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Accident: British Airways A319 near London on May 24th 2013, unlatched doors on both engines separated, fuel leak, engine on fire shut down
By Simon Hradecky, created Friday, May 24th 2013 11:47Z, last updated Thursday, Jun 13th 2013 13:52Z

A British Airways Airbus A319-100, registration G-EUOE performing flight BA-762 from London Heathrow,EN (UK) to Oslo (Norway) with 75 passengers and 5 crew, was climbing out of Heathrow's runway 27L when a loud bang from the left hand engine was heard and the left hand engine's (V2522) cowling doors went missing. The crew levelled off at 6000 feet reassuring passengers. While positioning for a return to Heathrow another loud bang was heard, this time from the right hand engine, and the right hand engine's cowling doors went missing, and the right hand engine was trailing smoke. The aircraft landed safely on Heathrow's runway 27R about 26 minutes after departure, stopped on the runway and was evacuated via slides while emergency services doused the right hand engine and extinguished the engine fire. No injuries occurred.

Both runways were closed to accommodate the emergency, runway 09R/27L re-opened shortly after the landing. Runway 09L/27R reopened after the aircraft had been towed to the apron about 2 hours after landing.

Pictorial evidence shows the left hand engine doors went missing in flight, both engines' cowling doors were missing in photos after landing.

The airline confirmed the aircraft returned to Heathrow due to a technical fault, the aircraft was evacuated via slides after landing.

The airport reported emergency services were assisting an aircraft with a fire.

The United Kingdom's Air Accident Investigation Board AAIB have opened an investigation and dispatched a team of investigators on site.

On May 29th the NTSB reported quoting the AAIB, that both engine cowl doors separated during takeoff and fell onto the runway, one engine was leaking fuel and had been shut down, they were returning to Heathrow. Later the crew reported the other (still running) engine was on fire, the aircraft continued for a safe landing, was shut down and evacuated. The NTSB assigned an accredited representative into the investigation led by the AAIB.

The aircraft seen from the ground (Photo: APA/Rex Features):
The aircraft seen from the ground (Photo: APA/Rex Features)

The right hand engine after landing with doors ripped off and soot (Photo: DPA):
The right hand engine after landing with doors ripped off and soot (Photo: DPA)

The left hand engine in flight (Photo: Reuters/Jon Chaplin):
The left hand engine in flight (Photo: Reuters/Jon Chaplin)

The left hand engine in flight before right hand engine emitted bang (Photo: David Gallagher):
The left hand engine in flight before right hand engine emitted bang (Photo: David Gallagher)

The left hand engine after landing with doors ripped off (Photo: DPA):
The left hand engine after landing with doors ripped off (Photo: DPA)


By Simon Hradecky, created Tuesday, Jul 14th 2015 11:38Z, last updated Tuesday, Jul 14th 2015 11:41Z

On Jul 14th 2015 the British AAIB released their final report concluding the probable causes of the accident were:

Causal factors

The investigation identified the following causal factors:

- The technicians responsible for servicing the aircraft�s IDGs did not comply with the applicable AMM procedures, with the result that the fan cowl doors were left in an unlatched and unsafe condition following overnight maintenance.

- The pre-departure walk-around inspections by both the pushback tug driver and the co-pilot did not identify that the fan cowl doors on both engines were unlatched.

Contributory factors

The investigation identified the following contributory factors:

- The design of the fan cowl door latching system, in which the latches are positioned at the bottom of the engine nacelle in close proximity to the ground, increased the probability that unfastened latches would not be seen during the pre‑departure inspections.

- The lack of the majority of the high-visibility paint finish on the latch handles reduced the conspicuity of the unfastened latches.

- The decision by the technicians to engage the latch handle hooks prevented the latch handles from hanging down beneath the fan cowl doors as intended, further reducing the conspicuity of the unfastened latches.

The AAIB analysed with respect to non-compiance with Aircraft Maintenance Manual (AMM) procedures: "The fan cowl doors detached from the aircraft because they remained unfastened following the overnight maintenance shift, and their unlatched condition was not detected during the pre-flight inspections by the co-pilot and the pushback tug driver. The technicians responsible for securing the fan cowl doors on G-EUOE had been trained in the required procedures for opening and closing the doors and were aware of the applicable AMM procedures, but in the interests of efficiency, they chose not to follow them. The fan cowl doors were left unlatched because the technicians intended to return to the aircraft to service the IDGs after collecting the IDG gun and oil from stores. The AMM procedure calls for the hooks to be disengaged, allowing the handles to project lower beneath the cowl, thereby increasing their visibility. The decision by both technicians to leave the latches unlocked but with the latch handle hooks engaged was made because they perceived that, in this configuration, the latch handles do not protrude as far below the cowl, thus reducing the risk of personal injury."

