Incident at Heathrow
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From the AAIB report on THIS incident
So, they do not hang flush when unlatched, and given it's getting light before 0500, and departure was after 08, the walk round should have been in broad daylight. The doors stuck out a little, and the latches were hanging down, but for whatever reason, it was missed.
Not practical to make 2 engineers sign off closing the cowls, there are not always 2 engineers at outstations or at overnight stops.
Painting the edge a good bright reflective colour, or a length of reflective tape on the inside might make the gap stand out more.
Switches that tie in to the ECAS in the same way as cabin, cargo and emergency doors might be a way to go.
This is the first time an in flight fire has happened as a result of cowls departing, but there have been over 30 previous incidents, so this is not as rare as some might think, and needs a proper fix, not just a gentle reminder to do the pre flight properly, as that clearly doesn't work all the time.
As with the 777, this could have been a LOT worse than it eventually was. For that we should all be very thankful.
The fan cowl doors can be propped open by two stays
mounted on the inside of each door, to allow access
for servicing. When the doors are lowered from the
propped‑open position, a ‘hold open’ device on the bottom
of the fixed engine inlet cowl prevents the fan cowl doors
from closing fully under gravity. In this condition the fan
cowl doors stand slightly proud of the nacelle (Figure 1),
to provide a visual cue that the doors are not latched
mounted on the inside of each door, to allow access
for servicing. When the doors are lowered from the
propped‑open position, a ‘hold open’ device on the bottom
of the fixed engine inlet cowl prevents the fan cowl doors
from closing fully under gravity. In this condition the fan
cowl doors stand slightly proud of the nacelle (Figure 1),
to provide a visual cue that the doors are not latched
Not practical to make 2 engineers sign off closing the cowls, there are not always 2 engineers at outstations or at overnight stops.
Painting the edge a good bright reflective colour, or a length of reflective tape on the inside might make the gap stand out more.
Switches that tie in to the ECAS in the same way as cabin, cargo and emergency doors might be a way to go.
This is the first time an in flight fire has happened as a result of cowls departing, but there have been over 30 previous incidents, so this is not as rare as some might think, and needs a proper fix, not just a gentle reminder to do the pre flight properly, as that clearly doesn't work all the time.
As with the 777, this could have been a LOT worse than it eventually was. For that we should all be very thankful.
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If it was a service check or daily, Big Airways must use a task sheet for it and if the doors must be opened, then the paperwork should state it and the closing of as well, with stamper requirement to sign. I would be surprised if it wasn't. I cannot remember if having fan cowls open affects operation of the slats (doubt it). There is an AMM reference for the closing/opening the things..
I doubt another BA engineer looked at them (CAT A will have approvals for that task) and the final cheese hole was a flight crew member propably with his mind on another facet of the sector..
I doubt another BA engineer looked at them (CAT A will have approvals for that task) and the final cheese hole was a flight crew member propably with his mind on another facet of the sector..
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the final cheese hole
It all could have been far, far worse.
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Given the extensive damage to the aircraft caused by the cowls detaching, as reported in the AAIB bulletin, it was nothing short of a miracle that G-EUOE made it back to LHR.
The only way to look at this is as a fundamental failure of processes and procedures of both BA maintenance and crew walkaround. Yes, the latches are badly placed. Yes, they may be diffucult to see. But the consequences of not checking that they are properly fastened could easily have been of the most serious kind with serious loss of life to PAX, aircrew and on the ground. Imagine the consequences of an A319 landing on central London?
Every time I hear the phrase "lessons will be learned" I wince. This type of incident had happened no less than 32 times up to July last year and Airbus made it clear then that latches should be checked carefully. How often does it have to happen for appropriate steps to be taken to prevent it?
The only way to look at this is as a fundamental failure of processes and procedures of both BA maintenance and crew walkaround. Yes, the latches are badly placed. Yes, they may be diffucult to see. But the consequences of not checking that they are properly fastened could easily have been of the most serious kind with serious loss of life to PAX, aircrew and on the ground. Imagine the consequences of an A319 landing on central London?
