JulianUK
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747-400 LAX-LHR 3 Engine Flight Report Now Out.

Fri Jun 09, 2006 3:30 am

http://www.aaib.gov.uk/cms_resources...ng%20747-436,%20G-BNLG%2006-06.pdf

the report is finally out from the UK's AAIB.

It raises many interesting questions - the whether it should continue one has been done to death so I won't dwell on that.

The interesting question is fuel management. There seems to be a lot of talk about how fuel should be managed differently when on 3 compared to 4 engines. Is fuel management on 4 engined or even 2 engined aircraft with an engine failure now routinely taught and if so what is the actual difference?

J
 
9V-SPJ
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 6:12 am

That is a very interesting report. Did BA change their engine out diversion policies after the report?

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IFEMaster
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 6:29 am

Interesting that they uncovered the FDR problem during the investigation as well. When this aircraft suffered the same failure just a couple of months later, was it the same engine that failed?
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motopolitico
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out

Sat Jun 10, 2006 7:07 am

Some thoughts on the investigation:
-F/O was unable to ascertain the extent of damage to the engine in question due to night-time.

Why did they continue if they couldn't tell whether the wing was damaged? If they were concerned enough to look out the window, why weren't they concerned enough to have mx look it over ASAP?

-CVR data was unavailable. Can it be that part of the reason for pressing on across the atlantic was in order that potentially embarassing or incriminating CVR data would be destroyed when the endless tape re-cycled itself? Was the transatlantic crossing in part a coverup?

-How many times did the PIC have to use the 'pan' designation? I count at least twice. That is once too many, he should have landed his plane.
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IFEMaster
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 7:15 am

Quoting Motopolitico (Reply 3):
CVR data was unavailable. Can it be that part of the reason for pressing on across the atlantic was in order that potentially embarassing or incriminating CVR data would be destroyed when the endless tape re-cycled itself? Was the transatlantic crossing in part a coverup?

Irrelevant. The document states that fuel dumping time would have been 40 minutes, so the tape would have recycled in that time anyway. And what on earth would they be covering up?

Quoting Motopolitico (Reply 3):
How many times did the PIC have to use the 'pan' designation? I count at least twice. That is once too many, he should have landed his plane.

Given that you weren't in the cockpit and, I'm guessing, not a BA 747 pilot, I'd love to know on what basis you know what the crew "should" have done. After reading this document, I think the crew made the correct decision based on the information available to them at the time of the occurence, and don't forget that they were still within the operating limits of the aircraft and the operating policies of British Airways and the operating rules of the FAA and the operating regulations of the CAA.
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David L
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 7:40 am

Quoting Motopolitico (Reply 3):
CVR data was unavailable. Can it be that part of the reason for pressing on across the atlantic was in order that potentially embarassing or incriminating CVR data would be destroyed when the endless tape re-cycled itself? Was the transatlantic crossing in part a coverup?



Quoting IFEMaster (Reply 4):
And what on earth would they be covering up?

I agree. Cover up the fact that they continued on 3 engines? Worst cover up ever.

Quoting IFEMaster (Reply 4):
and don't forget that they were still within the operating limits of the aircraft and the operating policies of British Airways and the operating rules of the FAA and the operating regulations of the CAA.

Yup. From the report...

"2. An additional engine failure was considered
and, with regard to the aircraft performance, it
was deemed safe to continue
.

6. The company policy was to continue to
destination as long as the aircraft was in a safe
condition
.

7. The manufacturer’s QRH procedure for
ENGINE LIMIT/SURGE/STALL did not
require
the crew to consider landing at the
nearest suitable airfield."
 
motopolitico
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 12:51 pm

I am not a BA basher. I fly BA transatlantic whenever I get the chance. I am still a bit bothered by their handling of this situation.

Quoting David L (Reply 5):
6. The company policy was to continue to
destination as long as the aircraft was in a safe
condition.