The AAIB analysed that the engineers doing maintenance identified that both IDGs needed servicing, due to the workload they did not anticipate however to be able to complete that task within their shift and decided to defer the task until later in their shift for work load planning. The AAIB continued: "Had an open entry for the required IDG oil uplift been made in G-EUOE�s technical log, as required by the operator�s procedures, it is unlikely that it would have materially affected the outcome in this instance, as the technical log was subsequently removed from the aircraft and taken to the maintenance office in Terminal 5A, where it was eventually completed by Technician A."

Later the technicians intended to return to the aircraft but drove past the stand of G-EUOE and began to work on aircraft G-EUXI without realising their misidentification of both stand and aircraft. The AAIB wrote: "The type of error, described in this report as an �aircraft swap error�, was classified by the human factors specialist1 as a �slip�, in that the technicians had intended to return to G-EUOE, but their actions did not match the plan. Slips are typically the result of automatic actions - well-practised activities that are not consciously monitored by the human and are therefore vulnerable to being miscued by stimuli in the environment, such as design or layout of signs and interfaces."

The AAIB analysed that a number of measures had been taken to prevent unlatched cowl doors in flight. "However, the continued occurrence of fan cowl door losses on A320‑family aircraft, including the G-EUOE accident, shows that such preventative measures have been only partially effective. A more effective mechanical, or electronic, means of detecting unlatched fan cowl doors is therefore necessary." and continued: "Whilst it is accepted that fan cowl doors were considered to be structure and certified accordingly, this accident, and other fan cowl door loss events, show that the results of failure to latch the fan cowl doors can cause them to detach in flight, potentially hazarding the aircraft. This hazard was not identified using the structural airworthiness assessment in the original type certification."

The AAIB analysed: "Inspection of the fan cowl door latches from G-EUOE showed that the latch high visibility paint was mostly missing from the latch handles. That which remained was partially obscured by blue paint overspray. In this condition, the open latch handles would have been significantly less conspicuous than if they had been painted according to SB V2500-NAC-71-0227. Therefore their condition was a contributory factor in reducing the prominence of the open latches."

With respect to flight preparation the AAIB analysed: "The photographs taken by the member of ground staff during the pre-flight activities show the outboard fan cowl door on the right engine to be open and resting on the hold-open device and two of the fan cowl door latches of the left engine hanging down. These photographs show that there were visual cues that the fan cowl doors were unlatched prior to departure. These cues were not identified by either the tug driver during his aircraft inspection or by the co-pilot during his external walk-around."

The AAIB analysed that a fuel leak was clearly visible from the cabin, passengers alerted the cabin crew to the fuel leak. However, the lead flight attendant, when finally reaching the cockpit 7 minutes after takeoff, did not convey the fuel leak but only reported the damaged engine cowl. The pilots thus remained unaware of the fuel leak until they received an ECAM fuel imbalance message. The AAIB wrote: "Had the flight crew been made aware of the fluid leak from the right engine at an earlier stage, they might have been able to identify the fuel leak more quickly and could have taken appropriate action to mitigate the severity of the event."

The AAIB continued: "Had the leaking fuel not ignited, or had the fuel leak been isolated sooner, there would have been no fire and the event would have been relatively benign. However, an external fire broke out on the right engine when the aircraft was already established on approach to land back at Heathrow. The immediate risk posed by the fire, at such a late stage, meant that a landing at Heathrow was the safest option." and continued: "The QRH fuel leak procedure required the right engine to be shut down and, given the location of the damaged fuel pipe, this would have isolated the fuel leak, preventing the fire. The commander, however, decided that shutting down the right engine would have exposed the aircraft to an unacceptable risk, as the condition and degree of damage to the left engine was unknown and there was no certainty of its continued operation. ... When the fire broke out in the right engine, the risk to the aircraft presented by the fire was greater than that of the condition of the left engine and the commander responded accordingly by shutting down the engine."

The AAIB analysed that following landing fire services immediately began to fight the fire at the right hand engine. The left hand engine however was left running while the crew assessed the situation and communicated with ATC and fire services. The AAIB wrote: "The fire chief was concerned about the risk to evacuation posed by the left engine which was still running. Hence, when asked by the commander if an evacuation should be initiated, the fire chief advised him to hold, resulting in the evacuation being delayed. The fire chief subsequently requested that the left engine be shut down and, once radio communications were re-established with the flight crew following engine shutdown, the fire chief requested that an evacuation be commenced."

