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BA762 report released (cowl doors openning)

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BA762 report released (cowl doors openning)

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Old 7th Aug 2015, 19:45
  #161 (permalink)  
 
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Originally Posted by akaSylvia
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Old 11th Aug 2015, 12:18
  #162 (permalink)  
 
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BA762 – AAIB Report

This event in May 2013 turns out to be a great deal more serious than many remote observers like me had realised, and the comprehensive report will merit further reading. For most of us pilots – retired or otherwise – it’s an eye-opener to the problems faced by our hard-pressed line-maintenance colleagues on a routine night shift. That a bespoke system such as presumably created for T5 should turn out to be so dysfunctional is disappointing.

The in-flight conduct of the flight crew is another matter, but I agree with the poster who points out that anyone who had previously suggested this scenario as a LOFT exercise for a recurrent sim check would probably have found the idea dismissed as improbable and over-complex.

As a retired A320 pilot, my main historic interest here has been the failure of the pilot’s external check to flag-up the unlatched cowlings. A bit more unexpected are the problems the pilots experienced in use of manual thrust after the #2 engine had been shut down. In the hope that the Moderators will permit it, these are the two aspects I’m going to discuss at some length in this post.

MANUAL THRUST

From the AAIB Report (pages 14 & 15):
“The commander informed the AAIB that, excluding simulator training, he had last flown the A320-series aircraft using manual thrust seven years before the accident.”
“The co-pilot informed the AAIB that, apart from simulator training, he had never flown the A320-series aircraft using manual thrust.”


The co-pilot had joined the fleet at the end of 2006. The BA policy for single-engine flying on the A320-series when the AP is not available may have changed since I left the fleet at the end of 2001. I’m not privy to a current FCOM, or to the one pertaining at the time of the accident (May 2013). Generally speaking, as PF, it’s easier to use manual thrust in single-engine flight because the rudder requirement can be anticipated and co-ordinated as you move the throttle/thrust-lever; provided, of course, you are the one handling it!

I gather that, since my retirement, BA has more or less banned the use of manual thrust in normal (twin-engined) ops when A/THR is available. I flew the A320 as a line captain from March 1988 (just after the A320 had received its type-certification) until the end of 2001. At Toulouse, Airbus trainers had encouraged the use of manual thrust for “manual” flying. For a manual landing in good visibility, I invariably disconnected A/THR, usually just before the AP, at least a minute before touchdown. The GS-MINI system is brilliant, provided you use the constantly-varying “managed” speed as a target, rather than a minimum speed. It greatly reduces the number of thrust adjustments required. The manual throttle/thrust-levers are, however, a delight: easily the best of the six jet types I flew.

If manual thrust is no longer permitted as an option in normal ops, it would explain the lack of recent experience of both pilots. They would be less well equipped in any A/THR failure. The essential learning experience would not be easy if the crew was simultaneously dealing with other failures, as in this case. If an engine is shutdown when A/THR is available, one of the essential actions is to increase the thrust limit on the remaining engine to MCT. On the A320-series, this is achieved by advancing its thrust lever from the CLB detent to the MCT/FLEX detent. Unless that much thrust is required immediately, it would be quite inappropriate to do that in the manual-thrust case. In the absence of an IAS trace in the Report, this is one possible explanation for the co-pilot advancing the #1 engine thrust lever well beyond the CLB gate after the #2 engine had been shut down (see next paragraph). Is manual thrust practised in the simulator for the single-engine case?


The other surprise for me, sitting in my peaceful retirement, was the captain’s decision, as PM (PNF), to take over the thrust management on the approach (see page 9) after completing the #2 (right) engine fire-drill/shut-down. This may have been in reaction to the co-pilot’s initial over-increase of thrust on the #1 engine to more than CLB thrust (see previous paragraph). The latter had led to a big yaw, and his corrective use of more than 10 degrees’ left rudder had disconnected the AP. But the co-pilot’s continuing difficulty in maintaining heading in manual handling may have been all the greater for not initiating his own thrust changes. In the following 2 minutes, the thrust-lever angle peaks 3 times, and varies between the CLB detent and idle (see Fig 16, page 41). That represents a lot of leg work and rudder re-trimming, which should not have been necessary. In any case, could an AP have been re-engaged?

Later, when the captain took control at about 500 ft agl for the landing, he delegated thrust control to the co-pilot. We are all prone to atypical mental processes under high pressure. I’m wondering if this may have been a case of reversion to the SOP of some previous type. The report (page 67) quotes the manufacturer’s SOP that the thrust levers are operated by the PF in abnormal and emergency conditions, and I assume BA still subscribes to that policy in the air, though not for the selection of reverse thrust on landing.



PILOT’S EXTERNAL CHECK

From the AAIB report, para 2.5.4, pages 97-98:
“The co-pilot had not been tested in his conduct of the walk-around and the operator did not carry out periodic checks of how flight crews were performing the external walk-around (nor was there any requirement for them to do so). Thus it was not possible to ensure that flight crews were consistently performing [it] to the standard shown in the operator’s training video and as set out in the FCOM procedure.”

