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Incident at Heathrow

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Incident at Heathrow

Old 6th Jun 2013, 12:14
  #981 (permalink)  
 
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http://www.pprune.org/rumours-news/5...ml#post7878875

Ornis: read that.

Secondly: broad statement "that's not acceptable" is wrong as a broad generalization, because sometimes it is.

Repeated for emphasis: when the situation arises, it isn't your vote.

I think we've beaten this horse about into glue.

Lastly: "A good plan, implemented now, is usually better than a perfect plan implemented tomorrow." G. S. Patton, Jr.

The dwelling on "what might have happened" (which didn't) is armchair quarterbacking and out of line.

Last edited by Lonewolf_50; 6th Jun 2013 at 12:16.
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Old 6th Jun 2013, 12:23
  #982 (permalink)  
 
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It's not as simple as " the pilot and the engineer didn't do their job".
That's an outdated way of viewing incidents and accidents.
Put it this way, if you are a passenger on an aircraft, would you rather the Engineer dealing with your aircraft had three aircraft to dispatch in the next 90 minutes or just the one? Which Engineer would be more likely to miss something?
I think working hard is something to be proud of and I don't mind getting my hands dirty, I'm not a "Union guy" either, but there comes a time when the resources allocated to the job are insufficient to maintain the acceptable level of safety that Joe Public expects. It's great to have a £30 airfare, but it's better to have a £35 airfare and frontline operational staff that aren't pressed for time even when things are running to schedule.
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Old 6th Jun 2013, 12:54
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To try to introduce some balance to this thread. The pilots mostly think the pilots did an amazing job and cannot be blamed for anything, if they missed the walkaround it's because it's too hard to lie down, god forbid. (by the way ask the average coach driver about getting mucky on the job). And you don't need to lie down as I'm sure all the pilots here know but it's inconvenient for them not to correct. It's on the SOP, if maintenance was being done on walkaround the interim report would mention it. Please don't another pilot excuse them because it's not their job. I imagine if a pilot of an airline named zion (i can think of 2) said that what the reaction would be.

On the over London issue. I think most rational people assume that a pilot, amongst all his decisions, considers the impact on people on the ground. Especially in planes/loadings where there could be more deaths on ground than on board. Until this incident I've never seen pilots before say people on the ground bear no consideration in their decision making. The arrogance displayed on this thread is breathtaking, some pilots really do take their 'commander had the right' far too literally and seem to think you can break any law in the land and if you save 3 people and kill 500 that's fine.

Sensible pilots I've heard value a life on the ground as much as one in their plane. And in situations where going to another airport doesn't extend risk to the aircraft, but does reduce risk to the ground, that is what they do. It terrifies me how much many current pilots think that a BA pilot wouldn't know that going to Stansted involves less time traveling over a population centre. It's open countryside there. Or that it would be 'challenging'. I'm not flying BA anymore after all these proclamations of how hard they find diverting to a world class airport in their own city bounds.

Sorry, I know this is a pilots club and I'll be shot down. Hell if BALPA hadn't immediately fingered the engineers I might not have felt the need to (I'm not a BA engineer, just a bystander fairly shocked at the closed ranks). Anyway I hope the more self aware BA pilots are taking on board the need for better checks, less complacency, engineering too, and remembering the walk about is not just for exercise.
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Old 6th Jun 2013, 13:57
  #984 (permalink)  
 
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On the over London issue. Especially in planes/loadings where there could be more deaths on ground than on board. Until this incident I've never seen pilots before say people on the ground bear no consideration in their decision making. The arrogance displayed on this thread is breathtaking, some pilots really do take their 'commander had the right' far too literally and seem to think you can break any law in the land and if you save 3 people and kill 500 that's fine.
You need to learn how to read. What you said there, bolded, is a false characterization of the discussion.

I think most rational people assume that a pilot, amongst all his decisions, considers the impact on people on the ground.
As I explained in some detail before, the consideration for avoiding populated areas under various conditions is part and parcel to what professional aviators, aviation companies, and the regulatory agencies establish as a baseline.

The "all or nothing" nonsense is what I objected to before, and the lie that you just wrote (in bold) is what I object to now.

Remember: the plane was still under power, and still flying.

Go back and read that sentence again.

Consider the profound difference between this scenario, and the problem Sully was faced with when he had a twin engine failure. Part of his decision process was to avoid landing in a densely populated area. There were pilots second guessing that decision (and some posted here on PPRuNe in the thread dedicated to that incident) claiming he ought to have dead sticked it into one of the nearby airports. That's a risk he had to weigh in a very short period of time, and make a decision. For my money, the right one.

