"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.

JohnFTEngDon't be daft. Are you comparing a commodity Airbus product to a finely engineered microwave oven?

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).

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. :confused:

No.

Did any other aircraft notice the cowls unlatched or is this pure supposition on your part?

And if the Tech Log entry had said "IDG oil replenished" would the Captain personally open the cowls and check the oil levels for himself? The Commander cannot personally check every aspect of the aircrafts airworthiness.

JO


Which organization put pressure on the majority?

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 :eek:

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".

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....

"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"

NigelonDraught said - What good reasons are there to not do maintenance of aircraft strictly by the book? :eek:

Frankly, I can't see any! :ugh:

"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?

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 :ugh:

No finger pointing at any individuals, the numbers of holes that lined up here throughout the organisation suggest endemic problems across the board. Yes there is a design issue, but that is all the more reason everyone else has to do their job. And stop shirking responsibility.

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?

There aren't any 'good' reasons not to do anything by the book.



But there are still reasons it happens. Everyone knows what those reasons are.

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? :O

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.

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.

Or different people. . .

No offence, but that is a very naive statement. Airlines want 'on time every time' and anything less will not do.

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.

indeed, isn't that what is known as a "work to rule" industrial action?

When is a door not a door?
 

JohnFTEng asked yesterday -

'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?'

The answer seems to be that fan cowls are not doors, but structure (according to EASA). As long as they do not break under 150% of expected flight loads (bending is acceptable), 'the theoretical probability of failure is zero and does not need to be considered further.' (Report 1.18.1, page 81).

So, as the fan cowl is not a door, it can never be ajar - as every schoolboy knows

I don't see the relevance of that.

Even if they had been certificated as doors, the requirements only state that they should be designed so that unlatching during flight from the fully closed/latched/locked condition is extremely improbable.

But that's not what happened here, of course.

Ref the possible manual thrust issues in this incident.
According to a current Airbus pilot, BA requirement is 777/787/Airbus pilots to practice manual thrust management once every three years in the sim. Not approved on route flying.

Structure vs system
 

A little further on in the report (1.18.1, page 82) a definition of 'extremely improbable' is given as less than 1 in 1,000,000,000 per flight hour. This is the requirement for an aircraft 'system'. The experienced rate of fan cowl opening (Report 1.18.2, page 84) is 1 in 1.28 million flight cycles pre EASA AD F-2001-381 (hold open device) and 1 in 2.42 million after that AD. I don't know the average hours per A319/320/321 cycle but say it is about 2 hours, then the occurrence of fan cowls opening is about 200 times over the acceptable limit of a 'system' and it would be more of an issue.

In addition, if they were a system there would be a cockpit warning for unlatched cowls. However EASA reasoned that if you have a warning system you get false alarms

Yes and that is slightly terrifying. At the end of the day, pilots are.needed when things go wrong with automation. If they only have to practice onnce every 3 years and never have done so in reality, how can we possibly rely on them when things go wrong? There is something deeply distrurving in the industry. I'm a Brit and i'd love BA to be the best but...

I've heard KLM and delta have started sending cadets up for acrobatics training. Seems a good idea

Virgin are apparently more flexible and allow airbus crews to use manual thrust at their discretion. It is increasingly worthwhile finding out an airlines SOPs before flying. Sad

Good point.
To avoid other false warnings, to facilitate keeping to schedule, and to save fuel, I'd like to suggest that TAWS/EGPWS, TCAS, and smoke detectors be removed from commercial transport aircraft.

As I've mentioned before, there is a tried and tested way of completely eliminating the risk of unlatched cowlings causing damage in flight.
Please compare the foreground and background aircraft in the image below. One of these aircraft will never suffer damage due to an improperly latched cowling.

http://www.trimotors.awiggins.com/im...nd707atSFO.jpg

Depressing report. But maybe a useful reminder that fatigue is not only an issue for the folk in the front seats.

Structure vs system
 

Again, that's not what happened, nor is it what the AAIB said. The occurrence rates you quote are for loss in flight of cowl doors that are effectively already open, not the rate at which fully closed cowl doors open themselves in flight (which I suspect is zero).

The difference being that certification requirements can't possibly mitigate against the effects of departing with unsecured cowls any more than they could against, say, an unsecured cabin door (albeit that the latter, of course, have warning systems).

Porter (PD) #617 ? 06-Jul-2015 ? CYTZ - CYTS ? FlightAware

It doesn't have to be an Airbus either..this Porter aircraft returned safely after losing a cowling according to AV Herald.

