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G-VIIO Las Vegas
The NTSB report into the engine fire at Las Vegas in 2015 has now been released. The reasons for the fire are pretty routine and remedies have already been implemented.
However the report does go on to criticize the actions of the Captain during the evacuation, which doesn't make for good reading either for the Captain or BA's training system. While the airplane was decelerating to a stop, the fire warning bell sounded. When the airplane came to stop, the captain called for the engine fire checklist. The third item on the checklist was to move the fuel control switch on the affected side (in this case, the left side) to the cutoff position, which shuts down the respective engine. The spar valve terminates fuel flow to an engine after it is shut down. Flight data recorder (FDR) data showed that about 28 seconds elapsed between the start of the engine failure and the time of the spar valve closure, and Boeing estimated that about 97 gallons of fuel had spilled onto the runway during this time. FDR data also showed that 22 seconds elapsed between the time that the captain initially called for the engine fire checklist and the time of the spar valve closure. (Thirteen seconds had elapsed between the time that the captain repeated his call for the engine fire checklist and the time of the spar valve closure.) If the left engine had been shut down sooner, there would have been less fuel on the runway to feed the fire. The captain commanded the evacuation (step three in the evacuation checklist) before calling for the evacuation checklist and performing the first two steps in the checklist. Step two of the evacuation checklist instructs the captain to shut down both engines. The left engine was shut down as part of the engine fire checklist, but the right engine continued operating for about 43 seconds after the captain's evacuation command. The unusual attitude of two slides (the 3R and 4R slides) resulted from the jet blast coming from the right engine while it was operating. The captain did not use the QRH to read and do his evacuation checklist items. The right engine was shut down after the relief pilot noticed EICAS indications showing that the engine was still running. Also, the captain's call for the evacuation checklist occurred after the relief pilot stated that the checklist needed to be performed. (The first officer had stated, just before the relief pilot, "we haven't done the engine checklist," but he most likely meant the evacuation checklist.) Because the captain did not follow standard procedures, his call for the evacuation checklist and the shutdown of the right engine were delayed. |
Yes because we are all robots and absolutely perfect in every action we do during a non-normal highwork load events........ |
Fly26 Evacuation is a mandatory check-ride item, reviewed to a pass standard by every ATPL captain at least once a year, more likely 4 times. Calling for EVAC with engine(s) running would be a fail on a licence re-validation day.
Understandably, in a real-life event, there are stressors not available in the SIM for training - such as fear for life - and the performance will be degraded. That is a physiological fact: https://en.wikipedia.org/wiki/Yerkes%E2%80%93Dodson_law At the same time, the training AND checking are in place for the sole reason of preparing us for that real-life event. It's hard to comment beyond what's displayed in the first post already. |
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It would be good to have a camera view of the engines since my strong impression from different cases of "an engine was kept running when the evacuation commenced" is about the mindset beside actions related to the checklist.
Even if a bang is heard and the aircraft yaws slightly and the fire warning goes on - it doesn't mean "catastrophic fire" automatically so it is fully possible to stop with the idea of taxiing clear of the runway after shutting the engine down and use the fire suppression system. The lack of visibility from the flight deck and therefore inability to visually assess the engine condition could lead to the "taxi mindset". A camera showing the engines would tell a different story and the need for immediate evacuation and therefore immediate shutdown of both engines would be evident already during deceleration after the take-off was aborted. It is also worth to mention that ATC didn't notify the pilots of fire on the left side of the aircraft. An appropriate conversation could have been: "Speedbird 2276, stopping." "Roger, Speedbird 2276, there are smoke and flames on your left side, smoke and flames on your left side, fire services are being dispatched." Even after stopping with more serious fire, no radio call about this fact were transmitted to the crew, which could have assisted in their assessment of the situation. I don't think the case is that easy that "blaming the captain" is the right course of action - there were several factors involved including a lack of information about the extent of the fire. It was a bit different in Manchester 1985 since the tower immediately told the captain about the fire when he radioed "28 Mike, we are abandoning take-off... it looks as though we've got a fire on the number one" - ATC: "Right, there's a lot of fire, they are under way now" - this provided immediate cues about the situation and got them to alert the cabin crew during the roll about "evacuate on the starboard side, please" before the aircraft stopped. The whole BA2276 story seems to revolve around a mindset that they had an engine failure, a serious one but nothing that would prevent them from taxi clear of the runway after assessing the situation. All videos of the aircraft when it comes to a stop before the doors open is a pretty good indication that the lack of information also meant that the sense of urgency weren't there. If I hear an engine "go boom" I would like to be able to view it through a camera so I know what it is all about. Especially knowing that immediate evacuation and shutdown will be necessary after stopping (i.e. no "taxi clear of the runway" mindset). |
If a situation had not reached the point of evacuating yet(which it seemd to be during the initial stages of the event), wouldn't one perform the memory items for an engine fire first which would hopefully get the fuel shut off fairly quickly and then call for the appropriate checklist(ie engine fire or evacuation checklist depending on which route one has decided to take). It can take a certain time period for one to get to the proper electronic checklist page or a paper one for that matter. Even when going directly to the Evacuation Checklist(back page of the QRH book and therefore very quickly accessed) takes a certain number of long seconds prior to getting the the point where one shuts down the engines as one is playing with outflow valves first.
