BA762 report released (cowl doors openning)
"If that is the case, and given that the maintenance error (classic fatigue mistake) was the initiating hole in the cheese, are BA going to cap hours and overtime?"
Nope, they will continue to sweat all the assets until the next incident.
Nope, they will continue to sweat all the assets until the next incident.
JohnFTEng
Don't be daft. Are you comparing a commodity Airbus product to a finely engineered microwave oven?
On most consumer appliances there is an interlock that prevents operation when casing is open. On a highly automated machine like an Airbus why is there nothing similar - Fan cowl unlocked > start-up inhibited?
Human beings do not operate at their best during the night and early mornings since evolutionary developments have led to a natural inclination to inactivity and mental recovery during these periods.
The report mentions undetected aircraft swap error. Many years ago a large airline operated a fleet of freighters at Heathrow. Most of the duties were scheduled for night operation. One night the three pilots of one crew (including self as a junior copilot) wandered out to the apron and started our pre-flight checks. We noticed that an adjacent aircraft was being loaded in preference to ours and grumbled whoever made these decisions needed to get their priorities right. Then the light dawned - the loaders were indeed loading the correct aircraft and we were checking the wrong one. Three sheepish pilots trudged across to the adjacent stand and started again.
It might be significant that the two worst accidents on Britain's railways (Quintinshill 1915 and Harrow 1952) occurred early in the morning after errors by operating staff (and failures to detect them by monitoring staff).
The report mentions undetected aircraft swap error. Many years ago a large airline operated a fleet of freighters at Heathrow. Most of the duties were scheduled for night operation. One night the three pilots of one crew (including self as a junior copilot) wandered out to the apron and started our pre-flight checks. We noticed that an adjacent aircraft was being loaded in preference to ours and grumbled whoever made these decisions needed to get their priorities right. Then the light dawned - the loaders were indeed loading the correct aircraft and we were checking the wrong one. Three sheepish pilots trudged across to the adjacent stand and started again.
It might be significant that the two worst accidents on Britain's railways (Quintinshill 1915 and Harrow 1952) occurred early in the morning after errors by operating staff (and failures to detect them by monitoring staff).
Last edited by Discorde; 13th Feb 2017 at 12:09. Reason: revision
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Captain's signature
Why did the report not mention the Captain's signature on the Tech Log and the clear responsibility that is implied and enshrined in CS 25? IMHO most Captains do the first walk round of the day to help satisfy themselves that the aircraft is fit to fly, particularly after overnight engineering work. Is this not usually the case?
It seems harsh to bring the tug driver into this without bringing in the eye-witness reports of all the other aircraft taxiing out/in - some of whom may have noticed the cowls unlatched (and flapping?) state - and the ultimate responsibility of the aircraft commander.
The report looks at Human Factors but was limited to the technicians only - why?
The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity.
All the company issues mentioned on the engineering side need addressing - but also on the FC side as well. The report does not look at that.
It seems harsh to bring the tug driver into this without bringing in the eye-witness reports of all the other aircraft taxiing out/in - some of whom may have noticed the cowls unlatched (and flapping?) state - and the ultimate responsibility of the aircraft commander.
The report looks at Human Factors but was limited to the technicians only - why?
The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity.
All the company issues mentioned on the engineering side need addressing - but also on the FC side as well. The report does not look at that.
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Is this not usually the case?
some of whom may have noticed the cowls unlatched (and flapping?) state
The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity.
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Which organization put pressure on the majority?
Sorry FL, poor choice of words on my part. PMA was indeed around prior to the ALAR project.
The ALAR project was established by FSF with support from CAAs and major airlines around the world. The project committee was all set to publish the final document which didn't include PMA. Pressure was brought to bear by a certain organization who had supported and participated in the project. That organization was also the only proponent of PMA on the team. The ALAR tool kit was subsequently amended to add PMA as a possible tool for reducing accidents, even though the majority of the project team felt it was a step in the wrong direction.
The ALAR project was established by FSF with support from CAAs and major airlines around the world. The project committee was all set to publish the final document which didn't include PMA. Pressure was brought to bear by a certain organization who had supported and participated in the project. That organization was also the only proponent of PMA on the team. The ALAR tool kit was subsequently amended to add PMA as a possible tool for reducing accidents, even though the majority of the project team felt it was a step in the wrong direction.
