'Scathing' report on BA Maintenance practices
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'Scathing' report on BA Maintenance practices
UK investigators have again criticised maintenance practices at British Airways (BA) after a lengthy investigation into a serious incident in which errors during work on a Boeing 757-200 led to roll-control problems during a diversionary approach to London Gatwick two years ago.
It marks the latest in a series of serious maintenance-related events at BA which have already prompted concern from inspectors.
In a scathing report into the 757 event, released today, the UK Air Accidents Investigation Branch (AAIB) reprimands the airline for ineffective supervision, poor standards of maintenance, and an inadequate safety culture. The AAIB adds that BA’s quality assurance programme was “not effective” in highlighting these “unsatisfactory” maintenance practices.
Shortly after the 757, registered G-CPER, departed London Heathrow for Paris on 7 September 2003, the crew opted to divert to Gatwick after detecting the smell of hot oil in the cockpit.
But during the approach the crew discovered that the twin-jet drifted to the right of the localiser after its flaps were deployed. Its pilot needed to use about 40° of left-hand control column input, applying some 75% of left aileron, to keep the wings level and prevent the 757 turning to the right. This situation remained all the way to touchdown although the aircraft landed safely at Gatwick with no injuries among the passengers and crew.
Investigators found that the 757 had been performing its first flight following a 26-day maintenance check, and determined that errors had led to personnel servicing engine oils incorrectly and failing to re-install two access panels on the aircraft’s right-hand outboard flap. Asymmetric aerodynamic effects caused by the missing panels led to the roll-control problems.
“The events were the result of a combination of [maintenance] errors on the part of the individuals involved and systemic issues that had greatly increased the probability of such errors being committed,” says the AAIB.
It says that the task of refitting the panels to the aircraft was “not performed to the required airworthiness standard” and adds: “Ineffective supervision of maintenance staff had allowed working practices to develop that had compromised the level of airworthiness control and had become accepted as the ‘norm’.
“There was a culture, both on the ramp and in the maintenance hangar, which was not effective in ensuring that maintenance staff operated within the scope of their company authorisation and in accordance with approved instructions.”
The 757 problem occurred just three months after another serious maintenance-related incident involving a BA Boeing 777 which lost a large access door in-flight. During the investigation into that event the AAIB highlighted three other serious events, across a ten-month interval, involving similar maintenance issues at the airline.
In a high-profile incident in June last year a fuel-tank door left open after maintenance on another BA Boeing 777 resulted in the aircraft having to return after trailing a stream of fuel vapour.
BA, which disputes some of the findings, has acted on seven AAIB safety recommendations directed at the carrier in response to the 757 investigation. It says that it has raised awareness of the problem of maintenance errors and discussed possible preventative action in open forums. Specific procedures for servicing the 757, it adds, have been reviewed and amended for clarity.
It has reviewed its quality management structure, as well as its internal maintenance error investigation process, and is implementing an enhanced supervisory structure to oversee maintenance standards.
“The supervisory function will provide team leadership and technical guidance to less-experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks,” says the airline.
“Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.”
BA says that quality issues are discussed regularly in forums to ensure that all maintenance areas have a good understanding of where working practice might be improved.
Courtesey ATI
It marks the latest in a series of serious maintenance-related events at BA which have already prompted concern from inspectors.
In a scathing report into the 757 event, released today, the UK Air Accidents Investigation Branch (AAIB) reprimands the airline for ineffective supervision, poor standards of maintenance, and an inadequate safety culture. The AAIB adds that BA’s quality assurance programme was “not effective” in highlighting these “unsatisfactory” maintenance practices.
Shortly after the 757, registered G-CPER, departed London Heathrow for Paris on 7 September 2003, the crew opted to divert to Gatwick after detecting the smell of hot oil in the cockpit.
But during the approach the crew discovered that the twin-jet drifted to the right of the localiser after its flaps were deployed. Its pilot needed to use about 40° of left-hand control column input, applying some 75% of left aileron, to keep the wings level and prevent the 757 turning to the right. This situation remained all the way to touchdown although the aircraft landed safely at Gatwick with no injuries among the passengers and crew.
