King Air down at Essendon?
Join Date: Feb 2004
Location: brisbane
Posts: 80
Likes: 0
Received 0 Likes
on
0 Posts
MickG0105
We appear to have read an entirely different report, I was however mistaken about my assertion about the gear not being retracted. I apologise unreservedly for that.
The last time I read this report was approx 35 years ago, however I used it extensively as a trading aid, as we were operating B200's at that time, and I was C&T on type.
Fact a/c took off on 25
Fact a/c impacted 34 rock wall, as best I can recall, approx hdg 130, that turn was accomplished as a largely flat skidding turn as observed by ATC
Talk to ATC what they do when an a/c declares a Mayday, it may surprise you to learn that lots of qualified people pick up binoculars and watch intently. What they see, and subsequently give evidence about revealed a lot of what happened to this a/c. ATC observed the aircraft flying on approx reciprocal heading of 34, at a very low level, the pilot was granted approval to use any runway, he chose 34, he flew towards the threshold. The impact damage and trajectory was consistent with a sudden VMC, indications that the pilot pulled up to avoid the 6 metre rock wall. When on an approx parallel downwind heading the pilot chose to fly towards the rock wall, even though the flight path since EFATO had been downhill. I ask you a question MickG0105, "how was he intending to climb to clear the rock wall?"
ATSB were absolutely confounded as to how the left engine appeared to have suffered damage at impact consistent with it operating at stabilised idle. The conclusion was that the engine 'auto-ignited' after all water was exhausted by the windmilling engine.
The company were complicit in this accident, reduced power T/off's per see are not necessarily a bad thing, but the misunderstanding that in the event of an EFATO all bets are off. The auto feather not being used because of fleet standardisation.
The bottom line, this aircraft was capable of climb OEI if flown competently, in spite of high density altitude, and slight over gross.
My role as C&T on type was to ensure none of my crew bought the farm, I unashamedly used this report to,
1) highlight about just how well the B200 really climbs OEI, as discussed in excruciating detail in this report.
2) emphasise that EFATO drills in a timely manner will save your life.
Cheers Gazumped
The last time I read this report was approx 35 years ago, however I used it extensively as a trading aid, as we were operating B200's at that time, and I was C&T on type.
Fact a/c took off on 25
Fact a/c impacted 34 rock wall, as best I can recall, approx hdg 130, that turn was accomplished as a largely flat skidding turn as observed by ATC
Talk to ATC what they do when an a/c declares a Mayday, it may surprise you to learn that lots of qualified people pick up binoculars and watch intently. What they see, and subsequently give evidence about revealed a lot of what happened to this a/c. ATC observed the aircraft flying on approx reciprocal heading of 34, at a very low level, the pilot was granted approval to use any runway, he chose 34, he flew towards the threshold. The impact damage and trajectory was consistent with a sudden VMC, indications that the pilot pulled up to avoid the 6 metre rock wall. When on an approx parallel downwind heading the pilot chose to fly towards the rock wall, even though the flight path since EFATO had been downhill. I ask you a question MickG0105, "how was he intending to climb to clear the rock wall?"
ATSB were absolutely confounded as to how the left engine appeared to have suffered damage at impact consistent with it operating at stabilised idle. The conclusion was that the engine 'auto-ignited' after all water was exhausted by the windmilling engine.
The company were complicit in this accident, reduced power T/off's per see are not necessarily a bad thing, but the misunderstanding that in the event of an EFATO all bets are off. The auto feather not being used because of fleet standardisation.
The bottom line, this aircraft was capable of climb OEI if flown competently, in spite of high density altitude, and slight over gross.
My role as C&T on type was to ensure none of my crew bought the farm, I unashamedly used this report to,
1) highlight about just how well the B200 really climbs OEI, as discussed in excruciating detail in this report.
2) emphasise that EFATO drills in a timely manner will save your life.
Cheers Gazumped
ATSB were absolutely confounded as to how the left engine appeared to have suffered damage at impact consistent with it operating at stabilised idle. The conclusion was that the engine 'auto-ignited' after all water was exhausted by the windmilling engine.
Join Date: Jun 2006
Location: Australia
Posts: 1,186
Likes: 0
Received 0 Likes
on
0 Posts
The auto feather not being used because of fleet standardisation.
