AI Operated 787 With Only 4 Of 47 Screws Installed

KarelXWB · Wed Nov 18, 2015 12:59 pm

Remember this?

Air India B787 Fuselage Panel Falls Off Mid Air (by ojas Oct 14 2013 in Civil Aviation)

The cause of this incident has now been determined:

Quote:
On October 12, 2013 an Air India Boeing 787-8 had its right hand side (RHS) heat exchanger access panel 196KR detach from the aircraft as it was landing at Kempegowda International Airport.

“the cause of the incident was due to human error and not adopting Standard Operating Procedures (SOP)”

“The Panel 196KR was only on four screws instead of 47 screws thereby the entire load was being taken by these four screws. As these four screws were not fully tightened, the air load caused fluttering of the panel further leading to fatigue crack around the four screw holes. Finally at touchdown in Bangalore the panel liberated from the aircraft, with three screws remaining on the aircraft”

Source
http://www.bangaloreaviation.com/201...only-4-of-47-screws-installed.html

AWACSooner · Wed Nov 18, 2015 1:04 pm

It's all Boeing's fault...give AI another $1 trillion in compensation.

moo · Wed Nov 18, 2015 1:23 pm

I like the fact that even while only four of the 47 screws were in place, even those four were a bodge job because they weren't tightened enough

Revelation · Wed Nov 18, 2015 1:38 pm

Quoting moo (Reply 2):
only four of the 47 screws were in place

I presume the 43 "spares" were in use keeping other AI aircraft in service?

S75752 · Wed Nov 18, 2015 1:57 pm

This is so absurd, I can hardly believe what I'm reading.

trex8 · Wed Nov 18, 2015 2:03 pm

Maybe they bought the story about "no fasteners" on 787s too literally.

IADCA · Wed Nov 18, 2015 2:38 pm

Quoting S75752 (Reply 5):

This is so absurd, I can hardly believe what I'm reading.

AI is now on the (very) short list of airlines for which I'd be delighted to arrive at the gate to see a plane covered in speed tape. At least there would be SOMETHING holding it together!

TheRedBaron · Wed Nov 18, 2015 2:41 pm

I bet there is no Home Mart in Kempegowda...

I find it hard to believe but this being AI, anything is possible.

TRB

aviationaware · Wed Nov 18, 2015 2:46 pm

Quoting Revelation (Reply 3):
I presume the 43 "spares" were in use keeping other AI aircraft in service?

Haha, the frightening thing is that you are probably right :P

goboeing · Wed Nov 18, 2015 2:51 pm

Quoting KarelXWB (Thread starter):
Finally at touchdown in Bangalore the panel liberated from the aircraft, with three screws remaining on the aircraft”

Liberated from the aircraft...ha.

I might have to start using that phrase.

yowza · Wed Nov 18, 2015 3:02 pm

Surely it's time that foreign regulatory bodies started keeping a closer eye on AI. It really does make the mind wonder what else is not being done properly...

YOWza

roseflyer · Wed Nov 18, 2015 3:10 pm

Quoting S75752 (Reply 4):
This is so absurd, I can hardly believe what I'm reading.

I can see this happening. The fasteners on some of the large composite panels do take a long time to remove. Once you remove the panels, they are fragile and quite large. You can't just put them on the ground so sometimes they are left with just a few fasteners holding it in place. I can picture mechanics removing almost all the fasteners and then expecting the next shift to finish the job and doing whatever work was required with the panel removed. Since the first shift didn't remove the panel, they probably didn't do the removal paper work since they expected the second shift to do it. However if the second shift changed the plan and didn't need the panel removed, they may never have checked to see if the screws were removed since there was no paper work.Good communication is important. Eventually things turn in to the blame game.

A good walk around would catch that. A good mechanic would go check to see if all the latches were closed and fasteners secured in any areas where work was done. I've seen pilots catch panels open on walk around as they do their inspections before flight. Unfortunately in bad weather or at night, it is much harder to see if the panel is secure or not.

Rdh3e · Wed Nov 18, 2015 3:37 pm

Quoting goboeing (Reply 9):
Liberated from the aircraft...ha.