Throughout my 14 years on the BA A320 fleet (referred to as the Airbus fleet), all pilots were assessed annually on the external check as part of what BA described as the route check (line check). Route checks were normally conducted by a specialist Route-Check Captain (RCC). When possible, the RCC checked the two pilots as a crew on a two-sector rotation, occupying the P3 seat as a supernumerary crew member. This enabled the RCC to evaluate both pilots in their P1 and P2 roles. Being free of any duties other than observation, the RCC could assess the whole operation dispassionately; including CRM within the cockpit, and the crew’s interaction with cabin crew and ground staff. The P3 seat affords a view of either pilot’s actions that the opposite seat cannot.

On arrival at the aircraft for the first sector, the RCC would observe the captain and co-pilot meeting the cabin crew, reading the technical log, and doing the safety checks. Then it was normal practice to observe most of the external check (on our fleet conducted by the pilot doing the P1 duties, which was typically the captain on the first sector). That gave the RCC the chance to verify that at least all the items on one side of the a/c had been checked properly, as well as the nose and the tail, before hurrying back to the cockpit. (Meanwhile, the pilot doing the P2 duties had covered a lot of ground. But no system checks are required on the A320-series, and his/her preparations would become clear during the pilots’ pre-departure briefing.)

When a line check or line training is conducted from a pilot’s seat, the check pilot or trainer is unlikely to have the time or capacity to accompany the candidate on the walk-around. The role of specialist RCC was discontinued by BA soon after I retired, and this may have coincided with a change of policy on the conduct of the line check.

Again, from the AAIB report (page 97):
“The co-pilot had watched the operator’s training video on the A320-series external walk-around when he undertook the type conversion course several years previously.
“When interviewed, he was unaware of the need to specifically check the fan cowl door for a visible gap between the doors and the nose cowl. His described method of how he checked the latches did not enable him to identify that the fan cowl doors were unlatched. This suggests that either the operator’s training video was ineffective, or that he had been aware of this at some point but had forgotten it with the passage of time.”


As someone has already pointed out on this thread, one is actually looking for the absence of a visible gap: i.e., that the L/Es of the fan-cowling doors are absolutely flush with the nose cowl. This applies to both makes of engine. When left hanging down and unlatched, both types hang much closer to the line of the engine nacelle than one might expect. The gap obviously increases from top to bottom. The CFM fan cowlings are a notoriously bad fit when closed, but from memory the latch mechanism is perhaps more intuitive (less complex) than the IAE. The latches are at the bottom of the cowlings in both types, very close to the ground (slightly less so on the IAE).

It’s essential to stoop and bend one’s head down quite close to the ground to ascertain that both doors are flush and the latches are secured. This can be done from the front of the engine, or from the sides.

During many years as a RCC, the bottom line for me was that, if the pilot didn’t lower his/her head sufficiently, the check could not have been performed properly. This was only too common, and became a standard bleat during de-briefs, not to mention my periodic route-check summaries. At the end of 1996, after nearly nine years of A320 ops, I estimated that between 5% and 10% of captains were omitting the check, and nearly 5% of co-pilots. That represented an improvement on our small, close-knit fleet. In those days, we still had only ten A320s, all CFM-powered. By the time I left at the end of 2001, we had added about eight IAE-powered A319s. The rate of pilots omitting the check remained similar, as I recall, despite the expansion of the pilot force.

I’m disappointed that the level of priority given to the training and checking of walk-around checks has apparently fallen. Pilots are the last line in the defence against serious defects on despatch. If the standard of routine walk-arounds has fallen accordingly, it would also represent a gap in an important aspect of the technical knowledge of the current generation of junior line pilots. This may imply a lack of motivation in some cases, but the main reason would be the ratchet of reductions of time available for pre-flight preparation, and never-ending demands for cost-savings in initial and recurrent training. Apart from the adverse effects on pilots’ broad understanding of aircraft systems and maintenance, a further side effect would be to hinder the development of the valuable rapport between them and line engineers.
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Old 12th Aug 2015, 18:10
  #163 (permalink)  
 
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Good post Chris. I was only on the fleet for 3 years until 91 (?) so won't comment other than to say that I didn't know BA had cut out the dedicated Route Check Captain position. That was really the Chief Pilot's independent "quality control" over both his Technical and Training subordinates. I am pretty unhappy with the idea that manual thrust is only done in the sim., since for exactly the handling issues you mention the occasions when it may be necessary are already generating high workload/stress levels.
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Old 13th Aug 2015, 14:41
  #164 (permalink)  
 
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LINE CHECKING

Thanks, Steve,

Great to hear from you after all these years! They were exciting times, even allowing for your missing that first summer at Gatwick, with night charters and the brand new North Terminal. In those early years we were all true volunteers, were we not? We joined the fleet from many others because we wanted to fly cutting-edge technology. I only ever heard of one pilot who was disappointed with his choice.

