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detected by passengers and reported to the cabin crew. This information was not adequately transmitted to the flight crew, badly affecting flight crew decision-making. The left engine operated normally, with cowlings opened and no fuel leaks. On return to Heathrow the right engine caught fire and was shut down. The aircraft landed without further event and passengers disembarked through emergency exits. From takeoff roll to landing the time was nearly 24 minutes. See Figure 1 for open cowlings and emergency evacuation. The A319 accident report, published by the CAA Air Accidents Investigation Branch, is about 120 pages long. This was a maintenance accident because, for a multitude of reasons, the maintenance crew did not secure the cowlings. The ground and flight crews also failed to notice the unlatched cowlings, an issue that created numerous previous events on this aircraft type. Many of the maintenance actions leading to the event were associated with failure to follow procedures. They were working overnight on line maintenance. Lacking all necessary tools, aboard their truck, they postponed a service for later in the shift. Contrary to procedures, they left the cowlings opened and did not properly placard that condition in the aircraft. When they returned to the task, later in the shift, they went to the wrong aircraft. Noticing that the doors were closed they assumed that someone else completed the task. They double checked the work and closed the cowlings. The cowlings remained open on the first aircraft they had serviced. The report outlines a number of organizational procedural errors, committed on a regular basis at that location. Further, the report suggested that the work schedules of the maintenance crew left them prone to fatigue and associated errors. It is a report worth reading and noting the errors by mechanics, ground crew, cabin crew, and pilots. It is an ideal learning tool for any human factors class. Example 2: Eurocopter AS350, Near Las Vegas, NV, Dec. 7, 2011 The helicopter, on a sight-seeing tour with a pilot and four passengers, crashed about nine minutes after takeoff. It crashed THE VERSATILE HARLAN APV Harlan Trans-Con Model HTSBAPV Many options available: • Beacons • Hitches • Suspension-style seats www.harlan-corp.com +1-800-255-4262 sales@harlan-corp.com As a manufacturer of our own parts and components, we have the ability to customize parts as well as support parts beyond standard expected part life in the industry. FIGURE 2. Flight control assembly. Split Pin Swashplate Fore/aft Servo Servo Control Input Rod Washer Bolt Servo Control Input Rod Castellated Nut FIGURE 3. The work schedule affecting mechanic and inspector fitness for duty. Personnel Normal Shift Shift Originally Scheduled for Dec. 6 Actual Dec. 6 Shift Mechanic 1200 to 2300 Off Duty 0550 to 1846 Inspector 1200 to 2300 Off Duty 0550 to 1846