Qantas Manila ATSB Preliminary report out

[Nudlaug]

200804689 (http://www.atsb.com.au/publications/investigation_reports/2008/AAIR/aair200804689.aspx)

[Critical Reynolds No]

Interesting the path of the cylinder!

Also is 4000ft per minute a plummet or a death dive as the media would have us believe?

[teresa green]

You wouldn't have wanted to be in that crew seat!

[Clearedtoreenter]

Absolutely amazing... I'm sure I'll be corrected but if in my totally amateur interprtetaion I read this right ...seems the damn thing punched its way up through the cabin floor, propelled itself up the inside of the cabin, moivng the door handle to two thirds open on the way, then went back through the floor into the baggage hold and out through the outer skin into the open air! I've sat in those aircarft so oftem for so so long - and nothing ever happens to aleviate the boredom - but that would have added some realy scary in-flight entertainment, especially if I got the emergency exit row. How it did not hit anyone..... or hit something more structural or damage more avionics or control lines or get ingested into an engine or, or or - seems like lady luck was really smiling that day.

[Kangaroo Court]

Yeah, I'm trying to figure that path out myself? Did the cylinder split in two and go in different directions, or did it bounce around as described above? It seems far fetched to think it went up, then came back down and then ruptured the fuselage?!

Just a quick edit; it reads as though the rupture on the fuselage happened at the same time as the inital explosion of the tank and that it fell out after travelling through the cabin. That makes more sense.

[Frank Burden]

The spirit of Australia media release:

About Qantas - Newsroom (http://www.qantas.com.au/regions/dyn/au/publicaffairs/details?ArticleID=2008/aug08/3812)

Frank

[Ultralights]

i am still amazed that the bottle, or half of the bottle, can enter the cabin, bounce around as it did, then exit the same hole in the floor it made on its way up, did i also read correctly that the crew portable oxy bottle is missing as well? but it still doesnt exolain why the bottle exploded in the first place, i cant say that exploding oxy bottles are a regular occurrence! was Oil used in its installation? incorrect pressure when the bottle was charged?

[Kangaroo Court]

I am also interested to know if they're still using steel bottles or kevlar ones?

[Howard Hughes]

The bottle did split in two, with the bottom half blasting the hole through the fuselage, with the top half going up into the cabin then exiting through the hole. Could it be something as simple as a manufacturing fault, or a faulty bottle?

Kangaroo, they showed the type of bottle on the TV news last night which weighed in at around 16 or 17 Kg's, so from that I would say steel.

[heywatchthis]

Just a thought... Could the skin have ruptured first, as a result the oxy bottle then going on its rampage.. :confused:

[rmm]

From the report, page 17

All passenger oxygen cylinders installed in VH-OJK were of a single piece, heat treated alloy steel construction

http://www.atsb.com.au/publications/investigation_reports/2008/AAIR/pdf/AO2008053_Prelim.pdf

[Kangaroo Court]

They'd be better off with the new kevlar ones wouldn't they?

[Capt Kremin]

HWT, the hole was caused by the bottle. There is absolutely no doubt about that.

[Nudlaug]

Word on the street is that the Oxygen bottle went up into the cabin near the attendant seat, hit the fire extinguisher and the portable oxygen bottle there (both are missing as well) where the valve of the big bottle was knocked off, which got propelled onto the door handle, which itself turned but the shaft (bolt) of the handle sheared, the big bottle itself with its valve now missing then went further up into the ceiling and, with the 2 smaller bottles (fire extinguisher and portable oxygen bottle), went back down and out through the hole into the open....... Rumours Network.... but thats the word on the street........

[Lookleft]

Just as well no one was standing there when it come through the floor. Unless they can find a fault with the bottles from the same batch as the failed one this could probably go into the too hard to explain category. Maybe the ATSB could ask Mythbusters to do some research.

[bushy]

i thought Mythbusters WERE doing the research.

[BigGun]

I also remember they also said the found some of the passenger bottle.

The door handle is designed to shear too.

They were steel bottles as said.

There are issues fitting full kevlar bottles as they are very slightly larger than the steel ones. Can not be fitted to crew positions or in the ceiling positions.

[18-Wheeler]

Also is 4000ft per minute a plummet or a death dive as the media would have us believe?

Is that a rhetorical question? - If there's the slightest doubt, you can safely assume that the media is talking utter sheet.

4,000 fpm is typical for a 747 with idle thrust, speed brakes extended, and up near Vmo.

