'Scathing' report on BA Maintenance practices
Join Date: Apr 2000
Location: uk
Posts: 121
Likes: 0
Received 0 Likes
on
0 Posts
Humans make mistakes
They will continue to make mistakes
Therefore you need robust systems in place to cope with this fact. If there is a blame culture within BA Engineering then this is counterproductive to any form of safety/quality/awareness. The Flywise magazine is just one part of the open reporting culture that exists within the BA Flight Ops division. It works.
Anectdotal "evidence" that I have heard points to this not being the case in BA engineering. I was told that the reason that a former head of Engineering/Technical (CM) left BA was due to his belief that this culture could not be changed before a serious incident occured.It works
They will continue to make mistakes
Therefore you need robust systems in place to cope with this fact. If there is a blame culture within BA Engineering then this is counterproductive to any form of safety/quality/awareness. The Flywise magazine is just one part of the open reporting culture that exists within the BA Flight Ops division. It works.
Anectdotal "evidence" that I have heard points to this not being the case in BA engineering. I was told that the reason that a former head of Engineering/Technical (CM) left BA was due to his belief that this culture could not be changed before a serious incident occured.It works
Join Date: Dec 1999
Location: Somewhere
Posts: 67
Likes: 0
Received 0 Likes
on
0 Posts
I have handled LY and their 757's are filled to the very top of the tank. They have not had this problem to my knowledge.
Join Date: Feb 2005
Location: KSA
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
If I ever forget to put the gear down I've gotta remember to blame "management's policies and the resultant lowering of my morale".
Apparently, there are those who would actually buy this.
Apparently, there are those who would actually buy this.
If I ever forget to put the gear down I've gotta remember to blame "management's policies and the resultant lowering of my morale".
Join Date: Jan 2002
Location: West Country
Posts: 1,271
Likes: 0
Received 0 Likes
on
0 Posts
Apparently, there are those who would actually buy this.
They even publish books about it
CAP 718: Human Factors in Aircraft Maintenance and Inspection
Join Date: Feb 2005
Location: KSA
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
Actually, I'd be wrong if I made that claim, and being guilty of either negligence or gross incompetence for forgetting something so basic and fundamental at this stage of the game, they'd be right to sack me.
Some things just aren't that complicated. If they were, we'd have gear-up landings and forgotten access panels every day.
Jet ll,
Well perhaps in it\'s infinite wisdom the CAA should publish a book entitled \"You\'re Not Supposed To Have Pieces Of An Airplane Left Over After You Reassemble It And Don\'t Expect Someone Who\'s Having A Bad Day To Remember This\".
If one has to be spoon-fed everything (including a good attitude) by management, can they really be considered a professional at what he/she does?
Some things just aren't that complicated. If they were, we'd have gear-up landings and forgotten access panels every day.
Jet ll,
Well perhaps in it\'s infinite wisdom the CAA should publish a book entitled \"You\'re Not Supposed To Have Pieces Of An Airplane Left Over After You Reassemble It And Don\'t Expect Someone Who\'s Having A Bad Day To Remember This\".
If one has to be spoon-fed everything (including a good attitude) by management, can they really be considered a professional at what he/she does?
Join Date: Jan 2002
Location: West Country
Posts: 1,271
Likes: 0
Received 0 Likes
on
0 Posts
Sorry AMF (& BOAC) I cannot agree.
The next time we are staring at a smoking hole at the end of the runway to explain it away to the relatives of those killed with - "Oh we found out who's at fault and he's an unprofessional idiot case closed" - is not in my opinion (and the opinion of the CAA, AAIB, FAA & NTSB) a professional response.
Considering that maintenance errors are increasing as a cause of accidents then the type of investigation by the AAIB into the causes of the error (rather than just blaming the individual as an idiot) seem to me to be the best way forward for flight safety.
If you have ever been involved in a post-accident investigation then you would know that there are many causal factors that come together to create one failure - there is no single cause. Yes sometime the cause may well be failure by the individual concerned, but then you need to investigate as to why he failed - did he have enough or the correct type of training?, did he have the correct tooling?, was he/she in a fit mental state to do the job, etc.
