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Incident at Heathrow

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Incident at Heathrow

Old 4th Jun 2013, 08:59
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Be careful when looking at that photo not to mistake the landing light for a fire.

That said, I think the risk posed by the engine fire has been downplayed on this forum & has raised the stakes on the consequences of a cowl detachment.
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Old 4th Jun 2013, 09:07
  #902 (permalink)  
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From the interim AAIB report I've gleaned the following facts:

The crew felt vibration which they thought might be the nose wheel running over the lights on the runway during the take off roll.

ATC reported to them that debris had been found on the runway.

They had a failure of the yellow hydraulic system and a significant fuel leak.

They had an indication of a fire warning on the right (no2) engine and upgraded their PAN to a MAYDAY.

Lastly, and here's the most important item, IMHO, the left engine continued to OPERATE NORMALLY.

By the way the Commander had 14337 hours of which 8036 are in type. That's quite a few LPCs under his/her belt not to mention years on the line. I said before "well done" and still see nothing except, perhaps, the issue of the walk round to criticise them. As others have said the walk round is frequently done with numerous doors/hatches still open.
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Old 4th Jun 2013, 09:24
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"[...] the walk round is frequently done with numerous doors/hatches still open "

This actually (if confirmed) seems to show that time pressure is a main contributing factor. I read this statement as "walkaround is often done while maintenance work is still ongoing". I have missed many of the posts where this was explicitely stated, I shall read the thread again.
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Old 4th Jun 2013, 09:31
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The assumption in all but the most extreme cases, is that you will safely navigate the aircraft back to an airport for landing. I cannot see why Heathrow is precluded because it is in a built up area.
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Old 4th Jun 2013, 09:32
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time for a reality check.

Damaged aircraft returning to Heathrow possibly worth a small discussion but nothing major.

Crew not spotting unlatched engine cowls during walk around. Worth a small discussion but nothing major.

Crew performance following incident. Worth a large discussion on how professionally they behaved and deserve nothing but praise.

Design issue. Worth a small discussion just to be sure but same design failure occurring at the same time on BOTH engines. That would be a major coincidence so look elsewhere for the cause. ALL aircraft types lose engine cowls normally because of a maintenance oversight.

The fact that maintenance left both cowls unlatched. Worth a major discussion as this company has history.

And especially for those like A&C who can't read, hang the engineer, blame the engineers. Absolutely not as has been consistently posted and I must thank BOAC for his observation.

BLAME the regulator and/or the company should there be findings of a systematic nature. ABSOLUTELY DUE TO PREVIOUS.
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Old 4th Jun 2013, 09:37
  #906 (permalink)  
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Pax2908

Not necessarily! You have to understand that the normal flow, at least in my company, is that the walk round is conducted earlier rather than later so if there are any issues you can contact the engineers to get them rectified.

Basically, if the engineers are working on the engines you trust them to close the cowlings afterwards, it is that simple. Clearly, something did go wrong and we should leave it to the AAIB to determine the cause.

Prior to pushback the crew, captain in my company, asks the ground operative to confirm their checks and the reply should be "all doors and hatches closed etc".
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Old 4th Jun 2013, 10:25
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I disagree about the "both engines" aspect in this case.

It is valid where the work, if not carried out correctly, would lead to loss of both engines e.g. the BMI 734 incident.

Until the recent BA event, no A320 series cowl loss had seriously risked an engine AFAIK? If the BA event had followed that pattern, there was little more thought involved for the crew in returning with 1 engine sans cowls, and 2.

This incident alters that aspect, as noted by the AAIB, in that the RH Engine damage / fire was something not yet seen. We shall see what recommendations are made, and cruically which are followed up. I am "optimistic" that the severity of certain aspects of this event might see some "mitigations" or "traps" put in place. It is fine for the MS Simmers just to be interested in HF and "blame", but apart from appeasing their smugness, it does little to enhance safety in the future. 32+ events suggests we need to do more than rely on HF

This actually (if confirmed) seems to show that time pressure is a main contributing factor
As noted, so long as the Pax are willing to regularly see 15+min delays. With short Turnrounds, the walkround is often performed before the refueller even arrives / baggage holds opened / engineering taks etc. If we find something requiring rectification (not infrequent) this is lttle scope to go out and reinspect. We have to give engineers 20+min notice*, they often rectify during Pax boarding, and the paperwork is signed by the engineer, then Capt and as the Engineer then leaves the door closes with pushback required within 3 minutes of that. Else we get the "blame" for the delay (which is all the airlines and Pax / compensation are really interested in it seems).