Personal favorite is when one of Elon Musk's Space X rockets blew up he called it a "Rapid unplanned disassembly."

KarelXWB · Wed Nov 18, 2015 3:41 pm

Quoting goboeing (Reply 9):
Liberated from the aircraft...ha.

Quoting RDH3E (Reply 12):
Personal favorite is when one of Elon Musk's Space X rockets blew up he called it a "Rapid unplanned disassembly."

How about this one: "a slat departed the aircraft's right hand wing".

Turbulence Rips Off Delta B767 Slat (by KarelXWB Jan 21 2014 in Civil Aviation)

2175301 · Wed Nov 18, 2015 4:03 pm

Quoting Revelation (Reply 3):

I presume the 43 "spares" were in use keeping other AI aircraft in service?

I suspect that AI will claim that this was Boeing's fault for designing an airplane that would allow fasteners to be missing; and that they are due compensation for this defect.

Have a great day,

smokeybandit · Wed Nov 18, 2015 4:30 pm

Well, if the screws were missing, you can't even say that AI's management has a few screws loose.

T prop · Wed Nov 18, 2015 5:11 pm

Quoting roseflyer (Reply 11):
Since the first shift didn't remove the panel, they probably didn't do the removal paper work since they expected the second shift to do it. However if the second shift changed the plan and didn't need the panel removed, they may never have checked to see if the screws were removed since there was no paper work.Good communication is important.

...And this is why, in the US anyway, it is required to have a shift turnover log and work interuption reports when jobs are in progress at shift change. This came about because of the Brasillia that lost a leading edge off the horizontal stabilizer and crashed.

audian · Wed Nov 18, 2015 5:20 pm

I think AI should take this matter seriously and take strict actions against who ever is responsible for this mistake.

bennett123 · Wed Nov 18, 2015 5:46 pm

Quite scary that this was allowed to flym

B52overSMF · Wed Nov 18, 2015 5:47 pm

Quoting 2175301 (Reply 14):
"a slat departed the aircraft's right hand wing".

Departed. That conjures up thoughts of a slat purchasing a ticket on Orbitz after determining the proper destination airport code (Ground Municipal - KGND), taking a shuttle to the airport, wading through security (of course after taking off it's fairings), boarding, turning off it's hydraulic devices...

Revelation · Wed Nov 18, 2015 5:56 pm

Quoting smokeybandit (Reply 15):
Well, if the screws were missing, you can't even say that AI's management has a few screws loose.

Yet the article reads:

Quoting KarelXWB (Thread starter):
The Panel 196KR was only on four screws instead of 47 screws thereby the entire load was being taken by these four screws. As these four screws were not fully tightened, the air load caused fluttering of the panel further leading to fatigue crack around the four screw holes.

So we can say that the few screws that AI had were loose screws!

Toni_ · Wed Nov 18, 2015 6:04 pm

"Post the “repairs”, Air India operated VT-ANK on six flights with only the four of 47 screws fitted. Two of these flights included the longest non-stop Dreamliner flights Air India operates, New Delhi to Sydney and from Melbourne to New Delhi."

"Wow", is all I can think of. Top quality screws!

Quoting roseflyer (Reply 11):
I can picture mechanics removing almost all the fasteners and then expecting the next shift to finish the job and doing whatever work was required with the panel removed. Since the first shift didn't remove the panel, they probably didn't do the removal paper work since they expected the second shift to do it. However if the second shift changed the plan and didn't need the panel removed, they may never have checked to see if the screws were removed since there was no paper work.Good communication is important. Eventually things turn in to the blame game.

You weren't far off according the Bangalore Aviation website:
"As per the report, the first shift engineering team removed all but four screws of the panel, but not the panel itself. The second shift engineers claim the first shift did not hand over the screws to them, nor did they make any notes in the records. The first shift denies this of-course. If the second shift engineers were unaware of developments in the first shift, they have obviously not done anything about the 196KR panel. The aircraft was released to service on October 10, 2013 with only four of the 47 screws fitted. On subsequent flights the panel fluttered in the high winds as the jet travelled at speed. Cracks developed near the screw holes in the panel, and finally, as the aircraft was landing at Bangalore, two days later, the panel detached from the aircraft."