There are many factors involved - the culture of blaming individuals had, I thought died out years ago, maybe not..
The next time we are staring at a smoking hole at the end of the runway to explain it away to the relatives of those killed with - "Oh we found out who's at fault and he's an unprofessional idiot case closed" - is not in my opinion (and the opinion of the CAA, AAIB, FAA & NTSB) a professional response.
Considering that maintenance errors are increasing as a cause of accidents then the type of investigation by the AAIB into the causes of the error (rather than just blaming the individual as an idiot) seem to me to be the best way forward for flight safety.
If you have ever been involved in a post-accident investigation then you would know that there are many causal factors that come together to create one failure - there is no single cause. Yes sometime the cause may well be failure by the individual concerned, but then you need to investigate as to why he failed - did he have enough or the correct type of training?, did he have the correct tooling?, was he/she in a fit mental state to do the job, etc.
There are many factors involved - the culture of blaming individuals had, I thought died out years ago, maybe not..
Join Date: Feb 2005
Location: KSA
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
Jet 11,
As I said before, there are some things that are so fundamental and basic they don't rise to the level of causation you are speaking of. I'll repeat..."fundamental and basic". Remembering to lower the landing gear is one of those things. Replacing access panels is another.
Much of what you refer to is the failure of a system to idiot-proof itself, which is entirely different. Many of the post-accident recommendations made by the authorities are attempts to do just that.
Case in point; the Pinnacle Airlines CRJ crash a little over a year ago...a smoking hole while trying to make a runway after flaming out both engines. Investigations and recommendations are the result, but in the end no system devised in aviation can be failsafe against such negligence and willful recklessness displayed in that cockpit from the moment of T/O. Had they killed anyone on the ground in addition to themselves, it would have been nothing less than negligent homicide.
Other basic, fundamental things; There's at least two accidents on the books where pilots tried to take off in twin jets on a single working engine in the hopes of air-starting the other one after T/O. Both attempts resulted in smoking holes off the end of runways. I think you'll find that in both cases the consensus of all the investigators was "we found out who was at fault...the pilots...and they were unproffessional idiots"
Case closed.
As I said before, there are some things that are so fundamental and basic they don't rise to the level of causation you are speaking of. I'll repeat..."fundamental and basic". Remembering to lower the landing gear is one of those things. Replacing access panels is another.
Much of what you refer to is the failure of a system to idiot-proof itself, which is entirely different. Many of the post-accident recommendations made by the authorities are attempts to do just that.
Case in point; the Pinnacle Airlines CRJ crash a little over a year ago...a smoking hole while trying to make a runway after flaming out both engines. Investigations and recommendations are the result, but in the end no system devised in aviation can be failsafe against such negligence and willful recklessness displayed in that cockpit from the moment of T/O. Had they killed anyone on the ground in addition to themselves, it would have been nothing less than negligent homicide.
Other basic, fundamental things; There's at least two accidents on the books where pilots tried to take off in twin jets on a single working engine in the hopes of air-starting the other one after T/O. Both attempts resulted in smoking holes off the end of runways. I think you'll find that in both cases the consensus of all the investigators was "we found out who was at fault...the pilots...and they were unproffessional idiots"
Case closed.
Join Date: Jun 2001
Location: Over The Hills And Far Away
Posts: 676
Likes: 0
Received 0 Likes
on
0 Posts
AMF, you choice of examples as comparisons would suggest that you know very little of how maintenance works. Particularly when it comes to large/lengthy checks.
AMF, I hope I never see an investigation regarding a maintenance error, but let me tell you about one I was taught about when working at Ansett.
It happened in 1966. An AN Viscount had an engine fire and the wing failed before they could get on the ground. there were 24 fatalities.
Now the Viscount had an accesssory gearbox on the wrong side of the firewall connected by a quill shaft to the Dart. On the gearbox was mouinted a generator, alternator and a cabin pressure supercharger.
