Reply To: Flight BA762 LHR – Oslo emergency landing

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Human Factors.

I recall, when at London Business School, having Sir Ian Gibson of Nissan Motor Manufacturing (UK) come along. He recounted the story of how an operative had wrongly allowed clutch fluid to be poured into engines and engine oil into the hydraulic systems on the Nissan Micra production line. They had to replace quite a few newly installed engines and hydraulic systems as a result.

Rather than just choose to blame the operative, Nissan chose to investigate how and why the incident could have occurred. The first point was that the line side storage area where the fluid drums were located was poorly lit so it was possible to fit the wrong nozzle to the wrong fluid drum. The next point was that the two nozzles were identical so they could have been fitted to either drum.

The answer was that Nissan (a) improved the storage site lighting and (b) redesigned the nozzles and drum fittings so that it was physically impossible to repeat the error.

If this is not a first with the engine cowl latches, is it not time for a redesign so that it is obvious that they are either open or closed?

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