Funnily enough, most pilots agreed with his decision.

As to the preflight issue, your characterization is again a lie regarding this extended discussion.

There are a lot of pilots who have posted in this thread who are critical of what appears to be a blown pre flight inspection.

Your summary is no better than bird feces.

Last edited by Lonewolf_50; 6th Jun 2013 at 14:00.
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Old 6th Jun 2013, 14:03
  #985 (permalink)  
 
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@Framer

I think the issue may be wider than you are considering. There is less discipline in society now and more people are unwilling to accept their responsibilities; less fear of consequences.

I'm with you, for what it's worth; pilots rely on engineers - they should check their work themselves. Have a protocol and stick to it. No excuses. Aviation is unforgiving.

I very much doubt fan cowls will depart aircraft again for a very long time. So what will be the next serious incident due to "I forgot"? And where might it be?
Chances are a big busy aerodrome, eh.
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Old 6th Jun 2013, 14:08
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The pilots mostly think the pilots did an amazing job and cannot be blamed for anything, if they missed the walkaround it's because it's too hard to lie down, god forbid
The pilots (and cabin crew) did their job to the letter once the engines encountered problems. They safely got back on the ground and evacuated the aircraft in textbook fashion. That the aircraft got airborne in an unsafe condition is a separate issue that will be thoroughly investigated. What the (very few) pilots contributing to this thread have said, is that there are a number of factors at play here that could have led to the cowl latches not being secured closed. It isn't simply a case of people not being "bothered" to complete checks and inspections properly.

I think most rational people assume that a pilot, amongst all his decisions, considers the impact on people on the ground. Especially in planes/loadings where there could be more deaths on ground than on board. Until this incident I've never seen pilots before say people on the ground bear no consideration in their decision making. The arrogance displayed on this thread is breathtaking
All this media-esque chatter about avoiding built up areas really is the preserve of sky news anchors who have to fill air time. Look at it this way, if an aircraft lost both its engines over London tomorrow what do you think the captain of that aircraft would elect to do - look out the window and locate a field with no houses that he can crash into? Or find the longest runway available (Heathrow) and attempt to save the lives of everyone aboard by landing there? In a Hollywood script he may well head for the farmers field. I can assure you in real life he would head for the runway and not worry himself unduly that he might be flying over a few houses to get there. The root cause of this hand wringing about the rights of those the aircraft may fly over comes from mis-guided and entirely sensationalistic media coverage. The Captain of the BA aircraft involved in this incident elected to fly an aeroplane that was flying perfectly safely back into Heathrow because that was the safest option available to him. At no point was anyone under the flight path in danger.

What you need to understand (and you are not alone on this thread) is that no pilot ever plans to crash. So this decision making process you suggest that must involve a risk analysis of how many houses we might take out if we were to hit the deck is I'm afraid a bit of a misnomer. If an aircraft encounters problems we consider the safest course of action to get back on the ground. How long we have to make the decision, how soon we need to be on the ground, where/how we are going to land and what we may need to do once safely on the deck are some (but not all) major parts of the process. Whose house we fly over on the way to the best available airport is the least of our worries. It's not that we don't care, it's just we are planning to land safely, nothing short of that.

Sensible pilots I've heard value a life on the ground as much as one in their plane. And in situations where going to another airport doesn't extend risk to the aircraft, but does reduce risk to the ground, that is what they do.
I'm not too sure what this mythical problem is that would render an approach to an airport unsafe to those on the ground but would present no risk to those in the aircraft. If anyone has any examples of such a strange situation then lets hear them. I can only refer you to my point above. The crew of this aircraft chose a perfectly safe option and landed at heathrow. At no point was anyone in danger on the ground.

I know this is a pilots club and I'll be shot down.
Pprune (R&N in particular) ceased to be a pilots club some time ago. It is now largely the preserve of armchair quarterbacks, enthusiasts and amateurs. I present you this thread as a prime example. You are perfectly entitled to an opinion, but you have made some suggestions and offered some assumptions that I'm afraid are entirely wide of the mark.
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Old 6th Jun 2013, 14:44
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All this media-esque chatter about avoiding built up areas really is the preserve of sky news anchors who have to fill air time.
You are presumably implying that the AAIB report into the last time this happened at Heathrow, and their conclusions and recommendations, all referred to above, was somehow written by Sky News journalists .....