My main point is that the condition of the aircraft was very much in doubt, sufficiently in doubt that the F/O was sent outside the cockpit to look out a pax cabin window for damage to the aircraft. He was unable to discern one way or another, so they should have had mx look it over ASAP.

Quoting IFEMaster (Reply 4):
don't forget that they were still within... the operating rules of the FAA

Really? The FAA doesn't seem to think so for some reason...

This was clearly an event that had the potential to cascade into a massive accident, and as it turns out nearly did. In almost every airline disaster, there is an unbroken chain of often unrelated events that, if one of them had been somehow avoided, it would have averted disaster. If the PIC had diverted to the nearest suitable airport, he never would have had to make a "MAYDAY" call and an emergency diversion to MAN.

Furthermore, the idea that dispatch wanted them to continue to their destination gives me no comfort at all. The CVR transcript from AS 261 demonstrates that AS dispatch was reluctant to let them land at LAX after they had already "floated" a cabin crew in an uncontrollable dive. Dispatchers are about saving money first, lives second.

I know BA are highly profitable as an airline, and they remain my and "the world's" favourite, but their profitability should not come at the cost of passenger safety. As a pax, I would not begrudge a day or two of delay because the aircraft I was aboard had lost an engine; I can't think of anybody who would.
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Max Q
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 1:12 pm

Outside the United states this particular incident would not have even raised an eyebrow.

This aircraft had more redundancy and performance capabilIty remaining available to it than any of our modern twins BEFORE THEY LEAVE THE GATE!

The FAA (just for a change) is responsible for raising hysteria about a non event.

For christ's sake THEY CERTIFIED IT TO CONTINUE ON THREE!
The best contribution to safety is a competent Pilot.
 
IFEMaster
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out

Sat Jun 10, 2006 1:25 pm

Quoting Motopolitico (Reply 6):
This was clearly an event that had the potential to cascade into a massive accident, and as it turns out nearly did.

Talk about an exaggerated, reactionary, sensationalist statement!! It was an engine out, the plane was flying safely, and it landed safely. How is that nearly an accident?

Quoting Motopolitico (Reply 6):
Dispatchers are about saving money first, lives second.

What an inflammatory, assuming remark. And downright wrong as well. Absolutely ridiculous thing to say.

EDIT: Typo

[Edited 2006-06-10 06:28:42]
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motopolitico
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 1:49 pm

The CVR Transcript from AS 261 tells me all I need to know about dispatchers. Read it, and you will see a subtle threat of sanction against the PIC who dared divert his doomed aircraft.
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PhilSquares
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 2:17 pm

Quoting Motopolitico (Reply 6):
My main point is that the condition of the aircraft was very much in doubt, sufficiently in doubt that the F/O was sent outside the cockpit to look out a pax cabin window for damage to the aircraft. He was unable to discern one way or another, so they should have had mx look it over ASAP.

Please, after an engine stall/surge, with a successful relight, there really isn't a huge probability of visible damage. (Page 18 & 19)

Quoting Motopolitico (Reply 6):
Really? The FAA doesn't seem to think so for some reason...

Then why do the FARs not dictate that a 3 or 4 engine aircraft land at the nearest suitable airport in terms of time like it does for a two engine aircraft?

Quoting Motopolitico (Reply 6):
his was clearly an event that had the potential to cascade into a massive accident, and as it turns out nearly did. In almost every airline disaster, there is an unbroken chain of often unrelated events that, if one of them had been somehow avoided, it would have averted disaster. If the PIC had diverted to the nearest suitable airport, he never would have had to make a "MAYDAY" call and an emergency diversion to MAN.

And just what kind of "massive accident" could this situation have cascaded into? Let's see, the crew elects to return to LAX, lands overweight and experiences braking problems and depart the runway. That doesn't sound like a smart move....You reference averting disaster, where was the aircraft even close to that? The diversion to MAN was completely unreleated to the engine shutdown. Most likely if the aircraft had all engines running and had flown the same route and altitude the same result would have occured.

