Incident at Heathrow
What to do IF an error was found on walkaround...
Just your maligned (with good reason seeing some of the comments) SLF here with a Q for those who sit up in the pointy end.
If on the walk around an engine cowl was found to have not been secured, does the pilot secure it himself or bring it to the attention of the ground engineer to be rectified?
I'm guessing the latter?
If on the walk around an engine cowl was found to have not been secured, does the pilot secure it himself or bring it to the attention of the ground engineer to be rectified?
I'm guessing the latter?
----- aren't "children of the magenta line", by any chance??
Clearly, you are unaware that the above expression is in common use in discussions of increasingly obvious shortcomings in current training systems and some operational systems.
Increasingly, it is obvious that those who know nothing but modern flight decks are showing, all too often, an inability to handle scenarios "outside the box".
In large part, the problem is often operators (and the regulators who approve) with increasingly complex SOPs and a punitive management approach to perceived non-compliance with SOPs. SOPs that are all about company CYA, and quite divorced from any reasonable version of "best practice".
It is a particular problem in Australia, with a regulator (CASA) that demands "Check Lists" that are, in fact, procedures lists, not vital actions check lists, at all. And Flying Operations Inspectors who have no respect for the AFM and the collected experience of the manufacturers, as reflected in the typical modern AFM.
Back to the incident, if the problem in this case turns out to be cowls that were not latched, I do hope that BA engineering and operations take a reasonable approach.
"Off with their heads" is not a reasonable approach. The way Qantas handled VH-OJH going off the end at Bangkok is a good example of how to handle a systemic problem, without destroying anybody's career. There was no shortage of proponents "fire the bastards", but "Reason" prevailed.
Looking through the incident record in the public domain, and the clear design problem of the latches, not limited to being hard to see during a walk-around, it is about time for an AD to fix the problem, once and for all.
Based on the published record, the basic design fails the "Reason" test.
I note that you haven't bothered to address the entirely legitimate examples I raised, where immediate and substantial departures from SOP's saved the day.
Last edited by LeadSled; 27th May 2013 at 05:09.
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Originally Posted by Mk1
If on the walk around an engine cowl was found to have not been secured
SC - according to an earlier post the a/c night-stopped LHR so that theory can probably go to bed.
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Video of a British Airways jet burning in the sky overhead London, trailing a plume of thick black smoke, broadcast all over the planet, causing the company untold reputation damage at a time when it can least afford it, and you think it's okay to praise the way 'OUR CREW' handled an 'aircraft emergency' that even you infer may have been self-induced because of a 'sub-standard' pre-flight (we'll know the truth behind this soon enough).
We know nothing until the official investigation reports in it's own good time. Speculation is pointless.
Regarding damage to BA's reputation, in my opinion as a passenger it enhances BA's reputation as they have shown on two occasions in recent years that when one of their aircraft develops troubles on takeoff and landing they have been able to bring the aircraft down safely at Heathrow, without loss of life, and in this instance the plane will (I assume) be flying again at some point. I dread to think what could have happened if it had been another airline run on a shoestring budget. So yes, the crew DO deserve praise for that happening no matter what the investigation finds.
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Post #46 any good?
EDIT: For the terminally confused, this and some subsequent posts were in reply to 'Safety Concerns' 'BA Engineering Glasgow' conspiracy theory from which I note he/she has retired 'hurt'
EDIT: For the terminally confused, this and some subsequent posts were in reply to 'Safety Concerns' 'BA Engineering Glasgow' conspiracy theory from which I note he/she has retired 'hurt'
Last edited by BOAC; 27th May 2013 at 08:10.
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G-EUOE
BAW747 seen @ 2013-05-23 18:56 UTC on route from SVG to LHR
BAW746 seen @ 2013-05-23 16:27 UTC on route from LHR to SVG
BAW335P seen @ 2013-05-23 14:07 UTC on route from ORY to LHR
BAW334P seen @ 2013-05-23 11:55 UTC on route from LHR to ORY
BAW991 seen @ 2013-05-23 08:59 UTC on route from TXL to LHR
BAW990G seen @ 2013-05-23 06:17 UTC on route from LHR to TXL
BAW747 seen @ 2013-05-23 18:56 UTC on route from SVG to LHR
BAW746 seen @ 2013-05-23 16:27 UTC on route from LHR to SVG
BAW335P seen @ 2013-05-23 14:07 UTC on route from ORY to LHR
BAW334P seen @ 2013-05-23 11:55 UTC on route from LHR to ORY
BAW991 seen @ 2013-05-23 08:59 UTC on route from TXL to LHR
BAW990G seen @ 2013-05-23 06:17 UTC on route from LHR to TXL
Loss of one cowl relatively regular event.