Investigators found that the 757 had been performing its first flight following a 26-day maintenance check, and determined that errors had led to personnel servicing engine oils incorrectly and failing to re-install two access panels on the aircraft’s right-hand outboard flap. Asymmetric aerodynamic effects caused by the missing panels led to the roll-control problems.
“The events were the result of a combination of [maintenance] errors on the part of the individuals involved and systemic issues that had greatly increased the probability of such errors being committed,” says the AAIB.
It says that the task of refitting the panels to the aircraft was “not performed to the required airworthiness standard” and adds: “Ineffective supervision of maintenance staff had allowed working practices to develop that had compromised the level of airworthiness control and had become accepted as the ‘norm’.
“There was a culture, both on the ramp and in the maintenance hangar, which was not effective in ensuring that maintenance staff operated within the scope of their company authorisation and in accordance with approved instructions.”
The 757 problem occurred just three months after another serious maintenance-related incident involving a BA Boeing 777 which lost a large access door in-flight. During the investigation into that event the AAIB highlighted three other serious events, across a ten-month interval, involving similar maintenance issues at the airline.
In a high-profile incident in June last year a fuel-tank door left open after maintenance on another BA Boeing 777 resulted in the aircraft having to return after trailing a stream of fuel vapour.
BA, which disputes some of the findings, has acted on seven AAIB safety recommendations directed at the carrier in response to the 757 investigation. It says that it has raised awareness of the problem of maintenance errors and discussed possible preventative action in open forums. Specific procedures for servicing the 757, it adds, have been reviewed and amended for clarity.
It has reviewed its quality management structure, as well as its internal maintenance error investigation process, and is implementing an enhanced supervisory structure to oversee maintenance standards.
“The supervisory function will provide team leadership and technical guidance to less-experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks,” says the airline.
“Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.”
BA says that quality issues are discussed regularly in forums to ensure that all maintenance areas have a good understanding of where working practice might be improved.
Courtesey ATI
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Not only that................. BA are pressing ahead with implementation of EWS , a computer system that makes an Engineers life and workpractices considerably more difficult than it was already. BA have already suffered lack of aircraft due to EWS problems, notably the Summer 2004 fiasco at LHR when repair overruns were refused by the CAA. The reason ? Lack of parts sourced by the EWS spares ordering system.
Recently BA have introduced EWS to control the hangar checks (all the paperwork , defects and work recording ) and the situation is that many people have not been trained to operate this system,in its current form, it has been forced through , due mainly because of embarrisment of the senior management ( EWS is many years late , vastly overbudget , circa £300 million and still does not deliver the product that was promised ) and confusion reigns................ hardly a re-assuring scenario for maintaining safety !
Recently BA have introduced EWS to control the hangar checks (all the paperwork , defects and work recording ) and the situation is that many people have not been trained to operate this system,in its current form, it has been forced through , due mainly because of embarrisment of the senior management ( EWS is many years late , vastly overbudget , circa £300 million and still does not deliver the product that was promised ) and confusion reigns................ hardly a re-assuring scenario for maintaining safety !
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Not only that Mk2................... BA removed the supervisor grade back in the early 90's. A large amount of the former, and more experienced, supervisors were promoted into "management" positions. This, with the introduction of "A3" personnel made life hard for the few remaining licenced people. Because of the new pay structure (and other factors) this meant that fewer newly licenced people were coming through. What was the point in studying for licences when you can earn almost as much as a mechanic.
Now 10 years later we have a situation that was so predictable it makes you want to cry. The number of licenced people has slowly declined. The statement from BA..........
..............Is only putting us back to where we were 10 years before. Where will they get these supervisors??
And this..........
Is rubbish. It will never happen!
If the management had spent more time dealing with safety, airworthiness and airmanship over these past 10 years or so rather than demotivating, demoralising the licenced people. Perhaps none of these incidents would have occured.
Please forgive this rant. I'm tired and its late.