[Kiwiguy]

IT strikes me as if the cylinder valve went upwards whilst the bottle itself was sucked out as a more logical sequence.

People are right to point out inconsistencies in the exploding bottle theory as we should be applying Ockham's Razor here. Not personal prejudices.:=

Have they found the cylinder valve yet ?

It does not sound to me as if the cylinder itself split open. Rather the valve unseated. For the bottle to have flown up they would have to have been stowed inverted and I gather the bank of bottles were stowed sitting on their bases the right way up. :rolleyes:

I think I would add that it is not inconsistent with failure of the fuselage to occur first and the ULD being sucked into the hole rupturing the tank as a secondary consequence.

[Philthy]

It's a good report, but what I find hard to credit is the theory that the remains of the oxy bottle fell out the hole it made on the way up. Consider these facts:
1. Bottle goes 'bang' - hole made in side of aircraft, depressurisation commences. Bottle shoots upstairs, rotating and moving inboard as it proceeds into the ceiling.
2. The hole in the lower deck floor was basically bottle-cross-section-shaped.
2. Cargo was found blocking most of the hole in the fuselage side.

Now it seems unlikely in the extreme to me that the bottle could have fallen back through the hole it made on the way up, then out through the hole in the side. Firstly this would require the bottle remnants to move back outboard in rebound, whilst not moving in a fore and aft sense. Secondly, the bottle would have to be pretty much aligned with the floor entry hole to fit back through, which would require it to rotate back to the vertical. Finally it would have to negotiate the cargo, which would almost certainly have moved to block the fuselage hole by then, to fall overboard.

Plausible?

[pussy.galore]

You just panned the findings of qualified and experienced accident investigators.
Yet you fail to offer an alternative explanation.
Criticism is not valid if it is made just for the sake of making criticism.

[Kiwiguy]

I don't think Philthy has to offer an alternative explanation as his criticism raises sufficient reasonable doubt...

Besides which in the post before his I did offer an alternative suggestion that the bottle rupture did not cause the fuselage to split.

Rather the fuselage split first and the cargo, including the ULD banged into aforementioned bottle cracking off the valve head which went ballistic upwards and the bottle itself got shunted sideways through the hole.

Ockham's Razor seems to favour that explanation more than a bottle going upwards and then returning downwards again before turning through 90- degrees to exit the hole.

[Capt Kremin]

The flight attendants in the first class section, ahead of the hole, reported hearing the explosion and seeing a pressure wave of dust and condensation coming forward through the cabin. The pressure wave then reversed direction as the the air left the cabin.
I would be interested to know how the proponents of "the fuselage failed first" theory explain that phenomenon?

[Ka.Boom]

What are the qualifications you posess that lead you to make these assertions.?
Have you been up close and personal with OJK?
It is suspected that you are playing devils advocate

[blackd]

Hi Folks,
I suggest you download the full report for more details, rather than just read the abstract. Heaps of good photos and the in-depth story so far.

[ozbiggles]

It was the guy on the knoll.... behind the tree!!!
Are we really going to have all this BS?
The report has the 'evidence' in it. Its a good report that shows/tells what happened. It may never know why.
Actually...go ahead its good for a laugh

[Kiwiguy]

I have in a previous incarnation worked on collision repair of cars and have seen how metal deforms in relation to various impacts. The kind of blow from inside by a downwards descending bottle would leave downwards stretch marks in the skin from above which are absent in photos posted on PPRuNe to date.

If the fuselage rupture was caused after the bottle went upstairs then how could suction have pulled the tank back down through the deck as Captain Kremin suggests ?

As Philthy notes by this time the hole was plugged by cargo.

For the accident investigator's theories to be correct requires the oxygen bottle to have performed several actions which defy the laws of physics.

They have approached the investigation having already made up their minds that the oxygen bottle flew around in the cabin and then directed their efforts to trying to make the facts fit their theory.

The energy required to make an oxygen bottle of such weight reverse course would have in fact been sufficient to shatter the bottle in which case the splintered fragments would have stayed inside the cabin.

Had the bottle propelled upwards through the hole and struck the door handle, the act of deflecting off the handle would have changed the bottle's attitude with respect to the hole.

If the bottle did not explode, but traveled upwards as an intact bottle then what caused the rupture at the wing root ?

Had the rupture at the wing root been caused by the bottle returning downwards how do you explain the suggestion that it was sucked back down before the wing root rupture ?

The energy required to make any massive object not only exactly reverse course are beyond the force which collision with a door handle could impart.

