Incident at Heathrow
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Hobbs report
I was browsing through the Hobbs report (An Overview of Human Factors in Aviation Maintenance - 2008)
http://www.atsb.gov.au/media/27818/ar2008055.pdf
... and was interested to see the section on Page 25 that clearly identifies accessibility and visibility as key issues in aviation maintenance
Its a good overview and most of the case studies are well known to PPrune readers
http://www.atsb.gov.au/media/27818/ar2008055.pdf
... and was interested to see the section on Page 25 that clearly identifies accessibility and visibility as key issues in aviation maintenance
Its a good overview and most of the case studies are well known to PPrune readers
Last edited by Pinkman; 30th May 2013 at 06:17.
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Quentic - can you explain, exactly, how you avoid populated areas in the south of England in a jet flying at several miles a minute... perhaps you could give us definition of "least populated" - last question - do you have a CPL?
Least populated: I can't imagine an approach to an airport in the UK, that would pass over more people than that to 27L/R at Heathrow.
CPL: No. PPL(A) expired
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I stopped flying 320 family aeroplanes nine years ago (V2500 and CFM). Back then this was a very well known problem. Obviously it's still ongoing and a better solution needs to be found.
However I was trained to always squat down to visually check the latches and check for a gap. Contrary to what some have written here it's hardly onerous and you don't get your knees dirty (if that's a worry change jobs). I'm sure thousands of 320 drivers do it every day. A nameless BA mate told me that until this incident he never checked the latches - he does now. I suspect the same may be true at other operators.
I'm sorry, but is a decent walk round too much to hope for? Isn't it part of our job to compensate for known issues with the machines we operate (for none are or ever will be perfect).
However I was trained to always squat down to visually check the latches and check for a gap. Contrary to what some have written here it's hardly onerous and you don't get your knees dirty (if that's a worry change jobs). I'm sure thousands of 320 drivers do it every day. A nameless BA mate told me that until this incident he never checked the latches - he does now. I suspect the same may be true at other operators.
I'm sorry, but is a decent walk round too much to hope for? Isn't it part of our job to compensate for known issues with the machines we operate (for none are or ever will be perfect).
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@Leftofcentre
"Some time in the fifties car makers discovered that if the bonnet opens while you are mobile bad things can happen.
They decided to have two latches one holds the bonnet closed good and proper the other just holds it more or less down but stops it coming any further up. It also allows it to project a bit so you notice the upsticking and vibrate a bit so you wonder what the noise is
They did this because they knew every so ofter one latch just isn't enough"
We call this method of working a FAIL SAFE do we not?
They decided to have two latches one holds the bonnet closed good and proper the other just holds it more or less down but stops it coming any further up. It also allows it to project a bit so you notice the upsticking and vibrate a bit so you wonder what the noise is
They did this because they knew every so ofter one latch just isn't enough"
We call this method of working a FAIL SAFE do we not?
A 'fail safe' is a situation whereby the failure of the mechanism 'naturally' fails in a safe way. An example would be (if you'll excuse the mention of railways) electro-pneumatic braking system on trains, whereby the natural state of the individual brakes on the wheels is that they are held on using jolly big springs, and the action of the train's braking system is to pull the brakes off using pneumatics. If any part of the train's system fails (for example the train splits, causing the brake-line to separate, releasing the pressure from the braking system) basic laws of physics (Newton & Hooke) cause the brakes to revert to the applied state rather than any backup mechanism* per se.
A fail safe cowl latching mechanism would be one whereby if the latch fails, the cowl nevertheless remains in the safest position while in flight (which is to say, closed.) You can envisage designing the cowls such that while in flight the flow of air passing the cowl naturally tends to push the cowl closed rather than tearing it off. (Simplistically, arranging the cowls such that their hinges were at the front and opened like the petals of a flower, would seem to be a 'fail safe' design in respect to the latches.)
(Note I'm not recommending that design - I'm sure there are plenty of reasons they're not designed like that and plenty of reasons why they are designed as they are, but that would be a design whereby the cowls would seem to fail safe in the event of latches not working.)
