Incident at Heathrow

[Safety Concerns]

I think the loss of both cowls should be kept in perspective. All eng cowls can detach from all aircraft if not properly closed. Any panel detaching from anywhere on an aircraft can cause unpredictable damage.

Eng cowls have long been seen as a weak point and so a second inspection by maintenance that they are in fact closed is pretty standard.

To miss both engines as in this case does perhaps suggest a more systematic failing in the system rather than an individual error or a design error.

British Airways has always been a leading airline and many will want to throw mud at it just for being there. That should not prevent justified criticism however.

Therefore and as they are a repeat offender I believe it is in everybody's interest to properly investigate and ensure that maintenance is being given proper funding and the respect it deserves.

And I will say again. If it should turn out that shortcomings are uncovered the CAA should be made to explain why they didn't uncover it.

[slip and turn]

Originally Posted by Del Prado

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.

OK so now I am being edit-quoted out of context I was suggesting that the reason it went back to Heathrow (if there was any conscious reason) would come out in the full report.

So I should then have said "So back to other lessons we might be able to learn immediately" or some such.

This ain't the usual type of incident where we all have to wait to discover the prime cause lest we go off half-cocked, now do we? The facts are already out there in the interim report.

You can speculate the engineers had a bad day or toothache or last night before finishing the job had just had a blinding row with the boss but it doesn't add up to much.

The bald fact was that no bugger on the ramp saw the latches were open before it went ... that's the one that demands heads banged

I tell you, if pilots everywhere this week are not more conscientiously doing the walkaround checks and asking questions about how well ramp staff communicate doors and hatches closed and whether they are seen to be very diligently checking then it is a rum do. We don't need a final report before we learn that one.

[quentinc]

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.

Both PAN and MAYDAY are emergency calls.

[Meikleour]

It will be very interesting to see how great the fuel leak was and whether the FUEL LEAK checklist was in fact actioned. If it was not then that may have been why they ended up with an engine fire!

[A and C]

Slip and Turn

The cowl latches were most likely closed, that is why no one picked up the fact that they were not engaged.

The reason for them being latched is that once they are disengaged and the cowl is opened to enable engine work to be done the catches hang down, if you catch your head on one of these usually it hurts a lot and requires the use of lots of industrial language. To avoid the chance of injury the catches are latched back into the closed position when work is taking place.

The cowls were the closed without opening the latches and engaging the hooks and re latching them.

I'm sure that if the latches had been in the unlatched position some one would have spotted this error.

[quentinc]

Meikleour

WRT the fuel leak checklist, if the fuel leak is from an engine and the checklist is followed, would you expect the relevant engine to have been shutdown?

[Sillert,V.I.]

Originally Posted by BOAC

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.

I would guess this too, and judging by the last paragraph before the safety recommendation in the special bulletin, so would the AAIB:

"This event has shown that the consequences of fan cowl door detachment are unpredictable and can present a greater risk to flight safety than previously
experienced."

Originally Posted by slip and turn

This ain't the usual type of incident where we all have to wait to discover the prime cause lest we go off half-cocked, now do we? The facts are already out there in the interim report.

We know what happened; we do not know why it happened.

Originally Posted by slip and turn

The bald fact was that no bugger on the ramp saw the latches were open before it went ... that's the one that demands heads banged

I don't agree.

Disciplining those immediately responsible won't address the underlying cause. If they are replaced with others who are trained, managed & motivated in the same environment, I'd suggest it's likely a similar type of incident could happen again.

We need to seek understanding, not blame.

[John Farley]

I have had to deal with a pilot who goofed. We were together in a two seat aeroplane at the time and luckily I was able to recover from the goof.

I decided it was the sort of mistake any of us could have made (in his circumstances at that time) and that he was the least likely one in the team to make that mistake again.

He never did make that or any other mistake and I never mentioned our incident to anyone else.

Judgement is needed. Assuming the Captain fully accepted he should have spotted the unlock then he would have my total backing all the way as he will never make that mistake again. . If he wants to blame Airbus or the mechs I would feel very differently.

[robert f jones]

Meikleour

Can you explain, to a non Airbus (ex) pilot, how would they know there was a fuel leak on the right engine from their onboard instruments ?

[Right Way Up]

Ask the cabin manager to look out the window.

From QRH:

Engine fuel leak can be confirmed by excessive fuel flow indication, or a visual check.

[slip and turn]

A and C / Sillert VI

When John Farley posts, we must all take special note.