Every time I hear the phrase "lessons will be learned" I wince. This type of incident had happened no less than 32 times up to July last year and Airbus made it clear then that latches should be checked carefully. How often does it have to happen for appropriate steps to be taken to prevent it?
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BOAC wrote:
"...latches closed, but cowling not locked. In this condition, they will protrude about one inch underneath the cowling. This is the normal condition of the latches after maintenance opens the cowling, until the latches are re-locked...
...It would seem that no 2 is NOT a good idea?..."
That´s exactly how it is done and that´s the crux. Health and Safety , you know
"...latches closed, but cowling not locked. In this condition, they will protrude about one inch underneath the cowling. This is the normal condition of the latches after maintenance opens the cowling, until the latches are re-locked...
...It would seem that no 2 is NOT a good idea?..."
That´s exactly how it is done and that´s the crux. Health and Safety , you know
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Just to clarify a few things on the fan cowls.
They are not opened on a daily check at all. Only on a weekly for the IDG oil level check and also on service checks.
The fan cowls can be unlatched and look like the photo from the report with a large gap between the cowls and engine OR they can be unlatched and be perfectly flush and without bending down can appear to be closed and latched.
The fan cowl closure is subject to a Verification check by 2 separate engineers at all times.
They are not opened on a daily check at all. Only on a weekly for the IDG oil level check and also on service checks.
The fan cowls can be unlatched and look like the photo from the report with a large gap between the cowls and engine OR they can be unlatched and be perfectly flush and without bending down can appear to be closed and latched.
The fan cowl closure is subject to a Verification check by 2 separate engineers at all times.
Another interesting point is that the cowlings were in a symmetrical unsafe position, both on either side of the engines and either side of the aeroplane. I've always thought it much more difficult to pick up multiple anomalies that were balanced in some way, as opposed to single defects that stuck out as not being ''right'' even though they were quite subtle.
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Given the extensive damage to the aircraft caused by the cowls detaching, as reported in the AAIB bulletin, it was nothing short of a miracle that G-EUOE made it back to LHR.
could easily have been of the most serious kind with serious loss of life to PAX, aircrew and on the ground
The only way to look at this is as a fundamental failure of processes and procedures of both BA maintenance and crew walkaround
Every time I hear the phrase "lessons will be learned" I wince. This type of incident had happened no less than 32 times up to July last year and Airbus made it clear then that latches should be checked carefully. How often does it have to happen for appropriate steps to be taken to prevent it?
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People (quentinc) should be very careful of assuming that what is shown in the AAIB 'generic' pictures, is what would have been apparent on this specific a/c, at this specific time?
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1min 50 secs in on this video.
Try an A319 when loading and you have to squeeze between the (operating) loading belt and the front on the engine - or sometimes you cannot. The refuelling pipe, ground air or other equipment under the engine. Or the day when the engineers are still working cowls open when the walkround is done. It's a "best as possible" but I would never suggest perfect everytime
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Try this then around 08:50
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A Licensed Engineers view from the Independent
This is the second incident of this type I am aware of the first was with another operators aircraft on a flight within UK.
Reason everyone wants to fly for peanuts hence the European Aviation Safety Authority was set up and have taken control of maintenance from CAA.These people are accountants, lawyers and politicians hence they do the bidding of the highest payer IE Airlines and European aircraft manufacturers .
Maintenance standards have been totally eroded at the bequest of board rooms and the UK CAA has became a "paper tiger" .
This incident will be ignored and we will keep going in the same direction until such times as we kill people and not necessarily the first time we kill them either, it will have to wait until its spectacular over London or another major city then "lessons will have to be learned".
The lessons were learned on the railways in the 1890's and the 1920's learned again in 1912 on the Titanic learned through the 60's 70s,80s 90's in aviation with the American industry controlling its regulators and again in the UK with privatization of rail.
If you put profit and Ego before proper and correct maintenance in a business in which you carry passengers eventually you will kill people.