* some smartarse (me!) is going to say, 'what happens if the springs don't work'. Well, that's a different failure than the train braking system failing, so doesn't affect whether or not the design of the braking system is fail safe. I suppose one could start to worry about whether or not springs need their own fail safe, but to a certain extent worrying about whether or not springs are going to spontaneously stop being springy is a bit like worrying about whether or not gravity is going to stop working mid-flight. Possibly worth worrying about if you worry about the Bermuda Triangle, but otherwise you have to draw a line somewhere...
Case One:
"A nameless BA mate told me that until this incident he never checked the latches."
If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?
Breathtaking.
"A nameless BA mate told me that until this incident he never checked the latches."
If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?
Breathtaking.
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Even when the maintenance forgot to lock the latches, it is part of flight crew "Exterior Walk-Around" acc FCOM PRO-NOR-SOP-05:
...
Fan cowl doors...................................................CLOS ED/LATCHED
...
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Fan cowl doors...................................................CLOS ED/LATCHED
...
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Originally posted by JW411:
If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?
If that is really true then I am absolutely flabbergasted. Was he completely unaware that such problems had happened in the past and might just ruin his day if he didn't have a bloody good look?
It's not however the first time I tripped over an inexplicable yawning gap in an experienced pilot's aeronautical knowledge. No doubt I have some myself. I place some of the blame on the curious emphasis of modern training systems. Certainly, to my eyes they don't seem to place "Rule 1 - don't crash" in it's rightful place. Still, I'm becoming a grumpy old fart.
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Allow me to put Wannabe024's question more specifically -
When was the last death attributed to the operation of a scheduled commercial passenger flight operated by a UK-based airline on a (a) scheduled, or (b) charter, flight?
When was the last death attributed to the operation of a scheduled commercial passenger flight operated by a UK-based airline on a (a) scheduled, or (b) charter, flight?
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A nameless BA mate told me that until this incident he never checked the latches
Then 'someone' mandated that checking the cowl latches was a maintenance procedure and 'not required' by the flight crew.
AFAIK 'most' crews still check the latches.
Not proportioning 'blame' in any way, just stating how the responsibilities changed with the reduced turnaround times.
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When was the last death attributed to the operation of a scheduled commercial passenger flight operated by a UK-based airline on a (a) scheduled, or (b) charter, flight?
May 1995.
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From what I am aware of, the manufacturer recommends that crew-memebers be required to check cowl latches during walk-around. If this was not the rule at BAW then God help them.
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That's the BBC report based on the statement from NTSB that AAIB has now said is wrong. The NTSB statement includes this: "The pilots subsequently reported that one engine was shut down and the other engine was on fire." According to the Guardian and others, AAIB say this is not true. Apparently we are to get an interim report/bulletin from AAIB later today (Fri 31 May).
For some reason, the BBC have not quoted AAIB, but are carrying links to eminent news organisations that have, such as the Huddersfield Daily Examiner and the Ellesmere Port Pioneer.
For some reason, the BBC have not quoted AAIB, but are carrying links to eminent news organisations that have, such as the Huddersfield Daily Examiner and the Ellesmere Port Pioneer.
Richard J
I getting more and more confused about these so called news stories and who they are quoting.
No where in your BBC link did I see anything that quoted an NTSB source saying that there was a fire in one engine. Yet you seem to mention that the AAIB disavowed this statement from the NTSB
I think I will have to wait for an official link to an NTSB site as well as an AAIB issued interim report and forget about BBC etc. releases of rumours.
That's the BBC report based on the statement from NTSB that AAIB has now said is wrong. The NTSB statement includes this: "The pilots subsequently reported that one engine was shut down and the other engine was on fire." According to the Guardian and others, AAIB say this is not true. Apparently we are to get an interim report/bulletin from AAIB later today (Fri 31 May).
No where in your BBC link did I see anything that quoted an NTSB source saying that there was a fire in one engine. Yet you seem to mention that the AAIB disavowed this statement from the NTSB
I think I will have to wait for an official link to an NTSB site as well as an AAIB issued interim report and forget about BBC etc. releases of rumours.
I getting more and more confused about these so called news stories and who they are quoting.
ENG13WA029
I think I will have to wait for an official link to an NTSB site
Last edited by wiggy; 31st May 2013 at 04:22.