Furthermore, the westerly approach to Heathrow is about the only one in the South-East of the UK which is sustained over a built up area. Any who are actually looking out of the window on approach to Gatwick, Stansted, etc will have noticed they are almost entirely over clear country. It follows that comments like "you would need London airport in the Hebrides to avoid built up areas" are just unprofessional hyperbole.
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Old 6th Jun 2013, 15:25
  #988 (permalink)  
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Safety Recommendation 2005-069
The Civil Aviation Authority (CAA) should review the guidance provided in the Manual of Air Traffic Services (MATS) Part 1 and Civil Aviation Publication (CAP) 475 (The Directory Of CAA Approved Organisations) and consider whether ATC unit Training for Unusual CircumstancesandEmergencies(TRUCE)plansadequately prepare controllers to handle aircraft in emergency, and in particular, whether sufficient guidance is provided on the avoidance of built-up areas when vectoring aircraft in emergency. Where considered necessary, this guidance should be amended as soon as practicable.
The AAIB make no recommendation about pilots decision making, just ATC and how they vector aircraft in distress.
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Old 6th Jun 2013, 15:55
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ABNORMAL PROCEDURES

FUEL LEAK

A fuel leak may be detected if:
The sum of FOB and FU is significantly less than FOB at engine start, or is decreasing, or
A passenger observes fuel spray from engine/pylon or wing tip, or
The total fuel quantity decreases at an abnormal rate, or
A fuel impalance develops, or
Fuel quantity of a tank decreases too fast (leak from engine/pylon, or hole in a tank), or
A tank is overflowing (due to pipe rupture in a tank), or
Fuel flow is excessive (leak from engine), or
Fuel is smelt in the cabin.

If visibility permits, leak source may be identified by a visual check from the cabin.

WHEN A LEAK IS CONFIRMED
LAND ASAP

LEAK FROM ENGINE/PYLON CONFIRMED:
Engine fuel leak can be confirmed by excessive fuel flow indication, or a visual check.
-THR LEVER (of effected engine): IDLE
-ENG MASTER (of effected engine): OFF
-FUEL X FEED: USE AS RQRD
if the leak stops the crossfeed valve can now be opened to re-balance fuel quantity, or to enable use of fuel from both wings. Do not restart the engine.

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Old 6th Jun 2013, 16:00
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Safety Concerns

I don't understand your post above

What or who are you replying to?

The recommendations cited are OK but to what incident do they apply?

They sound quite general in nature and quite easy to state that they have been adopted after the fact of what might have prompted them.
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Old 6th Jun 2013, 16:09
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G-CPER

Originally Posted by lomapaseo
The recommendations cited are OK but to what incident do they apply?
The incident appears to have been the G-CPER matter of September 7, 2003, for which a summary of the aaib accident report appears here

Last edited by archae86; 6th Jun 2013 at 16:53. Reason: correct characterization of the linked pdf from "report" to "summary of report"--as pointed out by DaveReidUK
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Old 6th Jun 2013, 16:18
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Synopsis on the above link, full report (93 pages) at http://www.aaib.gov.uk/cms_resources...n%20G-CPER.pdf
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Old 6th Jun 2013, 17:48
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Thanks to all for the replies immediately above.

Now, regarding the subject incident in this thread we'll have to wait and see what the AAIB says about the level of compliance.

I expect a restatement (nothing new other than human error again) but also a possibility of something more from their expert knowledge and lessons learned that didn't work out.
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Old 6th Jun 2013, 18:23
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The essence of Safety Management, now so beloved of all Regulators, is that when you identify a flight safety sensitive hazard you do something about it very promptly indeed, preferably remove it. (Avoid or Mitigate are the other 2 options, if Remove is not available.)

Obviously the cowling latches are such a hazard. "If it can go wrong, it will", and should never have been designed that way in the first place.

If EASA were not the useless bunch of whatsits that they are, shackled by EU Commission bureaucracy, some incompetence and political infighting, effective action would have already been completed to force Airbus to design within, say, 60 days a modification to eliminate this hazard totally and produce an AD to instal the mod, with all the necessary maintenance instructions, that must be complied with within another 90 days by all operators. Meanwhile some robust mitigation is needed.

All costs to be reimbursed by Airbus, which produced this blatant Murphy in the first place.

The cowling is not safe because thousands of flights take place every day without a problem. It's unsafe because a few flights have departed with the cowling improperly fastened, creating a hazard to flight safety, and it could happen again.

