Engineers' Laurel and Hardy moment caused British Airways 787 to take an accidental knee A British Airways Boeing 787's landing gear collapsed during a botched test after a short mechanic asked a taller co-worker to insert a lock-out pin into a hole he couldn't reach – only for the second mechanic to put it in the wrong place. The Laurel and Hardy-style failure was detailed in a bulletin from Britain's Air …
Maybe it's just me, but if I asked someone to do something for me and they weren't sure about doing it properly, I would have watched them do it, or at the very least checked after they had done it. Though as Zenubi said, it should not have been possible to do it wrong in the first place
"I would have watched them do it, or at the very least checked after they had done it."
They were too short to do it, so too short to check. I don't want to say anything politically incorrect, but short people are a constant hazard - there is a reason we don't let five year olds drive on motorways.
In the 1970s we used to make short people wear platform shoes to avoid industrial accidents.
Short is not equal to young. We don't let five year olds drive because they're not mature enough to handle driving, not because they can't reach the pedals. Short adults are very capable of driving.
Additionally, short people have eyes that generally work. He could very well have controlled that the pin was placed in the right socket.
He didn't.
P.S. : why is Danny 2's post no longer open to votes ? What is the reason of this special treatment ?
Like Randy Newman singing 'Short People', I was joking. And I assumed it was such an obvious joke that I didn't have to state it explicitly. I am fully aware the reason five year olds can't drive isn't a height restriction. And though you didn't pick up on this, we didn't make short people wear platform shoes in the 1970s. That was purely voluntary.
[For the record it was the article that blamed the accident on the engineer being short, I just picked it up and ran with it - like you would do with a short person]
I'm 6'2", and have found both advantages and disadvantages to my height. For the latter, consider my first job, running an amusement park ride. Our "office" was an enclosed space under the landing of a fire escape stairwell. My rather short supervisor had no difficulty dashing in and out, but the steel beam at forehead height for me was rather painful, and nearly induced unconsciousness on one occasion when I was in too big a hurry to pay attention.
I have a friend who is 195cm ( and a bit, as she keeps telling me) who has lost count of the number of street signs, overhanging branches and other hazards she's faceplanted simply because, when you're walking along the street with shorter friends, you're generally looking down at them and relying on their movements to alert you to headbang hazrds, and they don't, because to them there is no hazard.
I agree. But in the interests of accuracy, this isn't (quite) a "3 year old safety directive".
The Safety Bulletin from Boeing was 12 March 2019, so 2 and a quarter years old.
The Airworthiness Directive from the FAA, the regulator who has authority over Boeing, was 16 January 2020, so 1 and a half years old.
The FAA obviously didn't think it was urgent, they gave everyone 3 years to comply. And that time hasn't run out yet.
Joking aside, how many here have never done something utterly stupid BUT learned a lot of valuable lessons from it?
Yeah it was bloody stupid, they should have checked or got someone to check but mistakes happen. So long as no one was hurt and it wasn't mindless incompetance, a slap on the wrist and put under supervision for a month should be enough.
Cock-ups is why IT gets better or should, we're human, we do some stupid things when we're not concentrating but doesn't mean we're idiots, just human.
Reminds me of when I was a small child, living in Southend. My sister and I were playing in the garden when an extremely loud screaming noise, followed by a series of bangs and crashing noises, scared the shit out of us, I darted through the french windows into the dining room, and my sister ran into the kitchen. The frightening sounds were made by an English Electric Lightning crashing in the next road over (coincidentally named Electric Avenue), and various parts being liberally distributed over the neighbourhood. One of the jet engines went in through the roof of a house about three doors down from us, crashed through the bedroom, and ended up crushing the dining table flat. I was taken to see the crash site, where the intake nosecone of the fuselage was standing vertically, embedded in the pavement, with an apparently undamaged tree projecting out through it. The RAF were in attendance with a low loader, and they loaded all the bits they could find onto it before taking it away.
