Qantas flight flies without emergency oxygen

[jet_noseover]

Hear Qantas is quite upset, do not blame them:

passenger jet flew from Manila to Australia without emergency oxygen because it had been sealed off by Philippines maintenance workers.

A leaked maintenance report on the Airbus seen by the Herald Sun and dated March 11 says: "On investergation (sic) found crew oxy bottle shutoff valve in the closed position and lockwired."

The report notes the valve was opened to the flow position by engineering staff at Sydney's Mascot airport.

Angry pilots and maintenance engineers compared the problem with the situation Prime Minister John Howard confronted in a smoke-filled RAAF Hercules in Iraq at the weekend.

"If there had been smoke in the (Qantas) aircraft, the crew would have needed that oxygen," said Capt Mike Glynn, acting president of the Australian International Pilots Association and a qualified A330 pilot.

"This oxygen is meant to be provided to flight crew during an emergency."

Capt Glynn said if the problem was missed in a pre-flight check, it could have led to "potentially dire circumstances".

More:
http://www.news.com.au/dailytelegraph/story/0,22049,21426137-462,00.html

[nolimitholdem]

This is a sincere question, not pot-stirring.

Is O2 not checked for "Tested and 100%" on the A330? I do realize a gauge may show line pressure even if the valve is closed, but then testing via the mask would show that very quickly that O2 was not available? I'm not so much surprised that a valve was closed erroneously but that it made a flight with it in that position! Payne Stewart anyone?!

Of course maintenance should have some very serious questions asked, ie if they missed this, what else did they miss? But O2 seems like an item that we as flightcrew at least have a way of testing for ourselves - as well we should for such a crucial item!

From the number of outraged experts spouting off in the article, it sounds more like political axe-grinding than anything...

[Dream Land]

How much time are the crews getting to do the preflight, I fly the small bus on short haul, 30 minutes is plenty of time, for the the BIG bus on long haul, what is an adequate amount of time needed, quite a different cup of tea I'm sure. I don't think it's an item most crews would miss unless they were cramped for time.

[fox niner]

On my a/c type (B777) it's on the preflight checklist....and that's only 4 items, so you can't miss it.

[blue up]

A certain UK company that I fly for changed their O2 test procedure to run it for 5 secs since I found the bottle had been turned 99.9% off and the standard test of "one pull" on the "Emerg 100%-test" lever wouldn't drain the line down enough to show a drop on the pressure gauge. It would refill slowly but when I put on the mask it sucked onto my face like a limpet. 5 sectors since maintenance.

Remember the KingAir off the coast of France? Reminds me of the old adage about Cessna fuel gauges. "The only thing it can reliably tell you is whether there is one fitted or not."

[Sinbad1]

;)
Some insight to the Airbus O2 sys,


The HP pressure regulator transmitter is directly linked to the O2 bottle, this transmitter send the high pressure indication to the ECAM door/oxy page. when the O2 crew supply PB on the panel (211vu) is pushed to the off position after an inbound, it shows on the ECAM crew pressure in Amber (REGUL LO PR), IF for argument sake this was missed by the flight crew during the check list prior to departure, the Amber MSG of the crew O2 pressure QTY indication on the ECAM will always be displayed in amber. When the flight crew enable the O2 crew supply PB switch, this will allow the electrical valve to open and allow O2 distribution to the system and the MSG will be displayed in Green assuming the O2 bottle Manual shut off valve is OPEN. However all fail, with the bottle wire locked in the CLOSED position and having the PB switch enabled, the low pressure switch in the supply system will be activated (LP pressure less than 50 psi) and display a MSG on the upper ECAM.I think you all familiar with the MSG. ECAM HP pressure will indicate Zero psi when the valve is closed!!.

It seems to me that when the bottle was replaced and possibly the engineer had too many aircraft to deal with on his own, He may have just forgot to do the functional check and he may forgot to mention (ops check c/o) following the O2 bottle replacement in the tech log. No to mentioned the crew forgot to look at the DOOR/OXY page upper right hand corner.This by the way is not uncommon problem.:ok:

[Few Cloudy]

Removed reference to Helios
These bottles are turned on so tight that they have to be turned towards Closed to check valve was in fact fully open. There is no grease allowed anywhere near the valve due to fire / explosion risk so it is very stiff anyway.

