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Incident at Heathrow

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Incident at Heathrow

Old 31st May 2013, 23:41
  #681 (permalink)  
Join Date: Feb 2008
Location: Manchester UK
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There really isn't any need for crew to kneel or crawl on the ground to inspect the catches. Phones with cameras are now almost universal. Surely quickly holding the phone at or near ground level and a quick 'snap' up at the engine would allow easy inspection of the photo?

This has the added advantage their check would be documented!

While I'm sure it would be even better to get hands on the catches, this would be a lot better than not checking.
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Old 1st Jun 2013, 00:18
  #682 (permalink)  
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Originally Posted by FREDA
An engineering oversight left the cowls unsecured and we're still trying to blame this on pilot error?
Not just trying to blame this on pilot error, FREDA. The pilot error was in failing to spot the unlatched covers before committing aviation ! No pilot doubts that today, do they ?
A flight crews skills brought the bloody thing back in one piece and the cabin crews skills got everyone out of a burning aeroplane alive.
Yep but is the flight crew mentally still in one piece? They are surely deeply embarrassed even if it is one of the there but for the grace go I type unfortunate incidents, and of course the engineers will also be embarrassed for having handed over a loaded gun - but they didn't pull the trigger - pilots did that!

Take it on the chin, learn from it, and stop blaming the usual scapegoats.
Yes, pilots should do that and I am sure most would take it on the chin. To be clear, just like David Learmount when he said Yes to BBC's Chris Ekin, Yes I ultimately blame the pilot responsible for the walk round check on this one. Since 1903 he or she has been ultimately responsible for the team effort that puts each piece of tin safely into the sky as well as gets it down again safely but especially when something that should be picked up by the Mark I eyeball during the customary walk round is missed. So in analysing what went wrong here it would be preferable, would it not, if ideas of simple prevention next time rather than skilled cure again in future were the ones that were applauded?

Let's not forget too quickly that an incomplete undisciplined (unscripted/unprompted?) walk round inspection, depending on how diligently it is done of course, may be tantamount to Russian Roulette. Now unless we put money on it, and beancounters do of course, the rest of us have never applauded the Christopher Walkens of this world for surviving Russian Roulette now have we?

Unlike David Learmount I do not think it is right to dilute my "Yes" vote with phrases like 'design fault' or 'engineer error' to the extent we have incorrectly spun headlines in tomorrow's newspapers. Those responsible for those other errors are in play but they are not ultimately accountable for this incident.

Last edited by slip and turn; 1st Jun 2013 at 00:22.
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Old 1st Jun 2013, 00:22
  #683 (permalink)  
Join Date: Mar 2005
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True and the crew did a great job, I'm sure the AAIB will be looking into why one of the links in the chain (crew pre-flight check) didn't spot this known problem.

I'm sure any footage that is available from the stand cameras at Heathrow will show whether this check was sufficient or needs further amendment.

I'm sure any conscientious F/O doing the pre-flight would bend down and glance at the cowls but it's clear that this isn't always enough to spot a problem.

I hope that this re-focuses attention on the problems with this cowl rather than a quick hatchet job on the individuals involved and forget about it.
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Old 1st Jun 2013, 00:28
  #684 (permalink)  
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"I wonder if anyone has heard of that wonder devise called a telescopic mirror should allow the pilot to just crouch a little without getting his knees wet."
That level of technology? Not in our lifetime!
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Old 1st Jun 2013, 00:29
  #685 (permalink)  
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Accountant will say correct decision


So BA, I know you monitor this forum closely, before you hang an engineer or pilot out to dry (excuse the pun!) just remember the management decisions back in the 1987, and all the money you saved!

I was that angry young man in 1987 telling you what a bad decision it was.

You know who you are...
Well 1979 - an accountant will do just that. 26 years the cost of employing 7 or 8 engineers (full benefits etc which is around 3 times basic salary) - vs cost of this incident. The decision to stop engineers doing PDI was correct from their purely financial point of view.

Experts here - there are several saying that this was a 'minor' event will be the ones listened to by the suited accountant.

I have had just this type of argument in the past - the only time you will win is if you tell them to take responsibility as despite their name accountants never want to be accountable
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Old 1st Jun 2013, 00:31
  #686 (permalink)  
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Not that many years ago a colleague was called to head office to attend a disciplinary hearing in respect of a missing elevator closure panel that was spotted on a flight crew walk round.

He signed the last daily inspection the night before in the dark and failed to notice it was missing.

The panels location could be seen clearly from the ground as the green primer paint contrasted strongly with the aircrafts silver paint finish.