I am a Licensed aircraft Engineer for a UK Airline (not BA)and I fight this battle every day ensuring crew and passengers fly safely, I constantly battle against a board room who wish me to do it for less and with less people and they have the support of regulators NOT me.
By the way most probable reason for incident some over worked engineer left the latches securing the cowls open because he was rushed to go and do something else due to lack of staff.Reason for lack of staff to save money to pay professional gamblers in city dividends.
Reason everyone wants to fly for peanuts hence the European Aviation Safety Authority was set up and have taken control of maintenance from CAA.These people are accountants, lawyers and politicians hence they do the bidding of the highest payer IE Airlines and European aircraft manufacturers .
Maintenance standards have been totally eroded at the bequest of board rooms and the UK CAA has became a "paper tiger" .
This incident will be ignored and we will keep going in the same direction until such times as we kill people and not necessarily the first time we kill them either, it will have to wait until its spectacular over London or another major city then "lessons will have to be learned".
The lessons were learned on the railways in the 1890's and the 1920's learned again in 1912 on the Titanic learned through the 60's 70s,80s 90's in aviation with the American industry controlling its regulators and again in the UK with privatization of rail.
If you put profit and Ego before proper and correct maintenance in a business in which you carry passengers eventually you will kill people.
I am a Licensed aircraft Engineer for a UK Airline (not BA)and I fight this battle every day ensuring crew and passengers fly safely, I constantly battle against a board room who wish me to do it for less and with less people and they have the support of regulators NOT me.
By the way most probable reason for incident some over worked engineer left the latches securing the cowls open because he was rushed to go and do something else due to lack of staff.Reason for lack of staff to save money to pay professional gamblers in city dividends.
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Root cause
You can trace the root cause of this incident back to at least 1987.
When I was working as a PDI engineer at LHR Terminal 1 'the management' decided that there would no longer be an engineer attending departing a/c and that the only PDI would be done by the flight crew as they did at the outstations.
As an engineer I was equipped with a suitable pair of overalls, and a 'GS' screwdriver to insert in the gap between fan cowls etc and try to lever them apart. I was also given the time (while the fuel went on) to have a proper look around. We even had a tumble dryer in the crew room to dry the knees of our overalls, which was used frequently.
So 'the management' decided that the best 'bloke' (as it was in those days!) to kneel on the wet tarmac and check the low hanging cowls was a chap in a suit with no tools or protective clothing. This chap would then have to sit in the flight deck for the next few hours in a damp suit...
When I joined the Aircraft Maintenance Industry in 1979 I was taught about Murphy's law that states 'if it can go wrong it will go wrong'. This is why a/c and maintenance system are designed to make sure it doesn't go wrong.
If one of my colleagues on a long wet night shift didn't close the cowls etc there would be a good chance I would catch it on my walk around, and then there was still the flight crew walk around. Plus any previous comments in the Tech log, which would be be a good indication of possible problem areas.
It doesn't take a rocket scientist to work out what removing the PDI engineer might lead too.
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...
When I was working as a PDI engineer at LHR Terminal 1 'the management' decided that there would no longer be an engineer attending departing a/c and that the only PDI would be done by the flight crew as they did at the outstations.
As an engineer I was equipped with a suitable pair of overalls, and a 'GS' screwdriver to insert in the gap between fan cowls etc and try to lever them apart. I was also given the time (while the fuel went on) to have a proper look around. We even had a tumble dryer in the crew room to dry the knees of our overalls, which was used frequently.
So 'the management' decided that the best 'bloke' (as it was in those days!) to kneel on the wet tarmac and check the low hanging cowls was a chap in a suit with no tools or protective clothing. This chap would then have to sit in the flight deck for the next few hours in a damp suit...
When I joined the Aircraft Maintenance Industry in 1979 I was taught about Murphy's law that states 'if it can go wrong it will go wrong'. This is why a/c and maintenance system are designed to make sure it doesn't go wrong.