Please skip the uninformed opinions out of this forum.

Quoting Motopolitico (Reply 6):
I know BA are highly profitable as an airline, and they remain my and "the world's" favourite, but their profitability should not come at the cost of passenger safety.


Perhaps you can show us on this forum where profit was a motive and ever mentioned in the AAIB report?

One final note, I'd be careful about reading stuff into the AS291 CVR. No one was there, they can only offer their opinion as to what they think was going on.

[Edited 2006-06-10 07:20:28]
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motopolitico
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 9:17 pm

Quoting PhilSquares (Reply 10):
Perhaps you can show us on this forum where profit was a motive and ever mentioned in the AAIB report?

I think we all know that profit was never mentioned in the AAIB report. I never said that was the case, it was a matter of speculation on my part. I think it is clearly seen that BA would realize a substantial cost and convenience savings by having BA mx check the plane at a BA facility. I think the cost and hassle of stranded pax, and having to use non-BA mx at a non-BA facility were factors in the decision making. I don't believe they should have been balanced against passenger safety.

To make my point from a new direction, I believe that had the same 744 departed LHR bound for LAX and lost an engine in similar circumstances, said aircraft would never have completed its intended flight, it would have returned home. The motivation would still have been the same evasion of the additional cost/ inconvenience of having an aircraft grounded at a fairly remote location, but they would have been hailed for putting safety first. It's a counterfactual argument, I know, but I can't see that a single one of you criticising me on this forum would have criticised BA had they taken the more conservative course of action. Had I been on the plane, I for one would have wanted to get on the ground.

Quoting IFEMaster (Reply 8):
Quoting Motopolitico (Reply 6):
This was clearly an event that had the potential to cascade into a massive accident, and as it turns out nearly did.

Talk about an exaggerated, reactionary, sensationalist statement!! It was an engine out, the plane was flying safely, and it landed safely. How is that nearly an accident?

For the disaster at Tenerife, if just one of the many factors contributing to the crash had been different, be it the PA 747 having been where it was supposed to be, the KL captain waiting until takeoff clearance, the use of nonstandard phrases on the radio, or the plain unlucky timing of the simultaneous radio transmissions, the disaster would never have happened.

For Air Florida flt 90, if just one of the contributing factors had been eliminated, whether a proper de-icing of the aircraft, or turning on the aircraft anti-ice switch, or simply cancelling the flight for deplorable weather, those people would all have lived to tell the tale.

Each and every airline crash is precipitated by a chain of events, each necessary but not sufficient to cause it. It is an undeniable fact that had the BA flight merely dumped fuel and returned to LAX, it never would have run into fuel management issues and made a mayday landing at MAN. Furthermore, had they had all four engines, the flight would have been able to cruise at FL 350 across the congested North Atlantic, conserving fuel. I cannot and do not agree that the two events were wholly unrelated.
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David L
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 9:21 pm

Cheers PhilSquares!

Quoting Motopolitico (Reply 6):
This was clearly an event that had the potential to cascade into a massive accident, and as it turns out nearly did.

I assume you mean they might have lost another engine. As stated above, the 747 is certified to fly on three engines so it was "one engine away" from having to divert. The 777 is certified to fly on two. That means that on every flight the 777 is "one engine away" from having to divert. Does every 777 flight divert and land immediately after take-off?
 
PhilSquares
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 10:06 pm

Quoting Motopolitico (Reply 6):
I know BA are highly profitable as an airline, and they remain my and "the world's" favourite, but their profitability should not come at the cost of passenger safety

think we all know that profit was never mentioned in the AAIB report. I never said that was the case, it was a matter of speculation on my part.

That was my point your speculation is completely unfounded. Your second guessing, in my opinion is completely wrong. Re-read the AAIB report. You will see why the crew took the option they did. Departing from LAX they still had plenty of divert options before they coasted out. Had the same problem accrued out of LHR, the options of divert airports 4 hours after takeoff would have been completely different.