[EatMyShorts!]

Hi there!

In the article it is also said that the plane was on a C-check in Manila. If I don't trust a plane then it is definetely after maintenance work has been carried out! Not because the engineers are bad but because errors happen and primary safety items like the mask and its O2-pressure/-flow should be important to us as crew and not just because it would be "illegal" to fly like that A330 did.

Another nice reminder that checking your mask everytime you board a new plane is not such a bad idea ;)

[Capn Bloggs]

I do realize a gauge may show line pressure even if the valve is closed
Not on my Boeing it doesn't...:D

[ironbutt57]

Dont know about your Boeing Capt Bloggs, but on our 767's this scenario is entirely possible, hence the change by Boeing in procedures to test oxy flow from flt deck masks for ten (10) seconds and check for a drop in pressure not to exceed 100psi.

[MrBernoulli]

Ditto the 777 ironbutt57!

[Mud Skipper]

This aircraft is no longer and was not at the time operated by QANTAS but by the cheap/low cost offshoot Jetstar.

[Millski]

MS, That makes me feel a hole lot better. :sad:

[wesky]

This is what happens when your LAME's are getting paid a bucket of rice a week, it comes with out sourcing!

[chasb441]

Quote from post #8
"If I don't trust a plane then it is definitely after maintenance work has been carried out!"

I find the above statement rather upseting.:=
I have worked within the aircraft industry for a number of years and can honestly say that the aircraft leave there maintenance facility, in the places I have worked in Europe, in a far more serviceable condition than when they arrived. As for standards in 'far away places' being worse then its up to the 'users' ie pilots and crew to make a stand and stop the increasing use of these dubious facility's by the airlines purse holders just to save a few dollars.

[jetjockey737]

Sorry chasb, but I have got to say that whenever I strap myself into one of our a/c that has been in the hangar I always give it a thorough going over. Things do tend to get missed, purely because so much has to be done in so little time, and it is our job to check a few things before we launch! And that is in the UK by the way....

[Bus429]

From Few Cloudy I guess Quantas and Helios shouldn't be mentioned in the same sentence but that was one of the factors involved....
The Helios 737 did not pressurise and the crew suffered from hypoxia; the crew O2 was not turned off.

[foxmoth]

The way I see it is that it is not so much not trusting the engineers as, when an aircraft is in service, you know systems are working because generally they have been working and not fiddled with, on return from maintenance many systems have been turned off and parts replaced or otherwise fiddled with so there is much more chance of something not being right.:eek:

[Joetom]

If a world-wide inspection was made on these oxygen systems this weekend we would get a picture of how big the problem is, I would however guess many would not get recorded due to the power of the press etc etc.
.
Reminds me of cross-wired checks after the 737 at Kegworth. Think that 737 was ok, but remember lots of faults recorded world-wide. I wonder how many were not recorded.
.
Question, do oxygen systems get dual inspections like engines and flying controls ???

[BackPacker]

I agree with EatMyShorts too. After maintenance, double check everything. I'm just a low-time PPL but I got my scare on my very first flying lesson. We flew in the back of another plane to a small strip where our plane had been painted, to collect it. Shiny new paint job (shabby jobs, but that's another story) and the paint shop had already removed all the masking tape... Except for the tape on the pitot/static mast.

Fortunately we found out during preflight. But it would have been a short-field, soft-field take-off, in hot weather, with a lake at the end of the runway.

[B A Lert]

This aircraft is no longer and was not at the time operated by QANTAS but by the cheap/low cost offshoot Jetstar.

So? On whose AOC was the aircraft operating? Don't Qantas crews make mistakes? I thought the Pope was the only infallible human when at work!

[GetAround123]

That should be Jetstar's AOC. Understand the aircraft go to/from MNL for re-paint.

[Few Cloudy]

Bus 429,

Thanks for the deserved knuckle rapping!