Which organization put pressure on the majority?
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The report goes on to say that one of the immediate causes was that the aircraft was signed off as serviceable - which is where the Captain's signature comes in. The aircraft is not allowed to fly unless the commander has signed to say that it is - regardless of engineering activity.
This occurred some 30+ times prior this accident. Since that accident, and despite more sticking plaster solutions by Airbus, Operators and Regulators, it has occurred another 3x.
Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.
Maybe such a comprehensive report might actually get Airbus to do something now? As noted, until this one all other occurrences have had little Safety implication.
As I read the report, I felt that if a Sim instructor had given me that series of warnings and indications, I might well have got up halfway through and walked out saying it was ridiculously busy and unrealistic
PS When I sign the Tech Log, I am not stating the aircraft is fit to fly AFAIK? I am accepting the aircraft as "offered for service".
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Amigo
Yes strange that they mentioned that CC1 was on day 3 etc but not the Flight Deck. That said their flying hours in the last 28 were not anywhere near high (41?) so I have to suggest it wasn't deemed relevant.
The Engineers hours were interesting however, same old issue - social, money v fatigue. Wonder if some of these strange fatiguing practices are ignored by the Pilots also to generate blocks of more time off or are we not allowed to mention this....
Interesting that the report talks about duty hours for engineers but flying hours for the pilots. It is well known that BA SH Pilots spend lots of time on duty but not flying. Maybe the AAIB should report the crews duty hours up to the incident?
The Engineers hours were interesting however, same old issue - social, money v fatigue. Wonder if some of these strange fatiguing practices are ignored by the Pilots also to generate blocks of more time off or are we not allowed to mention this....
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"On behalf of myself".. To quote many a recently heard PA,
"Captain, Sally here,,the pax seem a bit distraught, as they say they can see the inside of at least one engine"
" Bugger, seems at least one cowl is flapping around, I remember a fatal Danair incident where the stabiliser was hit by part of detached fuselage."
"MAYDAY MAYDAY MAYDAY" request vectors for immediate return and landing!"
Quoting myself back in May of 2013........
Didn't the definition of CRM change from cockpit to "Crew resource management", to address just this kind of incident..
Are we really to believe that strongly voiced passenger observations and concerns,were not successfully communicated to the pilots?..I find this highly unlikely........
In my current airline,the first question asked after the "CA1 report to the flight deck immediately please" announcement is made,is..."give me a cabin report"
"Captain, Sally here,,the pax seem a bit distraught, as they say they can see the inside of at least one engine"
" Bugger, seems at least one cowl is flapping around, I remember a fatal Danair incident where the stabiliser was hit by part of detached fuselage."
"MAYDAY MAYDAY MAYDAY" request vectors for immediate return and landing!"
Quoting myself back in May of 2013........
Didn't the definition of CRM change from cockpit to "Crew resource management", to address just this kind of incident..
Are we really to believe that strongly voiced passenger observations and concerns,were not successfully communicated to the pilots?..I find this highly unlikely........
In my current airline,the first question asked after the "CA1 report to the flight deck immediately please" announcement is made,is..."give me a cabin report"
Last edited by Yaw String; 15th Jul 2015 at 17:41.
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NigelonDraught said -
What good reasons are there to not do maintenance of aircraft strictly by the book?
Frankly, I can't see any!
Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.
Frankly, I can't see any!
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"I am not stating the aircraft is fit to fly"
Nigel - I understand you have a thing called the ANO - what does that say?
EDIT: Just found it
"that the aircraft is in every way fit for the intended flight"
Even if your airline tells you this 'responsibility' is delegated to others such as engineering, it isn't.
Bit of a dilemma for we 'responsible' people, isn't it?
Nigel - I understand you have a thing called the ANO - what does that say?
EDIT: Just found it
"that the aircraft is in every way fit for the intended flight"
Even if your airline tells you this 'responsibility' is delegated to others such as engineering, it isn't.
Bit of a dilemma for we 'responsible' people, isn't it?
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Picking up on the fact that the Captain did not receive the whole picture..
What is wrong with the SCCM taking a picture on his/her phone and showing it to the Captain?