This is maintenance 101, really. Stunning how they messed this up. The action should be logged. The following shift should be acknowledged about the action taken. And since this is aviation and you always want to be better safe than sorry, they could've taped a maintenance tag or tape on the panel to alert others that it still needed attention. And I refer to "they", because I've done a good amount of these panels myself during my short carreer in MX (in my case on 747s), and those panels are a 2 men job. If I may use the nice photo that user "horstroad" posted on the initial thread 2 years ago to show the size of it:

And one thing that caught my attention in the Bangalore Aviation article:
"You might ask, why did the pilot and engineers not notice the lack of screws of the 196KR panel during their inspection performed before each of the flights? The General Visual inspection (GVI) that is performed during the “walk around” looks for obvious damage, obstructions, missing parts etc. on the visible exterior areas of an airplane. The 196KR panel is on the underside of the mid belly. To inspect it one must bend down, and there was no obvious indication that anyone would feel the need to do that."

I don't want to slag the article off, but do they have basketball players employed at AI or what? This doesn't seem right to me. I can easily stand up straight under a 747. I never been close to a 787 yet but I'm willing to bet I can do the same.

citationjet · Wed Nov 18, 2015 6:19 pm

Quoting moo (Reply 2):
only four of the 47 screws were in place

Quoting Revelation (Reply 3):
I presume the 43 "spares" were in use keeping other AI aircraft in service?

Easy solution; AI needs to order another 787 so they have some spare screws for this plane.

ODwyerPW · Wed Nov 18, 2015 6:32 pm

Quoting Revelation (Reply 3):
presume the 43 "spares" were in use keeping other AI aircraft in service?

Best comment on Anet today! Thanks for the moment of levity.

SonomaFlyer · Wed Nov 18, 2015 6:40 pm

So at what point do the agencies such as the CAA and FAA say to AI they can't fly into our airports or airspace unless...

As appalling as this is, it wouldn't be as big a deal if this isn't one of many gaffs by AI in the maintenance and repair of its fleet. Whats next, losing an engine because they didn't bother to tighten the strut holding the engine on the wing?

LAX772LR · Wed Nov 18, 2015 6:44 pm

Quoting SonomaFlyer (Reply 24):
So at what point do the agencies such as the CAA and FAA say to AI they can't fly into our airports or airspace

...when there's dead bodies. As always.

jacobin777 · Wed Nov 18, 2015 6:48 pm

Quoting audian (Reply 17):

I think AI should take this matter seriously and take strict actions against who ever is responsible for this mistake.

Revelation · Wed Nov 18, 2015 6:54 pm

Quoting CitationJet (Reply 22):
Easy solution; AI needs to order another 787 so they have some spare screws for this plane.

sunrisevalley · Wed Nov 18, 2015 7:08 pm

Quoting SonomaFlyer (Reply 24):
So at what point do the agencies such as the CAA and FAA say to AI they can't fly into our airports or airspace unless...

The Australian regulator, CASA has been alleged to have "blackballed " carriers for this sort of thing and called the country regulator to task , presumably through ICAO for inadequate supervision of the carrier .

76794p · Wed Nov 18, 2015 7:30 pm

Quoting Revelation (Reply 27):

Are there any 'terrible teens" left in Everret? I could see them picking one up for cheap and then delivering it and just using it for spares. It's probably the fastest way to depreciate an asset, but hey, I'm glad I am not in their accounting department.

AirbusBoeing · Wed Nov 18, 2015 9:41 pm

I remember when a panel form Continental Airlines fell off and caused the Concorde crash. A panel falling off surely is a sign of poor maintenance.

DarkSnowyNight · Wed Nov 18, 2015 10:00 pm

Quoting Toni_ (Reply 21):
I can easily stand up straight under a 747. I never been close to a 787 yet but I'm willing to bet I can do the same.

I'm only 6'3 (1.9m) and while I certainly don't have to bend to get under a 747, I do have to crane my neck pretty hard, especially if it's under load, and especially if I am looking up at something. The 787 is a little shorter, but not much. But yes, this is not excuse to ignore that part of a walk around.