Re your comments: yes, that was precisely my understanding, and what Pete Looker told me when hiring me for the job as RCC. For about eight months of each year, apart from the occasional contingency, we were ordinary line pilots; the remaining months were spent doing route checks (line checks). Whenever possible, each check was of a pair of pilots, and done from the P3 seat.

The fact that the pilot’s walk-around is no longer part of the line check leads me to conclude that the line-checking pilot, as well as being a trainer, must also be operating in a pilot seat – either as captain or co-pilot. In most cases, (s)he would be unable to observe the candidate’s walk-around. Being able to evaluate the external check is not the only advantage of line checking from the jump seat, as pointed out in my previous post.

For other readers: RCCs were employed in much smaller numbers than the trainers, and were regarded as something of an anomaly. (In BCAL, where I came from, the role hadn’t existed.) The fact that we evaluated pilots only on everyday line operations – every pilot’s bread-and-butter task – inevitably led to resentment in some quarters. It’s a bit like a workmate criticising your driving when you’re giving him a lift! And it wasn’t only line pilots that occasionally objected.

As you know only too well as a trainer, although training captains also had to conduct route checks from time to time on an ad-hoc basis if no RCC was available, it represented only a small part of their relationship with the line pilots. When it happened, the training captain usually did the check from a pilot’s seat. That made for a bond with the candidate, which has its pros and cons. You cannot scrutinise all aspects of a pilot’s performance when you have your own workload.

Mostly, trainers’ work is in conversion training (on the sim and the aircraft) and recurrent simulator checks. No one expects – or is expected – to perform completely flawless sorties in those situations. Most of us are only too ready to accept criticisms and help from trainers, provided they sign us up for another six months! But, on the line, more pride is at stake.

So, to put it bluntly, as I think you’ll agree, trainers were generally more popular than RCCs. That sentiment probably extended to management pilots, whom we also had to evaluate annually. A manager, who might only get one or two flights a month, may not take kindly to receiving banal debrief items they’ve seen RCCs list in fleet summaries. My feeling was that, despite their desk-bound lack of practice on the line, treating management candidates differently would be misleading to the manager and might lead to a decline in fleet standards, as well as being unfair and dishonest.

The demise of the role of the specialist RCC in BA may have been encouraged by the above, but another factor is likely to have been decisive, as always: costs. Checking one pilot at a time means twice the number of line checks. But, if in each case the crew is limited to the minimum crew complement of two, the check costs nothing. The line checks may not be as wide-ranging or objective as a RCC was able to do from the jump seat, but at least the training captains get to fly more often.
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Old 17th Aug 2015, 16:11
  #165 (permalink)  
 
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I have read the AAIB's report with great interest and clearly it raises a considerable number of issues that are of concern. I last flew a commercial flight in 1995 and have never flown an Airbus type other than their simulators in Toulouse, so for both reasons I will not comment here on the rights and wrongs of the conduct of the flight.

However, I am astounded to read in Chris Scott's posts above that BA do not permit pilots to fly using manual thrust during normal operations. In my view, it is essential that pilots should be encouraged to fly the aircraft manually whenever workload and weather conditions permit. A few practice sessions on the simulator is totally inadequate.

I know I am an old fossil but, after reading some of the accounts here on PPRuNe and in official accident reports, I cannot understand how or why BA pilot management have allowed this to happen. Pilots are there, not only to conduct normal flights, but, far more importantly, to act as long stop when things go wrong - including the automatics.
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Old 17th Aug 2015, 16:33
  #166 (permalink)  
 
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Agree, I have hand flown jet transports for 9 hours straight many times. It is a very necessary skill if you had to drive thru a serious squall line or make up for a loss of most of the automatics. Mr Murphy will rear his ugly head at the most inconvenient times. Everything works fine until you really need it.
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Old 18th Aug 2015, 01:22
  #167 (permalink)  
 
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Bergerie

I cannot understand how or why BA pilot management have allowed this to happen.
J T provided a pretty good explanation of management's reasoning for full time use of autothrottle on the Airbus in post #80 on this very thread. Management on other fleets subject to the same rules, such as the 777 claim (amongst other things) that use of Autothrottle reduces touchdown point dispersion and therefore reduces the risk of a runway excursion.

Please don't shoot the messenger, I am not saying I agree with the policy.
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Old 18th Aug 2015, 02:50
  #168 (permalink)  
 
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wiggy,

I wouldn't dream of shooting the messenger, I agree with too many of your posts.

I've re-read post No. 80 and am still appalled. I'm just glad I'm not flying any more.
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Old 18th Aug 2015, 08:20
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I've re-read post No. 80 and am still appalled.
Nearly all the pilots on the fleet were appalled too. Luckily we had/have a management that listen to the opinions of trainers and line pilots - oh no wait a minute, we don't.

This is a classic case of misuse of SESMA. The argument that banning the use of automatics leads to less low speed events is akin to arguing that if we don't fly at all we get no low speed events.
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