I knew I'd read this before but have only just had the chance to have a look for it. This is UNBELIEVABLE - remember this report is from an accident 12 years ago!
ATSB Report into QF1 VH-OJH - Bangkok, Thailand
Organisational factors: Qantas (see part 3)
The ATSB investigation examined the processes of the Qantas Flight Operations Branch for any systemic organisational issues that may have allowed the deficiencies mentioned above to occur. That examination included a detailed review of the company’s introduction of the flaps 25/idle reverse procedure, as well as company procedures and training relating to water-affected runways. The aim of the new procedure was to reduce costs (e.g. brake maintenance, noise levy charges at Sydney Airport, and thrust reverser maintenance) without affecting safety levels. Examination of the project development process revealed that a proper risk assessment of the new procedure was not undertaken, and that other important considerations were overlooked. There were also significant deficiencies in the manner in which the company implemented and evaluated the new procedures.
Overall, the investigation identified five deficiencies related to the organisational processes of the Qantas Flight Operations Branch:
• 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 was over-reliant on the decision making ability of company flight crew and cabin crew and did not place adequate emphasis on structured processes.
• The 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.
My bolding.
If that's not bad enough, the full reading of
Part 3 (Qantas) reveals the ATSB's statistical analysis of 744 QAR alerts re: high approach speed. The flap 25/idle reverse concept was introduced on 6 December 1996. The ATSB states:
The overall average rate in the 3 years up to (and including) December 1996 was 8.5, whereas the average rate in the 3 years after this period was 11.5, an increase of 35%.
This 35% increase came about, in all likelihood, because of QF management's cost-cutting, short-sighted decision.
From posters on here, we're currently looking at a three-fold increase in failure rates of the RB211. The QF1 report is so similar to the situation at hand that it's like reading an accident report in advance.
On a side note, this information is not difficult to find. I am certainly not a journalist yet less than an hour on the ATSB website and a bit of analysis has trumped EVERY story I've seen on SMH, The Herald Sun, Australian Financial Review etc.
Back to topic - can someone with more knowledge than me state the legal ramifications (if any) of not complying with the recommendations of an ATSB report? Should Bangkok round 2 occur (be it QF, JQ or QL), could you imagine the findings of a second QF accident report?!?
Safe flying.