I was convinced that crew O2 OFF had been a contributory factor in the Helios case but having reread the entire thread (took a while...) there is not a single reference to this.

I therefore apologise for the duff gen and will edit my previous post.

FC.

[Capn Bloggs]

My Boeing's a 717. :} Turn oxy bottle off? Oxy in the line is dumped. Line pressure gauge: on zero. Oxy mask check: no noise. Pretty hard to stuff that up.

It intrigues me that Boeing can continue to make real Boeings without such a simple safety feature. :{

[Terraplaneblues]

The oxygen bottle tap should have been redesigned/eliminated years ago, there should be a self sealing coupling that allows full flow when connected, no in between. Have seen on a 737 Jurrasic where, with tap open, but only slightly, one crew could breathe with his mask, but when both crew tried the crew oxy gauge descended to zero.
The oxygen bottle is common to both pilots and should not have to rely on anybody remebering anything in order to provide full flow.
Ideally, if a well designed self sealing coupling is disconnected the pressure should read zero and produce an EICAS/ECAM warning. If it is connected it can only supply full flow. Dream on......

[maui]

Would it be prudent to scuba dive without first checking the mask?

Should one be any less prudent when flying?

SOP's in the four airlines I have worked with during the past 30 + years, REQUIRE a mask/oxy system check. I would be surprised if the operator currently under discussion is any different.

What is it that is so difficult about following SOP's, which generally have been developed over many years and through hard won experience, and designed to stop the neophyte falling for the same traps as their predecessors.

When will we learn from others, rather than trying everything bad for ourselves.

I shakes my old head, cos I do not understand the mentality. Rushing is no excuse. MAKE TIME.

Maui

[Bolty McBolt]

If the crew oxy system was pressurised prior to the shutoff valve on the bottle (not the overhead switch) being closed on the A330 you can do the press test several times on the mask assy before the low pressure side of the system drops low enough to give you the ECAM pop up and indication on the SD door page.

Its quite feasable that the crew did thier test in MNL all looked good but when the crew in SYD did their test the pressure dropped to the trigger point and the rest is history.

One good thing came out of this.
We know EBA oxy system does NOT leak

[Bus429]

Thanks for the deserved knuckle rapping! - not a problem, glad to help.

After maintenance, double check everything. I'm just a low-time PPL but I got my scare on my very first flying lesson. We flew in the back of another plane to a small strip where our plane had been painted, to collect it. Shiny new paint job (shabby jobs, but that's another story) and the paint shop had already removed all the masking tape... Except for the tape on the pitot/static mast.
Backpacker: Although I can understand your concerns, it is not feasible or necessary to double-check everything. We in the UK have had duplicate inspections for years covering stuff like flying controls, engine controls etc focusing on so-called vital points. VPs are those that, if they were to fail, would cause catastrophic loss. Until recently, EASA had no similar requirement.
EASA Part 145.A.65 requires as system for prevent errors due to simultaneous maintenance on safety critical systems. Part M (Continued Airworthiness) requires duplicate systems a la UK BCAR requirement for Part 145 and M. Subpart F organisations. I'm not sure how your certification system works for aircraft such as the 150 flying for hire - is it CAT? Probably is. You can specify a duplicate inspection on whatever you like in addition to VPs (and O2 seems like a good idea!!) but I know organisations that specify dupes for first aid kits and fire axes - not a good idea; you can dilute awareness if you over dupe.

[llondel]

I recall something about human factors, wrong length screws were beside other screws, poorly lit storage and fatigue being a major factor. Was this work duplication checked ?.. curious, that's all.

That time it wasn't, but hopefully once the issue had been highlighted, procedures were changed to make sure it didn't happen again. Checking of safety-critical work should never be left to the person who did the work.

[Bus429]

lightly O/T but on the subject of duplication/checking.....

what about the BA chap that half went out the window when the windscreen blew out becasue the wrong length screws had been used (if memory serves correctly ?).

I recall something about human factors, wrong length screws were beside other screws, poorly lit storage and fatigue being a major factor. Was this work duplication checked ?.. curious, that's all.