Go back a few more legs and I will be happy.
The suggestion that the aircraft in question completed even one prior flight with the cowls unlatched is ridiculous.
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"As all other airlines, BA have a swath of paperwork required by the ANO and EU legislation eventually filtering down via proceedures and work instructions to describing "what should be done" and "how it should be done". All this information is promugulated by the company to satisfy the CAA. But when it comes to trying to comply with these proceedures, it can be neigh on impossible to comply. In the end you knowingly flout the rules to enable the task to be completed in a timely fashion."
ABSOLUTE RUBBISH!
Knowingly flouting the rules is unacceptable, criminal behaviour. If you can't comply with the rules, then you cannot certify a CRS. Next step raise a query note.
Please tell me you don't work for BA.
ABSOLUTE RUBBISH!
Knowingly flouting the rules is unacceptable, criminal behaviour. If you can't comply with the rules, then you cannot certify a CRS. Next step raise a query note.
Please tell me you don't work for BA.
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Yotty
As all other airlines, BA have a swath of paperwork required by the ANO and EU legislation eventually filtering down via proceedures and work instructions to describing "what should be done" and "how it should be done". All this information is promugulated by the company to satisfy the CAA. But when it comes to trying to comply with these proceedures, it can be neigh on impossible to comply. In the end you knowingly flout the rules to enable the task to be completed in a timely fashion.
As all other airlines, BA have a swath of paperwork required by the ANO and EU legislation eventually filtering down via proceedures and work instructions to describing "what should be done" and "how it should be done". All this information is promugulated by the company to satisfy the CAA. But when it comes to trying to comply with these proceedures, it can be neigh on impossible to comply. In the end you knowingly flout the rules to enable the task to be completed in a timely fashion.
Would it not be more prudent to discuss issues like that with your management, or use the company SMS procedures.
Last edited by F900 Ex; 27th May 2013 at 08:32.
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ABSOLUTE RUBBISH!
Knowingly flouting the rules is unacceptable, criminal behaviour. If you can't comply with the rules, then you cannot certify a CRS. Next step raise a query note.
Knowingly flouting the rules is unacceptable, criminal behaviour. If you can't comply with the rules, then you cannot certify a CRS. Next step raise a query note.
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BOAC - As I (SLF) read through the weekend's posts on this thread I wanted to raise the point you've made.
Quite a few times I've been on a plane where engineers are working on one of the engines (or at least one cowling has been up). Both pilot and co-pilot having been sitting up front -- the walk around presumably having been done.
The cowlings have been shut and off we go. There comes a point where you surely do have to trust the professionalism of others. Or are you meant to leap out and have a decko?
I assume baggage hold doors which are generally shut minutes or seconds before departure are not subject to being checked because there are warning lights in the cockpit to indicate that something is open.
Quite a few times I've been on a plane where engineers are working on one of the engines (or at least one cowling has been up). Both pilot and co-pilot having been sitting up front -- the walk around presumably having been done.
The cowlings have been shut and off we go. There comes a point where you surely do have to trust the professionalism of others. Or are you meant to leap out and have a decko?
I assume baggage hold doors which are generally shut minutes or seconds before departure are not subject to being checked because there are warning lights in the cockpit to indicate that something is open.
As all other airlines, BA have a swath of paperwork required by the ANO and EU legislation eventually filtering down via proceedures and work instructions to describing "what should be done" and "how it should be done". All this information is promugulated by the company to satisfy the CAA. But when it comes to trying to comply with these proceedures, it can be neigh on impossible to comply. In the end you knowingly flout the rules to enable the task to be completed in a timely fashion. 