BAe has form. In the late 1970's and on, the BAe 125 executive jet had the 'feature' that if the nose gear was not locked and the engines turned on powering the hydraulics, the nose gear would retract. This was particularly embarrassing when a Middle Eastern 'potentate' arrived to take possession of his flight of 3 BAe 125 aircraft, and they all 'bowed' as soon as the engines were powered up. There was a mandatory modification to ensure the nose gear stayed in place after that incident.
From the photo, it looks like the leading edges of the Roots-Royce engines impacted the tarmac, so maybe not just the nose cone will need replacing. Very expensive if any of the fan blades are damaged, let's hope not.
BAe 125 - https://en.wikipedia.org/wiki/British_Aerospace_125
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There are automatic lockouts to prevent the *pilot* from raising the landing gear on the ground. Probably including weight-on-wheels sensors, and/or checks on altitude and airspeed. However, as part of the maintenance, the *engineers* presumably disabled those safety systems. They're supposed to install the locking pins, so it's physically impossible for the wheel to move, before doing that.
Unfortunately, ground maintenance crews need to do a lot of things that you wouldn't want to be done in normal flight, as a normal part of their repair / diagnosis / maintenance work. So they have the ability to override the system, and safety is supposed to be assured by them following the procedures.
If you read the article, as part of the maintainance they had to actuate the landing gear retraction mechanism to cycle the operating fluids through the system, but without it actually retracting the landing gear. That's what the locking pin was supposed to be there for, so they could deliberately operate the "retract landing gear" controls without the landing gear retracting.
Dunno much about cars, but maybe like pressing the accelerator to make the engine speed up to clear muck out of the system, but with the brakes on so the car doesn't actually move and smash through the back of the garage.
Many moons ago, as an air cadet, I remember being allowed to spend time in the maintenance hanger. Whilst some were there happy polishing canopies, I got talking to one of the guys there an asked if I could help. He was working on the landing gear of a Jet Provost.
Whatever it was he was doing (I can't remember now), he was telling me about the locking mechanism on the gear - immediately followed by a 'thunk' as it locked. So I spent the next 5 minutes led on my back kicking the crap out of this oleo leg while he tried to release the lock so he could continue with the job.
RAF Linton-on-Ouse, back in the mid '80s. Fun times before I seriously had to find a job....
1) So this happened on 18th June? - one assumes 2021....and given that most aeroplanes have been in mothballs for some time, why had the directive to sort out this issue not been done already? The mechanics would surely have had great opportunities to fix many of the relevant planes as a) all the planes were parked up in large numbers around the country, not going anywhere and b) there were no time pressures to get the planes modified quickly.
2) I assume BOTH mechanics were trained to do the work? If so, was this a simple mistake by one mechanic who clearly had not read the guidance on how to fit the crucial lockdown pin....or maybe the short mechanic was in charge in which case why did he not "oversee" (sic) what the tall mechanic did, by getting a ladder to check it? The cost implications of getting it wrong are pretty huge, so someone must take responsibility for it?
> So this happened on 18th June? - one assumes 2021...
No assumption required. It is in the report.
> and given that most aeroplanes have been in mothballs for some time, why had the directive to sort out this issue not been done already?
Plainly, this aircraft was not in mothballs. Operating aircraft fleets are serviced to a schedule that is combination of manufacturer's recommendations, regulatory requirements, and operational requirements. Non-urgent modifications will be done when the aircraft is otherwise out-of-service for maintenance. The base maintenance check period for a 787 is around 36 months IIRC (heavy maintenance around 12 years). If, for example, this aircraft was finishing servicing at the time of the directive, then you could reasonably expect it will not be there again for a couple of years.
Aircraft in mothballs will only have the minimum work done to preserve their ability to return to service. They are generally neither in a fully functional state (e.g. fluids drained or replaced with storage versions) nor at a substantial company maintenance facility (e.g. in the Mohave desert [1] or central Australia[2]). Consequently, the necessary systems to perform this particular nose gear installation may not be present, even if the airline wanted to spend money on aircraft it may never fly again (an aircraft not flying is a money pit, not just lost revenue).