That was another factor in the incident; the window had not been identified as a vital point. Aircraft certified before 1986 - the 1-11 500 was certified in 1970 - had to have VPs identified by the operator. Aircraft certified after 1986 had VPs identified by the Type Certificate holder. The 1-11 incident had all the ingredients to make it happen: night shift, working on one's own, a shift supervisor doing a hands-on task, design of the window, no duplicate inspection required (a second set of eyes may have identified unfilled countersink revealed by the use of smaller bolts).

[Sinbad1]

:ugh:
I do not know why some of you are going around in circles. The O2 bottle was installed with the SOV closed. There is no residual pressure in the line because the aircraft was on a C check, The ECAM will show ZERO when the SOV is closed. A nice amber MSG on the Door/Oxy page will show ZERO. The maintenance crew F.:mad: .ed up and flight crew F..:mad: .ed up. that is the end of it. To avoid this situation from happening again during any maintenance visit is to alter the company procedure and raise a duplicate inspection after such maintenance task is performed.:ok:

[Joetom]

Sinbad1, nail on the head, two inspections should be reqd and system should be tested.
.
These oxygen systems fitted to aircraft can have Left and Right thread parts in the system, SOV's can be fitted in any location or orientation, very very easy for things to be fitted wrong.
.
As a general rule, Pilots can re-check each others work/functions, Cabin Crew even cross check doors man/auto modes, Engineers often work alone, work it out.
.
Another point to mention, parts/systems are often fitted wrong for long long periods of time, if they are never needed during service they will not come to light, even during parts/systems maint at a later time, incorrect fitting may not come to light, but the poss of new parts/systems being fitted in the same incorrect fashion can be increased.:sad:

[AerocatS2A]

...except for the tape on the pitot/static mast.
Pitot/static? pffft! She'll fly when she's ready and once airborne ya judge your speed by listening to the singing of the flying wires ;).

[Sinbad1]

:confused:
The thing I found surprising is not the fact that the O2 bottle has been installed with the SOV left in the closed position or having right or left hand thread, but the series of the events that have taken place following the installation of the bottle. For example, why the engineer did not check the ECAM and carry out verification of the QTY displayed?? was the installation procedure carried out as per the MM?? normally it requires functional check and the MM reference to complete the paper work.
After the aircraft left the hangar was the Daily check carried out?? That would have been required either in the hangar or on the line. I am sure the O2 check is on the daily sheet and I am even more than sure it is on the pre-departure check list which has to be performed by the flight crew prior to departure. Also, what baffled me the most is how could the Capt and the FO miss looking at the Door/Oxy page??? I think QAN..:mad: ..TAS airline should carry out their own investigation to find out what had lead to this unusual error. I would be very interested to read the flight crew version. My comments are obviously based on what has been posted on this forum. If it is true of course and not rumours......:ok:

[bubbers44]

We all know that when an aircraft has a lot of maintenance done on it that the plane will end up at the gate with nonstandard positions on switches and maybe a few circuit breakers pulled and forgotten, especially the TO warning CB annoying them everytime they add power. Pressurization left in manual, TO warning horn CB's pulled, dozens of other things too. Always look at everything when taking an aircraft maintenance has been working on. They have a different checklist than we do and sometimes don't follow that one. I had one experience when I got a 737 in Burbank in the afternoon, flew it until late at night, got the same AC the next morning, did the normal crew oxygen test and when I pushed the flow switch oxygen pressure dropped to zero. Just before I picked up the AC the previous crew at a down station had the bottle replaced because of marginal pressure. Even though it showed normal pressure when I got it, it was trapped pressure because the valve was off. Had to take a delay because the bottle was in the fwd baggage compartment and I couldn't get to it because of bags. Chief pilot asked me why I didn't write it up giving maintenance the delay because maintenance said it was our problem because it wasn't written up. Asked him how much the FAA would fine us knowing the bottle was installed noon the day before and we flew it all day until the preflight checks the next morning with the valve shut off.