Probably not very well phrased, particularly the "flout the rules", but the fact remains that there has been a vast expansion of very prescriptive regulatory paperwork in recent years, although the basic job to be done had changed little.
Very little of it advances aviation safety. Those of you who see it in "black and white" simplicity do not appreciate the problem.
Indeed, it is very clear (despite being criminal law) that much of the regulation is capable of interpretation to suit the whim of the inspector or investigator. This is not confined to aviation, ever more complicated environmental or taxation law are just two more areas where the problem proliferates.
Australian aviation law has become so complicated, and capable of almost infinite interpretation, that it is a standing joke that, if you become airborne, you must have committed a crime. But it is no joke, when laws are written so that they cannot reasonably be complied with, or you have to break one regulation to comply with another.
We live in an are where we are moving from the "rule of law" to "rule by law". It does nothing for air safety.
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In the end you knowingly flout the rules to enable the task to be completed in a timely fashion."
The reason that all the training has been wasted, in the UK at least, is that the CAA has, as always, failed to do anything effective to make sure that organisations actually have a good HF programme that highlights issues just like this and then does something to eliminate them. All the average Surveyor wants to see is a neat pile of certificates for HF courses so that he cam tick the box marked "Complies with HF Requirements" while ignoring the fact that the organisation does nothing of the sort.
Now thew CAA has produced one of the most fatuous documents I have ever seen emanating from SRG, about its HF strategy for the next decade, apparently completely independent of EASA and ICAO, full of fluffy management-speak. I pretty much switched off when I got to how we are all going to go on a journey together; that was on Page One, and it gets worse.
There's a glamorous pic of the now-departed Gretchen to decorate this piece of nonsense, but that's all you can say for it.
Sorry, it's not actually thread-drift although it might seem like it. Whatever happened to the flight in question, it is likely that human error was the cause, and the the root cause is the organisational culture, NOT the deliberate flouting of instructions/procedures by any one person. But will anything be done apart from lots of meetings? Don't hold yor breff.
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The big picture !
As usual here we get bogged down in paperwork, legislation and SMS systems that are all grist to the mill of those who sit in offices and polish the seat of their trousers while producing reams of paperwork to try to avoid repetition of the incident.
The simplest safety management system starts with having the discipline to step back from a task and take time to review the work done, this can be very difficult when faced with the pressure encountered on a busy line station.
Oversight is another thing that is necessary be it self inspection as above or another person inspection the task. All of this requires common sense........ And that is something that is very hard to write into procedures. ( I know of one company that insists its maintenance staff put on protective glasses when ever they leave the crew room, this is a typical Elf & safety overkill that hampers vision for very little benefit most of the time.......... The eye protection issue should be left to the common sense of the individual when they think that the risk requires such protection)
Totally independent inspection......... That is what the "walk around" inspection by the pilots is about, this should be a broad overview and gross error check.
All of this is of course not posable without the tools to do the job be that time, company culture or external pressure, I have alluded to this in post #295.
The simplest safety management system starts with having the discipline to step back from a task and take time to review the work done, this can be very difficult when faced with the pressure encountered on a busy line station.
Oversight is another thing that is necessary be it self inspection as above or another person inspection the task. All of this requires common sense........ And that is something that is very hard to write into procedures. ( I know of one company that insists its maintenance staff put on protective glasses when ever they leave the crew room, this is a typical Elf & safety overkill that hampers vision for very little benefit most of the time.......... The eye protection issue should be left to the common sense of the individual when they think that the risk requires such protection)
Totally independent inspection......... That is what the "walk around" inspection by the pilots is about, this should be a broad overview and gross error check.
All of this is of course not posable without the tools to do the job be that time, company culture or external pressure, I have alluded to this in post #295.
Mikleour, Fireflybob:
I am not sure, dont think, the fire handle WAS pulled on WE. When I joined BOAC on the VC 10 it was stressed that there was only ONE way to shut an engine down in the event of fire/failure etc. The drill was always to complete the fire drill upto the point if firing a shot into the engine ( no fire indication, no shot). It was explained that this was the result of the WE accident when there were numerous ways of shutting down an engine, with all crew members involved, and everyone on WE thought someone else had actioned the fire handle. Remember that very clearly even after 40 years.
