Will air safety in Australia be reformed promptly, or after a disaster? November 3, 2009 – 5:11 pm, by Ben Sandilands
Two safety critical issues arose today, in Crikey reports about a Qantas 767 descending too low with its wheels up as it approached Sydney last Monday, and about the informal relationship between Qantas and CASA and shoddy foreign maintenance.
They raise again the question as to whether the public administration of air safety in Australia is going to be reformed promptly, or after a major crash?
The Cityflyer incident , which occurred on a Melbourne-Sydney 767 appears to be unprecedented in a modern jet airliner in terms of triggering a Ground Proximity Warning System alert telling the pilots, who have been stood down, that they were flying the jet too close to the ground without the wheels down.
The pilots realised what was happening before the warning went off, and had firewalled the throttles and commanded flap changes in a go-around procedure, but at 700 feet and dropping, the jet continued to descend before responding to their inputs.
Just how low it descended will be determined by the ATSB, which is investigating the event as a ’serious incident.’
There is an interesting clue about the sequence of events in this statement issued by Qantas this morning:
This was an extremely rare occurrence but one we have taken seriously. The flight crew knew all required procedures but there was a brief communications breakdown. They responded quickly to the situation and instigated a go around. The cockpit alert coincided with their actions. There was no flight safety issue.
The incident was reported to the ATSB and the pilots were stood down. We are supporting the ATSB’s investigation and our own investigations will determine what further action might be warranted.
The reference to a ‘brief communications breakdown’ in intriguing. What the hell was going on in the cockpit of a 254 seat jet flying the premier domestic route in Australia to cause it to end up sinking toward the tarmac, wheels up and engines screaming, seconds from what could have been an extremely ugly crash?
Qantas is responsible for the flying standards and culture of the airline. No ‘ifs’ or ‘buts’. Why has this failure of standards occurred? Was it mechanical, or was it in the piloting? Qantas management and its directors are responsible for both.
It can be argued that standards at Qantas, and the degradation of its once unquestionable safety culture, became apparent in 1999 when the QF 1 service to London ploughed into a golf course off the end of a runway at Bangkok.
The use of full reverse thrust had been ‘trained out of’ pilots in order to save money through reduced wear and tear on the braking systems and wasted fuel. It was insanely stupid. Not even the lowliest carriers in the Asia Pacific hemisphere did such a wilfully dumb thing. The jet flew a crappy approach in bad visibility to the shorter runway at the Don Muang airport then in use, the captain told the co-pilot to go around, but then reached over and retarded three of the four engine throttles without telling him, resulting in a jet that didn’t know if it was landing or going around hurtling off the end of the runway at 89 knots.
What happened inside the jet in the next half hour was also a dismal farce, culminating in the appearance of the then CEO of Qantas, James Strong, on the Channel 9 Today show assuring the viewers that this was ‘a safety enhancing experience.’
It can be argued that since then Qantas has just been dead lucky, as necessary changes in work place practices and the emphasis on efficiency created a management culture that unfortunately seems to have also assigned lesser value to safety and standards.
Yes, the safety rhetoric remained. And CASA’s oversight of the airline deteriorated into the sort of informal relationships touched on by licensed engineers union federal secretary Steve Purvinas in the other Crikey story today.
Is there any room for informal reporting of safety matters between any airline and CASA? Given that there are formal procedures related to its obligations and processes, perhaps it is time to end the corporate capture of the safety regulator and enforce the rules, to the letter.
Has Flight Training suffered cuts along with the rest of the Airline? I wonder why is the mainline media so silent? Are they more concerned about "boat people" and the Melbourne Cup? Shocking.
At least the Qantas spin doctor/s don't appear to have claimed that the crew were not integral to the safe landing of the aircraft.
What the hell was going on in the cockpit of a 254 seat jet flying the premier domestic route in Australia to cause it to end up sinking toward the tarmac, wheels up and engines screaming, seconds from what could have been an extremely ugly crash?
Can someone take Mr. Sandilands up for a jumpseat ride and show him exactly "what the hell is going on".