[Sinbad1]

bubbers44 (http://www.pprune.org/forums/member.php?u=117172)

The airbus system (A330) is different from the Boeing 737, If you read my previous first post, I did explained the O2 system on the Airbus. On the Airbus when the SOV is off the ECAM shows Zero plus it has low pressure system warning as well, the ECAM Door /Oxy page will display the MSG in Amber When the pressure is less than 50 psi in the system.the first low pressure warning comes on when the pressure drop below the required acceptable level it will show on the ECAM the Numbers in green with Boxed amber, I am not sure but I think around 1500 psi, and when it drops below that, the whole Numbers go Amber, Surely you can not miss that. In a very good airlines when an aircraft complete a check usually the airline engineering has pre hangar departure check list which has to be signed off before it leaves the hangar. Malaysia airline is one of them.The condition you describe the aircraft after a hangar check is unbelievable ( I am not doubting you at all) but I think they must have quite a bad QA department. as for engineering trying to blame the flight crew for not writing it in the book, well I just do not find that answer acceptable at all.There is something seriously wrong with that airliner engineering department to deliver the aircraft in the conditions you described.:ok:

[bubbers44]

Actually, I wasn't upset, I knew maintenance screwed up and was trying to fix the problem without them getting into trouble with the FAA. When they threw their screw up back at me it irritated me a bit. I always think everybody is trying their best and once in a while you screw up. Why not let them learn from their mistakes so it doesn't happen again instead of frying them?

[F/O Bloggs]

As Sinbad says you get the indications on the door page.

Additionally with my company, you are supposed to do an oxy test with the normal and emergency setting before every flight. If you push the emerg button and no oxy comes out- something is wrong. Seems like a crew stuff up.

(Capn Bloggs- Your beloved 146s had the "leave the residual pressure indication in the line" system)

[Capn Bloggs]

Sinbad,
I think QAN.. ..TAS airline should carry out their own investigation to find out what had lead to this unusual error.
It wasn't Qantas, it was Jetstar. see the top of this page.

Back in your box, BLOGGS!

[Sinbad1]

Capn Bloggs
:confused:
Apology for the mis quote but the title of this thread was referring to QAN...TAS , I wonder how JE::T::::STA::::R got mixed-up with the RED KANGAROO....:ok:

[Capn Bloggs]

Yeh well it is a RUMOUR network isn't it...:= :{

[Sinbad1]

:confused:

Jetstar’s Australian operation is wholly owned by Qantas but is managed separately and operates independently. The headquarters are in Melbourne Australia. Jetstar’s intra Asian operation is a Singapore-based partnership between Qantas (49%), local businessmen Tony Chew (22%) and FF Wong (10%) and Temasek Holdings (19%) with the hub based in Singapore.;)

[MD11Engineer]

Not the first time it happened and it will not be the last time. I caught several planes myself with this mistake (fortunately it never happened to me so far, knocking on wood).
The system is not Murphy-proof. After installation of the new / refilled oxygen cylinder, the valve has to be opened fully and then closed by one quarter-turn, after which it gets lockwired in this position using copper wire.
If the engineer/mechanic gets distracted while doing the installation, he can easily foreget to open the valve completey. Usually by the time he walked up into the flight deck the lines have the full pressure, so he will not notice anything unless he does a oxygen mask test for at least a minute.
Often engineers/mechanics do the job alone and have nobody there to crosscheck.

This is why it is so important for you pilots to do a proper oxygen mask test, watching the gauge for pressure drop.

[Joetom]

Guess the powers that be have have completed a world-wide check on these oxygen systems by now and can report they found no problems with a lack of oxy for crew should the need arise.???:= := := :
.
Rumour is that some airlines will increase checks (two inspections) made on the oxygen systems fitted to their aircraft, both during maint on systems and routine checks, it's nice to get your head out of the sand and be pro-active when maintaining these aircrafts.:ok: :ok: :ok:

[MD11Engineer]

Most airlines do not allow oxygen servicing on board anymore (apparently some idiot a few years ago used a homemade non-approved adapter and accidentally serviced the oxygen system with nitrogen).
So the only approved method is to physically replace the cylinders (to be refilled using a stationary oxygen rig e.g. in the hangar). For this the cylinder valve will have to be closed. This leads again to the problem of the mechanic/engineer forgetting to open the valve fully after reinstallation.
The only option I see is to make the reinstallation of the oxygen cylinder a duplicate inspection, but there the airlines will cry out about the extra manpower costs at small stations.

