Incident at Heathrow
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Alber,
Not quite, there is a shift manager who has a number of AMSs under him at each location.
Each AMS looks after a number of staff and will be responsible for a given number of aircraft each day.
Not quite, there is a shift manager who has a number of AMSs under him at each location.
Each AMS looks after a number of staff and will be responsible for a given number of aircraft each day.
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Rtm
I can find nothing in my QRH or AFM about considering the area I am flying over, it's not there and never will be.
Captains are not always right, they make mistakes, that's where CRM comes to the fore and a good F/O speaks up, that's the beauty of two crew.
This cowl V2500 thing has happened some 32 times before, your assertion that it was a miracle that the aircraft didn't end up as a crash is laughable. It was pure bad luck that a fuel pipe was fractured on the right engine. In all of the other events the cowls left the scene at rotation, just as these did, none of those fuel pipes were fractured.
I stand by claim, apart from an inadequate walk around, the crew did a good job. They got handed a certified airworthy aircraft, correctly signed off, engineering should wear most of the egg on face. Management /manufacturer/and regulator sowed the seeds for this many many years ago, but will hide behind their desks.
Captains are not always right, they make mistakes, that's where CRM comes to the fore and a good F/O speaks up, that's the beauty of two crew.
This cowl V2500 thing has happened some 32 times before, your assertion that it was a miracle that the aircraft didn't end up as a crash is laughable. It was pure bad luck that a fuel pipe was fractured on the right engine. In all of the other events the cowls left the scene at rotation, just as these did, none of those fuel pipes were fractured.
I stand by claim, apart from an inadequate walk around, the crew did a good job. They got handed a certified airworthy aircraft, correctly signed off, engineering should wear most of the egg on face. Management /manufacturer/and regulator sowed the seeds for this many many years ago, but will hide behind their desks.
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Originally Posted by gazumped
I stand by claim, apart from an inadequate walk around, the crew did a good job. They got handed a certified airworthy aircraft, correctly signed off, engineering should wear most of the egg on face. Management /manufacturer/and regulator sowed the seeds for this many many years ago, but will hide behind their desks.
Gazumped,why should engineering have most of the egg on their face ?
You don't know (as yet) all the contributing factors,yet your happy to apportion blame? So much for just culture!
Its not about blame,its about finding out why it happened & mitigating against it happening again.
You don't know (as yet) all the contributing factors,yet your happy to apportion blame? So much for just culture!
Its not about blame,its about finding out why it happened & mitigating against it happening again.
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If the fuel line to the port engine had been severed also, where would they have landed? Victoria Station? The Natural History Museum? Kew Gardens? The Great West Road?
but if the mayday had occured earlier in the flight, would they have come back to LHR???
Maybe a bit quicker, taken in N London as well.
I genuinely think there is a real lack of appreciation by very many of the political and practical consequences of a plane on approach to LHR crashing on a populated area.
Do NB the aircraft that most closely came to taking out serious London population did not know it had a problem. So the crew's decision to overfly is not really the issue...
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When will they ever learn...
Great posts, Barkingmad 787 and 802, and Filler Dent 789.
Dear Airline management,
Once upon a time someone forgot to remove the ground lock pins in the u/c before departure and the a/c had to return after dumping the best part of 100 tons of fuel.
So the pins were fitted with big red flags with the words 'Remove before Flight' to make them very visible.
This helped and reduced the number of incidents of washing Hounslow in Jet A1.
However there were a more few incidents, and it was decided that when an engineer fitted the pins they must put an entry in the tech log, thus acting as a reminder to the departing engineer and the flight crew. The tech log entry would have to be signed off before departure.
This was the state of play when I was a young PDI engineer. I never witnessed an incident of the pins being left in.
So when the management wanted to reduce the number of engineers (because they were expensive! not in my pay packet), they wanted the towing crew to fit the pins but were not happy that they should be allowed to write in the tech log, therefore the requirement to create the 'tech log reminder' was lost.
I guess you have worked out what happened next..... when the aircraft returned the pins were found fitted (not the ones kept in the flight deck, but a set that the towing crew had managed to procure for their own use, with NO FLAGS.
At least the story ends with a happy ending in as much as no one came to any harm, but the cost of these incidents is not small and on a bad day people lose their lives.
