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Human Factors of Dash 8 Panel Loss

Posted by Aerossurance on Jan 21, 2018 in Accidents & Incidents, Fixed Wing, Human
Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety
Management | 0 comments

Home Accidents & Incidents Human Factors of Dash 8 Panel Loss

Human Factors of Dash 8 Panel Loss

We look at the human factors lessons after Flybe Bombardier DHC-8-402 / Dash 8 Q400 G-

PRPC was damaged by the loss of an engine access panel on departure from Manchester
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Airport on 14 December 2016.

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No 1 Outboard Engine Panel Missing from Flybe DHC-8-402 Dash 8 (Q400), G-PRPC (Credit:
AAIB) Report

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The UK Air Accidents Investigation Branch (AAIB) discuss the circumstances of the panel loss Hunter Downed by F-35A Jet

in their report.  The aircraft… Wash

…night-stopped at Manchester Airport…parked on a remote stand. The operator’s Recent Comments

contracted maintenance organisation [at Manchester] completed a routine daily check on

the aircraft that evening. This included checking the oil content of the No 1 engine, accessed
Archives
by opening the outboard main access panel on the engine nacelle.
 April 2020
The main engine bay of each engine nacelle has two large forward access doors, one
March 2020
inboard and one outboard. These access doors are made from a carbon/epoxy composite
February 2020
material with integral foam- lled sti ening ribs. Each door is hinged at the top, has a single
January 2020
telescopic hold-open strut and is secured in the closed position by four quick-release lock
December 2019
pin latches.
November 2019

October 2019

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August 2019

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June 2019

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April 2019

March 2019

February 2019

January 2019
Dash 8 Q400 Engine Panels (Credit: Bombardier with AAIB Annotations)
December 2018

Each latch, when closed, engages a pin into a receiver mounted within the engine nacelle November 2018

structure. The outboard door on the No 1 engine and the inboard door on the No 2 engine October 2018

allow access to service the engine oil system. The check was concluded by approximately September 2018

2115 hrs… The aircraft Technical Log entry for the daily check was signed by the engineer August 2018

at 0010 hrs. July 2018

June 2018

May 2018
At 0550 hr…the commander conducted the pre-departure inspection. As it was still dark, he
April 2018
used a torch to supplement the ambient airport lighting during his inspection. The
March 2018
inspection had a total duration of 3 minutes.  He did not identify any issues with the
February 2018
aircraft and the crew continued with their normal departure routine.
January 2018

December 2017
The ground crew, who were responsible for pushing the aircraft back o the stand,
November 2017
subsequently arrived and conducted their own walkround check of the aircraft, also
October 2017
identifying nothing of note.
September 2017

August 2017
The aircraft departed for Hanover and on arrival there about 90 minutes later it
July 2017
was noticed that the No 1 engine access panel was missing.  A search was initiated at
June 2017
Manchester and…
May 2017

April 2017

March 2017

February 2017
 January 2017
…the panel was recovered from a grass area to the side of the runway, approximately 440
December 2016
m from the runway threshold. Sections of the panel hold-open strut were also recovered
November 2016
from the runway and adjacent paved areas in the same vicinity.
October 2016

September 2016

August 2016

July 2016

June 2016

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April 2016

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January 2016

December 2015

November 2015

October 2015

September 2015

No 1 Outboard Engine Panel Lost from Flybe DHC-8-402 Dash 8 August 2015
(Q400), G-PRPC (Credit: AAIB)
July 2015

On inspection of the recovered panel all four latches were found to be in the closed and June 2015

latched position. There was no damage to the latch bolts or the receiving xtures on the May 2015

nacelle. April 2015

March 2015

As there was no damage to the latches the AAIB concluded the panel latches had been closed February 2015

correctly. January 2015

December 2014

Inspection of the aircraft vertical stabiliser showed puncture holes in the skin on both sides, November 2014

with impact marks also present on the leading edge de-icing boot. October 2014

September 2014

August 2014

July 2014

June 2014

May 2014

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Accidents & Incidents

 Damage to vertical stabiliser Flybe DHC-8-402 Dash 8 (Q400), G-PRPC. Similar damage occurred on Air Tra c Management /
both sides. (Credit: AAIB)
Airspace