On the other hand photos posted previously on another thread here have show part of the lap joint where a whole row of rivets were bisected by a split fracture along the length of that row of holes. In other words the rivet line unzipped by part of the skin fracturing lengthwise along the rivet line. It is self evident in photos.

Had the rupture at the wing root been caused by the bottle returning downwards there would be vertical stretch marks on the skin. There were none where the rupture occurred. :ugh:

[packrat]

A vehicle smash repairer who has virtually no experience regarding aircraft incidents and has not had a first hand view of OJK refutes the ATSB findings.
Son...you are punching way above your weight.
Have you sent a copy of your thoughts to the ATSB?
On your suppositions they may wish to review their findings.
Send a copy to Boeing while you are at it...it appears they got it wrong as well.

[Going Boeing]

C'mon guys, it's time for a reality check. A large number of investigators from a variety of organisations have independently examined the evidence and come to identical conclusions. We now have armchair experts using conspiracy theories to come up with entirely different conclusions and they are totally convinced that they are right. I suggest guys that you clear your mind of any prejudices and thoroughly read the interim report - it is an interesting read and comes with slides etc to make the visualisation of the events much easier. The "What" part of the question has been answered and is clear. We now wait for the final report which should tell us the answer to the "Why" part of the question. I'm certainly interested in what caused the oxygen bottle to split the way that it did.

[Kangaroo Court]

What do you guys think about TWA 800 now? I'm just wondering where the bottles are on the old 747-100 and if one could have let loose and gone on a rampage near the centre tank?

[Kiwiguy]

A vehicle smash repairer who has virtually no experience regarding aircraft incidents and has not had a first hand view of OJK refutes the ATSB findings.
Son...you are punching way above your weight.
Have you sent a copy of your thoughts to the ATSB?


Why would I bother packrat ?
They apparently have closed minds just like you.

...and since you raise the subject what experience have you got on the subject that would lead you to suggest that the ductile qualities of sheet metal in cars deforms in any way differently than that of an aircraft ?

By trading insults you've simply sidestepped answering the justified points which I raise.

Changing the subject with personal abuse is the first refuge of those who have no weight to their argument. :{

[packrat]

You are a bit thin skinned old chum.
I am agreeing with the findings of both Boeing and the ATSB who have far greater resources and experience than both you and I.
It is noted that you neglected to mention that Boeing concurred with the findings of the ATSB in your quotation of my previous post.
Send your concerns to the ATSB...they may learn something from you.

[Kiwiguy]

Even if one accepts that the oxygen bottle returned back down through the hole in the floor and then punched out through the fuselage, there would have been metal deformation typical of stretching at the point of failure.

At the point of failure however the fracture is along the rivet lines.

In a stretch caused by impact from inside you would expect the rivet holes to have elongated not laterally, but longitudinally.

You have expected each individual rivet to have torn away from the frame or stinger beneath, but instead the metal has cracked along the line of rivets.

The accident investigation report appears to have been a political response to exonerate Qantas from engineering faults rather than based in physics or fact.

Another point is why if the oxygen bottle as investigators suggest punched a hole out from the inside did the stringers or frames not deform. It is clear in the picture that the skin tore away from frames beneath, but the frames underneath were not themselves deformed.

Packrat, it's called Ockaham's Razor ... Look it up sonny. :8



http://i257.photobucket.com/albums/hh212/727Kiwi/RivetlinesQF744.jpg

[packrat]

Would you like me to forward your concerns to the ATSB for you?.
You seem reluctant to do it.
Perhaps you dont like being laughed at or are not fully convinced of your own musings.

[Going Boeing]

Kiwiguy, what you are offering as evidence talks about the expected deformation from the bottom part of the oxy bottle punching through the skin. What I see in that photo is subsequent damage caused by the massive volume of air flowing out through the hole plus possible further damage caused by airflow during the diversion to Manila.

Like I said earlier, it's best to clear your mind of any biased opinions and simply look at the facts reported by independent experts.

[obira]

Figures 14, 15, 16 and 17 show damage in the ceiling ABOVE the R2 door which match the size and shape of oxygen cylinder #4.

Just because the hole is the same size and shape as the cylinder does not mean that the entire cylinder must have passed through the hole. You can make a pencil shaped hole in a piece of paper without the entire pencil passing through the hole.