The proximate cause, I was told, was that the order of thrust washers in the Supercharger was wrongly assembled when the unit was overhauled. The manual was subsequently found to be ambiguous. The unit overheated and caught fire.
The hair of the Component overhaul department is said to have gone completely white during the three month of the investigation.
I've had to read two Coroners reports recently involving drownings during yacht races. The devastatingly simple questions the Coroner asks would make you cry.
You BA people are bloody lucky you are not having to answer a Coroners questions. You can play "lean and mean" for quite a while, maybe ten years or so, but eventually the rot will have set in and things will start failing.
Thats what happened to Ansett long after I left. Maintenance was gutted, especially the planning functions. One day someone woke up that a Boeing 767 AD had been missed. Subsequent investigations ended in the suspension of the AOC after it was demonstrated that AN could not guarantee it was complying with its own manuals.
Read the special report here and read between the lines. Do you ever want to see a report about BA that reads like this? Thank Christ they were grounded before an aircraft went in.
http://www.atsb.gov.au/publications/...00211_001.aspx
It happened in 1966. An AN Viscount had an engine fire and the wing failed before they could get on the ground. there were 24 fatalities.
Now the Viscount had an accesssory gearbox on the wrong side of the firewall connected by a quill shaft to the Dart. On the gearbox was mouinted a generator, alternator and a cabin pressure supercharger.
The proximate cause, I was told, was that the order of thrust washers in the Supercharger was wrongly assembled when the unit was overhauled. The manual was subsequently found to be ambiguous. The unit overheated and caught fire.
The hair of the Component overhaul department is said to have gone completely white during the three month of the investigation.
I've had to read two Coroners reports recently involving drownings during yacht races. The devastatingly simple questions the Coroner asks would make you cry.
You BA people are bloody lucky you are not having to answer a Coroners questions. You can play "lean and mean" for quite a while, maybe ten years or so, but eventually the rot will have set in and things will start failing.
Thats what happened to Ansett long after I left. Maintenance was gutted, especially the planning functions. One day someone woke up that a Boeing 767 AD had been missed. Subsequent investigations ended in the suspension of the AOC after it was demonstrated that AN could not guarantee it was complying with its own manuals.
Read the special report here and read between the lines. Do you ever want to see a report about BA that reads like this? Thank Christ they were grounded before an aircraft went in.
http://www.atsb.gov.au/publications/...00211_001.aspx
Join Date: Jan 2002
Location: West Country
Posts: 1,271
Likes: 0
Received 0 Likes
on
0 Posts
AMF
I agree that instances such as these are pretty basic - which makes it all the more important to discover exactly why they happen.
Aircraft have been landing with gear down since retractable undercarriages were invented, to simply say that when accident of this type happens its down the crew are unprofessional idiots is the easy way out.
To try and stop it happening again you need to look at the causes - was the checklist followed?, if not why?, if it was , is the checklist correct?, was there a breakdown in communication between the crew?, if so why? - does the airline have a hierarchical culture where the junior crews do not question the decisions of the Captain?, does the CRM system need attention?
With regard to panels - within BA the check papaerwork is in such a state that there can be several job cards for the removal and refit of each panel - it is quite easy at the end of a check for all the work to be completed and a decision made to panel-up the wing - at the end of shift the Engineer stamps up dozens of cards for the repaneling of the wing, then when he comes in the following day there is another routine card lying around for a panel refit - the Engineer knows he fitted the panel yesterday and assumes he missed it in the final stamp up. What he doesn't know is that the night shift found the cards in another area and trying to help removed the panel he had refitted earlier that day. So we end up with a panal not fitted but several cards stamped to say that it was..
So in each case its easy to say that those involved are unprofessional idiots but doing that will not stop it happening again. But if you look into the real causes of each incident you can find failures in the system that, if corrected, can prevent further safety incidents.
Obviously its cheaper to blame individuals which is what companies would rather do than addressing structural issues...
As I said before, there are some things that are so fundamental and basic they don't rise to the level of causation you are speaking of. I'll repeat..."fundamental and basic". Remembering to lower the landing gear is one of those things. Replacing access panels is another.
