§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. MacKay.]
§ 11.2 pm
§ Mr. David Wilshire (Spelthorne)
The matter that I wish to raise tonight is the Department of Transport air accident report 3/93, which is a terrible tale of human error by a ground engineer and what I can only describe as selfish attempts to avoid personal inconvenience by a pilot.
One of the results of all that was that my constituents were exposed to the catastrophic consequence of an aircraft crashing during an emergency landing at Heathrow airport. Mercifully, that did not happen, but if one reads the report, it appears to have been a pretty close run thing.
Although I readily accept that my constituents are not the only people living near Heathrow, they are always probably more concerned than most, because the last crash near Heathrow was at Staines in my constituency and that memory lives on in the collective consciousness of the people whom I represent.
I raise this matter in the House tonight because the report exposes loopholes in the current safety procedures and contains recommendations for Government action to close them. If those recommendations were implemented, the risks faced by tens of thousands of people living near Heathrow would he significantly reduced. I am therefore making no apologies for using every avenue open to an hon. Member to press the Government to take immediate action.
The facts of the matter are complex and highly technical. The report itself runs to 31 pages, plus highly technical drawings and graphs. I will try to summarise them as briefly and simply as I can, but I fear that that will not be easy.
On 7 March 1992, while landing at Heathrow, the pilot of a Lockheed TriStar belonging to West Indian Airways found that he could not get reverse thrust on his No. I engine. The airline's duty ground engineer correctly identified the problem at Heathrow as being caused by the reverser's cowl being jammed. As is permitted by internationally approved maintenance and safety procedures, the ground engineer disconnected the cowl and manually secured it in the in-flight mode. At that time, the relevant regulations permitted that aircraft to be operated in what I can only describe as a botched-up state for up to 10 days. Needless to say, things have changed since that accident. Having made those temporary adjustments, the ground engineer released the aircraft to fly to Trinidad. Unfortunately, and unknown to that ground engineer, in solving the immediate problem that he faced, he had created new ones which ultimately resulted in parts falling off the aircraft while it was in flight. Prior to releasing the aircraft at Heathrow, the ground engineer telexed the airline's home base in Trinidad, asking it to carry out further checks on the problem. However, by the time the aircraft reached Trinidad on 8 March, the airline's maintenance staff had been diverted to a much more serious problem on another of its TriStars. As a consequence, the TriStar from Heathrow remained unrepaired and was pressed into service as the replacement aircraft for a Trinidad to New York flight.
422 The airline's maintenance staff were still distracted when the aircraft returned to Trinidad from New York; that was still on 8 March. It was therefore allowed to fly to Frankfurt without any of the inspections or repairs being carried out. The original ground engineer from Heathrow did, however, carry out further work on the TriStar at Frankfurt and then released it to fly to St. Lucia on 9 March. Shortly after take-off, parts of the cowl fell off, causing damage to the aircraft.
That is the background. Complicated though it is, I hope that I have managed to summarise it accurately. I now refer to the air accident itself. The TriStar took off from Frankfurt for St. Lucia at 14.35 on 9 March 1992. The air accident report describes what happened next. It states:As it"—the aircraft—climbed through Flight Level 100 there was a thud, accompanied by what appeared to be a compressor stall, and the aircraft shuddered".A few moments later, as the report explains,there was a slight vibration and a passenger reported having seen… 'something come off the engine'. About four minutes after the initial accident, the commander shut down the No. I engine.At that point, as the report makes clear, an immediate landing was not necessary. The report goes on to explain what happened next. It states:As about 106,000 lb. of fuel would have to be jettisoned to reduce the aircraft's weight to the maximum permitted for landing, a procedure which he (the commander) estimated would take at least 30 minutes, the commander decided to divert to London Heathrow Airport, as this was the company's main European maintenance base.The commander subsequently carried out checks and concluded, correctly, that the thrust reverser translating cowl had come off and, incorrectly, that there was no other damage. However, the report reveals that the left wing suffered superficial damage while the left horizontal stabiliser suffered severe damage. At 15.20, the commander reported his situation to air traffic control on the Dover section and obtained clearance to dump fuel over the sea and to divert to Heathrow. The controller asked the commander whether he wished to declare an emergency. The cockpit voice recorder reveals the reply from the commander of the aircraft asNo, I don't think so. We'll be all right.The report, however, concluded that an emergency already existed despite the statement made by the commander of the aircraft and that that emergency became more severe as subsequent events unfolded. The voice recorder in the aircraft also revealsthat the commander's decision not to declare an emergency was largely based on the inconvenience which would consequently be experienced by him and his crew after they had landed, rather than the condition of the aircraft.That is a damning thing to find in such a report.