I'll probably read this in the morning and edit/add to it
PLM
Oh... Please read THIS from 2002.... More of the same really!!
Now 10 years later we have a situation that was so predictable it makes you want to cry. The number of licenced people has slowly declined. The statement from BA..........
“The supervisory function will provide team leadership and technical guidance to less-experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks,” says the airline
And this..........
“Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.”
If the management had spent more time dealing with safety, airworthiness and airmanship over these past 10 years or so rather than demotivating, demoralising the licenced people. Perhaps none of these incidents would have occured.
Please forgive this rant. I'm tired and its late.
I'll probably read this in the morning and edit/add to it
PLM
Oh... Please read THIS from 2002.... More of the same really!!
Last edited by PondLifeMan; 16th Dec 2005 at 11:35.
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But, of course, "Safety is our first Priority at British Airways".
What a crock it is all becoming. BA HAVE MISTREATED ITS ENGINEERS FOR YEARS - they have had to endure more debilitating and demoralising rationalisations than I can count, and now the inevitable result.
Ah, but we are in a culture where Big BA can never be wrong, so I am sure all will turn out for the best - cue an avalanche of lies and spin about how brilliant it all is - just read "The Firelighter" for a taste of how nauseating BA's self - delusional lies can be.
What a crock it is all becoming. BA HAVE MISTREATED ITS ENGINEERS FOR YEARS - they have had to endure more debilitating and demoralising rationalisations than I can count, and now the inevitable result.
Ah, but we are in a culture where Big BA can never be wrong, so I am sure all will turn out for the best - cue an avalanche of lies and spin about how brilliant it all is - just read "The Firelighter" for a taste of how nauseating BA's self - delusional lies can be.
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Management seems to have forgotten the lessons of the windscreen blow-out on a BAC-111 that resulted in the Captain being outside the aircraft all the way down to the ground.
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Any company that has an active Blame Culture and fails to Learn from Problems will just make more Problems.
History shows many times that some can only learn after a high price has been paid and the legal process force change.
From my understandings, in a Blame Culture, many problems do not get fixed because people do not report problems and do not record actual work that takes place incase they get the Blame.
I think all airlines should adopt a proactive safety culture and remove blame culture.....
History shows many times that some can only learn after a high price has been paid and the legal process force change.
From my understandings, in a Blame Culture, many problems do not get fixed because people do not report problems and do not record actual work that takes place incase they get the Blame.
I think all airlines should adopt a proactive safety culture and remove blame culture.....
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The snag is that BA suffers from a "latte" culture ie. headoffice is so far removed from the front line that many of the 1,000s of hot deskers in Waterworld don't even realise that they work for an airline!
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BA HAVE MISTREATED ITS ENGINEERS FOR YEARS
None the less, I don't believe it was management that serviced the oil incorrectly, or failed to install those two flap panels which lead to the incident.
Of course they do make easy targets don't they?
These remarks are not directed at any one person.
cod
Paxing All Over The World
Joetom
And this will continue to happen because the vast majority of human beings do not learn any other way - irrespective of the busienss that they are in. For example, did anyone hear about a problem at Buncefield fuel depot this week?
--------------------
"I tell you, we are here on Earth to fart around, and don't let anybody tell you any different." Kurt Vonnegut, Jr.
History shows many times that some can only learn after a high price has been paid and the legal process force change
--------------------
"I tell you, we are here on Earth to fart around, and don't let anybody tell you any different." Kurt Vonnegut, Jr.
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Trying not to be cynical but God forbid this thread had been about Ryanairs maintenance procedures or some other lo-co I would put money on that this thread would run to about 20 pages.
As well as the hysterical pontificating that would accompany it.
Curious to see how far and how long this thread runs seeing its about a traditional airline and our so called Flag carrier.
Just curious!
As well as the hysterical pontificating that would accompany it.
Curious to see how far and how long this thread runs seeing its about a traditional airline and our so called Flag carrier.
Just curious!