Moreover, Sod's Law says if an engine failure on take off occurs it will happen to an aircraft that has the Auto feather system available; but switched off
Join Date: Jun 2007
Location: SAYE
Posts: 281
Likes: 0
Received 0 Likes
on
0 Posts
auto feather not being used because of fleet standardisation...
It is indeed no simple task to write and implement SOPs, even more so in a fleet with different types. SOP have to be thought through. Unfortunately, many such [small] aircraft operators have SOPs that make no sense whatsoever and often go against the AFM and, against common sense.
Still, this does not excuse the PIC. The AFM/POH always takes precedence over SOPs.
Besides, the use of autofeather in King Air is a no brainer, according to the B200 check-list, AFM/POH, it has to be armed before every takeoff and before every landing.
Here are some excerpts of The King Air Book by Tom Clements. Every King Air pilot should take the time to read it.
[p. 212] A U T O F E A T H E R – W H A T A G R E A T S Y S T E M!
... the Autofeather system has become more prevalent and has proven itself to be trouble free, more and more pilots are realizing that this is a system that virtually cannot be over-used. I understand that a number of pilots are flying with the autofeather switch armed at all times. In my view, that is totally fine. However, my personal preference is to turn autofeather off in cruise when I am at an altitude that gives me plenty of time to analyze and troubleshoot any engine malfunction that may occur. On 90% or more of my flights, I leave the Autofeather switch Armed on the ground, during takeoff and climb, and during descent and landing. But during cruise, I usually turn the switch off for two very flimsy reasons. First, I like having a blank annunciator panel at this time. No big deal, I know, to have two green lights glowing, but I prefer the panel to be dark. Second, I know that I have lots and lots of time, at this high altitude, to think through a suspected loss of engine power and to make my own decision about whether I think immediate feathering is the best course of action. Just in case I decide to allow the propeller to windmill – perhaps to try for a windmilling airstart after I get down in thicker air below FL200 – I now have that option.
... the Autofeather system has become more prevalent and has proven itself to be trouble free, more and more pilots are realizing that this is a system that virtually cannot be over-used. I understand that a number of pilots are flying with the autofeather switch armed at all times. In my view, that is totally fine. However, my personal preference is to turn autofeather off in cruise when I am at an altitude that gives me plenty of time to analyze and troubleshoot any engine malfunction that may occur. On 90% or more of my flights, I leave the Autofeather switch Armed on the ground, during takeoff and climb, and during descent and landing. But during cruise, I usually turn the switch off for two very flimsy reasons. First, I like having a blank annunciator panel at this time. No big deal, I know, to have two green lights glowing, but I prefer the panel to be dark. Second, I know that I have lots and lots of time, at this high altitude, to think through a suspected loss of engine power and to make my own decision about whether I think immediate feathering is the best course of action. Just in case I decide to allow the propeller to windmill – perhaps to try for a windmilling airstart after I get down in thicker air below FL200 – I now have that option.
Actually Avionimc, EVERYWHERE I've ever worked, the SOPs over ride the AFM/POH.
Ive just read the full report from cover to cover. No mention at all that the engine was at idle or that ATSB was confounded why it "appeared", due the damage, to be at idle.
Ive just read the full report from cover to cover. No mention at all that the engine was at idle or that ATSB was confounded why it "appeared", due the damage, to be at idle.
Moderator
EVERYWHERE I've ever worked, the SOPs over ride the AFM/POH
.. now, that would really be an interesting concept to argue in court after the mishap ...
I would refer you, inter alia, to the following
(a) CAA 1988 S98 (3)(ka) through (kd)
(b) CAR 1988 138(1), notwithstanding 139(3)
(c) CASR Subpart 42M
.. and so it goes on.
I presume you meant to say something along the lines of "the SOPs comply with the AFM/POH" ?
.. now, that would really be an interesting concept to argue in court after the mishap ...
I would refer you, inter alia, to the following
(a) CAA 1988 S98 (3)(ka) through (kd)
(b) CAR 1988 138(1), notwithstanding 139(3)
(c) CASR Subpart 42M
.. and so it goes on.
I presume you meant to say something along the lines of "the SOPs comply with the AFM/POH" ?
Originally Posted by JT
.. now, that would really be an interesting concept to argue in court after the mishap ...