A short time later, the commander became concerned about the way in which the fuel was being jettisoned and therefore stopped the process. Some time later, it was recommenced. A little later again, a passenger reported that there was damage to the left horizontal stabiliser. He had noticed it at the time of the initial incident but believed that it was now becoming worse. Noting this information, and the length of time being taken to jettison the fuel, at 15.51 the commander requested an immediate landing at Heathrow.
423 Ten minutes before touchdown, the commander was requested to divert to Stansted. The report records that episode as follows:For operational reasons, BAA would have preferred the aircraft to land at Stansted.The air traffic controller therefore told the commander:'there's a request from BAA at Heathrow that you divert to Stansted'.The report continues:The commander replied that he would prefer to continue to Heathrow …Recorded flight deck conversation indicated that the commander thought that the reason was because the aircraft had lost part of its engine structure and BAA was concerned about it overflying a large built-up area.My researches suggest that the report may be covering up an even worse truth—hearing in mind the fact that the truth revealed by the report is pretty shocking anyway. I have been told that Heathrow's airfield operations department asked air traffic control to request the commander to divert to either Manston or Stansted for the following three reasons, and not just for the one quoted in the report. First, if the aircraft's controls and braking system were damaged and if it were overweight, it might need the longest possible runway to stop, and that happens to be Manston. Secondly, Heathrow landings on the day in question were to the west, involving a long approach over densely populated west London. Thirdly, if a runway at Heathrow were closed as a result of the landing, air traffic in much of western Europe could be disrupted; in that case, it would make sense to use a quieter airfield such as Stansted.
At 16.04, when the aircraft was at 4,000 ft and 18 miles from touchdown, it appeared to develop landing gear problems. That took the crew's mind off fuel dumping, which was still going on. As a result, the aircraft reported passing a marker just 7 miles from touchdown—in other words, right over the densely populated area of west London—and at less than 2,000 ft while still dumping fuel. However, regulations prohibit the dumping of aviation fuel at less than 7,000 ft in winter or 4,000 ft in summer.
Happily, a safe but overweight landing took place at 16.10, but not before Heathrow staff had decided to declare a full emergency, despite the commander's refusal to do so. As a result, Heathrow police called in the air accident investigation branch, which produced the report that we are considering tonight.
The report was published on 9 June, some 15 months after the incident. It contains two formal recommendations: first, that commanders be told why requests for diversion are made; and, secondly, that those selecting emergency routes for aircraft in such circumstances should make the avoidance of densely populated areas a primary consideration. I agree wholeheartedly with both those recommendations and ask my hon. Friend the Minister to assure the House that the Government not only accept them but intend to implement them immediately. Nothing less will reassure my constituents.
If my hon. Friend thinks that this is the point at which he can give that assurance and we all go off for a night cap, he is mistaken. Unfortunately, the matter raises other points on which I wish to press him. The first point is the shortcomings revealed in two written answers to my questions about the report. Those answers revealed that copies of such reports are sent to the Library of the House onlyin the event of accidents and incidents likely to attract considerable public interest".—[Official Report, 22 June 1993; Vol. 227, c. 99.]424 I wonder, therefore, whether my hon. Friend could tell us his definition of "considerable public interest". Does he consider a "considerable" number to be the hundreds of thousands of people who live under the flight path of this aircraft and who had highly flammable aviation fuel dumped on their houses and gardens? I certainly do. Since only three reports were issued in 1991 and only six in 1992, it is not asking much for the Government to deposit copies of all air accident reports in the Library. It would not add much to their work load.
