Hello All,

On November 30, 2018, an Airbus A320-214 operated by Frontier Airlines lost the fan cowl doors of engine no.2 upon takeoff from Las Vegas-McCarran International Airport, Nevada, USA. This incident was at least the 45th fan cowl door loss event involving an Airbus A320-family aircraft.

A common safety issue among these incidents is the fact that the cowl doors were not closed and latched following maintenance. This was not detected by the engineers, or by flight crewmembers during the walk-around check. 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.

Investigation reports into these incidents have found a multitude of human factor disturbances to be the main contributing factors. Fatigue, Pressure, Distractions, Compliancy and Back Check inspections not accomplished.

In 2010 Gary Burch of Crucial - Knowledge, developed a CBT program entitled “Remember to Close the Latches” in response to this human error failure which is still pertinent today.
Gary stated that the NTSB, Airbus, FAA and Transport Canada continue to hammer out defenses against the ongoing problem of in-flight fan cowl loss incidents due to latches being left unlatched. Since 2001, there have been 33 fan cowl loss incidents involving Bombardier CL-600 aircraft, with six incidents in 2007 alone. This 15-minute video provides methods and techniques to help all people remember the importance of assuring that the latches are closed.
Thank you Gary for allowing readers of our newsletter to view this training CBT free of charge. Once your on the Crucial - Knowledge website, you will see an announcement for HFIndustry News readers to CLICK onto the CBT. Use guest for the ID and Howdy for the password.

http://www.crucial-knowledge.info/index.htm

Click here for issue 23

Be Safe in the Region of Risk

Roger Hughes

Decoding Human Factors, LLC