Some of you may remember the British Airways Airbus 319 aircraft that lost the fan cowl doors from both engines on take-off from Heathrow Airport two years ago resulting in damage to the aircraft and an inflight fire. Fortunately, the aircraft was able to land safely and there were no deaths or serious injuries. Many of us suspected at the time that a likely precipitating cause of the accident was improperly performed maintenance, specifically improperly latched cowl doors.
Now the accident report outlining the maintenance errors – and the human factors behind them – has just been issued by the United Kingdom’s Air Accidents Investigation Branch – the equivalent of the US NTSB. The accident report can be found here: https://www.gov.uk/aaib-reports/aircraft-accident-report-1-2015-airbus-a319-131-g-euoe-24-may-2013 The report contains many lessons for those of us in the aviation maintenance business, lessons we may be well aware of but haven’t learned.
Reading the accident report – in particular the Human Factors Report - I can’t help but ask myself, could this accident have happened to me when I was working on aircraft? It’s a question well worth asking for anyone performing maintenance on aircraft today, whether as a mechanic actually performing aircraft maintenance, a supervisor responsible for overseeing that work or a manager responsible for the overall maintenance at a facility. And, of course, executives far removed from where the wrenches meet the aircraft, need to look at whether any of the policies they foster create the environment in which this type of accident can occur.
The report concludes, as many suspected at the time, that a maintenance error led to the fan cowl doors being left unlatched after scheduled overnight maintenance. But the report goes beyond the obvious conclusions and looks at the human factors that led to the mechanics leaving the doors unlatched and then failing to discover their error. Of course, contributing factors range beyond the errors of two mechanics and include airline management and the aircraft manufacturer, as the report points out. But the precipitating factors were the mechanics actions and inactions. Not surprisingly, the failure to follow maintenance manual procedures is at the heart of this accident. Yet, at this worksite, as at many others I have seen, the failure to follow at least some required procedures was routine. Luckily for us, the two maintenance technicians involved appear to have fully and candidly cooperated in the accident investigation. Without their cooperation, it’s doubtful that the human factors report would be so compelling.
I won’t try to summarize the report and risk you not reading it. Hopefully, I’ve piqued your interest. I will say that I’m hopeful that this report will cause maintenance professionals at all levels in the aviation industry to realize that a maintenance accident like this could happen to any of us unless we heed the lessons here. Next time, however, we may not be so lucky. And the accident could result in a catastrophic crash with tremendous loss of life in the air and on the ground.