Please remember that all these controls /countermeasures /procedures /remove before flight flags, were adopted for a reason and while they are in place you may not 'see' that reason because they are working.
Anyone can save money, you simply stop doing things, any schoolboy knows that.
The trick is to keep doing stuff, but do it more efficiently.
Wake up and smell the Jet A1 and I don't mean in Hounslow!
Dear Airline management,
Once upon a time someone forgot to remove the ground lock pins in the u/c before departure and the a/c had to return after dumping the best part of 100 tons of fuel.
So the pins were fitted with big red flags with the words 'Remove before Flight' to make them very visible.
This helped and reduced the number of incidents of washing Hounslow in Jet A1.
However there were a more few incidents, and it was decided that when an engineer fitted the pins they must put an entry in the tech log, thus acting as a reminder to the departing engineer and the flight crew. The tech log entry would have to be signed off before departure.
This was the state of play when I was a young PDI engineer. I never witnessed an incident of the pins being left in.
So when the management wanted to reduce the number of engineers (because they were expensive! not in my pay packet), they wanted the towing crew to fit the pins but were not happy that they should be allowed to write in the tech log, therefore the requirement to create the 'tech log reminder' was lost.
I guess you have worked out what happened next..... when the aircraft returned the pins were found fitted (not the ones kept in the flight deck, but a set that the towing crew had managed to procure for their own use, with NO FLAGS.
At least the story ends with a happy ending in as much as no one came to any harm, but the cost of these incidents is not small and on a bad day people lose their lives.
Please remember that all these controls /countermeasures /procedures /remove before flight flags, were adopted for a reason and while they are in place you may not 'see' that reason because they are working.
Anyone can save money, you simply stop doing things, any schoolboy knows that.
The trick is to keep doing stuff, but do it more efficiently.
Wake up and smell the Jet A1 and I don't mean in Hounslow!
The AAIB recomended in a similar case involving a Virgin A320 mentioned earlier in this thread to modify the V2500 fan cowls such that when closed but not latched they would sit proud of flush and therefore more likely to spotted on a walk round and until such times as a Mod was in place carry out Duplicate Inspections of the latches.
I wonder what the AAIB will recomend now as it would appear that this Aircraft had the Mod and BA were still doing Duplicate Inspections!!
Perhaps what they should recomend is that all tasks carried out in Line and Base Maintainance are actually inspected by Licenced Type Rated B1 or B2 Engineers who are given the time and the work culture etc etc to do the job right first time. Duplicate Inspections become 'diluted' in thier importance when they are used as the sticking plaster fix for Human Factor errors.
I may be jumping the gun here as the final report is yet to be released but I think the incident details so far are timely reminders for us all.
I wonder what the AAIB will recomend now as it would appear that this Aircraft had the Mod and BA were still doing Duplicate Inspections!!
Perhaps what they should recomend is that all tasks carried out in Line and Base Maintainance are actually inspected by Licenced Type Rated B1 or B2 Engineers who are given the time and the work culture etc etc to do the job right first time. Duplicate Inspections become 'diluted' in thier importance when they are used as the sticking plaster fix for Human Factor errors.
I may be jumping the gun here as the final report is yet to be released but I think the incident details so far are timely reminders for us all.
To an extent these events of cowls not being latched and detaching from the aircraft over circa 30 times with a number of different operators reminds me of the phrase coined after the Space Shuttle disaster after the O ring failure, namely "normalisation of deviance". (This is no criticism of BA and their procedures but if all these events happened with one or maybe two operators then maybe there would be a bit more joined up thinking as to devising a bullet proof system which means this can never happen again)
As professional aviators and engineers involved in flight operations we all know how important various checks are but are also too aware of our own limitations when doing such items especially when under pressure of quick turnrounds etc.
If I was in AIB I would be looking to recommend a physical fix to ensure this can never happen again.
As professional aviators and engineers involved in flight operations we all know how important various checks are but are also too aware of our own limitations when doing such items especially when under pressure of quick turnrounds etc.
If I was in AIB I would be looking to recommend a physical fix to ensure this can never happen again.
Last edited by fireflybob; 2nd Jun 2013 at 17:36.
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Pre-flight inspection.
http://www.pprune.org/private-flying...-concrete.html
When a GA pilot can miss a foot-square lump of concrete (and still take off without noticing the effect on the aircraft balance) . . .