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In reference to licensed Engineers I could not agree more as I used to be one,at one point I held approval on the F100,L1011 and B747-100,200 and 300,alas no more I got fed up with all the hassle that went with it and after 9/11 found myself out of a job so I simply moved into maintenace planning and tech services approvals have now lapsed but what the hell I am now in QA better paid easier life and treated like a human,its not only BA that have shaffted the Engineers as I have never worked for them but from what I have just read They are no better or worse than the ones that I have worked for.
the lunatic fringe
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Curious to see how far and how long this thread runs seeing its about a traditional airline and our so called Flag carrier.
BA has thousands of pages of abuse on these hallowed pprune pages.
A cough from BA and Pprune vomits bile.
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This is like another topic on R and N.
A320 with elec power problems in flight at night, AAIB were only advised as MOR paperwork run the course.
Me thinks that aircraft should have landed ASAP and inform the AAIB ASAP, change of culture reqd I think.
A320 with elec power problems in flight at night, AAIB were only advised as MOR paperwork run the course.
Me thinks that aircraft should have landed ASAP and inform the AAIB ASAP, change of culture reqd I think.
Thought police antagonist
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Quell surpise ! Before I comment, let me say this is not a "BA bashing" post, not that I would be overly concerned if it was construed as such--however.
The incident itself is the tip of the iceberg I feel. BA "managers" are simply the holders of a job title--nothing else. Which is but one of the many reasons why the standards have been in decline for years now--fortunately without a major incident. To compound the problems, there is the very pervasive and intrinsic problem of the culture that prevails. Change that, as other have suggested and you might, just might, begin to resolve some of the issues that plague Engineering. BA "managers" are immune from faults and failings--the workers are not--- hence the Blame culture. However, outmoded working practices also contribute---ever seen 6, yes 6 people attempt to change a 737 mainwheel ? Get real. Two max. and even then 90% of the work can be done by one engineer. Just one example I could offer. As for the flexibility of the stamp--hardly a first in any airline I agree, but more flexible than most seems to be the case within said organisation.
The whole organisation needs the equivalent of a "D" check--there's enough human corrosion in there anyway ! ---but unless the culture across Engineering changes pdq, then I have a nasty feeling that sooner, rather than later, the front pages will have the wrong and tragic headlines that nobody wants to read.
Lets not forget that, at one time, before they sold off the "family silver" BA Engineering, despite it's many failings, could actually offer a world class service compared to many others. Not anymore.
The incident itself is the tip of the iceberg I feel. BA "managers" are simply the holders of a job title--nothing else. Which is but one of the many reasons why the standards have been in decline for years now--fortunately without a major incident. To compound the problems, there is the very pervasive and intrinsic problem of the culture that prevails. Change that, as other have suggested and you might, just might, begin to resolve some of the issues that plague Engineering. BA "managers" are immune from faults and failings--the workers are not--- hence the Blame culture. However, outmoded working practices also contribute---ever seen 6, yes 6 people attempt to change a 737 mainwheel ? Get real. Two max. and even then 90% of the work can be done by one engineer. Just one example I could offer. As for the flexibility of the stamp--hardly a first in any airline I agree, but more flexible than most seems to be the case within said organisation.
The whole organisation needs the equivalent of a "D" check--there's enough human corrosion in there anyway ! ---but unless the culture across Engineering changes pdq, then I have a nasty feeling that sooner, rather than later, the front pages will have the wrong and tragic headlines that nobody wants to read.
Lets not forget that, at one time, before they sold off the "family silver" BA Engineering, despite it's many failings, could actually offer a world class service compared to many others. Not anymore.
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None the less, I don't believe it was management that serviced the oil incorrectly, or failed to install those two flap panels which lead to the incident.
However there is no proof that it was a licenced person who serviced the oil either. There are so few licenced people now in BA that the licenced guys HAVE to take the word of the mechanics.
Lets not forget that, at one time, before they sold off the "family silver" BA Engineering, despite it's many failings, could actually offer a world class service compared to many others. Not anymore.
We still do offer a world class service on our line stations. A service that could and should be making money. But, as the bosses only want to reduce our numbers, we cant compete. We are so top heavy that it just isnt viable.