Aircraft have been landing with gear down since retractable undercarriages were invented, to simply say that when accident of this type happens its down the crew are unprofessional idiots is the easy way out.
To try and stop it happening again you need to look at the causes - was the checklist followed?, if not why?, if it was , is the checklist correct?, was there a breakdown in communication between the crew?, if so why? - does the airline have a hierarchical culture where the junior crews do not question the decisions of the Captain?, does the CRM system need attention?
With regard to panels - within BA the check papaerwork is in such a state that there can be several job cards for the removal and refit of each panel - it is quite easy at the end of a check for all the work to be completed and a decision made to panel-up the wing - at the end of shift the Engineer stamps up dozens of cards for the repaneling of the wing, then when he comes in the following day there is another routine card lying around for a panel refit - the Engineer knows he fitted the panel yesterday and assumes he missed it in the final stamp up. What he doesn't know is that the night shift found the cards in another area and trying to help removed the panel he had refitted earlier that day. So we end up with a panal not fitted but several cards stamped to say that it was..
So in each case its easy to say that those involved are unprofessional idiots but doing that will not stop it happening again. But if you look into the real causes of each incident you can find failures in the system that, if corrected, can prevent further safety incidents.
Obviously its cheaper to blame individuals which is what companies would rather do than addressing structural issues...
Join Date: Dec 1998
Location: .
Posts: 2,997
Likes: 0
Received 0 Likes
on
0 Posts
..."fundamental and basic". Remembering to lower the landing gear is one of those things.
What I cannot get my head round is why it is that BA pilots on pprune are not exactly rushing up to the wicket to defend their engineers.
I have a hell of a lot of faith in the engineers who have looked after me for 47 years and I have only ever been let down once and on that occasion I was given "another opinion".
By that I mean that the despatching engineer had doubts but all the "experts" considered the problem solved. They were wrong!
I have a hell of a lot of faith in the engineers who have looked after me for 47 years and I have only ever been let down once and on that occasion I was given "another opinion".
By that I mean that the despatching engineer had doubts but all the "experts" considered the problem solved. They were wrong!
Join Date: Jan 2004
Location: Manchester
Posts: 181
Likes: 0
Received 0 Likes
on
0 Posts
AMF.
Flight Deck - tiny self contained environment, generally only contains 2 people. Also has been study of human factors since WW2. Has multitude of warning systems in case you mess up.
Hangar - huge multi-shift environment containing possibly hundreds of people. Has a mountain of paperwork/job cards which often contradict/duplicate. Has managers running around telling Tech's to do/leave tasks without their Surpervisor/LAE knowing anything about it. Usually under funded and unwanted by airline and every one there knows it. Not subject to any kind of work hours limit. Been study of Human factors for about 5 years.
Spot the difference.
Safety is about systems and people. The best professional in the world is only as good as the syetm they work within, by the same rational, a poor professional can be kept safe in a system that has the necessary checks against error.
It's not about the stand alone professional. You may not realise it, but when you are there in your little flight deck years of time and a fortune in money has been spent to make sure you don;t make an error.
As JETII states, it's about Human factors. Maintenance people do not have that investment or back-up.
Flight Deck - tiny self contained environment, generally only contains 2 people. Also has been study of human factors since WW2. Has multitude of warning systems in case you mess up.
Hangar - huge multi-shift environment containing possibly hundreds of people. Has a mountain of paperwork/job cards which often contradict/duplicate. Has managers running around telling Tech's to do/leave tasks without their Surpervisor/LAE knowing anything about it. Usually under funded and unwanted by airline and every one there knows it. Not subject to any kind of work hours limit. Been study of Human factors for about 5 years.
Spot the difference.
Safety is about systems and people. The best professional in the world is only as good as the syetm they work within, by the same rational, a poor professional can be kept safe in a system that has the necessary checks against error.
It's not about the stand alone professional. You may not realise it, but when you are there in your little flight deck years of time and a fortune in money has been spent to make sure you don;t make an error.
As JETII states, it's about Human factors. Maintenance people do not have that investment or back-up.