You have made an assumption that the outward moving cargo would have formed a plug before the falling cylinders reached the fuselage hole. On what evidentiary basis have you determined the time frame for this to take place? Surely this would depend on the size of the articles closest to the rupture, the orientation of the articles with respect to each other and the rupture, together with the rigidity of the articles, to name but a few variables.

You have made an assumption that the point of failure is along the rivet line. What evidence do you have that the point of failure was not somewhere else in the skin?

Kiwiguy you are claiming the report to be politically motivated. This is an immense slur on the professionalism of every single investigator involved. By claiming that the report is politically motivated you are saying that the report is the result of a conspiracy amongst the investigators to cover up the true cause of the accident. To claim that those who dedicate themselves to finding the cause of accidents so as to prevent them from occurring again in the future would hide true findings in order to protect a company is ridiculous slander. Where was Ockham's razor when you came up with this theory?

You are making your assumptions on the basis of the 'high resolution' photos available over the internet. The investigators are examining the actual damage with their own eyes and instruments.

obira

[flypy]

Is it usual for a 744 S/O to have 2290 hrs on type?

[Capt Kremin]

It's around three years of worth of flying on the 744 for an SO. Some would have even more than that after three years.

[ozbiggles]

I'm not sure how a bouncing oxy bottle makes Qantas look any better or worse from an engineering point of view than any other cause for a hole in the side of one of their aircraft? It all the responsibility of the owner! Maybe if they said it was a birdstrike with no evidence you might have a case but I'm confused as to how you think this is a good excuse(or cover up) for what happened.

[Philthy]

Philthy...Explanation Please

OK...firstly, I'm not panning the report in general. Secondly, I'm not proposing conspiracy theories or anything silly like that.

I find the explanation of the sequence of events perfectly plausible right up until the bit where the cylinder (or bits of it) retraces its steps and exits the aircraft. That's all I'm saying.

[BrissySparkyCoit]

I'm with kiwi guy..... kiwis are always right :rolleyes:

[601]

I find the explanation of the sequence of events perfectly plausible right up until the bit where the cylinder (or bits of it) retraces its steps and exits the aircraft. That's all I'm saying.

With the aircraft at cruise pressure diff, what rate of airflow would be expected through the hole in the fuselage created by the bottom of the bottle and what area of influence would that airflow have?

Also what rate of airflow would be expected through the hole in the passenger deck created by the top of the bottle and what area of influence would that airflow have on loose items in the surrounding area?

I would expect any fragments of bottle would have been moved by that airflow down through the hole in the passenger deck and then out through the fuselage as the ATSB explains. That is "not rocket science". Also you have to remember that the pressurisation system would have been pumping a lot of air in trying to maintain the selected press diff.

[TheShadow]

see this link (http://www.pprune.org/4359128-post1046.html) for a likely explanation for the bottle explosion/failure.
.
.

[Desert Dingo]

Unfortunately, in that link the poster lost all credibility for having any analytical skills with his statement
Every aircraft type I've ever flown has had a minimum oxygen pressure below which you should never allow the contents to drop. The reason for that is simply that, at low pressures (say <300psi) moisture then readily gathers inside the bottle and it can then corrode undetected from the inside outSo atmospheric moisture can get into a pressurised cylinder?
Surely, the point of having a minimum pressure limitation is to make sure the pressure never gets down to zero. Then, if the valve is left open, moisture could get inside and cause corrosion.
Internal corrosion could be a possibility, though.

[Jabawocky]

I thought that as you compress the gas the liquid drops out..... hence the reason you have a drain on your aircompressor!:hmm:

[lowerlobe]

We were always told by the company not to let the Oxygen bottles drop to zero because that would then allow the ambient air to enter the bottle which would then require the bottle to be purged...

If there is sufficient pressure left in the bottle it would stop any of the outside moisture laden air to enter when the valve is open and the bottle is in use.I was told that the air used to fill the bottle was medical air and that has no moisture content for the very reason of stopping or helping prevent corrosion inside the bottle.

Jaba....normal ambient air has a high moisture content which is is not the same as the air used in medical O2 bottles....
So this quote makes sense...
Every aircraft type I've ever flown has had a minimum oxygen pressure below which you should never allow the contents to drop. The reason for that is simply that, at low pressures (say <300psi) moisture then readily gathers inside the bottle and it can then corrode undetected from the inside out

[Sprite]

Lowerlobe; it is not air but oxygen used in medical and aviation bottles.

Additionally, the comment does not make sense. Simple physics tells us that with any pressure hgher than atmospheric pressure in the bottle, no outside air or moisture could possibly get in.