I am not naive to the point of believing costs had nothing to do with the decision. It should! The times I have had to divert you need to consider the whole equation and all the options. This situation was not a "get the aircraft on the ground now". There was plenty of time to analyze the situation and make an informed decision. What you're advocating is an uninformed decision.

From a safety perspective, please show me in the AAIB report where it criticized the crews decision. You won't find it. You are taking the position you know better than not only the BA crew but the AAIB.

Not knowing your background or profession, I doubt you have the experience or technical expertise to even offer an opinion.
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David L
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sat Jun 10, 2006 10:46 pm

Quoting Motopolitico (Reply 11):
I think the cost and hassle of stranded pax, and having to use non-BA mx at a non-BA facility were factors in the decision making.

Of course.

Quoting Motopolitico (Reply 11):
I don't believe they should have been balanced against passenger safety.

What "passenger safety"? Flying an aircraft in a certified condition?

Quoting Motopolitico (Reply 11):
I can't see that a single one of you criticising me on this forum would have criticised BA had they taken the more conservative course of action.

Of course not. There's nothing inherently wrong with either option.

Quoting Motopolitico (Reply 11):
It is an undeniable fact that had the BA flight merely dumped fuel and returned to LAX, it never would have run into fuel management issues and made a mayday landing at MAN.

Excerpts from the report seem to disagree with you:

"The ‘Eng Out’ fuel prediction indicated a landing at final destination with approximately 7 tonnes, compared to the required minimum reserve of 4.5 tonnes.

"As G-BNLG approached Ireland, the total fuel indicated was about 12 tonnes, which was evenly balanced between the four main fuel tanks. By now, the aircraft was at FL350 and, due to a stronger than forecast headwind, the FMC now predicted a landing fuel at London of 6.5 tonnes. The crew discussed the situation and decided to divert to Manchester; they advised ATC accordingly. Reprogramming the FMC resulted in a predicted landing fuel at Manchester of approximately 7 tonnes".

"With the possibility that this fuel might be unusable, which would result in the aircraft landing with less than the final reserve fuel, the commander declared a ‘PAN’ call to ATC."

"The commander, concerned that the useable fuel at landing would be below the minimum reserve fuel of 4.5 tonnes, declared a ‘MAYDAY’ to ATC, in accordance with the operator’s procedures"

"Data from the flight data recorder (FDR) indicated that the fuel on landing was approximately 5.8 tonnes".

"Safety Recommendation 2006-019
It is recommended that British Airways include relevant instruction on 3 engined fuel handling during initial and recurrent training.

Response to safety recommendation 2006-019
British Airways has accepted this recommendation and has taken the following action:

The revised fuel management procedures have been incorporated into the relevant manuals and training courses. All Boeing 747-400 flight crew have received additional engine-out fuel management training as part of their regular simulator training. Three-engine fuel management, including low fuel quantity procedures, have been added to the recurrent training cycle."


The three-engine fuel management procedures have been revised. Why no revision of the policy to continue on three engines if the aircraft is safe?

Quoting Motopolitico (Reply 11):
Had I been on the plane, I for one would have wanted to get on the ground.

If every flight landed prematurely because there was a passenger on board who wanted to "get on the ground" we'd never get anywhere. You're effectively saying you know better than a professional flight crew and those professionals who've commented.
 
PolymerPlane
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 12:02 am

Quoting PhilSquares (Reply 10):
The diversion to MAN was completely unreleated to the engine shutdown. Most likely if the aircraft had all engines running and had flown the same route and altitude the same result would have occured.

I know you fly 744 and know a lot about the plane and on board procedure. Just curious, how true is this that the insuficient fuel is totally unrelated to IFSD. The reason they divert is not because of the in ability to balance fuel, but because insuficient fuel due to wind and availability of flight level.

From the first paragraph:

Quote:
The winds and available flight levels were subsequently less favourable
than anticipated and, nearing the UK, the crew decided to divert to Manchester in order to maintain the required arrival fuel reserve.