There was also impact damage to both VOR/LOC antennas. Air elds / Heliports /
Helidecks

Business Aviation
Other Incidents and Earlier Action
Crises / Emergency
According to Bombardier there have been nine other engine access panel losses in- ight
Response / SAR
worldwide on the Q400 eet in similar circumstances.  One in South Africa on ZS-NMO in July
Design & Certi cation
2014 was subject to a more basic investigation by the South African CAA, who nally reported
FDM / Data Recorders
on 8 January 2018.  However in that case the lower two latches were found unlatched and
Fixed Wing
only the two upper/middle latches were in the latched position.
Helicopters

One occurrence had been on the same Flybe aircraft, G-RPPC.  The AAIB say that 9 November Human Factors /
Performance
2016 the No 1 engine access panel was found missing from G-PRPC after a ight from Belfast
HUMS / VHM / UMS / IVHM
to Glasgow.  In that case the departing panel caused damage to the left wing leading edge de-
Logistics
icing boot and wing skin.
Maintenance / Continuing
Three weeks later the operator issued Notice to Engineers (NTE) 22 that stated: Airworthiness / CAMOs

Military / Defence

Following completion of all work either an independent person carries out a walkround Mining / Resource Sector

inspection to verify all access panels are tted/secure, or the certifying engineer must return News

after a notable period of time for a double check of the security of the disturbed panel O shore

security. The independent person could be a technician or a pilot, or the notable period of Oil & Gas / IOGP / Energy

time could be after completion of paper work. Regulation

Resilience

The NTE did not require this inspection to be speci cally recorded. Safety Culture

Safety Management
Maintenance Human Factors
Special Mission Aircraft
Sta of the contracted maintenance provider at Manchester Airport stated that they were
Survivability / Ditching
unaware of the existence of NTE 22 at the time the December 2016 incident…
Unmanned (Drone / RPAS /
UAS / UAV)

…so had not conducted any additional post-maintenance inspection to check the security

of the latches and panels. The operator’s safety investigation established that, unlike the
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operator-owned maintenance subsidiary, there was no procedure in place for contracted

maintenance company sta to read and sign NTEs.

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The routine daily check requirement was laid out in a set of task sheets where each task,

once completed, required sign o by an engineer licensed on type. Checking the engine oil

content of each engine was listed as tasks 26 and 27.

 These tasks were highlighted as safety critical and had a requirement for an independent

check of the oil cap (or repeat inspection after a period of time, in the case of a licenced

engineer completing the task). There was no similar instruction regarding the closing of the

panel.

Whilst the task stated the oil contents check should be in accordance with the Aircraft

Maintenance Manual (AMM), a subsequent review with the aircraft manufacturer con rmed

that, at the time of this event, the AMM did not contain any instructions on opening or

closing the engine access panel.

No comment is made on whether this lack of AMM instructions was realised after after the

rst incident.

The operator’s expectation was that each item on the…task sheet would be signed for. The

individual pages would then be certi ed complete and an entry would be added to the

aircraft Technical Log, stating that the daily check had been completed.  [Copies] should

then have been posted to the operator’s HQ in accordance with their procedures.

The operator’s safety investigation identi ed that the contracted maintenance company

was not certifying the individual tasks or task sheet pages, but was just adding an entry

directly into the aircraft Technical Log. The hard copy documents were also not being sent

to the operator.

Its not explained why this was not apparently identi ed by quality control checks or audits. 

The AAIB then explain:

Interviews with the engineers involved in both the rst and second incidents identi ed a

common technique used to secure the engine access panel. This involved closing the two

upper [i.e. middle] latches rst, followed by the two lower ones.