If one of my colleagues on a long wet night shift didn't close the cowls etc there would be a good chance I would catch it on my walk around, and then there was still the flight crew walk around. Plus any previous comments in the Tech log, which would be be a good indication of possible problem areas.
It doesn't take a rocket scientist to work out what removing the PDI engineer might lead too.
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...
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RAISE THE BORESIGHTS!
Seeing as "CHIRP" has been highlighting the overstretch suffered by ALL those on the flightline over the last few years, can we picture the poor hassled, distracted and under-resourced engineer who makes the original error in not securing the aircraft?
The backstop is provided by a line pilot, possibly operating under the much publicised inadequate report times, who's fought his way through the security nightmare provided at most airports and who may be conscious of the approaching ATC slot and pressured by the "on-time" fanaticism practised by management who seem to have lost the picture BIG TIME since few of them have ever practised "on the line"!
If this working environment, as portrayed in "CHIRP" but ignored by CAA SRG in their mealy-mouthed responses to such alerts, is not drastically changed in favour of MANAGING the task safely, as opposed to cutting costs at all costs, then we will continue to see such holes in the cheese lining up again and again, until the "Tombstone Imperative" kicks in, together with the litigation in retrospect.
Please let's back off the troops at line level and direct our fire at those further up the food chain who are ultimately responsible for imposing the working practices and pressures which allow errors like this to slip through!
A well publicised attempted manslaughter trial of the smooth suits responsible would send a timely and strong message to those whose profession is paring the twig down so far that it breaks, but alas by that time they have moved on to cause chaos elsewhere!
The backstop is provided by a line pilot, possibly operating under the much publicised inadequate report times, who's fought his way through the security nightmare provided at most airports and who may be conscious of the approaching ATC slot and pressured by the "on-time" fanaticism practised by management who seem to have lost the picture BIG TIME since few of them have ever practised "on the line"!
If this working environment, as portrayed in "CHIRP" but ignored by CAA SRG in their mealy-mouthed responses to such alerts, is not drastically changed in favour of MANAGING the task safely, as opposed to cutting costs at all costs, then we will continue to see such holes in the cheese lining up again and again, until the "Tombstone Imperative" kicks in, together with the litigation in retrospect.
Please let's back off the troops at line level and direct our fire at those further up the food chain who are ultimately responsible for imposing the working practices and pressures which allow errors like this to slip through!
A well publicised attempted manslaughter trial of the smooth suits responsible would send a timely and strong message to those whose profession is paring the twig down so far that it breaks, but alas by that time they have moved on to cause chaos elsewhere!
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.
I am sure many on this forum will suggest this was not a particularly serious incident - to humble SLF a fractured fuel line and a fire external to the engine that could only be extinguished on the ground is to close for comfort.
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.
I am sure many on this forum will suggest this was not a particularly serious incident - to humble SLF a fractured fuel line and a fire external to the engine that could only be extinguished on the ground is to close for comfort.
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Further, the recommendation is aimed at Operators, not Airbus, suggesting the AAIB have a view as to who needs to raise their game
The following may be of interest to some:
G-CPER
G-YMME
G-VIIA
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Nice to see BALPA showing solidarity with engineering in this case:
David Reynolds, the head of safety at the British Airline Pilots Association said: “It is very unfortunate that the cowls were not locked. It is something the engineers to check.
“It is their job to make sure they are closed.
“A pilot’s role is to look out for anything obvious, but the only way in which they could have done this by lying on their back underneath the engines, which is not practical.”
David Reynolds, the head of safety at the British Airline Pilots Association said: “It is very unfortunate that the cowls were not locked. It is something the engineers to check.
“It is their job to make sure they are closed.
“A pilot’s role is to look out for anything obvious, but the only way in which they could have done this by lying on their back underneath the engines, which is not practical.”
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Jenny B - a voice of common sense at last. I am not sure this was easily spotted, and I have no doubt that changes to walk around procedures will be made. The fact that both engines were in the same state made it doubly difficult. I have great sympathy with the pilot who did the walk around, and I hope that the people who make the key decisions think likewise - past experience would suggest that they might not.