or negligence in that the intakes were never checked in the first place, either way, it does nothing for my already low confidence in this outfit to maintain an aircraft in a safe and serviceable state...
Last edited by Sir Loin; 30th May 2012 at 21:40.
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As one of the many thousands of "ordinary" people that have invested their own money in this project, I am utterly dismayed that FOD ingestion through human error may prove to be the cause of this incident.
Given the precarious and capricious nature of a project that relies solely on voluntary contributions I would have thought that at the least, industry "best practices" would be adhered to and one would like to think that even more care than that was being taken to maximise the value of each private donation.
It will be a sad day if 558 fails as a result of this, but I for one will be following the progress of the investigation closely and considering if my money would be better spent elsewhere.
It would be good to see a Mosquito take to the skies again......
Given the precarious and capricious nature of a project that relies solely on voluntary contributions I would have thought that at the least, industry "best practices" would be adhered to and one would like to think that even more care than that was being taken to maximise the value of each private donation.
It will be a sad day if 558 fails as a result of this, but I for one will be following the progress of the investigation closely and considering if my money would be better spent elsewhere.
It would be good to see a Mosquito take to the skies again......
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It would be good to see a Mosquito take to the skies again......
As one whose experience of aircraft does not go much beyond sitting inside them and navigating, I have to confess that my knowledge of engines is scanty to say the least.
I have always been suprised at the different ways engines to react to fod ingestion. Here it would appear that the damage has been cause by silica gel bags. There is a well documented story of a Victor K1 (with Sapphires) completing a refuelling sortie after ingesting a number of seagulls during its night take-off, the crew being entirely unaware of the event until after landing. Here's the story
Bear Hunting - 2 - Tony Cunnane's Life and Times
I can only assume that the Olympus is more choosy about what it eats than the Sapphire!
I have always been suprised at the different ways engines to react to fod ingestion. Here it would appear that the damage has been cause by silica gel bags. There is a well documented story of a Victor K1 (with Sapphires) completing a refuelling sortie after ingesting a number of seagulls during its night take-off, the crew being entirely unaware of the event until after landing. Here's the story
Bear Hunting - 2 - Tony Cunnane's Life and Times
I can only assume that the Olympus is more choosy about what it eats than the Sapphire!
Last edited by Tankertrashnav; 31st May 2012 at 08:45.
This was waiting to happen in my view, and the fact that they have been missed is scandalous. Anyone who has worked with and around aircraft constantly has the impact of FOD impressed upon them, and the steps taken to minimise any risks. This in my view is, as has been stated before, either incompetence in that a known and obvious FOD hazard was missed, or negligence in that the intakes were never checked in the first place, either way, it does nothing for my already low confidence in this outfit to maintain an aircraft in a safe and serviceable state...
Why was there not an open entry on a job card to remove the bags? Standard practice where I work when any engine preservation carried out!
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Sorry to hear about 558's problems.
Just wondering if the silica gel in question may have been in place since the last flight with the engine covers in place?
As has been mentioned, they can't do much good in an open environment.
It'll be interesting to discover exactly what happened. Such a shame how this project seems to lurch from one problem to the next.
Just wondering if the silica gel in question may have been in place since the last flight with the engine covers in place?
As has been mentioned, they can't do much good in an open environment.
It'll be interesting to discover exactly what happened. Such a shame how this project seems to lurch from one problem to the next.
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Out of curiosity how many check lists would have been gone through before the flight. Common sense suggests that there should have been:
Coming out of storage checklist.
Engineers pre-flight check list.
Flight crew pre-flight walk around.
Would any of those also included a cross-check by someone who did not do the job - either by visually checking or counting Remove before flight tags and items not tagged but needing removal?
Coming out of storage checklist.
Engineers pre-flight check list.
Flight crew pre-flight walk around.
Would any of those also included a cross-check by someone who did not do the job - either by visually checking or counting Remove before flight tags and items not tagged but needing removal?
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Thinking about Tankertrashnav's comments, I wonder if it wasn't actually the ingestion of an intact silica gel bag that caused the initial problem. Looking at the video there is a lot of smoke from the exhausts before the bang is heard, and yes I accept that the sound takes time to travel but surely not long enough for there to be a huge cloud of smoke already hanging around behind the aircraft?
To me it suggests, in concert with the heat damage comments from TVOC, that somehow the gel was already in the engine that failed first and possibly blocked cooling passages and melted on to rotating parts causing them to fail. If No1 surged first, spat debris forwards far enough to be re-ingested into No2 intake then that would explain the damage sequence.
So maybe the problem is not that the bags were left in but possibly that one or more of them had ruptured and disgorged their contents in such a way that it was not easy to see nor obvious.
Speculation on my part I know, but the engineering team have been using the same procedures for some years so some benefit of the doubt over any negligence comments is surely due?
To me it suggests, in concert with the heat damage comments from TVOC, that somehow the gel was already in the engine that failed first and possibly blocked cooling passages and melted on to rotating parts causing them to fail. If No1 surged first, spat debris forwards far enough to be re-ingested into No2 intake then that would explain the damage sequence.
So maybe the problem is not that the bags were left in but possibly that one or more of them had ruptured and disgorged their contents in such a way that it was not easy to see nor obvious.
Speculation on my part I know, but the engineering team have been using the same procedures for some years so some benefit of the doubt over any negligence comments is surely due?