The A319 interim report

Now the basic truths are known. The NTSB (see previous entry) had indeed exaggerated the nature of the problem the pilots had to deal with, but the pilots would still have had their hands full bringing their ship back home safely.

The engine – the right one (No 2) that was seen streaming smoke – was indeed the one that the pilots shut down, says the AAIB’s interim report.

The fan cowlings of both engines were not fastened properly, and detached soon after take-off. On the right side an engine fuel line received damage and a leak started. This leak, which appeared to continue after the shutdown, started an external engine fire which did not go out completely when the crew operated the extinguishers.

So the pilots had a working No 1 engine with degraded thrust control, but they were faced with vibration caused by the loss of the cowls, some damage to the high lift devices on both wings (but they were still usable), damage to the undercarriage (one of the main wheel tyres was completely deflated and the yellow hydraulic system had failed), and there was damage to the left horizontal stabiliser, 

The single recommendation in this interim report is that Airbus should formally notify all operators of the loss of the cowls, and the need to check visually that the cowl fasteners are latched before departure. This appears to identify the cause of the accident, although it is not a formal verdict until the final report is published.

No-one has called on Airbus (yet anyway) to consider redesigning the cowls so the fasteners are positioned more visibly to both technicians and pilots on their walkaround. They are right at the bottom of the engine casing, only about 2ft above the tarmac. You have to crouch to see them.

BA says it has already strengthened procedures for engineering technicians and crew pre-flight checks. There were at least two, and possibly more, opportunities for this mistake to have been noticed, but no-one did. The crew who did such a good job bringing the aeroplane safely back to base will be feeling pretty upset that they, the system’s final goalkeepers, let this one past them, even if mitigating circumstances are established during the remainder of the inquiry.

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11 Responses to The A319 interim report

  1. Peter 3 July, 2013 at 10:48 am #

    I must agree that the flight crew should have noticed that, especially since apparently photos were taken at the gate(?). But, how did this get by the ground crew in the first place. It really could have been a disaster. Don’t blame Airbus if no one can follow procedures. And the NTSB? I’m surprised they made a statement based on an erroneous report probably from a layman unfamiliar with the situation. Naturally the British and EU authorities are are bit…dismayed.

  2. Martin 3 July, 2013 at 10:48 am #

    As I understood, Airbus already attempted to mitigate this risk back in 2008/2009.

    Most of the modifications aimed at improving the visibility of unlatched doors.

    On SA family, the set of modifications includes :
    *Fluorescent paint on the cowl latch handles (IAE and CFM)
    *Caution decal on the outboard fan cowl doors (IAE and CFM)
    *Weighted latch and improved anti-swivel plate (to ensure that handles will hang down if unlatched) (IAE / mandated)
    * Hold open devices (IAE / mandated)

  3. Kevin Clark 3 July, 2013 at 10:48 am #

    The A319 interim report.

    If I’ve understood correctly you’re proposing that maintenance and flight crew failures ought to be excused if the items omitted are a bit awkward to see.

    The AAIB’s findings taken together with recent experience from the US indicate that, rather than a design issue, it was the matter of BA failing to carry out effective pre-flight checks that endangered this aircraft. As a known feature on this aircraft type, the failure to ensure the security of the engine cowlings becomes less and not more defensible.

  4. Bob 3 July, 2013 at 10:48 am #

    Although the situation of this event was not as desperate as first thought; was it sheer luck that not both engines were on fire, or that not more damage to the flight controls and hydraulics had occurred? If that is the case, than it seems odd that there is not more redundancy build-in with regards to the locking of the cowls. Simple handles in the wrong position would be able of bringing down a plane..

  5. Scott 3 July, 2013 at 10:48 am #

    So reading this, how likely do you think single-pilot airliners are? One fairly gifted pilot could have wrestled this wreckage to a runway and safe landing, but it would have been difficult. And gifted people don’t generally spend a decade and a fortune training to work for minimum wage.

  6. David Learmount 3 July, 2013 at 10:48 am #

    I think it’s only a matter of time. I think access to a remote copilot/relief pilot will secure it. But what I don’t know is how many years this will take. More than ten, I guess.

  7. David Learmount 3 July, 2013 at 10:48 am #

    No, it’s not an excuse, it’s a reason. The position of the latch is a design flaw in human factors terms, and airlines have to learn to live with it until it is corrected, or until it’s fitted with a cockpit warning. And if it never is, they have to learn to live with it forever.

  8. MikeSierra 3 July, 2013 at 10:48 am #

    And again we go to the old notion that systems safety is based on procedures to be followed and recommendations usually are limited to “try harder!”. There is a physical ergonomic design flaw that must be corrected (ergonomics and human factors are synonims). An error is not a cause. It’s a clue.

  9. Stuart Buchanan 3 July, 2013 at 10:49 am #

    I happened to glance over the AAIB Annual Safety Report for 2012.

    First item in the report is the closure of a safety recommendation dating from 2000 (and a similar incident at Gatwick) :

    “It is recommended that the DGAC mandate aircraft modification aimed at appreciably
    reducing the likelihood of A320 fan cowl doors inadvertently remaining unlatched after
    maintenance. It is considered that, while measures to exhot maintenance personnel to
    ensure that doors are latched and to improve the conspicuity of unfastened latches may
    assist, they are unlikely to be fully effectiv
    e and modification aimed at providing obvious
    indication of unlatched doors is required. ”

    Interestingly a subsequent modification _was_ made by IAE.


  10. David Learmount 3 July, 2013 at 10:49 am #

    Well spotted that man!

  11. Akliget 3 July, 2013 at 10:49 am #

    Thanks God,That was quite a near miss.
    Sorry for the person who signed the CRS.
    Good job by the crew!

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