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Incident at Heathrow

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Incident at Heathrow

Old 31st May 2013, 20:01
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Dave Reynolds is a former engineer so his remarks have some credence.
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Old 31st May 2013, 20:21
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I'm just wondering whether in BA the flight crew still carryout the pre flight or just a walkround and sign acceptance.

EU-OPS1 AND Part M clearly states what the pre flight should include. For whatever the reason, undoubted multiple human factor induced errors ensured in this case it wasn't it wasn't.

Maybe BALPA should actually consider the maintenance aspects and pressures engineers are under and provide more thoughtful statements rather than unhelpful statements that they have put out.

Still it was a miraculous landing considering it's practiced every 6 months in a sim. Maybe some more practical on the line should be included with weather thrown in.
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Old 31st May 2013, 20:32
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Agree with the previous poster that the key to this is the photo in the AAIB report (clearly not chosen at random) and the statement that they have photographic evidence to show the cowls were not closed. Further, the recommendation is aimed at Operators, not Airbus, suggesting the AAIB have a view as to who needs to raise their game.

If the picture is representative, all the stuff about the need to crouch or lie down to see the latches is not germane to this incident.
The AAIB photograph is purely representative. As a multi licensed and type rated aircraft engineer who has opened and closed the cowlings on this particular engine type more times than I care to remember, I can tell you categorically that the fan cowls can be in one of two positions when closed but unlatched.

The first instance is as shown in the AAIB photograph. This picture clearly shows the cowlings proud of the inlet cowl and thrust reverser translating cowl. There is a noticeable gap which is clearly visible when you are standing close to the engine and I find it very hard to believe that the flight crew would have missed it during their PFI that particular morning. However, if the 'hold open' device attached to the bottom of the inlet cowl at the 6 o'clock position has been depressed as the cowls are closed, they will sit flush under the weight of gravity and appear secure. There will be no visible gap and unless the crew physically stoop down and look at the underside of the engine, they will have no way of identifying the 4 latches hanging in the breeze.

There is no design fault with these cowlings. When correctly closed and latched they will not come undone. The final report will no doubt reveal a multitude of circumstances and failings that led to this incident. I'm almost certain a lack of qualified manpower and excessive workload within the engineering department will be at the top of the list.
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Old 31st May 2013, 20:39
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On the face of it it seems odd that a detaching cowl can a) Sever a fuel pipe, b) damage the airframe, and, c) damage other aircraft systems (which would be?). I wonder if the primary design criteria were "the cowl will never detach" or "damage would not be expected" if it did? Remember the light-weight foam insulation on the space-suttle fuel-tanks. Detaching foam lumps were tolerated until the Challenger disaster.

On a second point, someone mentioned the safety catch system on car bonnets, in relation to belt-and-brace systems. It's worth remembering that car bonnets also have a spring on the main lock, that holds the bonnet well out-of-line with other body work making it clear at a glance if the main lock us not engaged. One would think either a spring or just gravity could be used to hold such panels open or part-open until properly locked.
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Old 31st May 2013, 20:47
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Idle Thrust (and Blind Pew):Re Swissair 111

Wrong.

Read the TSB Canada report Refs 2.20.3. and 2.20.4

Nothing the pilots could have done would have saved the aircraft.

Slandering deceased colleagues is frankly despicable.

Ex BOAC, BAOD, Swissair

Last edited by hambleoldboy; 31st May 2013 at 20:49.
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Old 31st May 2013, 21:09
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"Detaching foam lumps were tolerated until the Challenger disaster."

Columbia, not Challenger.

Space Shuttle Columbia disaster - Wikipedia, the free encyclopedia
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Old 31st May 2013, 21:27
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Well said Jenny B we even had mr learmount on tv suggesting a re design of the nacelle cause it was a bit difficult for the pilot to complete his pre flight check!

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.
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Old 31st May 2013, 21:30
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Having a pin that protrudes when the cowling is LOCKED rather than devices that are flush when locked would undoubtedly help in situations like this.

2d worth.
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Old 31st May 2013, 21:35
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So, presumably BA are liable for compensation then to anyone who was delayed last Friday?
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Old 31st May 2013, 21:39
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Prohibited Items Airside.

"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".

Assuming Transec or DaFT can be persuaded we won't use the stick to beat the flight crew during hijack attempt or break the glass of the mirror and cut our own throats with the shards.

Ah I forgot, we're driving the plane but can't take nose-hair tweezers longer than 2" airside, in case.........?!

Interesting to see if the average UK or O'seas airport Stasi would permit a PILOT to take such an item through the obstacle course, without causing delay, leading to rushed external checks..............
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Old 31st May 2013, 21:40
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So, in 2013, pilots just don't take the walk round checks seriously enough ?