I believe the company tells you to not let the bottles below 100PSI. This is because it is enough (being higher than atmospheric pressure) to keep air from entering the bottle.

And i don't see any problem with the idea the bottle was sucked out. Imagine the amount of air rushing through a relatively small hole, i suspect the air velocity would be more than high enough to blow the bottle towards the hole and out into the atmosphere.

The thing i find amazing is how many people love to suspend reality and common sense and indulge in the most ridiculous conspiracy theories!

[lowerlobe]

Honestly ..some people can't see the forest for the trees....
Lowerlobe; it is not air but oxygen used in medical and aviation bottles.
Additionally, the comment does not make sense. Simple physics tells us that with any pressure hgher than atmospheric pressure in the bottle, no outside air or moisture could possibly get in.
I believe the company tells you to not let the bottles below 100PSI. This is because it is enough (being higher than atmospheric pressure) to keep air from entering the bottle.
...Is that not what i said...:ugh::ugh::ugh::ugh::ugh::ugh::ugh:

[18-Wheeler]

With the aircraft at cruise pressure diff, what rate of airflow would be expected through the hole in the fuselage created by the bottom of the bottle and what area of influence would that airflow have?

With all three packs running on a 747, they pass something like 22,000 cfm. That's quite a lot.

[tinpis]

Too lazy too look it up whats the distance Hong Kong-Manila?

[Sprite]

Lowerlobe...read your own post. Specifically

"the air used to fill the bottle was medical air"
and "the air used in medical O2 bottles"

Before you accuse me of being picky, air and oxygen are quite different. Air is a mix of nitrogen (78%), oxygen (21%) and other gases. It is like saying water is Hydrogen gas...

The quote does not make sense, the quoted poster has picked a random number that shows his lack of understanding of simple physics. There is actually no danger of moisture getting in the cylinder while pressure is above 14.7psi (atmospheric pressure at sea level). The 100 psi recommended as minimum is presumably to allow a buffer, and an easy number to remember for crew.

So no, it is NOT what you said. :ugh: :ugh: :ugh: :ugh: :ugh:

[speedbirdhouse]

WOOP!! WOOP!!

Pedant alert! Pedant alert! :rolleyes:

[Jabawocky]

I still think that Medical O2 being compressed and charged into a bottle will not contain any H20 to begin with so I think at any pressure, 500PSI or 50PSI there is no water present.

I may be very wrong, but until someone can verify this with absolute refernce to something we can all see for ourselves it is most likely to be a myth.

A Chocky Frog to anyone who enlightens us otherwise!

Cheers

J:ok:

[TheShadow]

Aviation oxygen should be IAW MIL Spec MIL-O-27210. This spec requires the oxygen to have no more than 2 millilitres of water per litre of gas.

CAA and FAA and presumably CASA air safety inspectors always tell aero-medevac operators to replace any medical oxygen bottles found aboard air ambulances with the aviation equivalent. And the medicos continue to carry their normal medical oxygen cylinders.

[lowerlobe]

Speedbirdhouse.....right again and pedantic is an understatement...

Sprite..I suggest you read more carefully....In the last sentence I said...used in medical O2 bottles
Sprite...here is a trick quesion.....what do you think I meant by Medical 02 and what is a Pedant?

Jaba...What we are saying is that IF the bottle is allowed to empty or is not filled with Medical 02 ( for sprite's benefit) in the first place or at some stage (by accident) then there might be moisture present in the bottle which we all agree is not a good thing and might be a reason to suspect internal corrosion.

Instead of a chocky frog.....how about a Kit Kat:E

[Jabawocky]

Gotcha!

Run out of Kit Kat's...... how about a black Jelly Bean.!

J:ok:

[lowerlobe]

Run out of Kit Kat's...... how about a black Jelly Bean.!
Nah...I only like the other coloured jelly Beans....you know the ones with artificial colouring like the ones that are going to be banned in the UK!!!

I wonder if that means there will be a black market for sweets with artificial food colourings and preservatives in the UK like there is with chewing gum in Singapore?

[employes perspective]

brissysparky did you say Kiwis are always right or tight:}

[Kangaroo Court]

I say the latter, based upon a personal experience with a certain Kiwi girl...

[BrissySparkyCoit]

Yep! Sotty, rypo. The "T" an "R" are tighr beside each orhet??

[BAZZA BOEING]

Tinpis Hong Kong to Manila is 618.30 nautical miles.