He listened to the charge against him then asked a simple question. Where is everybody else? He went on to point out that the aircraft had had several inspections conducted prior to his by pilots and engineers. Nobody had noticed this panel missing in a weeks flying.
The panel was found in a bucket on the tail dock in heavy maintenance.

A good question might be how many microswitches do you want given the large number of access doors and panels on a modern aircraft and how many duplicate inspections. The truth is you have to rely on human beings who are fallible.

Normally I make a point of not lowering the cowlings until I am ready to latch them.
On lowering them I latch them straight away and normally if possible have a second engineer confirm the latching.
However a leak check post a ground run on stand may well require the cowlings to be reopened.

As other posters have pointed out the pressure on line maintenance to reduce costs is immense with major airlines leading the charge. Anyone with an interest in this should get access to the information distributed by the Association of Licensed Aircraft Engineers. Many senior engineers (agewise) including myself are struggling to continue in the current climate and retirement can't come soon enough.

One thing I will guarantee is that the maintenance staff involved will be distraught and this will never be forgotten for as long as they work on aircraft.

Maybe flight crew should have access to a "prayer mat" to allow them to look under the cowling without getting their knees wet, though quite what the pax will make of the crew praying to the engine prior to flight is anybodies guess!!!!!!!!!

Last edited by ericferret; 1st Jun 2013 at 00:50.
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Old 1st Jun 2013, 00:49
  #687 (permalink)  
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I cannot believe that people are still suggesting that you cannot check the latches without getting on your back under the pod. Nonsense, you squat down, place one hand on the ground and lean over, it's not hard, just do it. It's well worth 10 seconds per engine to save your butt - regardless of what rules your company makes. You need to lie under the pod to open or close the latches, not check them.

As for doing walk-rounds whilst the aeroplane is still being worked on, that's another issue. Personally, that's the point I have to trust the re-fuelers, engineers etc to do their jobs, I simply don't have time to go out again.
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Old 1st Jun 2013, 01:52
  #688 (permalink)  
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Airbus think you can. Here's the reference from PRO-NOR-SOP05 (Exterior Inspection).

And what's more, I can confidently state this accident wouldn't have happened if I had done the walkaround check - as I check the catches!
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Old 1st Jun 2013, 03:17
  #689 (permalink)  
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I still would like to know where and how they got the all important snaps from pushback...

And why, assuming these weren't from CCTV, no one thought to bring this to someone's, anyone's, attention at the time?
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Old 1st Jun 2013, 04:15
  #690 (permalink)  
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This is a dumb question from a PAX.

Attach one of those long orange "Remove before flight"tags to the latch itself? It would trail on the ground and, if the a/c got to the stand, blow clearly in the wind.
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Old 1st Jun 2013, 04:16
  #691 (permalink)  
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Every year the pilots get a few more tasks to complete between sign on and push back, every year it takes a fraction longer to get through security and to the aircraft, every year the pilots face gets a little more somber.
The same is true for the Engineers and the gate staff, the folk at the Operations desk and the refuellers and caterers. Every year there is slightly less time for a chat and a " how do you do" as the aircraft is signed over from Engineer to Pilot. Every year information flows less and less.
Peak human performance occurs with moderate external stress, we are beyond the apex of the curve and moving steadily down the other side. If we add another task to the duty ( " here....carry this telescoping mirror" " Sir where is your IPhone for the latch inspection? ...what do you mean you have an old Nokia?" ) without extending sign on times or allocating more staff to Engineering duties, we will push ourselves even further down the steep side of the performance/ stress curve.
The answer is sufficient numbers of well trained crew with enough time to do a professional job. Anything else is more of the same.

Last edited by framer; 1st Jun 2013 at 04:17.
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Old 1st Jun 2013, 06:22
  #692 (permalink)  
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From London Evening Standard:
As the report reveals maintenance shortcomings at BA, lawyers may argue that the airline is liable. The total exposure to BA of compensation claims could total 10m.
That could buy a lot of flight crew walkaround overalls, inspection mirrors, screwdrivers and torches. Surely this sort of kit should be stowed on board?
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Old 1st Jun 2013, 06:59
  #693 (permalink)  
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Learn from this

Yes ... communication and team-work is the key. Many years ago, my copilot found a bent compressor blade on the walk-round. He told me, the Captain, and I asked for an immediate engineering assessment which led to a decision for an aircraft change.

Here is a line of communication that that is essential. It is the Captain's responsibility to initiate the correct actions from any adverse report from any information received.

This Captain, although unaware of the initial error, ensured that he brought the flight to a safe conclusion. He is to be congratulated for a job well done and saving the lives of all concerned.

Blame is an emotive word that the legal profession thrives on. All concerned must be thankful for a safe conclusion and I trust that we have all learned from this by improving procedures and inspections ... the best outcome!