It is our job to resist these commercial / admin "trivialities" over safety. But just to be clear, it is not "safety comes first". It is always a "risk balance", and human nature means that balance will be judged differently by different people.


* PS and the first concern of the engineers is then whether they, or we, will cop the delay code.
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Old 4th Jun 2013, 10:26
  #908 (permalink)  
 
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I cannot see why Heathrow is precluded because it is in a built up area.
Its not precluded. It is however undesireable and as per the AAIB report on N481EV provided by WHBM earlier here, if the Safety recomendations, have been implemented, then since the crew had already declared a PAN, ATC would be required to either come up with a routing that doesn't fly over a densly populated area (just a little hard here) or suggest alternative aerodromes... From the report:

10.10.2 It is desirable that aircraft in emergency should not be routed over densely populated areas. If this is inconsistent with providing the most appropriate service to the aircraft, for example when any extended routeing could jeopardise the safety of the aircraft, the most expeditious route is the one which should be given. Where possible, when expeditious routing is not required, suggestions of alternative runways or aerodromes together with the rationale that the routing would avoid densely populated areas and be consistent with safety, shall be passed to the pilot and his intentions requested.


It would be good to understand if ATC did offer the appropriate advice, and if they did, why the crew rejected the advice and continued to Heathrow.
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Old 4th Jun 2013, 11:49
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During the emergency briefing prior to departure, it is quite normal for the Pilot flying to brief that, in an emergency they will return to the departure airfield. Indeed, to that end they will both normally have the approach plate easily accessible to facilitate just that scenario. Poor weather, difficult terrain, likely contaminated sole runway, or other significant performance limitations would also sensibly require the nomination of an alternate airport. Heathrow (usually) has none of those considerations, and its use to facilitate the emergency scenario is perfectly normal.

What may be "desirable" for ATC, homeowners, daily mail readers, or anybody else is entirely secondary to the aircraft commanders intentions in such an emergency scenario, as indeed your quote makes clear.
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Old 4th Jun 2013, 11:57
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For those that say we as flight crew should always make sure that all panels, cowls, latches etc are closed you would never get anywhere on time, and I would go as far as to suggest if we don't trust other professionals to complete their tasks as trained then you would never be able to fly in known icing conditions.

Could you imagine getting to the drive through deicing in Toronto for example, after deicing you would have to go back to an area with steps, get off the aircraft to check the wings and the tail have been deiced properly then go again, oh hang on my holdover time has run out!

I trust our engineers to close and latch cowls, I trust deicing crews, I trust refuelers to close fuelling panels, I trust ground handlers to close GPU panels and so on and so forth. We are all trained professionals and as such we expect each and everyone of us to carry out our respective jobs on the ramp.

My 10 pence, the crew seemed to have managed, what was a dynamict situation very well. I'm grateful, as ever, to learn from other people's mistakes (you can bet your bottom dollar that engine cowls are being more vigorously checked on walk around now).
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Old 4th Jun 2013, 12:14
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I'm not a pilot but I've observed the UK civil aviation scene from the standpoint of an (I hope) informed observer for 40yrs.

The AAIB Special Report refers to the fire on right engine as follows:

During the approach to land, an external fire developed
on the right engine. An engine fire warning on the
flight deck prompted the crew to declare a MAYDAY
.

Whereabouts on the approach was the aircraft at the time of the fire warning? It seems from press reports of eye witness observations that it was fairly late on when the machine was over Central or West London. Not a good time to G/A and head elsewhere.

Until we know the definitive answer answer to that question speculation about alternatives to Heathrow is fruitless.

Before fire was detected this was surely a 'routine' engine out landing with a certainty of reaching the runway which was absent in the Evergreen 747 case.

Or am I missing something?

Last edited by Airbanda; 4th Jun 2013 at 12:15.
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Old 4th Jun 2013, 12:39
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What's all this about taking off in a densely populated area and remaining in it? That wasn't how it was. Another refresher needed from Ye Olde Pilot perhaps:
Originally Posted by Ye Olde Pilot
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.
It is now believed two engineers, one of them a supervisor, have been suspended while an investigation is carried out.
When the sh|t hit the fans the aircraft was 14 miles west of Charing Cross and heading away from London. From the moment it left the runway heading west it was over a sparsely populated area not a densely populated one. It then flew round London outside the M25 over open country (M25 wasn't built through conurbations and hasn't spawned that many yet!) until it was decided to go back to Heathrow.