When a GA pilot can miss a foot-square lump of concrete (and still take off without noticing the effect on the aircraft balance) . . .
1979 Engineer,
Agreed. A long time ago I realised that, if you have a system that works, then think long and hard before you change it; then take advice and think hard again; and, if possible don't change it.
Edited to say, that means all your own little personal checks and procedures as well.
Agreed. A long time ago I realised that, if you have a system that works, then think long and hard before you change it; then take advice and think hard again; and, if possible don't change it.
Edited to say, that means all your own little personal checks and procedures as well.
Last edited by Basil; 2nd Jun 2013 at 18:15.
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The Normalisation of Deviance, first described by Diane Vaughan:
Professionalism/Diane Vaughan and the normalization of deviance - Wikibooks, open books for an open world
Professionalism/Diane Vaughan and the normalization of deviance - Wikibooks, open books for an open world
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So, Airbus recorded 32 cowl events up to the summer of 2012.
So now, at least 34 recorded, plus some un-recorded I could guess.
I wonder if any data exists of incorrect fitment of cowls picked up after cowls closed. ie. Second inspection by maint. Pilot PDC. Ground crew/push back people.
I can only guess the number of incorrectly latched cowls after closure must be huge, but so many times before it gets picked up before flight by the 2nd inspection, pilot or ground/push back crew.
The industry records the data year on year, makes a few changes and hi-lights the events from time to time, job done.
The old saying that " History shows us that we don't always learn well from history events "
I would be very surprised if a good fix is not already designed, made and tested. It just needs the Industry/FAA/EASA to press the button and get it fitted.
Paying for the fitting of the fix ? with just about 5,300 320's in service, the total cost will not be cheap in £ terms.
I have just plucked/guessed of a 100,000 USD per Aircraft, if my mobile battery is working ok, the answer it gives is 530 M USD. That as they say is a " whole chunk of cake "
By the way. Looks like a great job by the pilots and cabin crew, well done.
So now, at least 34 recorded, plus some un-recorded I could guess.
I wonder if any data exists of incorrect fitment of cowls picked up after cowls closed. ie. Second inspection by maint. Pilot PDC. Ground crew/push back people.
I can only guess the number of incorrectly latched cowls after closure must be huge, but so many times before it gets picked up before flight by the 2nd inspection, pilot or ground/push back crew.
The industry records the data year on year, makes a few changes and hi-lights the events from time to time, job done.
The old saying that " History shows us that we don't always learn well from history events "
I would be very surprised if a good fix is not already designed, made and tested. It just needs the Industry/FAA/EASA to press the button and get it fitted.
Paying for the fitting of the fix ? with just about 5,300 320's in service, the total cost will not be cheap in £ terms.
I have just plucked/guessed of a 100,000 USD per Aircraft, if my mobile battery is working ok, the answer it gives is 530 M USD. That as they say is a " whole chunk of cake "
By the way. Looks like a great job by the pilots and cabin crew, well done.
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It's quite simple really - in some (most?) companies PF does the walk round, except if it's raining, then the FO does it.
Incidentally, just done my usual MPL - LGW commute with EZY. Watched (presumably) PF do the walk round out of the window - he carefully examined the underside of the engine - looked to be about 18 inches (about 45cm) from the ground - he didn't need to lie on his back!
Incidentally, just done my usual MPL - LGW commute with EZY. Watched (presumably) PF do the walk round out of the window - he carefully examined the underside of the engine - looked to be about 18 inches (about 45cm) from the ground - he didn't need to lie on his back!
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On the subject of flying over built-up areas, today's Sunday Express stated that the aircraft "overflew millions of houses"
That's one hell of a diversion, must have gone over every dwelling in the UK....
That's one hell of a diversion, must have gone over every dwelling in the UK....
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I was the first officer on the early morning departure MAN- LHR in a BA Super 1-11 when after take off we had a nose wheel green. We returned to MAN and having had a quick inspection by an engineer took the aircraft back to the gate. I still occupied the flight deck when an engineer appeared carrying the nose wheel ground lock which had caused the problem. It should have been stowed in the u/c ground locks box to the left of the captain's seat. With a grin and a "how stupid pilots are" expression on his face which quickly disappeared when he opened the box to find one already in its correct place. I'm sure that would have never been mentioned had I not still been there.