When my own critical failure arrived (failure of the HP turbine on a v heavy take off for NBO on a v warm night not long after we had passed the 400 feet height, the minimum BA height for any action) everything went like clockwork using that drill and the engine failure became almost a non event.
Perhaps it IS time to fit a warning system on the ecam to advise if cowls are unlocked, even on my car, unless doors are fully closed I get a warning and it won't allow me to engage drive.
I am not sure, dont think, the fire handle WAS pulled on WE. When I joined BOAC on the VC 10 it was stressed that there was only ONE way to shut an engine down in the event of fire/failure etc. The drill was always to complete the fire drill upto the point if firing a shot into the engine ( no fire indication, no shot). It was explained that this was the result of the WE accident when there were numerous ways of shutting down an engine, with all crew members involved, and everyone on WE thought someone else had actioned the fire handle. Remember that very clearly even after 40 years.
When my own critical failure arrived (failure of the HP turbine on a v heavy take off for NBO on a v warm night not long after we had passed the 400 feet height, the minimum BA height for any action) everything went like clockwork using that drill and the engine failure became almost a non event.
Perhaps it IS time to fit a warning system on the ecam to advise if cowls are unlocked, even on my car, unless doors are fully closed I get a warning and it won't allow me to engage drive.
Last edited by RetiredBA/BY; 27th May 2013 at 09:19.
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Quite a few times I've been on a plane where engineers are working on one of the engines (or at least one cowling has been up). Both pilot and co-pilot having been sitting up front -- the walk around presumably having been done. - yes
The cowlings have been shut and off we go. There comes a point where you surely do have to trust the professionalism of others. - yes
Or are you meant to leap out and have a decko? - no. This sort of work would normally require a Tech Log entry to clear which the eng would need to come into the cockpit, and you cannot 'accept' the aircraft until the entry is cleared. Nothing to stop you, of course 'leaping out' (ah! - in my younger days.....
), but if you cause a 'delay' to 'doors closed'/push back you may be asked (by a 'suit') why you did not 'allow' the system to work.
I assume baggage hold doors which are generally shut minutes or seconds before departure are not subject to being checked because there are warning lights in the cockpit to indicate that something is open.- yes
It is all about 'trust' in a team. There are other hatches which may be opened for servicing but have no 'warning system'. I hoped in my time that the pax like you 'trusted' me to operate safely, although admittedly there was a distinct personal incentive so to do as I was going to be in the same aircraft
The cowlings have been shut and off we go. There comes a point where you surely do have to trust the professionalism of others. - yes
Or are you meant to leap out and have a decko? - no. This sort of work would normally require a Tech Log entry to clear which the eng would need to come into the cockpit, and you cannot 'accept' the aircraft until the entry is cleared. Nothing to stop you, of course 'leaping out' (ah! - in my younger days.....
), but if you cause a 'delay' to 'doors closed'/push back you may be asked (by a 'suit') why you did not 'allow' the system to work.I assume baggage hold doors which are generally shut minutes or seconds before departure are not subject to being checked because there are warning lights in the cockpit to indicate that something is open.- yes
It is all about 'trust' in a team. There are other hatches which may be opened for servicing but have no 'warning system'. I hoped in my time that the pax like you 'trusted' me to operate safely, although admittedly there was a distinct personal incentive so to do as I was going to be in the same aircraft
Last edited by BOAC; 27th May 2013 at 09:18.
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BOAC - many thanks for your quick response.
And re trust from your pax, I always recall the words of of a school mate's dad who was a pilot for BEA (blimey, that makes me feel old). "The pilot wants to get home as well!"
And re trust from your pax, I always recall the words of of a school mate's dad who was a pilot for BEA (blimey, that makes me feel old). "The pilot wants to get home as well!"
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Something similar in my company's maint manual for engine runs.
Strange thing is if they have a Captain in the LHS they only need one engineer on-board in the RHS.
So I do a lot of engine runs.
Strange thing is if they have a Captain in the LHS they only need one engineer on-board in the RHS.
So I do a lot of engine runs.
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but if you cause a 'delay' to 'doors closed'/push back you may be asked (by a 'suit') why you did not 'allow' the system to work.
Safety seems to be way down the list of priorities nowadays.