Moderator
Just doing what the ops manual says, yer honour
If CAR 1988 139(3) applies to the aircraft in question .. perhaps. Now, I'm not a legal eagle but I think the earlier poster might be treading on thin ice.
If CAR 1988 139(3) applies to the aircraft in question .. perhaps. Now, I'm not a legal eagle but I think the earlier poster might be treading on thin ice.
I presume you meant to say something along the lines of "the SOPs comply with the AFM/POH" ?
Moderator
Indeed. Centaurus has a few tales to tell in that vein as well ... Having spent much time in the past teaching pilots about such things, it amazes me how the Industry lets the standard sit where it is.
CASA also has the problem that the average FOI is not an AFM (or, especially, a performance) specialist by any means. Marta would be stretched a bit thin to review the latter stuff for all the frontline FOIs doing the donkey work.
I suspect that the pilot would be covered reasonably well for a 139(3) AOC operation but, otherwise, he/she might find him/herself hung out to dry after the prang when everyone is gunning for whatever depth pockets they can find and the pilot did, indeed, have access to the AFM.
Now, I'm a rather conservative engineer .. and once the Defence had been lodged, that had me out of the firing line on a couple of occasions in the past ..
Really, I despair at some of the comments and throwaway lines we see on PPRuNe from time to time ... obvious tongue in cheek stuff excluded.
CASA also has the problem that the average FOI is not an AFM (or, especially, a performance) specialist by any means. Marta would be stretched a bit thin to review the latter stuff for all the frontline FOIs doing the donkey work.
I suspect that the pilot would be covered reasonably well for a 139(3) AOC operation but, otherwise, he/she might find him/herself hung out to dry after the prang when everyone is gunning for whatever depth pockets they can find and the pilot did, indeed, have access to the AFM.
Now, I'm a rather conservative engineer .. and once the Defence had been lodged, that had me out of the firing line on a couple of occasions in the past ..
Really, I despair at some of the comments and throwaway lines we see on PPRuNe from time to time ... obvious tongue in cheek stuff excluded.
And that's why CASA changed the laws about 20 years ago to "Accepting" rather than "Approving" Ops manuals. They shifted the legal burden away from themselves to the AOC holder and pilots.
I bow to your wise council John. The Ops Manual in question ordained that pilots were to comply with all instructions issued by the authorities, but then has an SOP of requiring use of dud take off data, where does that leave the poor pilot in the event of an accident caused by the dud data. Not complying with SOP has its own issues if, you want to kick the traces. It's a rhetorical question, because I know what the legal eagles would say.
The conundrum may have applicability on the King Air, where as has been pointed out, on some fits (if using Hartzell props - is in limitations section), arming auto feather is mandatory (a no go item), but folk may not be using it for SOP reasons.
The Bangkok QF brought to light the airline was using a procedure as SOP that the manufacturer counselled against. Once again, where does it leave the poor sod in seat 0A. So many masters wanting satisfaction.
The conundrum may have applicability on the King Air, where as has been pointed out, on some fits (if using Hartzell props - is in limitations section), arming auto feather is mandatory (a no go item), but folk may not be using it for SOP reasons.
The Bangkok QF brought to light the airline was using a procedure as SOP that the manufacturer counselled against. Once again, where does it leave the poor sod in seat 0A. So many masters wanting satisfaction.
Moderator
I guess the current morass eventually will be sorted out as the result of judicial findings after the inevitable mishaps.
They shifted the legal burden away from themselves to the AOC holder and pilots.
I suspect that present and recent protocols would tie CASA into a judicial action regardless of what they may choose to call the process ?
However,
(a) The Ops Manual in question
For what it may be worth CAAP 215-1(2) imposes the following -
(i) at 2A1.4
Note the requirement to operate company aircraft in accordance with the up-to-date Aircraft Flight Manual (AFM) or other equivalent document (e.g. the company Operations Manual Vol. 2A). (See CAR 54, 138 and 139).
The reference to "other equivalent" can only refer to a 139(3) situation, I suggest.
(ii) at 2AA.1.7
In respect of takeoff and landing data -
The manual must contain information on the method of derivation of the data presented, in agreement with the data presented in the flight manual.
Dud data directions probably get sheeted home to the AOC holder and, perhaps, CASA.