I hope my post here which I've been knocking around for the last hour or two doesn't detract too far from what he posted in between times:


That was interesting information A and C and as you have been around these parts longer than most I imagine you are very sure of it. I apologise if the information was available elsewhere in this thread.

I thought others had shown diagrams including one appearing in Canadian incident report that explained the position of latches as quite clearly standing proud when not secure ? BOAC reminded us in his post #656 that there is a risky but still visible half open latch situation where "they will protrude about one inch underneath the cowling . This is the normal condition of the latches after maintenance opens the cowling". He pointed out the Canadian Report which includes this photo:


The interim report is quite clear that there is photographic evidence of G-EUOE leaving the stand with unsecured latches - so if it isn't quite as I read from BOAC and from the Canadian photo then that's worth knowing about. Nevertheless AAIB say LHR stand photos show the unlocked position plainly enough, so the walk-around error is the same, isn't it, unless you are insisting now that unlatched cowls the way BA and others set them are totally unnoticeable except when the aircraft rocks slightly during pushback, or when engine starts or during taxy and that's when the evidence photos must have been taken?

If it is so difficult to spot until things start moving then all the more reason for walk-arounds to be bombproof everytime?

Perhaps A and C highlights a new risk that BOAC didn't mention, but kenjaDROP's post #641 then did i.e. that he thought it possible for maintenance to open the cowling and then click those latches back flush with the cowling even though they aren't locked? And that then the only way to notice it during the walk-around inspection is for someone to routinely thump the cowls or prise an anti-static rubber screwdriver type implement to test the latches are working? (I did see that mentioned quite some pages back as an old-times aviation procedure not necessarily for this type).


Sillert VI, I apologise for my use of language on banging heads - I was rebounding off that head-banging smiley used to comment against my earlier post. I am not really talking about hanging any one individual out to dry because there but for the grace of God and all that, but I'd have thought a 14,000 hour captain would be on top of this rather than prone to go with the modern aviation flow which NigelOnDraft talked about. From what he said, there seemed to be questionable, unconventional and inconsistent transfer of risk going on as the norm relying on individual pilot "judgement".

So I was rather talking metaphorically about all pilots needing to up their game on walk-around inspections if even at this stage they are still minded that it is an engineering problem. Not their job to be the back-stop on this kind of thing, maybe? The pilot's job/role may have been well and truly messed with over the years, but walk-around checks most definitely are still very much on the captain's accountability list, aren't they? That's the disconnect which is most surprising to me and might need reconnecting or banging into quite a few heads IMO.

All aircraft types have their quirks but this isn't really a quirk unless maintenance have modified the latches so they don't behave per the book - should not a pilot be able to name and locate with his eyes closed every single quick release panel on external skin of the airframe (and some). And if any is easily removable or unlockable without tools, surely each and every external one should be inspected on walk-around? I would expect them all to be in the FCOM external checks.

We have heard lots about how difficult it is to complete those checks in the time available especially with multi-tasking on the ramp. But how the captain actually ensures each panel latch is inspected immediately prior to flight is a whole different question. Ensure it he or she must however.

One thing is clear: the captain must not simply abdicate that accountability to some inanimate or abstract such as the SMS agreed with his employer or with the airport or the ground handler or maintenance department. The captain surely must remain consciously accountable and yes, always be prepared to testify convincingly that the system works, else he just shouldn't go?

[tubby linton]

I think that we are making a lot of the photographic evidence but we know nothing of its' source or how much manipulation has taken place of the image to obtain the evidence of the open latches.

[Safety Concerns]

tubby do be serious please.

[tubby linton]

I was being serious . The cctv picture has not been published and neither has the location of the camera. With the modern software manipulation of photographs a very fuzzy picture can be made razor sharp or have you never heard of photoshop?
The other important question is ,was there any human monitoring of the image ,and if there was why were the crew not alerted ?

[slip and turn]

Blimey TL - AAIB say

Following the event photographs of the aircraft, taken
prior to pushback, were provided to the AAIB. These
photographs show the fan cowl doors unlatched on both
engines

Surely you are not implying AAIB might have been sucked in to a particular agenda by doctored ramp photos?

[Ian W]

Airsmiles

Re; avoiding the need to overfly built-up areas, won't the Thames Estuary airport have runways aligned East-West like LHR? If yes, they'll still be a fair degree of over-flying London of approaching from the west. If taking off eastwards, the North Atlantic traffic will still need to turn west and overfly Greater London.

Correct me if I'm wrong but I don't see a vast difference in overflying London for either LHR or the Thames estuary airport.

