Earlier this year in June, the Air Accidents Investigation Branch released an anniversary statement for the incident of a British Airways Boeing 787-8 which suffered a collapsed Nose Landing Gear at London’s Heathrow Airport. And then finally, on November 3rd, the investigative body published the final report on the incident. Let’s take a look at what the report details.
When did the incident happen?
The incident happened on June 18th, 2021, when the majority of borders worldwide were still relatively closed off and several carriers were operating flights that carried more passengers than cargo. British Airways was an example, as on the morning of the eventful day, the flag carrier had one of its Boeing 787-8 Dreamliner aircraft loaded with cargo for a flight to Frankfurt International Airport.
Registered as G-ZBJB, the aircraft was the very first Dreamliner ever delivered to British Airways. Unfortunately, the aircraft was producing three fault messages associated with the Nose Landing Gear doors on the day of the incident. So while the cargo was being loaded and the flight crew was preparing the aircraft for flight, the ground maintenance team was working simultaneously to address these messages.
The maintenance personnel used the Dispatch Deviation Guide, essentially a guidance document published by the aircraft manufacturer to assist airlines in developing procedures required to operate the aircraft in non-standard configurations. According to the Dispatch Deviation Guide, rectifying the faults could be deferred to a later date only if the landing gear was recycled to confirm the Nose Landing Gear doors functioned correctly.
But what does this mean? Essentially, the Dispatch Deviation Guide asked the maintenance personnel to cycle the Nose Landing Gear selection level with hydraulic power applied to the aircraft. The procedure required downlock pins inserted in the nose and the main landing gear locks to prevent the landing gear from retracting during the cycling process.
What went wrong?
It was during the insertion of the pins that things went very wrong. According to the Air Accident Investigation Branch, the Nose Landing Gear downlock pin was incorrectly inserted in the downlock link assembly apex pin bore instead of the downlock pin hole.
Due to this incorrect insertion, the Nose Landing Gear retracted when the lead engineer pushed the lever up. As an unfortunate result, the nose of G-ZBJB struck the ground, and the lower front section of the aircraft suffered significant damage. The co-pilot and a member of the cargo loading team suffered minor injuries.
While the fault did lie in the maintenance team for not inserting the Nose Landing Gear downlock pin correctly, the Air Accident Investigation Branch determined that the design of the aircraft’s Nose Landing Gear downlock assembly had created a vast opportunity for error.
The investigative body determined that the design saw two holes in such close proximity that the pin had a higher risk of being inserted in the incorrect location.
Could the incident have been prevented?
Although the damage suffered by G-ZBJB was unfortunate, the Air Accidents Investigation Branch has determined that the incident could have been easily prevented if British Airways had considered the risks to personnel safety more significantly. The investigative body also decided that, albeit human error can never be erased, there are always preventive measures to reduce the risk.
The conclusion came as, before the incident, the Air Accidents Investigation Brand had already issued an Airworthiness Directive and Service Bulletin, with a three-year compliance period. Even though British Airways had initiated the remedial action, the completion of modification across its Boeing 787 fleet was consistently put on hold and deferred due to the ‘economic impact of the pandemic.’
Given the consistent delay in remedial actions from the oneworld alliance member airline, G-ZBJB remained unmodified, which contributed to the cause of the incident. In its report, the Air Accident Investigation Board said:
“If greater consideration had been given to the risks to personnel safety – which was clearly highlighted in the directive and service bulletin – the operator might have escalated the priority for the modification.”
Have things improved since then?
The Air Accidents Investigation Branch was pleased to report that British Airways has since completed all the necessary modifications to its Boeing 787 fleet, as it accelerated the process after the incident of G-ZBJB. The flag carrier also reviewed its internal procedures for assessing directives and service bulletins more effectively to identify health and safety risks efficiently.
Other preventative steps have also been adopted. For example, British Airways did have a Safety Management System in place during the time of the incident, but its maintenance organization did not, due to the lack of legislated requirements. Fortunately, the airline is beginning to implement a system for maintenance, especially since the UK Civil Aviation Authority had proposed that such introductions be made mandatory by the end of this year.
- IATA/ICAO Code:
- Airline Type:
- Full Service Carrier
- London Heathrow Airport, London Gatwick Airport
- Year Founded:
- Airline Group:
- Sean Doyle
- United Kingdom
- Stock Code:
- Date Founded:
- Dave Calhoun
- Headquarters Location:
- Chicago, USA
- Key Product Lines:
- Boeing 737, Boeing 747, Boeing 757, Boeing 767, Boeing 777, Boeing 787
- Business Type: