BA762 report released (cowl doors openning)
 

Tired technicians' plane mixup led to inflight engine fire, inquiry finds | UK news | The Guardian

Can't find a link to the report itself, doesn't appear to be on the AAIB website as yet. Anyway this doesn't make good reading for BA, maintenance, flight, or cabin crew. A tad worrying after the Transasia incident that the pilot didn't follow procedure on engine shutdown...

Looks like a leak or breach of publication embargo.

C Y A Exercise Complete??
 

I suspected the original holes in the cheese were lurking VERY high up in management, hence the delay in the final release.

There will be a ground engineer with standard qualifications viz overworked, understaffed and commercialy pressured, a similar flight crew and weal marks on their backs from the lashing.

However, the bean counters will sleep easy knowing their names, job titles and positions will never be held up the same scrutiny as the coalface workers.

I still maintain the lessons from this accident have been hidden from the Professional Aviation community, until soon if this news report is to be believed, to the detriment of Flight Safety and thereby denying other organisations from learning and initiating their own preventative measures.:ugh:

Stable door and horse. This was a real wake up call.:=

"I can categorically state that all BA Engineers have been fully briefed on exactly what happened, the reasons why it happened and the measures put in place to prevent it happening it again."

So that's all right then, all SLF and other airlines can sleep easy in their beds because the subject airline's engineers have been (so far exclusively) told what happened and how to prevent it??

I must contact AAIB and tell them there's no need to PUBLISH the full report, as required by legislation, thereby saving lotsa money and effort, as well as sparing the blushes of the subject airline's senior management.

So that's it folks, move along, nothing to see here...........:rolleyes:

AAIB been merged with the NTSB?

:rolleyes:

Send an email to :[email protected] and tell them how poor the aaib website is now it has been migrated to gov.uk. Try searching for an accident report and you will find that most have been deleted.

Contact the Cabinet Office too. The migration to .gov is their doing based on advice from their web 'guru' Martha Lane Fox of Last Minute.Com fame. Obviously she knows far more about technical websites than the punters who actually use the damn thing.

We can take some small comfort from the fact that there are a few dozen archived snapshots of the old AAIB site from Feb 2001 to Feb 2015 here: Internet Memory | UK Government Web Archive

From the report;

No comment!

Long line of accidents and incidents - purely luck has averted major loss of life over more than a decade.....IMHO need to get rid of the old boys club from both the airline and authority - but that will never happen.
What happened to professionalism?

Report here
 

Still looking through the report, but I am surprised to read this... how can it be possible?

Because as I understand it ;) the company involved has an SOP that if "full time" auto thrust/autothrottle is available it must be used....the rule applies to almost all types, not just Airbus. That said you can despatch with autothrottle/auto thrust inop as per the DDG and the FCOM, you're obviously (?) trained and checked on in the sim on flying with manual thrust, but you can't opt to fly manual thrust on the line simply because you want to....

IMHO and that of many others for somewhat obvious reasons it's a somewhat a flawed SOP !!!!!! and has been the subject of much heated debate elsewhere, but ultimately management and the lawyers write the Ops manual. I wonder if it will now be amended.....

And if you must know I haven't operated my type on the line using manual thrust for well over five years...........

Amazed to read these BA pilots had never flown the aircraft using manual thrust!. Presumably the large heading changes mentioned in the report due to the yaw caused by manual thrust mismanagement.
I flew the BA 744 for a number of years and the SOP was, when manual handling, the auto throttle had to be disconnected when ever the autopilot not used. ie manual handling manual thrust control
Kept us in good handling practice in suitable conditions, why the difference on other types 777 etc.?
During my time with GSS on the B744F the SOP was even better, in that we did not use the Monitored Approach and were able to hand fly the aircraft at any time in suitable conditions. Its called Airmanship, and seems sadly lacking in these automated times.

In BA a retrograde step, in view of the ever increasing accidents happening due to poor manual handling.
I'm surprised British Airways subscribe to this procedure.

A "comedy" of errors?

cessnapete

I'd agree, it's bizarre isn't it?

With the caveat that I'm not a trainer, but I went 744 - 777 a few years back I'll offer the following (IMHO very weak) explanation that I've heard:

AFAIK the 744 SOP remains as you remember it, the argument for manual flight=manual thrust being that if you do hand fly the 744 with autothrottle in the pitch/power couple could be destablising, ( theory being if you handfly with manual thrust you are knowingly making the thrust inputs and therefore supposedly are able to anticipate any pitch changes).