Retired after 31 years
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Old 1st Jun 2013, 07:03
  #694 (permalink)  
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Quote PAXboy ''This is a dumb question from a PAX.

Attach one of those long orange "Remove before flight"tags to the latch itself? It would trail on the ground and, if the a/c got to the stand, blow clearly in the wind.''

Like this?

Not such a dumb idea. This is the Airbus modification for IAE engines introduced last year. It's fitted to the lated A320 series and it holds the doors open slightly to make it obvious they aren't latched and the red flag dangles out of the cowling as well. Of course, it requires the engineer to engage and stow the pin the flag is attached to, but it's a major improvement
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Old 1st Jun 2013, 07:55
  #695 (permalink)  
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Slip and turn: great post. I'm work in a responsible job in another sector where I have to do the equivalent of "getting my knees dirty" every single damn day. I work on the basis of assuming that other people haven't done what they are supposed to have done, and about 1% of the time I'm right. Sure, in situations like this problems often have organisational causes as much as individual ones but checks and double checks are built into systems for a reason. Complacency can quite literally be a killer.
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Old 1st Jun 2013, 08:02
  #696 (permalink)  
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Post 710 just about sorts it for me.Little bit surprised this hasn't been done already considering the number of incidents with these cowlings.There needs to be a hardware change e.g. as above.
Don't forget the outcome to this event.....Congratulations to the crew(s) for a job well done.
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Old 1st Jun 2013, 08:10
  #697 (permalink)  
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Why is it that accountants think that their job is to decide how a company's money is spent.

Surely their job is to account for all money coming in, and all money going out. How it is spent should be left to others.
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Old 1st Jun 2013, 08:20
  #698 (permalink)  
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I work on the basis of assuming that other people haven't done what they are supposed to have done, and about 1% of the time I'm right.
I would say finding snags on a walkround is probably higher than 1% - trouble is it very rarely is the Eng Cowlings.

So the walkround needs to "target" the frequently found problems (lights cracked, birdstrike, brake wear, tyres etc.) and the "high danger" points. Also, as engineers have been withdrawn / servicing less frequent, the walkround has altered from "second checking the engineer" (cowls) to an actual turnround - what has fallen off / got damaged / worn out? Bear in mid the cowl check is just one, not emphasised / highlighted line, in the checklist.

It's academic now for most A320 operators, especially BA - people will check cowls closely for a year or 2. But we must make sure we don't enhance that to the loss of something else (the brigade of lights, knee pads, mirrors miss the point the cowl is but one of many elements), and the "solution" outlasts the awareness period.

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Old 1st Jun 2013, 08:30
  #699 (permalink)  
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NoD - agreed, but it seems to me as a complete outsider that there's a big list of things which need to be checked, all of which are mission critical, and so they all need to be checked, not just some of them. I take the point that is coming across loud and clear on here from industry professionals that pressure is applied by the "beancounters" to do ever more with decreasing resources and not a lot of time to do them but surely the choice is this: be safe, or be on time. Again in my own work (an entirely different field but there are some comparable aspects) I have faced equivalent situations and firmly said "no - we are doing this the right way not the quick way". Or am I wide of the mark with this comparison?
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Old 1st Jun 2013, 08:38
  #700 (permalink)  
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"framer" - yes you are right we get more tasks, and with 25 minutes turn-around we learn to be more efficient, but no way will I avoid spending 20 seconds on checking this or other things that is of importance, to cut corners, simply because what we think we are saving in time, is of no insignificant.
That's great, I hope you are the pilot when I am paxing. I take a similar attitude to my duties but do you want all of your flights to be safe or all flights to be safe? You go on to say:
I have seen it with few commanders etc., where they love to play a game to see how close to the edge they can fly, perform with regards to descent, configuring to get established by 1000 ft. Sure when it works it is sweet, however one day "Murphy's law will hit them" and they will run out of options and time, as they leave themselves no margin for the unexpected!
Fortunately this is the minority, but still one incident is one to much!
That makes the point quite clearly, a system has to be tolerant of behaviours other than just the most exemplorary. The same commanders you speak of cannot be trusted to be as diligent as yourself with checking the latches etc, and they will always be there, in every company to a greater or lesser extent.
So if you are tasked with ensuring that this never happens again you have to go deeper than " it wouldn't happen if I was flying" if you wish to be successful.
The trick is know that these errors will occur, and to design systems that are tolerant of those errors. Ensuring that the accountants that run the airlines don't reduce time available to operational staff to a degree that encourages rushing is key. It is the make-up of the system itself.

Last edited by framer; 1st Jun 2013 at 08:40.
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