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For some reason, the BBC have not quoted AAIB, but are carrying links to eminent news organisations that have, such as the Huddersfield Daily Examiner and the Ellesmere Port Pioneer.
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600 largly missed points
There was nothing wrong with this aircraft, the fault was the faiure to lock the cowling latches, those who seek to fit a " Fool proof system" are the types who would fit enough systems to ensure that there could be no human error and end up with a totaly safe aircraft because it is to heavy to fly.
No one deliberatly released this aircraft to service, it slipped though the inspection net for reasons that we dont yet understand, but some above have shown a total lack of understanding of the pressues put on line maintenance personel and flight crews. These presures have slowiy been built up one small step at a time, minor increases in inappropriate H & S and Security measures may not seem to be a burden by those in walm offices who mandate these regulations but the cumulative effect of the mountain of non aviation regulation on those who have to work in a cold, wet and noisy ramp enviroment is a major distraction to the primery task in hand.
For instance I as a pilot cant get a security pass for a major UK airport because my one of my employers who was based abroad went bust and cant verify that I was contracted to a UK airline that also went bust. The fact that during this whole period I held a security pass and was based at the very UK airport that now wont issue me a pass is irritating to say the least. the problem is that without the pass for that airport I cant park in the staff car park, some idiot has closed the road that gives me easy access to the office for no apparent reason and I cant get out onto the ramp to do my walk around inspection without having someone let me in and out of the door on the jet way. All of this is individualy trivial but it makes for a longer working day and so the picture of the errosion of flight saftey by a thousand small cuts is clear.
The flight safety people like to go on about all the airport staff being part of the flight safety system, this is very good in theory but those in managment who impose more and more small reguations have yet to get the message that all this regulation is distracting people from the task of keeping aircraft safe.
The question both the airline and airport managers should be asking themselfs is "did the small bit of nifnaf & trivia regulation I put in place to cover my own six destract a guy from his flight safety task ?".
Individualy it is unlikely that one regulation will do this but collectively the answer is a very big YES you are building an accident one reguation at a time.
No one deliberatly released this aircraft to service, it slipped though the inspection net for reasons that we dont yet understand, but some above have shown a total lack of understanding of the pressues put on line maintenance personel and flight crews. These presures have slowiy been built up one small step at a time, minor increases in inappropriate H & S and Security measures may not seem to be a burden by those in walm offices who mandate these regulations but the cumulative effect of the mountain of non aviation regulation on those who have to work in a cold, wet and noisy ramp enviroment is a major distraction to the primery task in hand.
For instance I as a pilot cant get a security pass for a major UK airport because my one of my employers who was based abroad went bust and cant verify that I was contracted to a UK airline that also went bust. The fact that during this whole period I held a security pass and was based at the very UK airport that now wont issue me a pass is irritating to say the least. the problem is that without the pass for that airport I cant park in the staff car park, some idiot has closed the road that gives me easy access to the office for no apparent reason and I cant get out onto the ramp to do my walk around inspection without having someone let me in and out of the door on the jet way. All of this is individualy trivial but it makes for a longer working day and so the picture of the errosion of flight saftey by a thousand small cuts is clear.
The flight safety people like to go on about all the airport staff being part of the flight safety system, this is very good in theory but those in managment who impose more and more small reguations have yet to get the message that all this regulation is distracting people from the task of keeping aircraft safe.
The question both the airline and airport managers should be asking themselfs is "did the small bit of nifnaf & trivia regulation I put in place to cover my own six destract a guy from his flight safety task ?".
Individualy it is unlikely that one regulation will do this but collectively the answer is a very big YES you are building an accident one reguation at a time.
Without wishing to second guess the outcome of this particular incident, I think it is generally recognised that BA engineering is having a few problems with overstretch at the moment. The 777 diversion due to a lack of engineering checks springs to mind.....
Last edited by hunterboy; 31st May 2013 at 07:32.
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Pinkman - thanks for the link to the Hobbs Report on Maintenance staff work issues. As an ex-maintenance person, I'm pleased to see this issue being taken seriously. Good for the Aussies!
Last edited by Sunnyjohn; 31st May 2013 at 07:43. Reason: typo