Possible configurations of fan cowl door latches (Photo: AAIB):
Possible configurations of fan cowl door latches (Photo: AAIB)

The engine fire during landing roll (Photo: AAIB):
The engine fire during landing roll (Photo: AAIB)

The engine fire during landing roll (Photo: AAIB):
The engine fire during landing roll (Photo: AAIB)

The possible configurations of fan cowl latches (Photo: AAIB):
The possible configurations of fan cowl latches (Photo: AAIB)

A pilot during inspection of fan cowl door latches (Photo: AAIB):
A pilot during inspection of fan cowl door latches (Photo: AAIB)

By Simon Hradecky, created Friday, May 31st 2013 14:32Z, last updated Tuesday, Jul 14th 2015 11:41Z

On Jun 13th 2013 The Aviation Herald received another passenger photo (see below) showing the right hand engine just before fire broke out.

On May 31st 2013 the British AAIB released their special bulletin rating the occurrence an accident.

The AAIB reported that the flight crew felt the takeoff from Heathrow's runway 27L was quite normal though they felt a small bump, which the crew believed was a wheel running over a center line light. During initial climb air traffic control informed the crew they had left debris behind. Subsequently cabin crew reported panels were missing from both engines.

The AAIB reported the separation of the engine doors caused secondary damage to airframe and systems including: thrust control degradation, loss of yellow hydraulic and a substantial fuel leak. Following the loss of the yellow hydraulic system the crew declared PAN with the intention to return to Heathrow, ATC provided vectors for an ILS approach to runway 27R.

During the approach to land a fire developed in the right hand engine and the engine fire alert activated on the flight deck prompting the crew to declare Mayday. The right hand engine was shut down, both fire bottles were discharged into the right hand engine, the fire indication however continued.

The left hand engine performed normally throughout the flight.

The aircraft landed on runway 27R and was evacuated. Airport emergency services quickly extinguished a fire on the right hand engine.

Post flight inspection revealed that inboard and outboard fan cowl doors had separated from both engines, the remnants of the doors were found on the runway. The detached doors had caused damage to inboard leading edge slats, left and right fuselage skin close to the wing root, overwing fairings, inboard flaps and left belly fairing. The right hand engine outboard fan cowl had impacted the outboard end of slat 3 and inboard end of slat 4 damaging both slats. The outboard right hand flap fairing on the right wing was punctured, the left horizontal stabilizer's leading edge and lower skin were damaged. Debris had also struck the left hand main gear damaging the leading edge of the left main gear door and a hydraulic brake pipe. The right hand outboard main gear tyre was damaged during landing and fully deflated.

The right hand engine showed extensive fire damage concentrated in the left and right thrust reverser C ducts and common nozzle assembly. A low pressure fuel line was punctured by remnants of the inboard fan cowl that remained attached to the engine. The source of ignition is still under investigation.

The AAIB received photos after the event, that showed the aircraft before the events and confirmed both engine fan cowl doors had not been latched. The aircraft had undergone scheduled maintenance over night, which required the opening of both fan cowl doors to check the integrated drive generator oil levels.

The right hand engine before fire broke out:
The right hand engine before fire broke out


Reader Comments: (the comments posted below do not reflect the view of The Aviation Herald but represent the view of the various posters)
Latched/Engaged
By James on Monday, Apr 11th 2016 22:43Z

Is it me or is the solution really obvious.

Remove the ability to engage the latch. The way I see it (confirmed by the pictures above), is there are three positions for the latch: Unlocked, Engaged, Locked.

As far as secure fairings go, engaged is no better than unlocked. So remove the option, Locked or unlocked. problem solved.


By Martin on Tuesday, Aug 11th 2015 07:28Z

There is no Electronical System to check if the latches are open or not and it is difficult to install a system that works well to report something like this. Until this problem is solved it is on hands of the technicians to proof that the latches are closed and locked. There are many ways to find out if they are open and there is a more then four eye procedure to be sure they locked.


By mcv on Monday, Jul 20th 2015 19:10Z

Shouldn't this be reported on EICAS? Why on Earth pilots weren't notified by the airplane itself that the latches are open?


By Gari on Sunday, Jul 19th 2015 18:21Z

I am with OldPro on this. I try to worry about everything but the "is this really my job?" policy. And if one day I screw something, which can happen even with all the best procedures and training of the world, then my attorney will sort it out.

