Incident Investigation
Llanbury Consulting is available to run or participate in any aviation incident/accident investigations.
They have considerable experience in a wide range of investigations, with significant experience in both ATC and engineering maintenance related incidents.
State investigations where Andrew Rose has participated in the investigation:
Runway Incursion at Paris CDG. Investigation still in progress with the AAIB & BEA.
Power failure leading to instrument failures. Investigation still in progress with the AAIB.
Interim AAIB special bulletin: http://www.aaib.gov.uk/cms_resources/Special%20S2-2005%20G-EUOB.pdf
Airprox and TCAS event in French Airspace. Investigation still in progress with the AAIB & BEA.
Fuel panel left off during maintenance resulting in significant fuel leak on departure. Investigation still in progress with the AAIB.
Interim AAIB special bulletin: http://www.aaib.gov.uk/cms_resources/dft_avsafety_pdf_030051.pdf
The incident to the Boeing 757 aircraft occurred on the first flight following a 26-day major maintenance check. Shortly after takeoff on a scheduled passenger flight from London Heathrow to Paris, a hot oil smell, that had been present in the cockpit on engine startup, returned. The flight crew donned oxygen masks and immediately diverted to London Gatwick Airport. During the autopilot-coupled ILS approach to Gatwick, the aircraft drifted to the right of the localiser after selection of Flap 30. When the autopilot was disconnected, a large amount of manual left roll control was needed to prevent the aircraft from turning to the right. It was necessary to maintain this control input until touch down. The aircraft landed safely despite these difficulties, with no injuries to any of the passengers or crew.
Final AAIB report: http://www.aaib.gov.uk/publications/formal_reports/3_2005_g_cper/g_cper___report.cfm
A large access door, measuring 4 x 6 feet and weighing 70 lb, detached from the aircraft shortly after takeoff from Gatwick Airport, causing substantial damage to two cabin windows and minor damage to the fuselage and fin. Fragments of the door penetrated into the cabin and large parts of it landed close to persons on the ground. It was likely that only one of the thirteen door catches had been fastened and that the door had suffered overload failure due to aerodynamic forces as the aircraft accelerated, allowing it to open and detach. Multiple walk-round inspections of the aircraft by different personnel had failed to detect the open catches. The inadequate fastening had apparently occurred during a routine maintenance check due to a deviation from standard procedures; a practice that reportedly had been fostered by features of the maintenance system and may have been commonplace. It appeared likely that the human performance factors evident in this event could be affected beneficially by improvements in the operator's maintenance and inspection systems. One safety recommendation has been made.
Final AAIB report: http://www.aaib.gov.uk/cms_resources/G-VIIA_3-05.pdf
Whilst in the cruise the crew began to feel some discomfort in their ears. This was shortly followed by the cabin altitude warning horn which indicated that the cabin altitude had exceeded 10,000 feet and this was seen to continue to climb on the cockpit gauge. At the same time, the primary AUTO mode of the pressure control failed, shortly followed by the secondary STBY mode. The crew selected the first manual pressure control mode, but were unable to control the cabin altitude. An emergency descent and subsequent diversion to Lyon was carried out. The failure of the pressurisation control system was traced to burnt electrical wiring in the area aft of the aft cargo hold. The wiring loom had been damaged by abrasion with either a p-clip or 'zip' strap that, over time, resulted in the conductors becoming exposed, leading to short circuits and subsequent burning of the wires. There was no other damage. The wiring for all the modes of operation of the rear outflow valve, in addition to other services, run through this loom.
Final AAIB report: http://www.aaib.gov.uk/cms_resources/dft_avsafety_pdf_029046.pdf
Whilst climbing through FL240 the flight crew noticed a small amount of smoke appear on the flight deck, accompanied by a smell of electrical burning. They decided to carry out a diversion but were hampered by difficulties in communications with the cabin crew and locating the appropriate checklist, since it was not clearly identified on the index page of the QRH. Fire damage had occurred to electrical wiring in the area of the 'drop-down' ceiling panel immediately aft of the flight deck door. A braided steel water supply hose to the forward galley had been attached by means of a simple electrical 'tie-wrap' to a wiring loom, and there was evidence of abrasion and arcing between the wires and the hose. This had resulted in the severing and shorting of a number of wires. It was determined that the hose was too long for this application and that the excess length had been looped through this overhead area and then secured by the tie-wrap to adjacent wire bundles. It was not conclusively determined when this had been done but it was most likely that the attachment was simply a short-term expedient while systems were being disconnected and disassembled, and that the error was then missed during reassembly.
Final AAIB report: http://www.aaib.gov.uk/cms_resources/dft_avsafety_pdf_029045.pdf
TCAS induced Airprox in Chinese airspace. Company investigation leading to the issuing of Airworthiness Directives in several states. Public report not available.