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Being able to see the engine would make a couple of important differences, especially when it comes to the assessment of the severity of the situation and the following execution of the engine fire checklist with the associated closure of the spar valve and activation of the suppression system would be more prompt. It would also be evident that evacuation were necessary immediately after stopping.
It seems like the whole "slowness" were caused by a lack of cues about the gravity of the situation, which slowed everything down. |
...the report does go on to criticize the actions of the Captain during the evacuation, which doesn't make for good reading either for the Captain or BA's training system. Anyhow my internet is playing up so the following comments are based on what I remember reading a few months back, plus some of the comments above. Firstly and most importantly how often have we been told in the sim or read accident reports ourselves and thought : “if only they had engaged their brains for a few seconds before moving controls”.... yet here we are in the cold light of day follow a nasty and the investigators and some commentators are running a stopwatch and commenting on timing.... As I recall it the abandon in question happened at fairly high speed. In the time between the fire bell sounding/fire eng EICAS message appearing and the fuel control switch being moved as the third action item of the “Fire Engine ....Checklist” the following had to be done: The emergency had to be recognised and appropriate action recognised. The abandon initiated and completed in an orderly manner, The nature of the malfunction confirmed once stopped, A decision made as to which checklist(s) to action, that command verbalised.....etc etc I suspect you get my drift....quantifying the delay in terms of gallons of avtur spilt is interesting but as we know the process is a bit more involved than: fire bell/slam brakes on/ whack a fuel control switch to cutoff... As has been said the flight crew got no info from ATC as to the seriousness of the fire. As I recall it and as I heard it elsewhere the captain only found out how bad things were when the relief First Officer went back into the cabin, saw the situation and either contacted the flight deck by inter phone or returned to the flight deck to pass the message directly. Can anyone confirm or correct that? As for the evac checklist - it is a “fair cop” that for whatever reason it wasn’t actioned in a text book manner ( I think at the time of this accident it was a recall checklist, with a Boeing version on the yoke as a back up, and the BA version on the back of the paper QRH/in the ECL.) Nevertheless the evac was successful.... The team here will however be pleased to know that the evac checklist BA use on it’s T7s have been completely rewritten as a result of this accident. It now it is very definitely a very prescriptive “read and do” involving both operating pilots..and because of that I suspect any stopwatch watchers still won’t be happy if we get around to forensic analysis of a future evacuation of a BA T7. |
BA engineer
The reasons for the fire are pretty routine and remedies have already been implemented. |
Originally Posted by FlightDetent
(Post 10178477)
Fly26 Evacuation is a mandatory check-ride item, reviewed to a pass standard by every ATPL captain at least once a year, more likely 4 times. Calling for EVAC with engine(s) running would be a fail on a licence re-validation day.
