Aircraft Accidents and Quality

Recently an airline in Europe had dispatched an Airbus with both its engine cowls unlocked; the aircraft took off, shed the two sets of cowls, and then declared an emergency before returning to the airport of origin with wing damage and an engine fire.
When the investigation was over the findings were indicative of a perfect example of system failure; the mistakes were blinding, the errors simple and repairable. To anyone who worked inside the airline industry, the recommendations should have been as simple and effective as the idiom, “once bitten (burned), twice shy”.
You would think.
Unfortunately the occasion was missed. The mistakes made were glaring; the recommendations-to-be-made vital to safety, speaking not only to the industry’s practices, but to the airline’s distinct problems. So why would this opportunity at positive change be lost. It is my feeling that the investigatory branch may have the pulse of operations and engineering, but just as with the NTSB, they don’t understand airworthiness issues. More importantly, they do not understand maintenance cultural issues.
And that will prevent them from being effective.

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