Copies of reports are sent only to those hon. Members who show an interest in the interim bulletin. Perhaps my hon. Friend the Minister could tell us how we are supposed to show interest if we are not told about the existence of an interim bulletin. I should be fascinated to know how we are supposed to do that. Surely it is not beyond the ability of my hon. Friend's extensive and highly paid staff to identify the local Members in such an incident and see that they are properly briefed. As the representative of 70,000 people who were put at risk by this accident, I believe that I have the absolute right to be kept informed. However, I was left to read about the report in the national press several days later.
The second point that concerns me is the Government's failure to notify the local press. I regret having to tell my hon. Friend that, despite the enthusiasm of his publicity department to brief the national media and journalists based many miles from Heathrow, it failed to brief my local newspapers. I hope that that failure was nothing more sinister than an accidental oversight. Kim Chapman, the editor of my oldest local newspaper—the Staines and Ashford News—asked me to tell my hon. Friend that she is absolutely furious. Perhaps in time someone will apologise to her for not sending a copy of the report.
The third point is the need to review the hours worked by and the qualifications of ground engineers. The report revealed that the ground engineer who made the temporary repairs to the aircraft worked on it for 12½hours at Heathrow on 7 March. He then worked on other planes at Heathrow for five hours on the morning of 8 March before flying to Frankfurt and spending a further nine and a half hours repairing the offending aircraft. I make that a total of 27 hours work, plus travel, in only two days. We should not, therefore, be surprised that some errors of judgment occurred.
The report says that the ground engineerallowed himself to operate beyond his own knowledge of the aircraft and, because of misunderstandings, beyond what was permitted …(he) did not recognise the structural or procedural significance of the disconnections …made in the reverser.The report also criticises the engineers at the airline's main base in Trinidad for failing twice to carry out the inspection requested by the ground engineer at Heathrow. Does my hon. Friend the Minister agree that those matters and the two recommendations in the report need urgent attention?
The fourth point is the low-level dumping of aviation fuel over London. If anyone stops to think about it, the implications of that are horrendous. Large quantities of highly flammable and toxic liquid were released at very low levels over a densely built-up area. In the circumstances, does my hon. Friend agree that air traffic control should be required to insist on a diversion to 425 another airfield when such dumping may clearly become necessary? If so, will he issue immediately the necessary instructions to air traffic controllers?
The fifth point is the question of taking action against pilots who wilfully endanger—I choose my words deliberately—life for their convenience or the commercial convenience of their employers. In case that sounds somewhat strong, I quote again from the report. The report says:the crew decided not to declare an emergency because they believed they would have to undergo medical checks and would not be able to operate the following day.One needs to let that sink in.
The report also states that the commander requested to go to Heathrowas all of their facilities were there … Meanwhile the flight engineer consulted Air Canada, the handling agent, who were adamant that the aircraft should come to Heathrow.The House and the Minister will note the absolute and complete absence of any safety considerations whatever in those two statements. I cannot help wondering whether that constitutes grounds for legal action against the commander and/or the airline. If it does not, I believe that it should and that the law needs changing. I urge the Minister to do something about it.
My last comment is on the misleading comments in the report about the request to divert to Stansted. The report says:BAA would have preferred (the aircraft) to land at Stansted Airport; the reason was that, had it been necessary to close a runway after the aircraft had landed there would have been less disruption to traffic flow".As I have already explained, my research reveals that that was but one of three considerations leading to a request to divert and that two airfields were considered by BAA.