OTOH with the 777 operating in normal FBW mode the pitch power couple is automatically removed...so, in theory at least in normal circumstances regardless of thrust changes the aircraft shouldn't respond in pitch, therefore..... autothrottle isn't destablising when handflying...., therefore it can be used without detriment to manual flying...which BA management decided to convert to an SOP of autothrust must be used for manual flying...(because in their eyes it offers another level of protection to the flight envelope). I have to add that the 777 (in the sim at least) is a beaut to fly fully manually, however on the line at BA it's mandatory that the autothrottle is used if available.


I suspect given the above if BA mainline ever had the 744F and the pitch/power couple has been engineered out (has it?) the SOP would have been autothrottle on at all times.

I can promise you that BA line pilots have been making this point for years, sadly we don't write the BA OM.....

Thought you bus-drivers could not fly man/thrust (?). Aren't those armchair pilot 'Thrust Selectors' dummy Thrust Levers ? Couple of detents on the quadrant to be hit at the same time in order to satisfy the computers and "she does it for you"..................? Now, thrust levers like in my old Boeing had to be paddled, re-checked and targeted very carefully or you could blow things like EPR, EGT etc etc..................Gosh, these clever Frenchies ; They actually have convinced you lot that YOU are FLYING the aircraft !........................Ok, crash helmet on, heading for the bunker..............incoming !

Flew with a red-nosed carrier not long ago, on a cockpit fam flight. Beautiful visual approach into a fairly long and unobstructed runway, flown manually with manual thrust from around 9000ft. Aircraft was a strange mix of modern forward panel and jurassic overhead, jumpseat quite horrible but doable for a 45 min flight.

The take-off was manual flight and auto-throttle to around 15000ft.

Would rather, as in any day of the week and twice on Sundays, fly with a crew who are free to exercise judgement, and use automatics as and when it's the best option. Flying a short sector on a clear skies day, off a fairly quiet airport and into one that's even quieter, encountering almost no other traffic either enroute or in the terminal areas, is obviously a perfect opportunity to take the bull by the horns and do a spot of driving yourself. Any operation which has SOPs written specifically to prevent that, is run by a bunch of idiots. Probably the un-holy and culture destroying trinity of Lawyers, Accountants and Consultants.

First of all I would not want whatever I would do wrong in a similar situation been analysed in the court of Pprune but there is one thing that stood out for me as probably caused by stress hormones and a good learning moment of what not to do Almost a Kegworth or another AirAsia due to too quick actions. Like my favourite TRE always used to say: have a coffee first, then shut the engine down...

So, to be clear: this is no judgement as it can happen to all of us and the ones claiming that it will not happen to them should mail their licences back to the Beehive! :}

Another victim of the secure (not safe) cockpit door?

Virgin Atlantic more enlightened in this area, allowing manual thrust practice at the crews discretion. (A330)

Although a physical barrier, I'm not too sure the flight deck door can be blamed these days for a break down in communication.

Personally if I had the CC calling in the climb out, the auto pilot would go in, PF takes the radio and the PM investigates. Cabin crew don't normally call so urgently so it's pretty obvious that something serious has happened.

Wiggy
 

No, the 744F identical automatics to pax version. (Didn't fly the -800 version)
At the start of operations the GSS Ops manager ( ex BA Short Haul) wanted the BA split approach SOP but was outvoted by Training and crew opinion.
IMO we therefore had a more relaxed operating environment where manual handling was at the Capt/ crews discretion at all stages of the sector, and gave us much more freedom to hand fly, and maintain our skills on a long haul operation.

Even then the BA SOP was becoming comical in some respects. I remember on a severe CAVOK arr into LHR on a Route Check, I took over the handling from the co-pilot on a split approach, passing approx WOD, <10000ft., no Holding and landing westerly.
On the debrief the RTC criticised me , in that I should not have resumed control until on final, as I did not have the runway continuously in sight, ie when past downwind to base leg. A requirement of the split approach philosophy apparently.

Back to Victorian working practices?
82 shift working hours in 7 days...absolute disgrace - where is health and safety or for that matter having a life when BA condone and probably expect this sort of "loyalty".:ugh:

I know something of the genesis of the PMA / split approach philosophy and of how it got into the ALAR document in the first place. Let's just say that politics and influence won the day, rather than good sense. In my personal opinion, it remains one of the strangest notions I've ever seen in aviation, especially in a highly automated flight deck.