Practical assessment of this technique showed that occasionally, as a result of a slight

misalignment of the panel, it did not close correctly… Given the height of the panel and

shorter distance to the hinge line, it was di cult to apply the necessary force to fully engage

the panel at the level of the top latches, when compared to applying a similar force at the

bottom of the panel. This could result in the top latches being closed, without the panel

being properly located. As a consequence, the locking pin would not be engaged in the
 receiving xture on the nacelle side, but the latch would externally look and feel as if it was

properly closed. Once the upper latches were closed in this manner, the panel would rest

on the upper latch pins. Signi cant force could then be applied to the bottom of the panel

while the lower latches were closed, but the pins would not engage in their receiving

xtures. The only external visual con rmation of the incorrect closure of the panel, was a

small gap between the access panel and the surrounding nacelle panels.

Panel gap resulting from an incorrectly latched panel viewed from the ground under
similar lighting conditions to both incidents (Credit: AAIB)

The engineers in both incidents involving G-PRPC were standing on steps to access the

engine which meant once the access panel was closed, they were looking downwards at the

panel and using a head torch to supplement the ambient lighting on the stand.

View of the panel gap following incorrect closure, from the perspective of the engineer
conducting the task (Credit: AAIB)

[The image above] shows how the perspective of the gap in the panel changes, when viewed

under these circumstances. This would have been further exacerbated on the incident

aircraft as the surrounding panels were painted purple rather than white, providing much

less contrast to the shadow cast by the access panel.

Flight Crew Human Factors

The AAIB say operator’s Operations Manual provided clear guidance on how a pre-departure

inspection should be completed. However, there was a degree of inconsistency in the way in

which this is demonstrated to ight crew during their type training.

Following the rst access panel loss in November 2016, the operator’s Flight Operations

department issued Notice To Air Crew (NOTAC) 146/16 – ‘Engine Cowling and Hatches

Inspection’, to request extra vigilance whilst conducting pre-departure inspections. The

aircraft commander from the second incident on G-PRPC con rmed that he had read this

document prior to the ight, but commented in interview that as he had previously been a

ight engineer it did not contain any information that was new to him.

This highlights one of the limitations of safety promotion material that simply highlights

known information.

The commander stated that he was aware that a daily maintenance check had been signed

for in the aircraft Technical Log and that this involved opening the engine access panels.

When asked how he would normally assess that the access panel was secure, he stated that

the latches would be ush. He advised that this was taught to him during his recent Q400

type conversion course, and was shown to him during the hangar visit and during his line

training [ ve months earlier].

Ground Ops Human Factors

Ground handling sta are not required to have any technical quali cations and routinely

work on various aircraft type.  They were not sent the operator’s NOTAC or NTE and had only

generic training on con rming that “doors, panels and latches are closed and secure”.

Operator Safety Actions

Flybe…

…subsequently revised NTE 22 post-incident to introduce a procedure where a sticker is

placed over the bottom of the panel, when it is closed post-maintenance. This provides

visual and tactile con rmation to the engineer that the panel is correctly closed and

secured. Two further NOTACs (63/16 and 64/16) have subsequently been issued by the

operator, to provide speci c guidance in identifying correct panel and door closure during

the predeparture inspection and to highlight the engineering requirement to use a sticker

over the engine access panel to con rm correct closure.

Manufacturer’s Safety Actions

Bombardier issued AMM Temporary Revision 71-197, which now gives instructions on how to

close the engine nacelle access door.  It is also developing a modi cation to add a placard

which provides pictorial guidance.

AAIB Analysis and Safety Recommendations

The engineers conducting the maintenance daily check prior to both incidents were

experienced and well trained sta , who had safely completed the same task many times

during the years preceding these incidents. They came from di erent companies, with

separate training organisations and operated at di erent airports.

No signi cant contributing factors were identi ed which di erentiated these two incidents

from any previous occasions that they had completed the same task successfully. The only

apparent common links were the technique used to close the panel, the physical

positioning of the engineer as this was done and the lighting conditions at the time.