We got a notification a bit after the accident in my company, before that I had no idea about the location of these latches. The only thing I got was my book, I thought I was thorough by checking the latches above. And even when you ask an engineer, since the companies don't organise a walk around for you nowadays, not sure he will think to show you. Of course he knows about them, but it is easy to forget what you don't see. Yes the new design is better.

The Avherald is an amazing safety tool. I am flying tonight, I won't forget!


By (anonymous) on Friday, Jul 17th 2015 07:42Z

At the engineers
By Willy on Friday, Jul 17th 2015 00:26Z

"Not only did they forget to fasten the hatches but they forgot to do the IDG top up"

They didn't forget to do the top up!!! - Read the report.
They remembered too, however didn't pay enough attention to the aircraft they were doing it too and when they noticed the job they thought needed doing had been done by the Maintenance fairies they still didn't cross check the reg.!!
But rather put it down to the fact the engine has had time to settle and cool increasing the oil level and therefore thinking the job didn't need doing.

not only where they different registrations, and Stand, They were different types, A simple check of the registration would have solved the whole issue.
The basic and normally boring part of a job is what normally saves your arse.

Type Swiss Cheese situation,
Look up Swiss cheese model on wiki,
Seems all the holes lined up for a crash but fate/ luck / good flight crew saved the day.




At the engineers
By Willy on Friday, Jul 17th 2015 00:26Z

Not only did they forget to fasten the hatches but they forgot to do the IDG top up so I guess these two are demoted and have a job sweeping up at the the BA workshops!

BA Airbus accident
By Noonray on Wednesday, Jul 15th 2015 18:14Z

I've finished reading the report and my goosebumps have not settled yet at how narrow, nay providential was the escape.

The ground engineers' overlooking the latches is a grave offence. Even more grave is the copilot's lackadaisical overseeing of the engineers' inspection. Surely the latches being secured is part of his/her walkaround checklist.Surely, prudent copilots would give, apart from the visual inspection, a thump, tug, pull or prod to each latch to doubly ensure it is locked.

There should be no excuse or pardon for the ground engineers and copilot. The member of the cabin crew who did not report the matter to the captain is also culpable.

Too many A320s are flying in the world today with more being delivered constantly, for Airbus Industrie not to issue a remedial safety bulletin at the very earliest.


Wow
By msquared on Wednesday, Jul 15th 2015 14:01Z

So many oversights at so many levels ...

@Gabor
By (anonymous) on Tuesday, Jul 14th 2015 23:33Z

They (the nacelle vendor) did. There's a new V2500 cowl with an IDG access hatch.

@ Gabor
By (anonymous) on Tuesday, Jul 14th 2015 19:56Z

Fair comment but in this case the damage would have been just smaller (probably). It's the PROCESS that failed, not the size of the cowl.


By Gabor on Tuesday, Jul 14th 2015 18:30Z

What reason Airbus does not modify the fan cowl design with a small separate access panel to check / service the IDG; like the engine oil tank service door...

@the legacy
By Martin on Tuesday, Jul 14th 2015 18:30Z

Re Bard, I guess Bard is a confused guy as G-EUOE was based at Gatwick during June and BA flights don't fly from Oslo to Gatwick but fly into Heathrow. As we haven't heard from him perhaps it wasn't fine!!


By Old Pro on Tuesday, Jul 14th 2015 16:44Z

There are only two kinds of pilots. Those who are paranoid about making sure the cowls are latched and those who should be.

Remove Before Flight
By gadfly on Tuesday, Jul 14th 2015 16:16Z

Given many accidents occur because maintenance crews leave work in an incomplete state, planning to return and complete it, and later not returning (or handing off to shift change).

Why not have a place on the engine that a lock out "Doors unlatched" tag needs to be affixed as they often are to controls in the cockpit? Or perhaps just a fancy red "Remove before flight" ribbon and locking pin needed to unlatch the doors? Keeps coming to mind each time I read an incident like this where the latches are so hard to see on walk around... do something to make the state easier to detect.

@ Bard
By The Legacy on Tuesday, Jul 14th 2015 15:19Z

It's been a month since your flight, but I assume that since there's been no reports on it, I assume it went fine. :)

I should state though that with the final report out, it should help explain why this is not a normal occurrence, and that the plane should be safe to fly in.

I am sitting in the same aircraft now
By Bard on Tuesday, Jun 23rd 2015 20:06Z

We are taking off from oslo today. Same reg number. Not feeling safe. The plane looks old

@4M2
By The Legacy on Wednesday, Nov 13th 2013 21:20Z

They probably landed at Heathrow because the right engine was on fire; though having parts land on people is a huge risk, an uncontained engine fire could be fatal to those on board - and on the ground. I feel they made the right call.

procedures
By xyz on Sunday, Jun 16th 2013 18:48Z

New procedures introduced at many airlines. It will be good only to break the balls of ground engineers. Problems probably will not be solved.