I think you meant aerobatics.
Acrobatics is stuff like juggling, tightrope walking and trapeze.
Although given this sorry situation it might be worth giving it a go!:sad:

What is annoying with airline management putting restrictions on manual thrust is that the first rule of Airbus is that if you don't like what the automatics are doing, revert to manual flight. Management see the recommendation to use Autothrust in most circumstances (which is entirely logical) but ignore the necessity to be fluent in manual thrust flying because of a perception of risk.:ugh:
The irony is, that the Airbus is very easy to fly in manual thrust/ap off, with all the protections there if you should be daft enough to cock it up.

Last year at LHR I was on a 767 that had issues locking the cowling- they appeared to be trying to fix it with a hammer and swiss army knife

It did not look like a very robust or easy to use fitting TBH

If you think an RB211 cowling is difficult to latch closed (and as I recall it usually wasn't) then you should have seen what the old JT9's were like! They never got left open or came open in flight though.

JohnFTEng asked yesterday -

'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?'

One more level of complication - well intended as it is = one or more failure modes that could affect propulsion.

At the risk of starting another Boeing versus Airbus thread, I'd like to point out a pretty obvious design fault on the Airbus (though obv I stand to be corrected by engineers various)

The Airbus engines' doors just hang when unlatched. They fasten underneath and so it's very difficult to see when they're in that position.

Boeing's doors open differently and have to be fully in either position. They 'pop' semi-opened if not latched properly.

That's what I've been told anyway!

If, as the previous poster suggested, it's startup that's to be inhibited with the cowls unlocked, then you won't get as far as having any propulsion to affect.

And anyway the AAIB's recommendation isn't for that, it's for an unlatched condition warning system, not one that commands an engine to shut down.

cowl/start interlock
 

let's say you run into a flock of birds, or encounter icing severe enough to give a spurious cowl open indication........

you now can't start your engine should the need arise :D

manual thrust
 

If BA flt ops management think there is a risk involved with pilots operating manual thrust, then it is they, the management who have created that risk by not allowing pilots to practice when circumstances allow. Do they not appreciate just how easy and pleasant to fly these modern aeroplanes are, and that hand flying is both enjoyable and professionally rewarding.

Perhaps they should ponder how we coped on VC10s, 707s and 737-200 etc, etc., with NO autothrottle, (or a Canberra with not even an autopilot !!) we just got on with it and flew the damned things, and on the 75/76 when hand flying we were required to disconnect the AT !!.

...........and am I to believe that BA allows dispatch with u/s autothrust yet the pilots may not have flown with manual thrust lever operation for 3 years, as CessnaPete reports ??

Worrying.

You are correct in your belief.


I will add that in the days when there was a usable in house BA intranet forum this whole topic was often the subject of lively debate (usually led by our Airbus colleagues). Management were consistent in voicing their belief that the current policy was a "good thing" :oh: :oh:

Prior to the arrival of the A321, the use of manual thrust lever use on the Airbus Fleet was encouraged, when appropriate. There was a concern that with the longer body of the A321 a low speed event on approach would lead to a higher chance of a tail scrape on landing - a view borne out by the history of tail scrapes on the A321 of other operators. There was a heated debate with most of the trainers and line crew on one side and a few key managers on the other as to the future and how to should proceed with the introduction of the A321. The managers, with the typical "I've made my mind up now I will pretend to consult experts" approach decided they knew best, ignored all advice and went ahead with the ban on the use of A/T on the bus fleet.


A few years later the official line had changed and the management could now "prove" it was safer as they had had significantly fewer low speed events across the bus fleet since the introduction of this policy. It could be proven statistically. A poor argument at best as the stats will also conclusively prove that if you never fly there are zero low speed events and that is much safer. What the managers have actually done is mis-employ a little bit of NUTA; they noticed a problem, they understood the problem may lead to an increased likelihood of a tail scrape and they thought ahead and put in place a way to avoid the problem. All the time failing to understand that the use of manual thrust is not an inherently dangerous practice, but deliberately deskilling your pilot work force is.

Put another way, the managers identified a potential weakness in the skill set of their pilots and then decided to train IN that weakness. To deliberately re-enforce the potential failure, to strengthen the likelihood, following a failure of the system of a dangerously low speed event. A sim requirement for triennial currency? No substitute for daily competence. Surely by this flawed logic pilots should be banned from any form of manual flying.