One of the pre departure checks was "ground locks stowed" and only one set was supposed to be used on each BA aircraft but obviously not in this case!
One of the pre departure checks was "ground locks stowed" and only one set was supposed to be used on each BA aircraft but obviously not in this case!
Normalisation of deviance is surely one of the most fundamental reasons we have a Regulator, EASA should be aware of any 'creep' of inspection standards in Airline Maintenance and stop it from happening, not sure if the FAA had anything to do with the space shuttle but I suspect they didn't, they probably left most of the technical stuff to NASA who got it wrong with the O rings and anyway the feds are too busy with the Airline boys.
What worries me is if the outcome of this investigation is 'Normalisation of Deviance' then what happens next? What will EASA and the CAA do about it? Our national flag carrier oh dear.........................don't hold your breath!
What worries me is if the outcome of this investigation is 'Normalisation of Deviance' then what happens next? What will EASA and the CAA do about it? Our national flag carrier oh dear.........................don't hold your breath!
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You can try to pass the buck as much as you like but the responsibility for this incident rests squarely on the captain and co-pilot. In this case it was unlatched cowlings but it could just as easily been something else. The incident was the result of a poor walkaround.
I question the logic of flying the track below instead of diverting over less densely populated area to Stansted.
I see that ground crew are facing the blame.
I question the logic of flying the track below instead of diverting over less densely populated area to Stansted.
I see that ground crew are facing the blame.
It is now believed two engineers, one of them a supervisor, have been suspended while an investigation is carried out.
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I nearly left one in once....
Ahh the 1-11, that takes me back.
I had been sent out to refuel a 1-11 ready to be a 'backup' in the days of Shuttle (sheds a tear).
The a/c was on one of the 'November' stands, I think it was N41. As the fuel went on I did a walk around and took the nose gear lock out and put it on the flight deck.
The a/c was then 'stood down' and I returned to the crew room. Half an hour later, I was then told 'it's back on' can you go and depart the aircraft. So off I go, did another quick walk around and shut the hold doors all ready to push.
As I sat on the tow bar I noticed something just poking out of the nose u/c bay. It was the flag on the lock!.... quickly removed and delivered to the flight deck just before the doors were shut.
I was somewhat confused as to how it had been fitted, only to find that in the 30 mins I was in the crew room the a/c had been moved to the next stand (not sure why) and the towing crew had put the lock in.
I have gone to the a/c and located it by it's reg and not the stand, as there were so many 'November' stands in a line it was easy not to spot it had moved.
There but by the grace of God go I...
I had been sent out to refuel a 1-11 ready to be a 'backup' in the days of Shuttle (sheds a tear).
The a/c was on one of the 'November' stands, I think it was N41. As the fuel went on I did a walk around and took the nose gear lock out and put it on the flight deck.
The a/c was then 'stood down' and I returned to the crew room. Half an hour later, I was then told 'it's back on' can you go and depart the aircraft. So off I go, did another quick walk around and shut the hold doors all ready to push.
As I sat on the tow bar I noticed something just poking out of the nose u/c bay. It was the flag on the lock!.... quickly removed and delivered to the flight deck just before the doors were shut.
I was somewhat confused as to how it had been fitted, only to find that in the 30 mins I was in the crew room the a/c had been moved to the next stand (not sure why) and the towing crew had put the lock in.
I have gone to the a/c and located it by it's reg and not the stand, as there were so many 'November' stands in a line it was easy not to spot it had moved.
There but by the grace of God go I...
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Easy, you build a new London Gateway airport in the Thames estuary.
.
Quentic - can you explain, exactly, how you avoid populated areas in the south of England in a jet flying at several miles a minute...
Easy, you build a new London Gateway airport in the Thames estuary.
.
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How about diverting to Manston with little traffic and approaching along a sparsely populated coastline? If it all goes wrong few on the ground will die.
Of course we all know the pressure is on to get the bird back to base and when it goes wrong we have another Kegworth.
Looking at this picture I'd say the captain was reckless to take this aircraft back to Heathrow.
Of course we all know the pressure is on to get the bird back to base and when it goes wrong we have another Kegworth.
Looking at this picture I'd say the captain was reckless to take this aircraft back to Heathrow.