(b) arming auto feather is mandatory (a no go item), but folk may not be using it for SOP reasons
As a certification chap, but not legally competent, I see that as being culpable. No philosophical difference to requiring the pilot to fly outside any other certification (AFM) limitation.
(c) The Bangkok QF brought to light
I don't have sufficient information to comment specifically. However, the usual airline practice is to seek an NTO for any variation to AFM procedure. I would be surprised if QF had not done this ?
One of the points which tends to confuse folks is that parts of the AFM are approved and required per certification standards while other parts are advisory and may be up for discussion.
As to who gets hung out to dry after the wreckage has been cleared away, I guess that is up to the presiding Judge.
It was much simpler when Megan and I were involved in the coalface activities .. an AOC setup involved a straightforward Statement of Compliance analysis of the documentation and procedure set which could then be ticked off by the Regulatory representative. Now, with the likes of some of the CAAPs, one wonders just who is responsible for keeping track of the tie up between the rule book (regs, etc) and the process book (CAAPs and similar CASA documents). It seems to me that a (basically) simple and straightforward bit of work has become a convoluted nightmare by comparison.
Probably we both are better off thinking more about grey nomad things and pleasant places along the GRR and like goat tracks ?
They shifted the legal burden away from themselves to the AOC holder and pilots.
I suspect that present and recent protocols would tie CASA into a judicial action regardless of what they may choose to call the process ?
However,
(a) The Ops Manual in question
For what it may be worth CAAP 215-1(2) imposes the following -
(i) at 2A1.4
Note the requirement to operate company aircraft in accordance with the up-to-date Aircraft Flight Manual (AFM) or other equivalent document (e.g. the company Operations Manual Vol. 2A). (See CAR 54, 138 and 139).
The reference to "other equivalent" can only refer to a 139(3) situation, I suggest.
(ii) at 2AA.1.7
In respect of takeoff and landing data -
The manual must contain information on the method of derivation of the data presented, in agreement with the data presented in the flight manual.
Dud data directions probably get sheeted home to the AOC holder and, perhaps, CASA.
(b) arming auto feather is mandatory (a no go item), but folk may not be using it for SOP reasons
As a certification chap, but not legally competent, I see that as being culpable. No philosophical difference to requiring the pilot to fly outside any other certification (AFM) limitation.
(c) The Bangkok QF brought to light
I don't have sufficient information to comment specifically. However, the usual airline practice is to seek an NTO for any variation to AFM procedure. I would be surprised if QF had not done this ?
One of the points which tends to confuse folks is that parts of the AFM are approved and required per certification standards while other parts are advisory and may be up for discussion.
As to who gets hung out to dry after the wreckage has been cleared away, I guess that is up to the presiding Judge.
It was much simpler when Megan and I were involved in the coalface activities .. an AOC setup involved a straightforward Statement of Compliance analysis of the documentation and procedure set which could then be ticked off by the Regulatory representative. Now, with the likes of some of the CAAPs, one wonders just who is responsible for keeping track of the tie up between the rule book (regs, etc) and the process book (CAAPs and similar CASA documents). It seems to me that a (basically) simple and straightforward bit of work has become a convoluted nightmare by comparison.
Probably we both are better off thinking more about grey nomad things and pleasant places along the GRR and like goat tracks ?
Just for info John.
In attachment H, the conclusion is drawn that the informal risk assessment process used by the company in evaluating the flaps 25 and idle reverse proposals contained several weaknesses. These included:
• There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• Qantas examined the flaps 25/idle reverse procedures of two other operators as part of the project development process. This examination was incomplete and did not identify that the procedures used by these operators were more conservative than the proposed Qantas procedures, and had additional safeguards in place for operating on water-affected runways (see airlines D and E in attachment I).
• The performance differences between idle and full reverse thrust, and between flaps 25 and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required.
• There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• Qantas examined the flaps 25/idle reverse procedures of two other operators as part of the project development process. This examination was incomplete and did not identify that the procedures used by these operators were more conservative than the proposed Qantas procedures, and had additional safeguards in place for operating on water-affected runways (see airlines D and E in attachment I).
• The performance differences between idle and full reverse thrust, and between flaps 25 and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required.
Join Date: Oct 2002
Location: ɐıןɐɹʇsn∀
Posts: 1,994
Likes: 0
Received 0 Likes
on
0 Posts
Originally Posted by megan
The Bangkok QF brought to light the airline was using a procedure as SOP that the manufacturer counselled against. Once again, where does it leave the poor sod in seat 0A.