Last edited by AUTOGLIDE; 23rd Dec 2005 at 12:10.
Join Date: Apr 2005
Location: UK
Posts: 459
Likes: 0
Received 0 Likes
on
0 Posts
Remember.
Pilots work as a team, checking each other.
Cabin Crew work as a team, cross checking Doors Auto or Manual.
Engineers often work alone with no one around to cross check.
Engineers working hours are not well regulated.
Engineers often working many Aircraft at the same time.
Work it out for yourself.???
Pilots work as a team, checking each other.
Cabin Crew work as a team, cross checking Doors Auto or Manual.
Engineers often work alone with no one around to cross check.
Engineers working hours are not well regulated.
Engineers often working many Aircraft at the same time.
Work it out for yourself.???
Join Date: Feb 2005
Location: KSA
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
Wow,
This kinda reminds of that scene in the Blues Brothers movie where a groveling John Belushi is blaming his jilting of Carrie Fischer (while she's holding an M-16) at the altar on everything from "had a flat tire" and "ran out of gas", to "locuuuusts!".
Looks like I made a big mistake over all those years spending time on shop floors getting to know the engineers on a first name basis, babysitting various aircraft through routine, pre-buy, and pre-sale inspections, signing work orders, reviewing job cards, taking advice etc. etc....why, it was all a big waste of time.
I didn't know it then, but what I've learned here, is if something were to have gone amiss with the work they performed, or they made assumptions about work they guessed had been performed....why....."it would all be management's fault because they didn't devise a system that lets me...a self-proclaimed professional...assume and guess!"
Which was the issue, after all.
This kinda reminds of that scene in the Blues Brothers movie where a groveling John Belushi is blaming his jilting of Carrie Fischer (while she's holding an M-16) at the altar on everything from "had a flat tire" and "ran out of gas", to "locuuuusts!".
Looks like I made a big mistake over all those years spending time on shop floors getting to know the engineers on a first name basis, babysitting various aircraft through routine, pre-buy, and pre-sale inspections, signing work orders, reviewing job cards, taking advice etc. etc....why, it was all a big waste of time.
I didn't know it then, but what I've learned here, is if something were to have gone amiss with the work they performed, or they made assumptions about work they guessed had been performed....why....."it would all be management's fault because they didn't devise a system that lets me...a self-proclaimed professional...assume and guess!"
Which was the issue, after all.
Join Date: Jan 2004
Location: Manchester
Posts: 181
Likes: 0
Received 0 Likes
on
0 Posts
AMF.
Actually I'd say you haven't learnt anything 'here'. You also seem to know nothing of large scale aircraft maintenance, other than in theory.
No-one is saying that they don't take responsibility for what they do.
What you cannot do is take responsibility for something, like a panel, that has to be removed numerous times for access, yet is only in the system once and all it's subsequent removals are not recorded because the system doesn't do it despite 'management' being told this over and over again. We are not talking about single step part removal/replacements on Cessna's, but serious maintenance inputs on complicated transport aircraft. I'm afraid that even you wouldn't 'walk' these aircraft through any check, the Engineers wouldn't have time to talk to you and in any case they could be diferent people day to day as line/hangar workloads alter and they are picking up where others left off. Ah, the myth of the LAE in control of the check, must have been in some bygone era. You also wouldn't have time to all those differing paperwork tasks - because there's too much. Are you cloned?
Actually, your heroic actions above are exactly the scenarios when things do go wrong. 'Kinda' get it now? Probably not.
Hero's and smoky holes have a strange way of attracting each other. Actually the 'I'm a pro/can do attitude' is identified one of the primary causes of aircraft crashes.
Actually I'd say you haven't learnt anything 'here'. You also seem to know nothing of large scale aircraft maintenance, other than in theory.
No-one is saying that they don't take responsibility for what they do.