And later in the text:

Quote:
For the crossing, the crew had requested FL320 but ATC could only clear the aircraft at FL350 or FL290 due to opposite direction traffic. Aircraft performance precluded FL350 and, when FL290 was entered into the FMC the
landing fuel at London Heathrow was indicated to be between 7 and 7.5 tonnes. The crew had agreed to plan on a minimum landing fuel of 6.5 tonnes at Heathrow.

I am not an expert, so all I am trying to do is asking questions and offers no opinion on the safety of the flight. I think pilots know better than me. Heck I do not even understand how to plan my fuel on my flight simulator  Silly

Had the 4 engine running, Is that particular aircraft capable on reaching FL350 in that situation? Is there going to be more available fuel if they were to cruise at FL350 or higher? if there is how much is it going to make a difference?
How accurate is FMC in determining landing fuel? Do you usually take the FMC landing fuel and put extra padding to it or just use it?

One more thing, there has been a reported further damage to the engine due to extended windmilling. If it were to happen in this flight, how is it going to affect the overall safety of the flight?

Cheers,
PP
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airxliban
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 1:06 am

The findings of this report, in my mind, serve to confirm what I have known all along about the caliber of British Airways crew training and the corresponding culture of safety.
PARIS, FRANCE...THE BEIRUT OF EUROPE.
 
IFEMaster
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 1:15 am

Quoting Motopolitico (Reply 11):
For the disaster at Tenerife,



Quoting Motopolitico (Reply 11):
For Air Florida flt 90,

Good grief. I can't believe you brought those up. They don't serve as any form of illustration in this scenario whatsoever.

Quoting Motopolitico (Reply 11):
Each and every airline crash is precipitated by a chain of events, each necessary but not sufficient to cause it

For crying out loud. In that case, the Captain shouldn't have gotten out of bed that day, because his decision was in the chain of events. In fact, he should never become a pilot, because then he wouldn't have ever been in a cockpit.

I'm still waiting to hear how it is that you know what the crew "should" have done? What do you know that the crew didn't at the time of occurence?
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David L
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 1:33 am

Quoting IFEMaster (Reply 17):
Quoting Motopolitico (Reply 11):
Each and every airline crash is precipitated by a chain of events, each necessary but not sufficient to cause it

For crying out loud. In that case, the Captain shouldn't have gotten out of bed that day, because his decision was in the chain of events. In fact, he should never become a pilot, because then he wouldn't have ever been in a cockpit.

I was going to address that, too, but I thought my post was long enough.

Quoting Motopolitico (Reply 11):
For the disaster at Tenerife, if just one of the many factors contributing to the crash had been different, be it ... the use of nonstandard phrases on the radio...

So, on hearing a non-standard phrase on the radio a pilot should land immediately because it could be one of the many factors contributing to an accident?
 
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Aaron747
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 1:50 am

For crying out loud. In that case, the Captain shouldn't have gotten out of bed that day, because his decision was in the chain of events. In fact, he should never become a pilot, because then he wouldn't have ever been in a cockpit.

I deflated a lung on that one...welcome to my RR!
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PhilSquares
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 2:37 am

Quoting PolymerPlane (Reply 15):
I know you fly 744 and know a lot about the plane and on board procedure. Just curious, how true is this that the insuficient fuel is totally unrelated to IFSD. The reason they divert is not because of the in ability to balance fuel, but because insuficient fuel due to wind and availability of flight level.

Yes, the two events are unrelated. Even if the engine problem hadn't occur and the flight couldn't get the planned flight levels and the wind forecast was wrong, it still would have been in the same situation. The crew decided to divert to MAN when the FMS fuel prediciton had the fuel at 6.5 at LHR. After re-programming the FMS to MAN the FOA was 7 tons. During the descent they became concerned about the fuel quantity in #2 tank didn't appear to be feeding. In reality that was because of the design of the tanks and the body angle. The Fuel Low EICAS Warning came on and the fuel system is automatically reconfigured so that all pumps are on and all cross-feeds are open. All fuel will go to all engines. However they were now concerned about total usable fuel they had.