COMMENTS OF ANONYMOUS
By ROBERT LANG on Saturday, Jun 15th 2013 21:05Z

why do you make a fool of yourself......maybe because you will not use your name you feel safe

Leaks from #2
By 4M2 on Saturday, Jun 15th 2013 11:29Z

@ Dave f/e

If I had been on the ground under the plane's flight path and had known the condition of the right engine I think I would have been nervous also.

That damaged inboard cowl door is obviously insecure and any falling debris could have posed a serious risk to people on the ground. Perhaps if the captain was fully aware of it's condition and it's potential threat both to people on the ground and to the aircraft's air worthiness then landing earlier on an airfield other than Heathrow might have been a safer decision?

Airbus Cowls
By JetMech on Saturday, Jun 15th 2013 11:00Z

All too common of an issue with Airbus A319/320's. UAL lost fan cowls on a #1 engine on an A320 (15+) years ago, as a result they painted all their latches bright orange so they could be detected when not latched.

America West (at least I believe it was AW) lost fan cowls on an engine as well, there's plenty of pictures of it on the internet..

The composite design of these cowls is very stiff and doesn't sag down like it does on other engines so it looks closed and latched when it's merely closed (and obviously not latched). There should be some sort of sensor installed with a flight deck effect before a serious incident occurs.. The UAL incident didn't result in a fire but it did result in an IFD because the engine throttle was uncontrollable and set at max thrust.

@ IFixPlanes
By Dave f/e on Saturday, Jun 15th 2013 07:23Z

Thanks for your 02:51 response, It holds then more than one may be up on the carpet. This was or could have developed into a more serious event. In any case not good PR for BA.

Leaks from #2
By Dave f/e on Saturday, Jun 15th 2013 07:12Z

I suspect leak from inboard side of #2 is from FCOC or associated plumbing. This definitely would make a few passengers nervous.

@ flysafe
By Jock on Saturday, Jun 15th 2013 06:22Z

I have no need to defend WorldWideWelshman. He can take care of himself.

But, with all due respect, flysafe, it is not because he disagrees with you, or anybody, that he is , or even comes across as, a "Mr.know-it-all"...(your words).

We can all have minor disagreements with each other (and we do), and that includes WorldWideWelshman. He tends to have the quality of being much longer on fact and shorter on unfounded opinion. That should be a good pointer for most.

Can't we leave this troll "personal attack" approach in the locker room ?

@ IfixPlanes
By chris on Saturday, Jun 15th 2013 03:45Z

"FCOM says : Fan cowl doors...................CLOSED/LATCHED"

Does that means the fan cowls latches or any access door latches on the fan cowls ?

Do the pilot has actually to sit down the engine to check the fan cowl latches ?

@ Anonymous
By Chris on Saturday, Jun 15th 2013 03:40Z

Anonymous ,

Every staff is responsible for whatever duties he has to do .
Pilot is not the last one to do walkaround before departure . end of the story .



@ Dave (f/e?)
By IFixPlanes on Saturday, Jun 15th 2013 02:51Z

Both are responsible. The mechanics sign off the closing and the crew sign off the preflight.
If the mechanics do their checks at night they also have to do "numerous items". So thats no argument.
FCOM says : Fan cowl doors...................CLOSED/LATCHED

You say that the preflight "is usually cursory to spot anything obvious". I think that a open latch (which can be seen on a photo) is obvious enough.
I expect that the mechanics close the latches as much as the crew see more than a missing engine.

@ IFixPlanes Jun 14th 2013 10:32Z
By Dave f/e on Friday, Jun 14th 2013 21:57Z

Also FBW Jun 10th 2013 13:12Z I would like to see supporting documentation of who should be considered responsible, Flight crews check numerous items on pre-flight walk around which is usually cursory to spot anything obvious. How would the flight safety dept. or chief Pilot respond to this ( if they have such)I think it logical the primary responsibility should lay with ramp crew.

@ Push back chris
By (anonymous) on Friday, Jun 14th 2013 19:06Z

"Maintenance people they do".

A push back guy is not a maintenance guy. I can assure you British Airways will not be trying to use the pushback guy as the scapegoat.

Fuel leak seen on new picture?
By Josh Lyman on Friday, Jun 14th 2013 17:35Z

Can anybody tell me if that new picture shows fuel leaking out of the damaged fuel lines?

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