As Airbanda says perhaps the emergency situation wasn't realised until they were back over East/Central London and track distances to Heathrow versus Stansted then made it no contest. We'll no doubt learn the full story when the full report comes out on that.

So back to lessons to be learned - yes BA maintenance clearly have a chequered history when you go digging for dirt but no maintenance company gets applauded for getting it right I guess. BA maintenance have for years had a very large and varied fleet to maintain and no doubt many other operations have learned from BA mistakes. You can find Investigation reports on many types where unsecured latches have been missed on walkarounds in all sorts of operations, not just Airbus and BA. That's why unsecured latches is something the lowliest student PPL has drummed into them as a BAD THING all round the world! Engineers no longer do walkarounds at Heathrow - but the sad thing is that it seems that due to time pressures no-one else seems to do them particularly effectively either - anywhere perhaps.

Instead we now learn of some kind of "risk balance" regime from NigelOnDraft. Is he really saying that it is down to the gut feeling of individual pilots on the day whether they feel lucky/comfortable? I am not sure that a commercial pilot is an expert in probabilities any more than a derivatives trader and I believe some are now the other anyway!

The likelihood of two engines both failing simultaneously is designed to be so low as to mean we have had 2 engine EROPs for well over 20 years, but contrary to what you might be tempted to believe when installed on the flightdeck you are not flying in a neatly designed world. You are of course flying in a real world within an environment that tests human design mercilessly on every flight. What we may have neatly skipped in our walk-around the argument is that it has always been known that if the same external/environmental cause affects both engines (didn't BA38 get us thinking?) then you end up stuffed just the once and that's enough.

I take NoD's point that it is perhaps an argument for introducing more mitigation or capture traps, and I wonder if that might for example mean that no work shall ever be carried out on both engines by the same engineer in the same session even to the point of checking oil levels.

That talk of who cops the delay code is a bit worrying, so is gatbusdriver's blind trust in everyone else on the ramp who apparently warrants the label "professional" just because they are there! That's bloody scarey actually. Do you ever fraternise with ramp agents and de-ice crews gatbusdriver? Many may be well meaning boys and girls but they ain't professionals. They get a bit of training in this and that and bits of paper may swap hands but do you realise what you are saying?
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Old 4th Jun 2013, 12:48
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So back to lessons to be learned - yes BA maintenance clearly have a chequered history when you go digging for dirt but no maintenance company gets applauded for getting it right I guess. BA maintenance have for years had a very large and varied fleet to maintain and no doubt many other operations have learned from BA mistakes. You can find Investigation reports on many types where unsecured latches have been missed on walkarounds in all sorts of operations, not just Airbus and BA.
In isolation this would probably be a genuine mistake, human factor. There are however other factors here that need to come out and I hope they do. Then it should be very clear why this happened.

engineers forum:

at the end of the day its clear that the cowls were left unlatched ,one may have been a fault but two maybe not .

It will never come out that we are very short of the correct manpower ,we may have had a few new starters and a load of mechanics that are pushed onto the Licensed Engineers but we dont have enough experience people at the front end.

The Aircraft Maintenance Supervisors (introduced due to a previous incident) are a complete waste of time because all they do is chase ADDs and try to make themselves look good so that they can get an even bigger bonus, there are some AMSs that dont even know what the hell to do and this has been reported to quality with no help from them either.

I understand that these cowls have a second inspection or a verification check ,that means there may be two engineers on suspension and as it led to the aircraft and its passengers being in danger ,we know where that will lead .