Quoting KarelXWB (Reply 13):

How about this one: "a slat departed the aircraft's right hand wing".

That's actually a pretty standard term for that. Would you like something more colloquial? Perhaps we can log that the slat Wandered Off?

rj968 · Wed Nov 18, 2015 10:06 pm

Quoting audian (Reply 17):
I think AI should take this matter seriously and take strict actions against who ever is responsible for this mistake.

Then they would accuse AI of "screwing them over"

mfranjic · Wed Nov 18, 2015 10:39 pm

I read all this and nothing is clear to me! Just nothing... I can´t understand why they were using the screws at all??! They could just stick the steel spiral nails, those for the concrete, in the holes. The four pieces of 8 x 50 would perfectly done the job, believe me! But !! ... necessarily in a way that a nail´s head sticks out a little, just in the case you have to remove them...

Nice regards

Mario

P.S. The screws?!!...Gimme a break!! Who use the screws today anymore?! And after this ... how can I exist not asking myself: ´Where is this world going?! Where?...´

747megatop · Wed Nov 18, 2015 10:43 pm

Quoting goboeing (Reply 9):
Liberated from the aircraft...ha.

I might have to start using that phrase.

Thankfully nothing else was liberated!

B737900ER · Wed Nov 18, 2015 10:52 pm

Quoting AirbusBoeing (Reply 30):

A piece of metal came loose, not a panel falling off. Nobody catching a body panel missing 90% of its screws is inexcusable.

fallap · Wed Nov 18, 2015 10:57 pm

As an aircraft technician, I'm somewhat baffled of how you are able to forget to place 43 screws in their respective holes at one place. Granted, I'm well aware of the human factor complex, and I have made my share of screw ups - but an error of such proportions should have been caught by the ones signing the plane off.

Hopefully AI will impose a more strict control of those maintaining their metal, those screws are there for a reason.

csturdiv · Wed Nov 18, 2015 11:04 pm

Reminds me of my time working desktop support for a company and I had to replace a motherboard in a laptop. I had a lot of extra screws when I was done.

Grummancat · Thu Nov 19, 2015 7:33 am

Quoting csturdiv (Reply 37):
Reminds me of my time working desktop support for a company and I had to replace a motherboard in a laptop. I had a lot of extra screws when I was done.

Thankfully, that laptop is not carrying a couple hundred people from Melbourne to New Delhi!!!

Wait until the jokers at CNN get a hold of this. I can see it now; "Possible cause for MH370 found!"

[Edited 2015-11-18 23:37:41]

BestWestern · Thu Nov 19, 2015 7:54 am

Two comments.

1 - this demonstrates how over engineered aircraft are in that less than 10% of screws kept the aircraft intact for so many rotations.

2 - many easily overlooked tasks are flagged with flags or signs to say - don't forget - like the remove before departure for the slides, etc.

A simple post-it style reminder that panel not secure could ensure this happens less frequently.

Quoting csturdiv (Reply 37):
I had a lot of extra screws when I was done.

Just like IKEA furniture.

aerorobnz · Thu Nov 19, 2015 8:05 am

This is just one of many examples of deliberate incompetence. They should be banned from flying to Europe, Australia, USA and the rest of the developed world. They are a disgrace and deserve to be on any aviation blacklist there is. I hope the Star Alliance boots them out.

KLRU · Thu Nov 19, 2015 8:34 am

Back in school I worked two Summers at the Swedair maintenance at Bromma Airport. From that time I remember that anything you took of an Aircraft was bagged/tagged and put in one location, ie when the Aircraft was released from maintenance, there should be no remaining bags with parts on that desk. Didn't anyone notice they had 40+ screws remaining when they signed off the Aircraft for return to service?

[Edited 2015-11-19 00:36:10]

BestWestern · Thu Nov 19, 2015 8:41 am

Quoting aerorobnz (Reply 40):
is. I hope the Star Alliance boots them out.

Star don't care.