I too couldn't believe the bird-strike suggestion and concluded the engine covers must have been left undone on at least the left engine, but resisted the temptation to post as I am no longer a regular and it may have been a bit presumptious of me But today I couldn't resist popping in to see the inevitable thread and how Pprune posters had developed it from the outset, and what the reaction was to the interim report. I then saw David Learmount answer Yes to BBC's Chris Ekin's suggestion as to who was ultimately responsible and then to proceed to dilute his answer with allusions to design flaws and other stuff ... So I am only posting because I fear lessons are not much learned yet, particularly by pilots who seem to think there are more important things to worry about and it is a design problem or an engineer problem.

The importance of walkround checks is drummed into all student PPLs and walkround inspection quizzes are still to be found at air cadet events, flying club events and airshows, right? But move on up into the commercial world and due to over-confidence and over-work the walkround so often becomes more and more of a chore it seems, and it can so easily become a subconscious going through the motions exercise - one rarely rewarded by the identification of any significant anomaly during the inspection and conversely even when inspection is inferior, rarely resulting in memorable frights through incidents like this.

Part of this tendency is perhaps due to the fantastic current day reliability of airframes and engines and yes well honed engineering procedures, and yet part is still due perhaps to a misplaced blind faith and political or marketing 'spin' in the consistent quality of the "brand" and its processes and procedures. There's a disconnect there somewhere.

These both give everyone an over-optimistic take on aviation risks generally and do nothing to help keep in mind the risks posed every day by simple human error. That's why we still have checklists, isn't it?

Every pilot's walk round check has an official checklist associated with the type does it not? How many commercial pilots do you see with a checklist in their hand outside the airframe? More often one or both hands are in pockets and the boys and girls are hardly dressed for getting down and dirty as has been said. Maybe on this type a kind of prayer mat should be standard equipment, or would that cause further delays at security?

Lessons to be learned? Simulator training obviously helped overcome the walk round failings and thank goodness for that, but now how about introducing mandatory attendance to regular walk round quizzes in the hangar ? Or is that suggestion beneath contempt ?

I do however now know this much: engine cover latches on this one are beneath most things, and whilst I don't think anything can be achieved by seeing heads roll or even seeing any extra persons put on their back, I do think this incident has been a great leveler for some pilots who need revision training of a most basic kind, engineering cost managers who needed a wake up call, and all those who might otherwise equate "leading brand" with a tendency to infallibility.

... just my two-pennorth if regulars will allow

Last edited by slip and turn; 31st May 2013 at 21:44. Reason: ,
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Old 31st May 2013, 21:49
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Surely it is not rocket science to have a microswitch to engage when locked.
My old Range Rover tells me if my tailgate/bonnet or sunroof is not locked.

Failing that a basic check can be carried out with the mirror and stick devices used in Northern Ireland decades ago to check under vehicles.

Of course today new pilots come straight from the sim/computer game and have little or no mechanical knowledge. It's not on to have to bend down and get the
trousers dirty. That a job for the oilys

Last edited by Ye Olde Pilot; 31st May 2013 at 21:52.
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Old 31st May 2013, 22:02
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Slip and turn
I'm not excusing poor walk rounds but I feel you underestimate commercial demands . Given that our every minute is a cost on somebody's budget I reckon your chances of getting the pilots in to do some walk round training or quizzes is about nil. Similarly nobody is going to produce a checklist you can walk round with - though I guess a copy of the FCOM on a IPad might do the trick.

That said we could all do with spending less time in security and more time at the aircraft, but that's one for the politicians....

Last edited by wiggy; 31st May 2013 at 22:02.
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Old 31st May 2013, 22:19
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Unless the pilot does the walk around at Dep-10 mins or so, then they are likely to see all sorts of ground equipment attached and engineering still crawling over the aircraft. Half the time I do the walk arounds the engineers are topping up the oils. I believe BA is one of the few airlines where the same engineer can work on both engines...I know it has been brought to mgmt attention before . Who will take the fall? Some poor overworked line engineer being ordered and timed from aircraft to aircraft, or the designer of a time management system that allows this?
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Old 31st May 2013, 22:38
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An engineering oversight left the cowls unsecured and we're still trying to blame this on pilot error? 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.
In most incidents crew get the blame as they're usually already dead. This isn't one of those. Take it on the chin, learn from it, and stop blaming the usual scapegoats.
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Old 31st May 2013, 22:41
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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 31st May 2013, 23:18
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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; 31st May 2013 at 23:22.
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Old 31st May 2013, 23:22
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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 31st May 2013, 23:28
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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 31st May 2013, 23:29
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Accountant will say correct decision

@1979Engineer

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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