You are wrong

Of course if the airport were to be build just East of the Dartford crossing then you would be right. However, the current plans put it somewhere South East of Canvey Island and North of the Isle of Sheppey. Given the use of curved RNP approaches there would be no need for extended straight in approaches or departures, I accept what everyone will say about transport to London although that would be achievable.

The incident in this thread was handled as one expects it to be handled recovery ASAP to the nearest suitable airport controllers keeping everything else away and the flight crew handling the emergency and upgrading as required landing safely no lives lost. Nevertheless, had that engine fire turned into a really bad fire on long finals and it was only luck that it didn't - or had the other engine been equally sick or perhaps loss of another hydraulic system then that recovery could have been a little too exciting. This incident is perfect ammunition for those who would close Heathrow and who object to a 3rd runway on safety grounds. The very people who are hurrying/harrying their engineers and thus raising the chances of these incidents are the ones that would lose most if the 3rd runway does not go ahead.

[framer]

The motivation of individuals analysing incidents/ accidents is key to weather the industry gets safer after an event. Those who seek blame are often motivated by a need to feel good about their own abilities and work history. True motivation to improve safety shows itself within statements like these

Disciplining those immediately responsible won't address the underlying cause. If they are replaced with others who are trained, managed & motivated in the same environment, I'd suggest it's likely a similar type of incident could happen again.

The mistakes and differing levels of diligence will always be part of our flight line folks.when the Engineer makes a mistake, our pilot needs to have the time and brain space to catch it. When our pilot makes a mistake, the Engineer needs to have the time and brain space to catch it. When our refueller makes a mistake, our Engineer and pilot need to have the time and brain space to catch it. Appropriate allocation of manpower and regular high quality training is the weakest link in the chain at the moment, we should ensure the regulator addresses it.

[Ornis]

When I remove the top cowl of my light aircraft I put the screws and screwdriver on my seat. To remind me, should the cowl be replaced, it is not secure.

One reason people "forget" is distraction. When the latches are unlocked at least one needs to be flagged; a hole and a hook might do it, or even an elastic band.

Other than that, what else can you say except "be careful"? As banal as it sounds it need repeating regularly. This is too simple a task to be ignorance.

Speaking as an airline passenger, I don't expect pilots to check engineers have locked latches. I expect engineers to do that.

On the other hand, I do not accept pilots may demand to fly a damaged aircraft over large populations. Whatever some claim, it is a compromise and the people on the ground have a say.

[A and C]

Slip & Turn

You are starting to catch on as to how the securing latch position can me ambiguous, in the photo in your last post the catch B positron is seemingly clear but when veiwed from some positions and with the cowling not quite together as in this picture.

As said about six hundred posts ago I at one time carried a screwdriver that I could use to ( among other things ) use to load the cowling and test the security of the latches. The screwdriver was with me during the time I was in line maintenance, then as a flight engineer and finally as a pilot.

Unfortunately a few years back the aviations security system in the UK decided that as a pilot I could not be trusted with such a dangerous impliment as a screwdriver so the days of by being able to check cowling security or even the level of the fuel on the aircraft using the sticks are over.......... I will let you draw your own conclusion as to the relationship between flight safety and the security system.

What I do find totaly stupid is that some people think that Boris island is the answer to the fallout from eight cowling latches being left undone, we need to look much closer to home and see what pressures and distractions are imposed of the working lives of pilots and maintenance staff that was at the root of this problem.

[Lonewolf_50]

On the other hand, I do not accept pilots may demand to fly a damaged aircraft over large populations. Whatever some claim, it is a compromise and the people on the ground have a say.

The same canard is once again raised.

First off, on a practical basis, no you don't have a say. You (or me were I in London) are already on the ground, the pilot is trying to get there with his load of pax. All of them.

Secondly, they have to fly over a populated area any time they want to get to that airport, damaged or not.

Thirdly, pilot has X evidence of the extent of the damage 'in situ' and you are looking at this with hindsight.

Fourthly, with the cowlings gone, in the terminal area, there is a limited ability to triage (i.e. go back out of the cockpit and have a look) if what one needs to do AS A CREW is get that thing back to the airfield safely. (Or at another field, which is a PILOT's judgment call, not a "I am standing on the ground" person's judgment call.

This line of wrong has been addressed again and again in this thread already. With respect, sir, you are out of line regarding the bolded part of your post.

EDIT: for ye olde pilot and your picture. See my last sentence in the paragraph above this one in re your game with photographs.