FFP: The Buck Stops with Me

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Take some time to learn the role that FFP played in an event involving an Airbus 319-131.

Select each of the headings below to learn more about the investigation. You can also view the full accident report.

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On May 24, 2013, a British Airways flight took off from London Heathrow Airport. During takeoff, the fan cowl doors from both engines detached from the aircraft, damaging the airframe and a number of aircraft systems.

 

The plane returned to Heathrow, but not before catching fire due to leaking fuel from a damaged fuel pipe igniting. There were no injuries reported after this event.

Two technicians were scheduled to work on six aircraft, all requiring a Daily Check and two requiring a Weekly Check, during a twelve-hour overnight shift. This aircraft was the second on the list.

 

Neither technician stated that this workload was unusual, excessive, or unachievable.

Without placing warning notices in the cockpit, the technicians opened the fan cowl doors to check the Integrated Drive Generator (IDG) oil levels, which were low in both engines.

To replenish the oil, the technicians needed an IDG oil gun and the oil itself, which they didn't have on-site. Against procedures, they did not create an open entry for the oil uplift in the technical log.

 

They decided to work on other aircraft before retrieving those items, and the latches remained unlocked but with the latch handle hooks engaged so they did not protrude as far below the cowl.

After retrieving the IDG gun and oil, they returned to what they believed was the aircraft in question. This aircraft – which was not the original aircraft in question – showed normal IDG oil levels. Therefore, the technicians determined that no service was necessary.

The technicians then latched the fan cowl doors and checked each other's work, per the company's verification check procedure, and completed the original aircraft's Weekly Check worksheet.

The shift manager reported that he had requested additional manpower to work the night shift and that the planned level of manpower for this shift was insufficient to meet the likely workload.

 

This manpower problem was a long-standing situation that had not been rectified.

The investigation also found that due to the dynamic operational environment at this terminal, it was normal for arrival times and stands for the allocated aircraft to change as the shift progressed.

 

None of the six aircraft for the two technicians arrived at the expected stand.

Though described as an occasional, infrequent occurrence, all five of the maintenance staff interviewed during the investigation had previous experience of aircraft swap errors, characterized as "right stand, wrong aircraft."

 

One of the technicians had recently been involved in an incident like this.

It was difficult or impossible to tell the scope of work the aircraft would need during the shift, and both technicians cited this as a reason for opting to return to this aircraft later in the shift, after gathering supplies.

The only measure of fatigue for the technicians was their working hours.

 

In the seven days prior to the event, one technician worked 70.2 hours (less than two hours shy of the maximum allowed in a week), while the other worked 55.8 hours.

The co-pilot stated that during the pre-flight walkthrough, he leaned over, but did not "get on his hands and knees" to check the position of the fan cowl door latches.

Select the bold text and each graphic for more information, and then Next to continue.