Ah well, let's not dream. When someone gets killed, if that ever happens, is time enough to get excited about it, in aviation's traditional way.
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Old 6th Jun 2013, 18:46
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Blame the pilot

A long time ago when I was serving that great lady our Queen I recall a light trainer, Bulldog perhaps, having a donkey quit because the oil filter had not been tight after a change. He did a forced landing into a field and hooked an unseen wire fence on top of a wall

Guess what, pilot error because he should have been competent to make the forced landing

The philosophy seemed to be that pilots aught to cope and if the risk is increased by others to create a hazard this makes no difference. That attitiude seems to continue. Of course blame or not is according to the circumstances at the time

Last edited by Tinribs; 6th Jun 2013 at 18:50.
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Old 6th Jun 2013, 19:50
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The cowling is not safe because thousands of flights take place every day without a problem. It's unsafe because a few flights have departed with the cowling improperly fastened, creating a hazard to flight safety, and it could happen again.
If it had been properly fastened and then come off, I could go with you, but
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Old 6th Jun 2013, 20:53
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Lonewolf:

There was no lie, and this is exactly what I mean. Maybe you didn't see the posts, but pilots earlier were quite direct in saying people on the ground should not factor into their decision at all. And seemed quite proud in saying it. That's the kind of attitude we don't need in passenger transport. An AAIB report has been quoted saying that they think it matters and still these guys think they know better, that is what bothers me. Of course if you're on 3 mile final from Heathrow you are commited but if you have time to make a decision that means not flying a plane dropping bits over a city, that makes sense no? Even if this plane wasn't about to fall to the ground, they were told bits were falling off it, which makes me wonder if they were too 'SOP' oriented. Why is this kind of not even particularly creative thinking so sneered at? Some humbleness would be good to see, particularly from those who love to condescend to other airlines.

It seems to me these guys are getting a lot of slack because of who they fly for. the walkaround is part of their job. People have claimed every pilot goes into work wanting to be a professional, that they couldn't possibly have screwed up by anything other than the system. I contest that like any profession, there are gifted, average, bad, hard working, and lazy pilots. Some maybe just don't take the walkaround seriously. If that is the case, yes we need to reform the system, but I don't think blaming someone in a safety critical position for not taking it seriously is unfair? Train drivers who go through red lights and kill people are prosecuted, truck drivers who crash into trains are prosecuted, why do pilots think they are above the law? If someone is negligent about this, what else might they be negligent about? Are people really saying there is no-one in a cockpit who shouldn't be there?
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Old 6th Jun 2013, 23:24
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@Framer
I think the issue may be wider than you are considering. There is less discipline in society now and more people are unwilling to accept their responsibilities; less fear of consequences.
I'm all for considering the issue broadly and don't disagree with you. What I do disspear at is when it is considered so narrowly, ie only the front line operational staff's actions are considered. People who are focussing only on the actions of the pilot and the engineer are considering only half ( or even less) of the factors/ decisions that lead to the incident.
This has been well accepted since the mid 90's and I can only assume that the people focussing so narrowly have never recieved any education in the basic anatomy of an accident.
The working environment that the incident occurs in is a key player in determining why it happened and it is likely that changes to the environment ( shifts worked/ training matrix/ workload/ communication lines/ SOP's etc) will be more effective in reducing further incidents than changes to individual front line staff......very likely.
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Old 7th Jun 2013, 11:21
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Originally Posted by Lonewolf_50
Remember: the plane was still under power, and still flying
Originally Posted by BitMoreRightRudder
The Captain of the BA aircraft involved in this incident elected to fly an aeroplane that was flying perfectly safely back into Heathrow because that was the safest option available to him. At no point was anyone under the flight path in danger.
@Lonewolf_50, @BitMoreRightRudder,
I also think that choosing a return to Heathrow was as good a decision as diverting to Stansted. There are so many little things that matter when dealing with an emergency : staying with the same APP controller, assessing controlability at low speed, checking what is lost...

However I can only disagree with the suggested reasoning : "One engine was providing enough thrust, therefore the airplane was safe". The crew of G-EUOE was aware of or suspecting structural damage and must have been worried of low speed controlability. I guess that the length of the flight before final landing is caused by a climb request to a level where low speed controlability tests could be performed safely.