[1] https://goo.gl/maps/8vRpLwWki9AQAAF39
[2] https://www.escape.com.au/news/incredible-images-of-plane-graveyard-near-alice-springs/news-story/186572ec9da57bb6e6248f915effe876
Human nature. If you need something from a high shelf and there's a taller person next to you, do you follow the regulations to the letter and go and get a step ladder (or a cherry picker, picking up the Cabin Pressure theme again ;-) or just ask your mate to reach it down? Unfortunately in this case the downside was a bit worse than getting the wrong breakfast cereal.
The maintenance guys are copping the blame here - with some justification - but the fault goes all the way back to the initial design.
What idiot thought it might be a good idea to have a pin-sized hole immediately adjacent to the safety critical hole that the pin *should* have gone into? There is no way that that pin should have been able to fit into anything other than the lockout place it was intended to to go.
This isn't a doh moment. This is a basic design flaw, an engineering review flaw, and oversight flaw and a management flaw. Someone signed off on that design and they never should have.
Smells like Boeing beancounters in action. Again.
"Logic" (I use the term generously) that perhaps went something like this: Why have the cost of machining two differently shaped holes and corresponding differently shaped pins, when a single hole and pin shape will suffice?
Classic failure to understand the vital reason for the differences. Just another line item to be cut.
Yup, UI design is not just about computer interfaces.
Without prior knowledge, I would have done exactly the same thing, because t'wrong 'ole has that circle around it making it look even more like a target.
I think it's because it looks like a pivoting part, so it's a surface phlange for the internal pivot, but that very plain hole adjacent does not look functional at all.
So the surface "decoration" should indeed look different and preferably, the holes have different dimensions and/or shapes to prevent accidents happening.
So many engineering accidents have happened due to ambiguous controls, and planes downed multiple times. You think that designers would have a better handle on this kind of thing by now.
Reminds me of the Monsters v. Aliens 'buttons' design:
https://www.youtube.com/watch?v=L1CxlyMoFRs
When I was involved in life-critical safety & protection systems, a major mantra was "If something can possibly happen, it eventually will" and thus the aim was to spot bad things that could possibly happen in order to make them impossible, which is where abilities such as foresight, deductive reasoning and basic intelligence play a major part. Unfortunately, such qualities seem to be in short supply these days. I blame leaded petrol...
IIRC a nuclear reactor control panel had two adjacent identical levers . One for orderly shut-down - one for immediate shut-down. The operators attached differing beer pump knobs to distinguish them.
Murphy's Law is always a potential error - but the crunch comes with the Sod's Law rider "at the worst possible moment".
"Unfortunately, such qualities seem to be in short supply these days."
It is a recurring factor for each generation. When people don't know or understand the underlying constraints of the technology they use - then they may inadvertently breach them. Our modern society's technology is a Tower of Babel built on foundations of shifting sand.
Donald Rumsfeld was mocked for his statement about the factors of "unknown unknowns" that can affect an outcome.
British tank designers made a new design with vertical sides - when it was already known that sloping sides gave some protection against enemy projectiles.
The Comet jet suffered catastrophic metal fatigue cracks at the corners of its originally square windows. Yet that was not many years after Liberty ships had been diagnosed as sinking owing to fatigue cracks at the sharp corners of cargo hatches.
The original one
"If an aircraft part can be fitted two ways around, and one of those is the wrong way around, somebody will do it"
It then goes on to elaborate that you can write as much documentation as you want, it _will_ still happen
(The same applies if there are 2 identical looking holes to put pins in and one is the wrong one, diesel in petrol tanks, gravity sensors(*), etc)
(*) In that particular instance, the sensor was keyed to prevent being installed upside down but a Roscosomos engineer managed to make it fit anyway.
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