From the NTSB report: The captain commanded the evacuation (step three in the evacuation checklist) before calling for the evacuation checklist and performing the first two steps in the checklist. Step two of the evacuation checklist instructs the captain to shut down both engines. The left engine was shut down as part of the engine fire checklist, but the right engine continued operating for about 43 seconds after the captain's evacuation command. The unusual attitude of two slides (the 3R and 4R slides) resulted from the jet blast coming from the right engine while it was operating. The captain did not use the QRH to read and do his evacuation checklist items. The right engine was shut down after the relief pilot noticed EICAS indications showing that the engine was still running. Also, the captain's call for the evacuation checklist occurred after the relief pilot stated that the checklist needed to be performed. (The first officer had stated, just before the relief pilot, "we haven't done the engine checklist," but he most likely meant the evacuation checklist.) Because the captain did not follow standard procedures, his call for the evacuation checklist and the shutdown of the right engine were delayed. Some outfits took memory items to an extreme I'm told. A friend who upgraded to captain at Air Canada a couple of decades ago claims that he had to memorize all of the emergency checklists for the DC-9 even if the items weren't boldface or boxed for emphasis. I've flown with folks who tried to impress me with their mental abilities by doing normal checklists from memory (and then sometimes messing them up :ugh:). Here's the pertinent BA Evac checklist from the NTSB report: Evacuation Checklist The British Airways B777 FCOM QRH, dated June 2012, stated the following regarding an emergency evacuation: "The Captain will decide if an evacuation is necessary. Whenever an evacuation is required, the Evacuation Checklist must be used. The aircraft will be brought to a halt and the parking brake will be set." The QRH also stated, "all other checklists will be stopped. The Evacuation Checklist is independent of other non-normal checklists." The evacuation checklist procedure, dated June 2013, was provided on the back cover of the QRH. The checklist detailed the responsibilities of each pilot if an evacuation was needed, which were as follows: CAPTAIN 1. PARKING BRAKE. . ... ..Set 2. FUEL CONTROL SWITCHES (both). ......CUTOFF 3. PA . "This is an Emergency. Evacuate, Evacuate (Hazard at ___)" 4. EVAC COMMAND switch . . ON 5. Notify ATC/Ground crew of evacuation. FIRST OFFICER 1. OUTFLOW VALVE switches (both). ... MAN 2. OUTFLOW VALVE MANUAL switches (both) ...Hold in OPEN until the outflow valve indications show fully open to depressurize the airplane 3. Engine fire switches (both) . .. PULL Warning! Do not pull the ENGINE FIRE switches before the FUEL CONTROL switches are in the CUTOFF position. 4. APU fire switch . . Override and Pull 5. If an engine or APU fire warning occurs: Related fire switch . Rotate to the stop And hold for 1 second |
Originally Posted by JammedStab
(Post 10178488)
If a situation had not reached the point of evacuating yet(which it seemd to be during the initial stages of the event), wouldn't one perform the memory items for an engine fire first which would hopefully get the fuel shut off fairly quickly and then call for the appropriate checklist(ie engine fire or evacuation checklist depending on which route one has decided to take).
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Unusually commendable work by the NTSB. Too often, poor flight crew performance is omitted from ‘reports’, and previous BA events have lacked adequate exposition in this regard. |
Originally Posted by lomapaseo
(Post 10178545)
BA engineer
I must have missed that. All my quick scan caught was possible causes, not specific remedies |
Well the remedy for the disk failure was increased inspection criteria for the web area of the disk. I would agree it doesn't 'fix' the basic cracking issue but it allows any defects to be caught before catastrophic failure of the disk. |
Why do checklists always put the WARNING after the item on the list they are warning you about? Surely better to put it first? We have a number like this on our aircraft! |
Fair point, FWIW on actual 777 documentation any Warnings are highlighted much more clearly than in the pure text version pasted above, and I’ll reiterate my earlier comment that the current BA 777 evacuation checklist is structured completely differently from the one pasted above/current at the time of the LAS accident. |
Originally Posted by Father Dick Byrne
(Post 10178682)
Unusually commendable work by the NTSB. Too often, poor flight crew performance is omitted from reports, and previous BA events have lacked adequate exposition in this regard. |
One can't help but suspect that if this had been an Emirati or Chinese crew some of the posters on here would be adopting a slightly more critical stance........
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I noticed on the Checklist it says shutdown the engines with the fuel cutoff switches & only then the firewall cutoff switches. Do not shut down the engine with the firewall shutoff valves. Why is that.
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"Fuel control switch, spar valves, fuel cutoff switch, firewall cutoff switch, firewall shutoff valves..." For those of us on other types trying to follow, could we stick to some sort of standard terminology please.? |
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