[coax]

Thats is not quite true most uk airlines carry out oxygen top ups in situ every couple of days which takes out the need to open and close the valve every time.Also with reference to duplicate inspections on oxygen system where I work it is part of the daily check to check the oxygen system and then the pilots come on and do the same check again so a duplicate inspection is a already being carried out.Although it was a maintenance error that caused this problem the pilot obviously did not check the doors page as he would of seen the oxygen contents reading zero so he failed to carry out his checks correctly too.

[MD11Engineer]

Well, the airlines I worked for during the last about ten years didn't and in fact many had the in situ oxygen charging equipment removed per mod. The pilots can not do a visual inspection of the cylinder valve before every flight, especially if the cylinders are sited somewhere behind cargo sidewall panels or in the E/E bay. So it up to us to do a proper check upon installation.
Not all aircraft have the option to check for the valve status like on the Airbus. In most cases it boils down to do an ops check of the masks while watching the gauge for pressure drop.

[NAS1801]

The cone heads at Qantas do the oxy recharging. They use a cart and there is a fill point on the forward panel in the forward cargo door opening and a panel in the forward access hatch on a 767. They still charge from the cart. I think though they are not allowed to recharge the portable oxy bottles. They have to send em U/S and order out full ones. Anyone who takes the time to make up adapters to fit a nitro cart to the oxy system should be sacked on the spot. (and likewise, anyone that spends half a shift making up adapters to fit an oxy cart to charge a landing gear strut should be sacked. But at QF, they send him up to Brisbane from Melbourne)

[ericferret]

O2 charging is only permitted if a charging panel is provided.

If not and I believe that Boeing no longer provide this option then a cylinder change is necessary.

I remember hearing that Boeing deleted the option due to a small fire risk during charging. I am happy to be corrected if this is inaccurate.

I have been on the receiving end of a home made O2 adapter stripping its threads in the fwd cargo of a 737-300. Being located with a whipping snake spewing oxygen aint funny.

I have only seen one servicing panel on a UK 737 in the last 5 years and that would be one out of about 70 300/700 series.

So as far as the above problem goes yes it could easily happen and I have caught at least 2 aircraft in the same period with the o2 switched off.

However I have never been called to an aircraft that has been offered to service in this condition.

I tend to agree that the only check that makes sense is for the crew to perform a flow check at the mask till they are sure they have flow.

I wonder if closing the shutoff valve behind the F/Os seat on a 737 bleeding the guage down by using the mask then opening the valve again to watch the guage recover would be a sufficient check? This would also exercise this
little used valve.

To check at the cylinder is impractical due to access issues. The only real way to check it is to close the valve fully the open it all the way then back of a quarter of a turn. I think this would induce as many problems as it fixes.

[B A Lert]

Jetstar’s Australian operation is wholly owned by Qantas but is managed separately and operates independently. The headquarters are in Melbourne Australia. Jetstar’s intra Asian operation is a Singapore-based partnership between Qantas (49%), local businessmen Tony Chew (22%) and FF Wong (10%) and Temasek Holdings (19%) with the hub based in Singapore

Pigs will fly when Jetstar can be said to 'operate independently' of Qantas, or anyone else for that matter. Were it not for the extraordinary support of Qantas, Jetstar and Jetstar Asia would have bitten the dust long ago.

[SWBKCB]

Quote:
"My Boeing's a 717. Turn oxy bottle off? Oxy in the line is dumped. Line pressure gauge: on zero. Oxy mask check: no noise. Pretty hard to stuff that up.

It intrigues me that Boeing can continue to make real Boeings without such a simple safety feature. "


Could it be that the 717 didn't start off as a Boeing, and this system was inherited from the DC-9?