The fact that the engineers were then looking down on the panel, which was predominantly

illuminated by the beam from a head torch, meant that the main indication of the gap at

the bottom of the panel was only visually identi able by the shadow that was cast. As the

surrounding panels were painted purple this may not have been obvious, particularly

considering that the engineer was not expecting the panel to be open once the latches were

closed, was not speci cally checking for the presence of a shadow, and may not have

appreciated the implication of the presence of a shadow in this position.

If ight crew are not shown the di erence between correctly and incorrectly closed panels,

misunderstandings such as the belief that closed latches con rm the panel is secure can

become accepted custom and practice, and incidents such as this may continue to occur.

The AAIB raised the following Safety Recommendation:

 Safety Recommendation 2017-014: It is recommended that Flybe introduces de ned

and consistently delivered  ight crew training on pre-departure inspections for the DHC-8-

402 (Q400), compliant with the inspection procedure documented in its Operations

Manual. This should include a practical element on the aircraft and a demonstration

of correctly secured main engine access panels.

Inspection by the ramp sta :

…should only be considered a gross check and cannot be relied upon to address issues

such as closed but incorrectly secured panels. However, there is potentially some bene t to

the operator in increasing general awareness using speci cally targeted guidance

information relating to safety issues.

The AAIB raised the following Safety Recommendation:

Safety Recommendation 2017-015: It is recommended that Flybe considers introducing

a means of disseminating pertinent safety information to ground operations sta in an

appropriate format.

UPDATE 12 February 2019: A Jazz Dash 8 Q400, C-GGMU, lost a panel on take o

from Toronto-Pearson International Airport (CYYZ) on 25 January 2019.

During the takeo from CYYZ, the left-hand engine cowl door separated from the nacelle

and struck the left wing leading edge, causing damage to the de-icing boot.

…maintenance had performed a pre- ight inspection before the departure from CYYZ,

which included engine oil quantity checks in the area of the missing cowl.

Other Safety Resources

BA A319 Double Cowling Loss and Fire – AAIB Report
BA A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update
ANSV Report on EasyJet A320 Fan Cowl Door Loss: Maintenance Human Factors
Tiger A320 Fan Cowl Door Loss & Human Factors: Singapore TSIB Report
United Airlines Su ers from ED (Error Dysfunction)
James Reason’s 12 Principles of Error Management
Back to the Future: Error Management

UPDATE 11 March 2018: EC120 Forgotten Walkaround

UPDATE 24 June 2018: B1900D Emergency Landing: Maintenance Standards & Practices  The

TSB report posses many questions on the management and oversight of aircraft
maintenance, competency and maintenance standards & practices. We look opportunities for

forward thinking MROs to improve their maintenance standards and practices.

UPDATE 25 August 2018: Crossed Cables: Colgan Air B1900D N240CJ Maintenance Error  On

26 August 2003 a B1900D crashed on take o after errors during ying control maintenance.

We look at the maintenance human factor safety lessons from this and another B1900

accident that year.

UPDATE 16 October 2018: Russian o cals have attributed to procedural failure the loss of

an engine door on a Bombardier Q400 shortly after departing Vladivostok.

Rosaviatsia…says the nature of the locks enabled a “false” closure, and that the work –

performed in low light – was not subsequently checked. Nor was the oversight detected

during the preparation of the Q400 for departure.

Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance

Observation Program (MOP) requirement for their contractible BARSOHO o shore helicopter

Safety Performance Requirements to help learning about routine maintenance and then

to initiate safety improvements:

Aerossurance can provide practice guidance and specialist support to successfully implement

a MOP.

Aerossurance is pleased to sponsor the 9th European Society of Air Safety Investigators

(ESASI) Regional Seminar in Riga, Latvia 23 and 24 May 2018.

Aerossurance is pleased to be both sponsoring and presenting at a Royal Aeronautical Society

(RAeS) Human Factors Group: Engineering seminar Maintenance Error: Are we learning? to be

held on 9 May 2019 at Cran eld University.

Aerossurance has extensive air safety, operations, airworthiness, human

factors, aviation regulation and safety analysis experience.  For practical
aviation advice you can trust, contact us at: enquiries@aerossurance.com
Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates.

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