Here are some rough figures taken from the 2003 Airline Personnel Costs Survey (CAA 2003 )
Airline .............. Flt Crew ............ Engineering
BMI ................... 600 ........... 650
Britannia .............. 420 ............ 530
BA ...................... 3300 ................ 7000
Virgin .................. 520 .............. 890
These figures speak volumes. BA has around 300 B1 licenced engineers. Who are the rest??
PLM
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pondlife....you didn't report the full facts:
Airline .............. Flt Crew ............ Engineering
BMI ................... 600 ........... 650
Britannia .............. 420 ............ 530
BA ...................... 3300 ................ 7000
Virgin .................. 520 .............. 890
Ryanair.................800................2
Airline .............. Flt Crew ............ Engineering
BMI ................... 600 ........... 650
Britannia .............. 420 ............ 530
BA ...................... 3300 ................ 7000
Virgin .................. 520 .............. 890
Ryanair.................800................2
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It has reviewed its quality management structure, as well as its internal maintenance error investigation process, and is implementing an enhanced supervisory structure to oversee maintenance standards.
Airline .............. Flt Crew ............ Engineering
Ryanair.................800................2
Ryanair.................800................2
If anyone wants to read the whole report it is here
seems that BA is also telling porkies to the AAIB
5.4 Safety Recommendation 2005-119
British Airways Maintenance Organisation should review the level of supervision on the \'shop floor\' to satisfy itself that it is adequate to maintain the required standards of airworthiness. -
Recommendation reviewed and implemented. !!!!
All full review regarding the role and responsibilities for enhanced supervision of maintenance standards has been carried out. The review has included the scope of technical decision-making, responsibilities for team leadership and supervision of maintenance standards. Additionally a review of feedback from LAE\'s following maintenance incidents, together with visits to other BA partner airlines, to carry out \'best practice\' reviews of LAE duties has been carried out. All true
Implementation of the enhanced supervisory role is expected in Autumn 2005, this will provide a clear definition regarding the scope of LAE responsibilities, including renaming of the grade as \'Maintenance Supervisor\' to differentiate from other certifying grades who are licence holders. The supervisory function will provide team leadership and technical guidance to less experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks. Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.Never happened
British Airways Maintenance Organisation should review the level of supervision on the \'shop floor\' to satisfy itself that it is adequate to maintain the required standards of airworthiness. -
Recommendation reviewed and implemented. !!!!
All full review regarding the role and responsibilities for enhanced supervision of maintenance standards has been carried out. The review has included the scope of technical decision-making, responsibilities for team leadership and supervision of maintenance standards. Additionally a review of feedback from LAE\'s following maintenance incidents, together with visits to other BA partner airlines, to carry out \'best practice\' reviews of LAE duties has been carried out. All true
Implementation of the enhanced supervisory role is expected in Autumn 2005, this will provide a clear definition regarding the scope of LAE responsibilities, including renaming of the grade as \'Maintenance Supervisor\' to differentiate from other certifying grades who are licence holders. The supervisory function will provide team leadership and technical guidance to less experienced maintenance staff, and will ensure that all activities are certified at the appropriate level by the staff involved in maintenance tasks. Formally recognising the supervisory level as part of the management of maintenance activity will also provide a defined line of communication between hangar management and staff performing tasks on the aircraft.Never happened
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This is fun now.....
From the AIIB report
Section 5 - Airline's response to Safety Recommendations
Dont know anyone who has been to one of these!
Not had one of these
Blame culture at work!
Excellent idea. Tell the pilots all our errors but make sure we dont get a copy!
PLM
From the AIIB report
Section 5 - Airline's response to Safety Recommendations
LAE Safety Symposium, attended by over 600 certifying staff and their local management
Systems and Procedures booklet issued to all 6,000 staff in Engineering describing systems for safeguarding maintenance standards
Examples of maintenance errors included in bi-annual Continuation Training for certifying staff as awareness of human error events
Addition of an engineering related section in the 'Flywise' periodical issued to all flight crew to review significant maintenance issues.
PLM