Pressure of work ,not enough of the correct manpower and running the damn operation on continual overtime so that we have an overworked and tired engineer. nothing will be done about all this because we like overtime as it supplements our low pay ,yes low pay

but as i say nothing will be done about it , BA will say that things will be changed ,there will be more human factors things which do sod all apart from create a job for the instructors .......what we need for this is far more real engineers not bloody mechanics that dont know the front from the back and are put with the LAE because the teams do not want them .and we need to get rid of the self serving AMSs and replace them with the supervising LAE who is not TMG .
i
unless somthing is done it will get worse and one day things may not be so lucky........i like my job at BA at times but we seem to have lost our way in what we do and why ,why are we engineers .......
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Old 4th Jun 2013, 12:50
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Or am I missing something?
They declared a PAN, stating the intention to return to Heathrow after they had fully assesed the situation. At this point, with an emergency declared, ATC are to provide a route that doesn't overfly built up areas, or suggest alternative aerodromes. We don't know if that happened or not.... It's not in the brief report we have. We do know that ATC provided vectors to Heathrow and then later the crew declared MAYDAY.
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Old 4th Jun 2013, 12:55
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It's not blind trust. i go to work knowing that the peolple who carry out most jobs on the ramp are trained to do that job. If I undertook responsibility to oversee every operation from maintenance actions to deicing with everything else inbetween the aircraft would never get off the ground.

I think they call it workload management.

There is an element of risk getting into a metal tube and getting airborne then getting it back on the ground. There is SMS in place to look at all the risks involved and mitigate them as best as possible whilst still managing to perform commercially in all sorts of weathers etc.
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Old 4th Jun 2013, 13:04
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All this flying over entral London garbage, is just ridiculous.

Nothing is going to stop an aircraft commander from executing his judgement as to what field he takes his aircraft to after a PAN. You can bleat on endlessly about re-directing an re-routing, if the crew don't like , they simply won't do it.

You see the overall responsibility for the aircraft and its compliment rests with the captain, and we do not take our responsibility lightly. If the crew do all in their power to bring the aircraft back safely, they are also saving everyone's lives under the flight path, the two outcomes cannot be separated.

Now having made that clear, I doubt there is a pilot who has ever drawn breath, (kamikaze pilots excepted), would attempt to minimise the risk to people on the ground if faced with a totally stricken aircraft. Captain Sullenberg, is an excellent example. As soon as he was aware the he was going no place but down hill, he did two things, maintained flying speed, and sought out an area to minimise the impact on the poor unsuspecting. It just so happens that minimising the damage on the ground is almost always going to be the best outcome for the crew and passengers.

Let me restate my firm belief, no amount of pressure from ATC (or anyone else), re population centres, is going to change the track an aircraft operating under emergency procedures flys over. Save for the extremely rare event when the aircraft is rendered unflyable(as in Sullenberg's case).

This aircraft did not look pretty, but it was eminently flyable, and would have remained so for a significant amount of time.

I am an aircraft captain, and I have high praise indeed for the way this crew handled themselves.

If I ever find myself in a similar circumstance, I would not at all take kindly to someone telling where I should fly over. (I could probably be convinced by a couple of close formation Tornados).

All heavy jets operate IFR, and as such have no way of avoiding a certain flight path IMC. The whole concept is so utterly ridiculous.

So all you concerned citizens on the ground, rest assured that every crew will do their best to save their own skin, and by default be saving yours as well.
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Old 4th Jun 2013, 13:04
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I would guess that attitudes like "It's just the cowls that are missing or mashed up." - which may well have been 'trivial' incidents to some folk in the past - need to be reviewed in view of what happened this time. The thought of LP fuel-line punctures on two engines does not make for relaxation.
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Old 4th Jun 2013, 13:06
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I interpret the AAIB report to say that both engines were functioning through most of the event. It was only during the approach to land that the right engine was shut down in response to the fire alert. The pilots were told by cabin crew that both engines had panels missing, but presumably had no reason to think that this was likely to dangerously compromise the engines.

So, for most of the flight the pilots had a reasonably stable two-engine plane whose main problem was going to be stopping after touchdown - is that right? Landing at Heathrow seems quite sensible to me in those circumstances.
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Old 4th Jun 2013, 13:17
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Slip and turn
We'll no doubt learn the full story when the full report comes out on that.

So back to lessons to be learned.
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Old 4th Jun 2013, 13:18
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They declared a PAN, stating the intention to return to Heathrow after they had fully assesed the situation. At this point, with an emergency declared, ATC are to provide a route that doesn't overfly built up areas, or suggest alternative aerodromes. We don't know if that happened or not.... It's not in the brief report we have. We do know that ATC provided vectors to Heathrow and then later the crew declared MAYDAY.
Isn't PAN intended to convey urgency or a need for possible assistance rather than a 'full on' emergency? No emergency until MAYDAY or other phraseology invoked.
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