Whilst I enjoy a lot of his articles which question airline management, service standards and other issues, I'd love to know what his flying background is, if any. His Plane Talking website doesn't give too much away.
The communications breakdown could have been anything, ATC, crew mis-hearing "gear" for "flap" (it has happened) or any number of things. They went round, the warning sounded, aircraft landed safely.
Yes, "the system" ultimately did work but I think the world needs to know why these drivers got themselves into the situation they did. Why should that not be questioned as well as what may appear to be a cosy arrangement between the airline and the regulator? One does not require to be a pilot to pose these questions - no wonder a lot of you have the scant respect of many in the airline industry. Do you think you are deities and therefore enjoy infallibility?
I think that some people miss the point. It's not a matter of whether it was Qantas, Jetstar, Virgin, Emirates or any other airline, these things DO happen. Should they happen? No. This is why there are always back-up procedures. The question should always be WHY did it happen, and HOW can we avoid this in the future. Witch hunts and sniggering at individual airlines doesn't really help anybody, most professional pilots would breathe a sigh of relief and thank god it wasn't them this time and wait to see what they can learn. Everybody makes mistakes.
I cant recall exactly (and they have taken out the very specific mode/warning triggers from the 767 ops manuals)
this is unlikely given QFs stable approach criteria,
...but could it have been no landing flaps (ie they had forgotten to select flap 30) so they commenced a go around, during the go around as gear was retracted the gpws was activated. (I know sometimes in the sim you can get the spurious warnings as things take their time to retract).
Whatever happenned to managing safety and reducing incidents/accidents to a level 'As Low As Reasonably Practicle' ??
If Mr Sandilands wishes there to be nil incidents ever within aviation, someone had better advise him that 'all aircraft need to be grounded immediately and indefinitely'.
The interphase between humans and technology will always present challenges, and incidents are part and parcel of life in every industry.
The true test of QF`s safety standards appears to be on track.I emphasize the word appears because just like Mr Sandilands,I do not know every single detail of the incident. However,
The incident has been reported.
The pilots stood down pending an investigation (stood down and not sacked) which is the correct approach, not sack them and then investigate.
Obviously back-up measures,training and S.O.P's did prevent a serious outcome from occurring.
So although the incident mentioned is not an ideal occurence to have take place, the way in which QF conducts its internal investigation and mitigates is what will truly test their commitment to safety.
"Yes, the safety rhetoric remained. And CASA’s oversight of the airline deteriorated into the sort of informal relationships touched on by licensed engineers union federal secretary Steve Purvinas in the other Crikey story today."
"Is there any room for informal reporting of safety matters between any airline and CASA? Given that there are formal procedures related to its obligations and processes, perhaps it is time to end the corporate capture of the safety regulator and enforce the rules, to the letter."
One sensationalist reporting on another sensationalist reporting on a rumour whispered to him by unionist.
Now there's a sound basis for a witch hunt. What next Mr Sandilands, "How speed cameras are ripping off motorists", "Top 100 hundred suburbs for your real estate dollar", "Do beauty creams really work".
Skip - 'Let alone on an RPT flight full of unsuspecting punters fat, dumb and happy coz they believe buying a QF ticket assures they'll arrive in one piece.'
Isn't that what happened? It was because of the crew's ability to react in a timely and efficient manner that led to this occurrence being successfully resolved. What the details are that led to the aircraft and crew being in less than optimum landing configuration is yet to be determined.
I dont particularly like QF as an airline but I do have respect for their flight crews and the safety attitudes of the crews. What went wrong? I dont know but I do not think that we should hang people to out to dry just because they fly for QF and before the FACTS are known.
It is easy to judge, blame and convict sitting here at a keyboard. I am unaware of any positive lessons being learnt by doing so though.
Didn´t know the 767 has a firewall!!! Maybe they meant pressure bulkhead but got confused...is it a Cessna or a Boeing?....ah what the hell... Plus on a normal go around the autothrottle commands for a 2000fpm climb, seldom requiring full EPR. Someday they will get it right?