Regarding flaps 25 vice flaps 30, Boeing said;
Regarding the 747-400, Boeing recommends Flaps 30 be used to minimise landing distance and landing speed. Flaps 25 will provide better noise abatement and reduce flap wear. Therefore, flaps 25 is an acceptable flaps setting as long as the crew is satisfied that there is ample runway available for the given conditions.
PREFERRED LANDING FLAP IS 25. This will normally be used. The wear characteristics of the B747-400 carbon brakes are such that maximum life is obtained by maximising energy absorption and minimising the number of applications. This leads to the choice of Flap 25 with its higher landing speeds as the preferred landing flap setting. Use of Flap 25 also reduces fuel, time, and noise.
Flaps 30 gives lower landing speeds and hence the shortest landing distances. This setting should be used when:
• landing field length requirements are critical (for e.g. when you land too long, too fast, and too gently on a wet/patches runway and one engine at TOGA);
• landing at HGK [Hong Kong] R/W [runway] 13;
• landing on a contaminated runway; and
• landing in LOW VIS [visibility] conditions.
Flaps 30 gives lower landing speeds and hence the shortest landing distances. This setting should be used when:
• landing field length requirements are critical (for e.g. when you land too long, too fast, and too gently on a wet/patches runway and one engine at TOGA);
• landing at HGK [Hong Kong] R/W [runway] 13;
• landing on a contaminated runway; and
• landing in LOW VIS [visibility] conditions.
Boeing does not consider the standard practice of going to reverse idle (idle detent) only to be patently unsafe, but does think that it reduces the existing performance margins. It is acceptable pilot technique to do this (using good judgement) as an exception to the normal procedures when landing on a long, dry runway. We perceive, however, that there is a human factors issue of developing a habit pattern of not using reverse thrust beyond the idle detent. The pilot may then fail to respond quickly when such reverse thrust is needed during an RTO [rejected takeoff] or landing in some type of performance-critical situation. We therefore do not provide a “No Technical Objection” for this as the standard operating policy.
At times and locations as specified in Company manuals, reverse thrust may be left at the reverse thrust idle position after touchdown. Sufficient runway must be available to provide the required Performance Manual landing field length increment. The Pilot-In-Command shall also consider runway surface conditions and be satisfied that a safe operation is assured.
IDLE REVERSE THRUST Idle Reverse Thrust should normally be used for all landings provided at least 300 metres of surplus runway is available. Use of idle reverse maximises carbon brake life by putting more energy into the brakes, reduces noise and reduces reverser maintenance costs.
This does not preclude the use of full reverse thrust should abnormal conditions exist.
This does not preclude the use of full reverse thrust should abnormal conditions exist.
the autobrake system on the B747-400 aircraft sets a particular deceleration rate and modulates the brake pressure to provide that programmed rate. If the thrust reverser is achieving a higher deceleration rate than required by the autobrake setting, the autobrake system will then reduce the pressure to the brakes. Therefore, to maintain a relatively high brake pressure, a comparatively lower r everse thrust setting is now desirable.
Initiation of idle reverse thrust after main gear touchdown will nullify all forward thrust from the engines, and permit the carbon brakes to operate at their peak efficiency.
In cases where landing field length is limited, or if any other operational considerations are likely to affect the landing roll or procedures, the Captain should elect to use full reverse thrust during the landing roll.
Initiation of idle reverse thrust after main gear touchdown will nullify all forward thrust from the engines, and permit the carbon brakes to operate at their peak efficiency.
In cases where landing field length is limited, or if any other operational considerations are likely to affect the landing roll or procedures, the Captain should elect to use full reverse thrust during the landing roll.
Last edited by Hempy; 11th Mar 2017 at 17:06.
Moderator
Now, I'm speculating that QF used the 139(3) exemption - I can't imagine that they wouldn't. [Some may recall that, when the ANRs were in vogue, this reg was 113(3), as I recall .. same, same .. just in case the reg number call out is causing any confusion].
If that be the case, the pilot does not have access to the AFM as it lives in the ops eng tech library or some similar place. The pilot only has the information in the ops manual so the operator must, necessarily, carry the can for providing the information upon which the pilot is directed to rely.