Look no further than Egyptair who were inches from an EU ban a few years back and Thai and their current ICAO issues

aerorobnz · Thu Nov 19, 2015 8:51 am

Quoting BestWestern (Reply 42):
Look no further than Egyptair who were inches from an EU ban a few years back and Thai and their current ICAO issues

Sadly I know you are right.

moo · Thu Nov 19, 2015 9:07 am

Quoting BestWestern (Reply 39):
1 - this demonstrates how over engineered aircraft are in that less than 10% of screws kept the aircraft intact for so many rotations.

Not really, because the panel is supposed to stay on for *all* the rotations. Chewing gum might have held it on for one or two rotations, but that isn't an indication that using screws is "over engineering"...

Lentini2001 · Thu Nov 19, 2015 9:10 am

Kudos to the four screws...

WIederling · Thu Nov 19, 2015 9:29 am

Quoting DarkSnowyNight (Reply 31):
Perhaps we can log that the slat Wandered Off?

"Did a choreographed solo performance"

This ganging up on AI has a strong taste of racism imho.

"Freed up" Aircraft parts taking residence in suburbia isn't all that uncommon.

Primary difference seems to be that most other places reasons for departure
are kept out of sight.
Sole focus is on "If that piece had hit my pet or kid! Oywey, the skies are coming down, this is just the beginning, we will all die, ... !"

MATURRO727 · Thu Nov 19, 2015 9:56 am

Quoting Toni_ (Reply 21):
I don't want to slag the article off, but do they have basketball players employed at AI or what? This doesn't seem right to me. I can easily stand up straight under a 747. I never been close to a 787 yet but I'm willing to bet I can do the same.

Quoting DarkSnowyNight (Reply 31):
I'm only 6'3 (1.9m) and while I certainly don't have to bend to get under a 747, I do have to crane my neck pretty hard, especially if it's under load, and especially if I am looking up at something. The 787 is a little shorter, but not much. But yes, this is not excuse to ignore that part of a walk around.

Well guys, am a 787 F/O myself and I’m 6'2(1,86m) and let me tell you one thing, us pilots are not trained to inspect every single panel and its screws in our walk around as the article says. And it doesn’t have anything to do with a specific height to be able to check it or not, its simply not our job. When you are walking in that section of the plane or "Right Wing Root, Pack, and Lower Fuselage" as it’s written in our FCOM, we are supposed to check the following:

-Probes, sensors, ports, valves and drains

- Exterior Lights (Landing Lights)

-Pack Inlet and pneumatic access door

CAC inlet and FOD deflector door

-Leading edge slats and flaps

Then you check the engine, go all the way trough the wing checking the leading edge and back under the wing checking flaps, jettison nozzle, flap actuators, vents, and fuel access panels (check they are on and in their place, not if the screws are complete as it will be impossible to see from that low on the ground and specially at night) to the right main gear and all its components, a quick glance at the right main wheel well and back to the right aft part of the fuselage.

Point being that pilots are actually not trained to look at every panel and its screws, that’s a maintenance job... when we get to the cockpit and the mechanic releases the airplane and sign the book, you trust that you are working with professional and qualified people for the job and that every screw its where it needs to be, other ways it would be an impossible operation to run.

Just my two cents.

MATURRO727

moo · Thu Nov 19, 2015 10:10 am

Quoting MATURRO727 (Reply 47):
Point being that pilots are actually not trained to look at every panel and its screws, that’s a maintenance job... when we get to the cockpit and the mechanic releases the airplane and sign the book, you trust that you are working with professional and qualified people for the job and that every screw its where it needs to be, other ways it would be an impossible operation to run.

Yup, your job is to spot the obvious - if this particular panel was half hanging off, I bet you would have spotted it and had it dealt with, but if it was still flush with the airframe then you assume it is fine. Your job is to carry out an inspection of the items most likely to be a flight issue, not check to see that the aircraft is still built correctly...

aerorobnz · Thu Nov 19, 2015 10:49 am

Quoting WIederling (Reply 46):
This ganging up on AI has a strong taste of racism imho.

No, it comes from having an audience with operational airline experience, If any of the airlines I have dealt with did what AI do consistently I would inform any applicable governing body. Criminal negligence has nothing to do with skin colour.

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