Remember El AL 1862 : the crew was unaware that a safe landing was impossible unless coming in at high speed (>260 kt) and on a steep slope.
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Old 7th Jun 2013, 11:44
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It terrifies me how much many current pilots think that a BA pilot wouldn't know that going to Stansted involves less time traveling over a population centre. It's open countryside there. Or that it would be 'challenging'. I'm not flying BA anymore after all these proclamations of how hard they find diverting to a world class airport in their own city bounds.
It is clearly not easy to convey to the flying public how we pilots manage emergencies, but I will have another go.

Firstly, an Airbus A319 has:

2 Pilots,
3/4 Cabin crew, (trained for aircraft emergencies such as smoke, fire, evacuations, and a wide range of medical emergencies, such as CPR and defibrillator use)
2 Engines,
3 separate hydraulic systems,
4 Hydraulic pumps, 2 main engine driven, 1 main electrical, 1 standby electrical,
4 Electrical generators, 2 main, 1 standby and 1 emergency,
5 separate fly-by-wire computers,
2 Flight augmentation computers,
1 emergency hydraulic generator "Ram Air Turbine" (RAT), which can be deployed into the slipstream to provide back-up hydraulic power for the flight controls and/or the emergency generator.
2 Batteries,
2 Autopilots,
2 Flight management and guidance computers (some have 3),
6 flight display screens,
3 Display and management computers (which drive the display screens),
3 "artificial horizons"; 2 main plus 1 back-up,
3 Altimeters; 2 main plus 1 back-up,
3 LASER gyro Inertial reference systems
2 GPS receivers
3 main fuel tanks including 2 'collector' tanks which feed the fuel pumps,
6 electrical fuel pumps,
2 engine driven low pressure fuel pumps,
2 engine driven high pressure fuel pumps,
2 Air conditioning packs,
1 Auxiliary Power Unit, (APU), which can provide electrical power and high pressure air to run the air conditioning and pressurisation systems, and for starting the main engines, (and restarting them in the air if necessary),
2 Separate and independent wheel braking systems, plus one emergency wheel braking system.
2 Fire extinguishers per engine,
1 Fire extinguisher for the APU,
2 Fire extinguisher systems for the cargo holds,
Each main flying control surface has 2 separate sources of hydraulic power, the rudder has 3, and each hydraulic system powers 1 or 2 pairs of spoilers.

In addition, every control system for all of this has 2 channels or more, providing automatic back-up.

Now; An Airbus A319 can continue flying straight and level, and land with just ONE each of ALL the things I've listed above, (including the pilots).

For example, either one of the engines can continue a take off with a fully laden plane if one of the engines fails DURING THE TAKE-OFF ROLL. The remaining engine is designed and certified to continue the take-off, climb to a safe altitude (safe in this context being clear above any high ground), and fly to a suitable runway or holding pattern so the pilots can deal with the consequences of the engine problem. These may be for example the loss of an engine driven hydraulic pump which might lead to the loss of one hydraulic system, leaving 2 working ones left.

In such a (totally unlikely) eventuality of all except one of each system failing, the flight won't be as comfortable or refined as you are used to, (and you won't be continuing to Oslo), but IT WON'T fall out of the sky. Any one who thinks it will has been watching too many films, (where the slightest engine 'cough' has both pilots wrestling with the controls as the aircraft inexplicably dives to towards the ground???? Why would it do that??).

{Even Captain Sullenberger (spelling?) who suffered a once in a billion chance of a major bird strike taking out both engines (and by the way, airports have ways of keeping birds away), continued flying under full control. Obviously, he could not fly level, and although he initially tried to reach another runway, ran out of height and used the Hudson - a completely brilliant tactic and landing, Sir}.

It may need a longer than normal runway to land on. Luton's runway is quite short, and is on a hill with a steep drop at one end onto a dual carriageway. If an aircraft had reduced stopping ability, pilots would obviously elect to use a longer runway.

So an aircraft with both "bonnets" missing, (is that the "hood" in America?) may look awful but apart from having lost one or two systems from the list above, and probably needing a longer runway, is going to be able to fly perfectly safely. So no reason to make a drama out of a situation by landing at a non-company airfield if there is no need to. At one's home base, there will probably be a spare airplane and crew who can take the passengers on their way. (THIS IS NOT THE PRIMARY CONSIDERATION, OF COURSE).

None of this is arrogance at all, but a crew calmly and professionally assessing the situation and taking the appropriate actions to ensure a safe flight.


Why the cowls were not checked is another argument.


(I am not a BA pilot by the way).

Last edited by Uplinker; 7th Jun 2013 at 12:07.
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