What you cannot do is take responsibility for something, like a panel, that has to be removed numerous times for access, yet is only in the system once and all it's subsequent removals are not recorded because the system doesn't do it despite 'management' being told this over and over again. We are not talking about single step part removal/replacements on Cessna's, but serious maintenance inputs on complicated transport aircraft. I'm afraid that even you wouldn't 'walk' these aircraft through any check, the Engineers wouldn't have time to talk to you and in any case they could be diferent people day to day as line/hangar workloads alter and they are picking up where others left off. Ah, the myth of the LAE in control of the check, must have been in some bygone era. You also wouldn't have time to all those differing paperwork tasks - because there's too much. Are you cloned?
Actually, your heroic actions above are exactly the scenarios when things do go wrong. 'Kinda' get it now? Probably not.
Hero's and smoky holes have a strange way of attracting each other. Actually the 'I'm a pro/can do attitude' is identified one of the primary causes of aircraft crashes.
Last edited by AUTOGLIDE; 23rd Dec 2005 at 17:00.
Join Date: Feb 2005
Location: KSA
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
Autoglide,
Don't know where you got the "hero" thing from, or that i was talking about Cessnas. You're the one who seems to think it requires heroic effort to do a job correctly.
An aquaintance of mine went through heroic efforts (probably) the day he, the other pilot, and airplane wound up in a hole. According to the findings of the investigation, the jackscrew on the horizontal stab was impoperly re-installed, something not detectable on a preflight since it backed out in-flight later on descent. Witnesses on the ground said the aircraft went through a few vertical up and down thousand-foot occilations before crashing vertically, killing everyone.
You see, that's where assumptions and guesses regarding job cards and the inconvenience of shift changes wind up. My desire, sitting in the seat, exceeds yours with regards to you getting it right.
So you can try and reduce my desire to learn more from engineering and do my job better...which in large part is knowing the airplane....to something akin to being "the problem" or an arrogant prick. Pretend I don't believe in causes like "human factors" etc when it comes to aircraft accidents if that's convenient. You'll not find anyone I've flown or involved with in 30 years of professional flying saying I'm not a firm proponent and hands-on user in dealing with potential problems on that level, CRM, or listening...all those things you apparently think you're giving me an elementary primer lesson but we use every day.
Saying "do your job" isn't the same as telling you how to do it. Flying or fixing, neither of them are rocket science. If you can't handle the focus, communication, organization, and paperwork that goes with it, then you're in the wrong business.
And by the way, how can one be a "poor professional".. The kind that a desirable system will have "necessary checks against when they make errors", as you put it? The "System" is just people after all, so who checks the checkers if they're "Poor professionals" too?
At some point, someone has to assume responsiblity for their own actions.
Don't know where you got the "hero" thing from, or that i was talking about Cessnas. You're the one who seems to think it requires heroic effort to do a job correctly.
An aquaintance of mine went through heroic efforts (probably) the day he, the other pilot, and airplane wound up in a hole. According to the findings of the investigation, the jackscrew on the horizontal stab was impoperly re-installed, something not detectable on a preflight since it backed out in-flight later on descent. Witnesses on the ground said the aircraft went through a few vertical up and down thousand-foot occilations before crashing vertically, killing everyone.
You see, that's where assumptions and guesses regarding job cards and the inconvenience of shift changes wind up. My desire, sitting in the seat, exceeds yours with regards to you getting it right.
So you can try and reduce my desire to learn more from engineering and do my job better...which in large part is knowing the airplane....to something akin to being "the problem" or an arrogant prick. Pretend I don't believe in causes like "human factors" etc when it comes to aircraft accidents if that's convenient. You'll not find anyone I've flown or involved with in 30 years of professional flying saying I'm not a firm proponent and hands-on user in dealing with potential problems on that level, CRM, or listening...all those things you apparently think you're giving me an elementary primer lesson but we use every day.
Saying "do your job" isn't the same as telling you how to do it. Flying or fixing, neither of them are rocket science. If you can't handle the focus, communication, organization, and paperwork that goes with it, then you're in the wrong business.
And by the way, how can one be a "poor professional".. The kind that a desirable system will have "necessary checks against when they make errors", as you put it? The "System" is just people after all, so who checks the checkers if they're "Poor professionals" too?
At some point, someone has to assume responsiblity for their own actions.