I find the most eye opening part of the report so far on page 101, 2.6.6:

' the commander then quickly selected the right thrust lever to idle, the No 2 (right) engine master to off and pushed the No 2 fire switch. Contrary to SOPs and training, he did not confirm with the co-pilot his identification of which engine to shut down, nor was the co-pilot given the opportunity to confirm the commander’s individual switch selections. "

Wow......

Oh dear oh dear oh dear!

If the first morsels of feedback are correct, though I have not yet read the full report, then I am not surprised this one was sat on for so long.

How embarrassing for the affected company, both the reports thrust and the scathing comments and opinion it will attract.

Someone high up in the company's food chain needs to grasp this problem, own it and flush out the dinosaurs who encouraged the Swiss cheese holes to line up.

For those who have read it in full, have a look at the accident to G-OBMM and then compare how similar they are, right down to the CC v Flight Deck communications breakdown.

Do we never learn from previous accidents???

Unfortunately for the safety case, since the long ago CC unrest in BA, a large minority of the senior cabin crew still treat the F/C with disrespect and hardly communicate in normal situations. They still blame the pilots for the failure of their industrial action.
I presume Flight Ops Management accept the situation so as not to annoy the Unions.

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?

J. O.When did it first appear in the ALAR document?

I ask because the split approach (Monitored Approach) was SOP in BEA when relying on instruments after passing the holding or main approach beacon by the mid 1960s.

The BA decision to adopt and adapt the BEA procedure following the merger wasn't universally popular, to say the least, according to Capt Hugh Dibley who BOAC/BA pilots of a certain age here will know. He told me the story (many years later) in characteristically strong, and amusing, terms. :)

Please excuse a question which is not directly on topic, and from someone who isn't a professional pilot.

Oooooooh I love the ever so but tempting thread creep. Alluded to in a minority of my posts, but ,I am moved to say that all of this started in 1973 ! Cheese holes lining up, bean counters etc , etc,. Here's the thing (for you yankeeddoodles), When Northeast & Cambrian were integrated into BARD (British Airways Regional Division), we lonely FO's lost everything. The Monitored Approach procedure loved by those who got the Cat111 stuff approved but was not THE most desirable in conditions other than blinding fog, became STANDARD. So, Capt was always Capt. Well, he always was. I was not allowed to do ANY R/T , not allowed to taxi and P1/s, clearly out of the window, endangered my hours build up to the ATPL. BUT, BEA guys logging Panel Operator time as P2 got away with it.

I left.

We do talk about Management buy outs. I loved my Trident 1e- check with the UK CAA present. Checker stated that this was my CONTINUED opportunity to " demonstrate my continued ability to operate as pilot in command of a multi-engined aircraft in controlled airspace ". With the Flight Engineer's foot on my leg, I remonstrated that I would not be able to do that under current BEA SOP procedures because I was NEVER the Pilot in Command in regular practice because of the appalling Monitored Approach SOPS adopted by BEA. I got my way, passed, but my future was severely compromised.

I left.

The dumbing down of the industry with high levels of reliance on automated flight not really understood by those who operate it will lead to more of this.

Click..................click.............................off to the bar thanks !

Unfastened cowlings have nothing to do with reliance on automated flight...

It's good practice to use a level of automation appropriate to the workload, and it's very unfortunate if the situation/snag/defect/occurrence has led to the absence of said automation.. just when you could do with it.

But is it not a concern that the pilots seem to have struggled to manually fly a one engine out approach, which should be a very well trained procedure, to the point of splitting handling/thrust duties, which doesn't seem ideal. And a captain panicking and shutting down the engine without following procedure, there's a very good reason for that procedure and a lot of pointed remarks were made about the ability of the transasia captain who did the same.

I hope a humble approach will be taken in the organisation, there are issues raised all the way through in this report, and the fact they occur at every level from management to maintenance to crew suggests they are not one-offs...

Automation or not... regardless of aircraft manufacturer.. if you can't fly the aeroplane purely manually without automatic assistance and flight directors then you should not be sitting in that seat... you MUST be able to fly the aeroplane yourself .. that's why you are called A PILOT... it ain't rocket science for heaven's sake .... Off thread sorry

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.

Working hours
 

Agree totally with Blind Pew - those working hours by maintenance staff are incredible - any human factors professional would raise one if not two eyebrows.

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?

Fan Cowl Interlocks
 

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?