Normally flights from the US to EU have a tail wind. Tailwinds were forecast for that flight, but they didn't get them. There is no way you can prepare for that other than adding 10 tons of fuel on every flight. I can assure you that's the fastest way to have a real close meeting with the chief pilot.

Quoting PolymerPlane (Reply 15):
Had the 4 engine running, Is that particular aircraft capable on reaching FL350 in that situation? Is there going to be more available fuel if they were to cruise at FL350 or higher? if there is how much is it going to make a difference?
How accurate is FMC in determining landing fuel? Do you usually take the FMC landing fuel and put extra padding to it or just use it?

A 4 engine aircraft could have been capable of 350 assuming it's weight was in the area it should be. As it was the BA flight could have made 320, but was restricted due to traffic. That happens all the time in the NATS. My last trip from LAX-BRU we were planned to cross at 35/37/39. We spent the whole time at 350.

Please remember that most airlines have flight planning computers that will determine the optimum flight plan for that specific day. Then you have one way jet routes so it's not quite as easy. But, once the data is given to the FMS, the FMS does a good job of fuel prediction. If the winds are all bad, the FMS will over time use less and less of the winds and more and more of the spot winds.

Sometimes you're not in a position to put on extra weight. You could be at MTOW for Departure or MLW for arrival. So, now we off load people or payload. Or your climb performance might preclude any additional fuel. Finally if you put 5 tonnes of fuel on for that flight, you in reality only have 5 when you arrive.

Hope that helps.
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bri2k1
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 3:38 am

Quoting Motopolitico (Reply 11):
Each and every airline crash is precipitated by a chain of events, each necessary but not sufficient to cause it.

There was no crash.

Quoting IFEMaster (Reply 17):

For crying out loud. In that case, the Captain shouldn't have gotten out of bed that day, because his decision was in the chain of events. In fact, he should never become a pilot, because then he wouldn't have ever been in a cockpit.

What Motopolitico says is true, but it's taken out of context. Every event doesn't contribute to a crash. It's a series of incorrect or out-of-order steps. That's the reason for checklists, callouts, configuration alarms, and the like. In this case, one alert was raised - the EIACS low fuel alert. The crew responded appropriately.

Do you work for the news media, Motopolitico? Your posts are ripe with the juimping to conclusions and ignorant finger-pointing found in most mainstream aviation-related news items. Another example of why only properly trained and certified persons are permitted to actually operate the controls.
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Pihero
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RE: 747-400 LAX-LHR 3 Engine Flight Report Now Out.

Sun Jun 11, 2006 7:33 am

What does the report say ?
1/-the crew acted in accordance with BA policy and SOPs.
2,-The aircraft hadn't lost any system
3/-The performance penalties had been taken into account : the cruise alt capability and the subsequent loss of a second engine.
4/-These procedures had been agreed upon by the CAA and were in accordance with FAR part 121-565
5/-The diversion to Manchester and the subsequent management of the flight were also in accordance with company SOPs, although the report found the BA manual to be lacking in the one-engine-out-fuel-management characteristics of the 744
6/-The FAA should get their act to-gether and liaise with other "relevant agencies".
7/-The main subject of the report becomes an issue with that particular FDR.
(For the conspiracy theorists, the aircraft QAR had recorded everything and is, in many ways more complete than an FDR.It is just not as crash-resistant).

Now, this very same FAA is now pushing for an ETOPS 330 certification (which will remove ALL twin engined aircraft route limitations). So, if I'm not mistaken, it will be quite alright for a 787/777/330/350...etc... to lose one engine and proceed, with the remaining one for five and a half hours over the Pacific while a quad losing 1/4 of its power would be "unairworthy" ? I have this sinking feeling that the OPS division of the FAA is not talking to their SYS people. Or am I missing something ?
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