This is an unusual situation and I am sure the cabin crew management would allow the phone to be turned on. Or maby not
What is wrong with the SCCM taking a picture on his/her phone and showing it to the Captain?
This is an unusual situation and I am sure the cabin crew management would allow the phone to be turned on. Or maby not
Thread Starter
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Maybe try reading the report.
This occurred some 30+ times prior this accident. Since that accident, and despite more sticking plaster solutions by Airbus, Operators and Regulators, it has occurred another 3x.
Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.
Maybe such a comprehensive report might actually get Airbus to do something now? As noted, until this one all other occurrences have had little Safety implication.
As I read the report, I felt that if a Sim instructor had given me that series of warnings and indications, I might well have got up halfway through and walked out saying it was ridiculously busy and unrealistic
PS When I sign the Tech Log, I am not stating the aircraft is fit to fly AFAIK? I am accepting the aircraft as "offered for service".
This occurred some 30+ times prior this accident. Since that accident, and despite more sticking plaster solutions by Airbus, Operators and Regulators, it has occurred another 3x.
Flight Safety does not get far by just finger pointing individuals as your post suggests. The AAIB have produced a wide ranging report, and even where the engineers directly contradicted AMM requirements, they noted this practice was carried out by other engineers and operators, and for good reason.
Maybe such a comprehensive report might actually get Airbus to do something now? As noted, until this one all other occurrences have had little Safety implication.
As I read the report, I felt that if a Sim instructor had given me that series of warnings and indications, I might well have got up halfway through and walked out saying it was ridiculously busy and unrealistic
PS When I sign the Tech Log, I am not stating the aircraft is fit to fly AFAIK? I am accepting the aircraft as "offered for service".
BA maintenance is shown to be a complete shambles, god knows what else they are missing. I'd like my engineer to be as fit and fresh as my pilot, and a lot more equal in pay than currently. I'd like my pilot to follow procedure for shutting down engines, and to be able to fly a fully manual approach without someone else having to control thrust, because they've never done it before. Pilots of other reputable airlines are rightly incredulous at what went on here.
We're always told Asian airlines/AF won't admit they have a problem so won't fix it. It's beginning to look like BA are no different. So Airbus fix the cowling issue, great. Is this the only threat BA engineers and pilots have to deal with, and do you think maybe the report suggests the organisation has its own issues to address as well?
What good reasons are there to not do maintenance of aircraft strictly by the book?
Frankly, I can't see any!
Frankly, I can't see any!
But there are still reasons it happens. Everyone knows what those reasons are.
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Super VC-10
If you mean carry out maintenance "strictly by the book" then you're into a situation which is pretty much unworkable, if, the company expects to get anywhere near it's dispatch reliability targets. If you would like me to check the revision status of all the manuals I'm required to work with, and to check the validity of any technical data that I normally store in my head, plus carrying out or checking for the latest risk assessments, any new health and safety legislation, any new information from the airfield operator,( I could go on ) prior to each Engineering operation I carry out, you wouldn't get an aircraft away on time ever! So how "strictly by the book" do you want me to be? 
Gender Faculty Specialist
But that's not your problem Yotty, it's the company's.
If flights start leaving late because people are doing their jobs properly all of a sudden you'll have more people to do the job.
If flights start leaving late because people are doing their jobs properly all of a sudden you'll have more people to do the job.
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Resources v TDR.
Exactly Chesty, Any airline could ensure 100% reliability, it's "just" a matter of having enough Engineers, Aircraft spares, spare aircraft and crews and that would pretty much get that figure close to 100%. It's a conscious calculation by the operator to accept less performance for a lot less cost.
If flights start leaving late because people are doing their jobs properly all of a sudden you'll have more people to do the job.
Gender Faculty Specialist
It's far from naive.
I know it'll never happen but if everyone did their jobs exactly by the book there would be delays and the airline would have to do something about it.
Trouble is not everybody is as bloody minded as me so here we are, under partly self induced time pressure, with bits falling off aeroplanes.
I know it'll never happen but if everyone did their jobs exactly by the book there would be delays and the airline would have to do something about it.
Trouble is not everybody is as bloody minded as me so here we are, under partly self induced time pressure, with bits falling off aeroplanes.