I would speculate further that the procedure hadn't gone through Tech Services and was a Flight Ops matter ? Ignoring the absence of an NTO concurrence would have produced much navel gazing in the engineering empire.
I preferred the AN approach .. the pilot exercised considerable autonomy in such decisions on the line .. just don't embarrass the boss by doing something stupid.
Curiously, I recall the complementary problem with another operator in the past. An optional mod to the fleet was assessed by maintenance only. The decision was that it was not worth the cost.
Had it gone through operations, the Chief Pilot would, most definitely, have required its embodiment. You guessed it, some time later its absence caused damage in the lots and lots of dollars region ... Needless to say, the internal processes were changed very rapidly so that all relevant stakeholders had a say in such matters thereafter.
If that be the case, the pilot does not have access to the AFM as it lives in the ops eng tech library or some similar place. The pilot only has the information in the ops manual so the operator must, necessarily, carry the can for providing the information upon which the pilot is directed to rely.
I would speculate further that the procedure hadn't gone through Tech Services and was a Flight Ops matter ? Ignoring the absence of an NTO concurrence would have produced much navel gazing in the engineering empire.
I preferred the AN approach .. the pilot exercised considerable autonomy in such decisions on the line .. just don't embarrass the boss by doing something stupid.
Curiously, I recall the complementary problem with another operator in the past. An optional mod to the fleet was assessed by maintenance only. The decision was that it was not worth the cost.
Had it gone through operations, the Chief Pilot would, most definitely, have required its embodiment. You guessed it, some time later its absence caused damage in the lots and lots of dollars region ... Needless to say, the internal processes were changed very rapidly so that all relevant stakeholders had a say in such matters thereafter.
In QF1's case, if there had been fatalities, the sod in seat 0A would have been legally required to carry the can, CAR 224 notwithstanding.
Significant latent failures
Significant latent failures associated with Qantas Flight Operations Branch activities were:
• Company-published information, procedures, and flight crew training for landing on water-affected runways were deficient.
• Flight crew training in evaluating the procedural and configuration options for approach and landing was deficient.
• Procedures and training for flight crew in evaluating whether or not to conduct an emergency evacuation were deficient.
• Procedures and training for cabin crew in identifying and communicating relevant information during an emergency were deficient.
• The processes for identifying hazards were primarily reactive and informal, rather than proactive and systematic.
• The processes to assess the risks associated with identified hazards were deficient.
• The processes to manage the development, introduction and evaluation of changes to operations were deficient.
• The design of operational procedures and training were over-reliant on the decision-making ability of company flight crew and cabin crew and did not place adequate emphasis on structured processes.
• Management culture was over-reliant on personal experience and did not place adequate emphasis on structured processes, available expertise, management training, and research and development when making strategic decisions.
Responses to the pilot survey, along with information obtained during interviews, indicated that the Qantas One flight crew were not atypical of most other company B747-400 pilots. There was, therefore, an unquestionable link between the performance of the crew and the company flight operations system in which they trained and operated
The flight crew did not use an adequate risk management strategy for the approach and landing. Given the minimal level of procedures and training provided to the crew regarding landing on water-affected runways, they were not equipped to appropriately handle the situation they faced. It is, therefore, unreasonable to expect the crew to have developed an adequate risk management strategy for the approach and landingBoeing's opinion was not sort until after the event.
Significant latent failures associated with Qantas Flight Operations Branch activities were:
• Company-published information, procedures, and flight crew training for landing on water-affected runways were deficient.
• Flight crew training in evaluating the procedural and configuration options for approach and landing was deficient.
• Procedures and training for flight crew in evaluating whether or not to conduct an emergency evacuation were deficient.
• Procedures and training for cabin crew in identifying and communicating relevant information during an emergency were deficient.
• The processes for identifying hazards were primarily reactive and informal, rather than proactive and systematic.
• The processes to assess the risks associated with identified hazards were deficient.
• The processes to manage the development, introduction and evaluation of changes to operations were deficient.
• The design of operational procedures and training were over-reliant on the decision-making ability of company flight crew and cabin crew and did not place adequate emphasis on structured processes.
• Management culture was over-reliant on personal experience and did not place adequate emphasis on structured processes, available expertise, management training, and research and development when making strategic decisions.