I hope that my hon. Friend the Minister agrees that the report, as written, invites us to conclude that Heathrow airport staff—who could well have been my constituents—concerned themselves only with delay and disruption at Heathrow on this occasion. That is grossly unfair because the airport is clearly worried about passenger safety and public risk. I believe that the record should be put right. Will my hon. Friend take steps to have that erroneous impression of Heathrow staff rectified?
Through you, Madam Deputy Speaker, may I thank Madam Speaker for allowing me the opportunity to raise all these issues. I thank my hon. Friend the Minister for giving up a little of his beauty sleep to listen to me and to reply. I hope that I have persuaded him and the House that the matters that I have raised are deeply worrying and potentially raise issues of life and death for those whom I represent.
My constituents and I accept that eliminating all risk for those who live near Heathrow is beyond the scope of all human endeavour. However, we at Heathrow believe that we have the right to expect that everything possible should be done to reduce all the risks to the lowest possible level. The report reveals a catalogue of avoidable risks. Happily, it goes on to identify ways of getting a little closer to the perfection that we all seek. Therefore, I beg my hon. Friend the Minister to act and to act quickly.
§ The Minister for Transport in London (Mr. Steve Norris)
I congratulate my hon. Friend on his good fortune in having obtained this debate on an issue which I know that he takes seriously, and which the Government acknowledge is important. Air accident report AAR3/93 which led to the debate demonstrates clearly the international nature of aviation. The essence of the incident was that a part of one of the aircraft's thrust reversers became detached and damaged the tailplane before falling to the ground soon after take-off from Frankfurt. The aircraft, which was registered in Trinidad and Tobago, diverted to Heathrow, where the company had significant maintenance facilities available. Although the failure occurred over Germany, it was agreed with the German authorities that the investigation would be carried out by the UK's Air Accident Investigation Branch because the aircraft was available for inspection in London.
Although the accident report properly deals largely with the technical problem, it also highlights two important points about air traffic control advice to, and routing of, aircraft in emergency situations. It is understandable that there is public concern to minimise the risk to people on the ground. Safety is always the first priority.
I should make it clear that in the United Kingdom the regulation of civil aviation safety is a matter for the Civil Aviation Authority. Indeed, the Secretary of State's letter to Christopher Chataway setting out the CAA's objectives when he was appointed chairman of the CAA in 1991 makes it very clear that safety is the responsibility of the CAA and that the Government do not intend to interfere in the discharge of those duties.
However, the United Kingdom is an active member of the International Civil Aviation Organisation, whose safety standards are accepted by virtually all countries. The United Kingdom recognises the adherence to these standards by foreign operators and in return British aircraft are accepted overseas. As a major aviation trading nation, the United Kingdom benefits greatly from this reciprocity and, of course, the communities around our airports share in the prosperity generated by international flights in and out of the United Kingdom.
Aircraft accidents in the United Kingdom are investigated by the Air Accident Investigation Branch of the Department of Transport. This organisation is deliberately separate from the CAA so that the regulators are not put in the position of having to judge the effectiveness of their rules and regulations. The AAIB is very widely respected in the aviation community. For instance, its painstaking reconstruction and report of the Lockerbie disaster has drawn worldwide acclaim.
In this case I can assure the House that the CAA has studied the AAIB's report carefully as it does in all such cases. In particular, I can report that the CAA has accepted the AAIB's safety recommendations and that supplementary instructions to air traffic controllers on the handling of aircraft in emergencies will be included in the manual of air traffic services within the next week.
The CAA has given this matter detailed consideration in formulating its response to the safety recommendations. It has been careful to avoid taking away responsibility from the aircraft commander, while giving him all possible assistance in an emergency. It is important not to increase 427 the pilot's workload at a critical time. It is also important to avoid circumstances which might dissuade pilots from declaring emergencies when they should do so.