Responses to the pilot survey, along with information obtained during interviews, indicated that the Qantas One flight crew were not atypical of most other company B747-400 pilots. There was, therefore, an unquestionable link between the performance of the crew and the company flight operations system in which they trained and operated
The flight crew did not use an adequate risk management strategy for the approach and landing. Given the minimal level of procedures and training provided to the crew regarding landing on water-affected runways, they were not equipped to appropriately handle the situation they faced. It is, therefore, unreasonable to expect the crew to have developed an adequate risk management strategy for the approach and landingBoeing's opinion was not sort until after the event.
Boeing - we do not advocate intentionally increasing brake temperatures as a means to increase carbon brake life. We have concerns that such techniques could result in increased occurrences of fuse plug melting and dispatch delays for brake cooling. Additionally, some of the techniques we have heard discussed, such as reduced landing flap settings and the use of idle reverse thrust, have a negative impact on airplane stopping performance. Therefore, these techniques are not recommended as standard practice…
Boeing did not support the use of idle reverse thrust as a standard practice for normal landings or for increasing brake temperatures of carbon brakes. Further, they were concerned with the human factors implications of having idle reverse thrust as the standard practice
There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• The performance differences between idle and full reverse thrust, and between flaps 25 and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required.
The post-implementation review of the effects of the changes was shallow, informal, and undocumented. Flight crew were asked in newsletters to provide feedback. Fleet management received limited written and verbal feedback. Although mainly critical in nature, this feedback appeared to be disregarded as the number of sources was relatively small, and many of the sources were perceived to be resistant to change. There was no method of actively obtaining information from flight crew or check-and-training personnel. It is reasonable to conclude that a more detailed and positive feedback program would have identified the strong views of many line pilots about the operational benefits of flaps 30 over flaps 25 (see section 1.7). Such a process should also have identified the lack of flight crew understanding of aspects of the procedures, such as the meaning of the term ‘contaminated runway’.
Boeing did not support the use of idle reverse thrust as a standard practice for normal landings or for increasing brake temperatures of carbon brakes. Further, they were concerned with the human factors implications of having idle reverse thrust as the standard practice
There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• The performance differences between idle and full reverse thrust, and between flaps 25 and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required.
The post-implementation review of the effects of the changes was shallow, informal, and undocumented. Flight crew were asked in newsletters to provide feedback. Fleet management received limited written and verbal feedback. Although mainly critical in nature, this feedback appeared to be disregarded as the number of sources was relatively small, and many of the sources were perceived to be resistant to change. There was no method of actively obtaining information from flight crew or check-and-training personnel. It is reasonable to conclude that a more detailed and positive feedback program would have identified the strong views of many line pilots about the operational benefits of flaps 30 over flaps 25 (see section 1.7). Such a process should also have identified the lack of flight crew understanding of aspects of the procedures, such as the meaning of the term ‘contaminated runway’.
The comment that it may become the "norm" seems prescient in hindsight.
The lack of training about the implications of rejected landings and especially the changes to the auto spoilers, auto brakes and autothrottle responses and indications is very significant. Given that we almost never saw these situations on line, an exercise during the triennial cyclic matrix would have been valuable.
A massive human factors fail was the fact that nobody knew who was flying after the attempted G/A. Had even idle reverse been selected the outcome would almost certainly have been OK, a bit scary maybe, because the auto spoiler would have extended the spoilers and enhanced the braking enough to stop her.
A massive human factors fail was the fact that nobody knew who was flying after the attempted G/A. Had even idle reverse been selected the outcome would almost certainly have been OK, a bit scary maybe, because the auto spoiler would have extended the spoilers and enhanced the braking enough to stop her.
Join Date: Oct 2002
Location: ɐıןɐɹʇsn∀
Posts: 1,994
Likes: 0
Received 0 Likes
on
0 Posts
Originally Posted by megan
As much as some people hate the Reason model, when holes line up is it reasonable to place the entire blame (hate the word) on 0A.
, I just said that's the way it would have most likely gone down. I'd liken it to Überlingen, the swiss cheese there had more holes in it than a gold-diggers diaphragm, but that didn't stop the ultimate conclusion from occurring. Grieving families need someone to blame, it would be a bit hard, not to mention extremely unsatisfying to try and scream at, vent at, punch or launch a murderous vendetta against an 'Ops Branch'..