In response to the AAIB recommendations in respect of this accident the following instructions and advice will be issued for handling aircraft in an emergency. When a pilot has declared an emergency and stated the aerodrome to which he wishes to proceed, controllers will acknowledge this message. IF the controller is instructed to inform the aircraft that it is required or requested to divert to another aerodrome, the reason for this change should be established. The message, including the reason, will then be passed to the captain and his intentions requested.
It is desirable that aircraft in emergency should riot be routed over densely populated areas. If this is inconsistent with providing the most appropriate service to the aircraft, for example when any extended routing could jeopardise the safety of the aircraft, the most expeditious routing is the one that should be given. Where possible, suggestions of alternative runways or aerodromes which would avoid densely populated areas and be consistent with safety should be passed to the pilot and his intentions requested.
These instructions to air traffic controllers emphasise that the decision on whether to comply with advice or instructions to land at an airport other than his selected diversion lies with the captain of' the aircraft. It is stressed that the captain has ultimate responsibility for the safety of his aircraft. The controller will do everything he can to assist the aircraft commander, but the latter is in the best position to judge the hazard to his aircraft. He has that ultimate responsibility. That is an internationally accepted principle and it is one from which it is difficult to resile.
In this case, the aircraft commander's decision to proceed to London was reasonable, given that he was initially unaware that the separated part had damaged the tail. Also it provided the time to reduce the weight for landing and meant that rectification would be easier. His reluctance to declare an emergency, even when he became aware of the tail damage and asked for an immediate approach into Heathrow, is a matter which has been brought to the attention of the state registry and the international aviation community by the AAIB's comprehensive report. Fortunately, the air traffic controller took the initiative to treat the flight as an emergency, and all facilities were on standby at Heathrow, where the aircraft landed safely. The controller concerned is to be congratulated.
The unfortunate feature of this incident was that the aircraft continued to dump fuel until a few minutes before landing. As my hon. Friend said, it is normal practice for responsible airlines, when fuel must be jettisoned to avoid an overweight landing, to do so above 5,000 ft. From such 428 heights the fuel dissipates and evaporates. In addition, air traffic control tries to arrange for dumping to occur over the sea, if possible. Regrettably, the aircraft in question had difficulty in jettisoning fuel. In the event. it made an overweight landing, albeit safely.
I have no wish to suggest that this was other than a serious incident—the fact that it was the subject of a formal United Kingdom investigation emphasises this point—but I want to put matters in perspective. Since January 1988 there have been only 11 occasions on which objects falling from aircraft have been reported as causing any damage to property. There are no records of any third party having been injured or killed. This is in the context of about 1.25 million air traffic movements handled by the London air traffic control centre in 1991–92.
My hon. Friend raised one or two other points on which I should like to comment. He correctly identified the questions that have been raised about the role of the ground engineer. He will appreciate that the report did indeed spell out a number of inconsistencies in the way in which the ground engineer operated. He was right to draw attention to the seriousness of the issues raised. These have been highlighted in the report. On the matter of the briefing provided to his local media and to himself, I should say that aircraft accident reports are specialised reports with a high technical content. They are of interest principally to the aviation community. They are preceded, soon after the event, by a bulletin that sets out the essential facts but draws no conclusions.
On the day of publication of the final report a press notice is issued. Copies of AAIB reports are sent to the Library in the event of accidents thought likely to attract considerable public interest. These are normally fatal public transport accidents, such as those at Lockerbie and Kegworth. Our understanding is that numerous copies of this press release were sent to both national and local media. My hon. Friend was kind enough to suggest that his local radio station discovered its copy in the wastepaper basket. I can only say that my Department is clear about the fact that it issued the reports to as many people as possible. If my hon. Friend is concerned, I shall discuss with him afterwards ways in which his keen interest in affairs at Heathrow can be translated into his receiving more regular reports.
This is an important incident, and I am grateful to my hon. Friend for giving me an opportunity to set out some of the background to it.
§ The motion having been made after Ten o'clock and the debate having continued for half an hour, MADAM DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at twenty-eight minutes to Twelve o'clock.