QF risk

[Groaner]

The prior thread has been locked, probably because of all the cheese jokes (sorry I even mentioned it).

I would normally leave it at that, except for the risk attitude displayed. GaryGnu said "There was never any mention of "no risk"."

Actually there was. Try Qantas Suspends Pilots After Landing Gear Not Lowered in Sydney - Bloomberg.com (http://www.bloomberg.com/apps/news?pid=20601081&sid=aWv9KiWS0Ato) which has Simon Rushton saying “There was no risk of the aircraft landing without its gear.”

And plenty of reported comments about "There was no flight safety issue." - all the News Corp papers had a similar story.

Admittedly these are as-reported, but I suspect we can trust journos to get direct quotes right (cross my fingers). Qantas' risk attitude is, IMHO, degraded somewhat as a result.

[MaxHelixAngle]

This is an 'operational incident' and one that Qantas is reported as taking "very seriously". As to the comment regarding there was no risk of the aircraft landing without the gear down, I think this comment is poorly phrased, there is always risk of a gear up landing, or a wing falling off for that matter. Perhaps it should have been worded as no immediate risk as there was other layers of protection there to prevent a landing occurring (ldg config warning, GPWS).

As to the comment regarding 'no flight safety issue', there wasn't. If anyone has a problem about this I suggest the read the ICAO accident investigation definition / ATSB definition of flight safety issue.

Please everyone re-read the reasoned post presented by Cactus Jack, as this is one of the only posts with merit in the entire discussion. Why is everyone looking for more story to this than there really is???

http://www.pprune.org/dg-p-reporting-points/394483-another-qantas-incident.html#post5292656

Regards,
MHA

[woodja51]

My company just had a similar incident and it got a few lines in the safety report, a bit of a debrief and that was that..no apparent witch hunt etc.. and it was a training upgrade flight...other factors but hey they went round and fixed the problem... move along ..

A friend of mine who worked in QF safety used to attend incident briefs at which QF staff where ashen faced over and 'needing to remedy the safety holes... he just used to yawn and say... you have not seen anything like goes on out in the big wide world.. I am sure the QF guys will have done the right thing to mitigate the original error, trapped and sorted!:ok:

[speeeedy]

Whilst it is never possible to there is "zero" risk of anything, I believe it is fair to say that there was no "real" risk of that aeroplane landing without gear.

The pilots should have put the gear down earlier, no doubt, but when the mistake was realised the aircraft commenced the go-around before the SOP's require the aircraft to be stable (if it was VMC) or only just after (If it was IMC).

Would the pilots be proud, NO. Would the company be proud, NO. But were they going to stack it.....NO WAY!

In order to land without gear the following would have to happen.

1. Pilots miss putting gear down (only a memory item - albeit a pretty fundamental one) at say 1500 to 2000' - Seems to have happened in this case - perhaps (facts yet to be established).

2. Pilots pass 1000ft without being stable (Not technically required if VMC, but in the SOP's it is the AIM, so everyone obviously tries to be stable by 1000') - It is only 20 seconds from 1000 to 700 so it is likely this particular defence actually worked as intended in this case, i.e. pilots pass 1000, not happy, assess the situation and after deciding it is not possible to be stable by 500' they go around... Exactly as intended.

But, what if defence 2 had failed also, the following defence are in place prior to landing with the gear up....

3. Landing checklist is missed or incorrectly done - Checklists are there for when we forget things, they have work quite well for decades - no reason to think it would have been any different in this case.

4. PF passes 500ft without being stable - Highly Unlikely - he/she would have noticed that the Thrust would have been all wrong for the situation, probably speed too.

5. PNF calls out "STABLE" at 500' without being stable - again highly unlikely - The PNF has a very good look around at thrust, speed, and CONFIGURATION before calling "STABLE" as per the SOP's.

6. Gear Warning (Flap Related) Fails - ties in with previous because if the flap wasn't in the final flap AND no gear there is NO way that the aircraft would have the trust or speed anything like required for a "STABLE" call at 500.

7. Flap warning (Radio Altitude) Fails - this ties in with number 6, in that if the gear warning didn't occur because the flaps were not in final config then the flap warning would have.

8. EGPWS Warning (Terrain floor) Fails.

9. GPWS Gear Warning (Radio Altitude) Fails.

So lets put it in perspective please. Of the 9 holes in the cheese that needed to be lined up, these pilots went through the 1st one only.

Therefore I am very confident that I can say there was no real risk to this aeroplane at any time.

The media should realise that forgetting something (even really important stuff) is a well recognised fault of the human being, that is exactly why in aviation we don't rely purely on memory, there are multiple layers to pick up errors because we know for a fact that errors do occur.

[ALAEA Fed Sec]

Between 1000' and ground, those holes can start to line up very quickly, just ask the Ansett 747 crew.

Some errors can knock a bunch of them out together such as a defective component in the GPWS system or a crew that have too much on their plate to carry out the visuals. There are countless other scenarios that could have seen this lead to a gear up landing.

[Capt Claret]

The previous thread, in my opinion, epitomised the sad state of Australian culture, and the sad state of professionalism in Australian aviation.

It seems to me that the majority of posters wanted to lambast the crew for their perceived mistake, with out any one knowing all the facts. In psychological terms, I believe this phenomena is typically human, to reinforce the confidence of the critic.

I for one can imagine any number of scenarios that could see the gear not down when "normally" expected. I have been guilty of getting the gear out of sequence on the odd occasion, when managing a multitude of inputs during a busy and changing approach. Fortunately I haven't got to the point of being < 1000 AAL, and always picked it up, either noticing myself, or, wondering why Bloggs hasn't responded to my incorrect call for more flap but at the same time, hasn't actually annunciated their query, or confusion at more flap instead of gear.

Short of a gear malfunction, it's probably safe to say that no pilot has ever intentionally landed with the gear up. Ergo, they all thought the gear was down. Obviously making a mistake, something humans are very good at.

If the public statements, that the crew had initiated a missed approach and during that manoeuvre, the GPWS sounded, are correct, why are so many, presumably Australian, fellow pilots so happy to criticise? Why not take the attitude of, "I wonder what circumstances caused the crew to make that error"? And, why flame some one for making an error?

I believe that fearing that I am not immune to making a gear up landing, reduces my chances of doing so, because of the heightened vigilance on final. As some one posted on the last thread, FUC.

[speeeedy]

There are countless other scenarios that could have seen this lead to a gear up landing.

As I said in my post, the crew only made 1, repeat 1, mistake.

If you as a member of the aviation community really believe that 1 simple memory based mistake makes for "countless" opportunities for an accident then you display your ignorance of the defences put in place. Push your industrial barrow elsewhere.

We can play scenarios all you like, but the fact is that there is not a shred of evidence that more then one layer of the numerous defences was breached in this event.

Like it or not, single defence layers are broken during probably every single flight, maybe not all as exciting as this one, but all capable of "theoretically" bringing down an aircraft if another X number of problems arise.

[ALAEA Fed Sec]

Push your industrial barrow elsewhere.


My comments have nothing to do with Industrial Relations. This thread seems to me to be a discussion about Swiss cheese. I've just pointed out that the holes can line up very quickly.

Plenty of accidents have occurred due to one person making a mistake. If you think the defences are always going to be there to back you up, it might not be my ignorance but your complacency that lets you down.

[Ultergra]

Goodness me. It was butter on the last one, now it's onto cheese.

Could this thread please be closed? I mean, come on. It's becoming a slog fest again. Everyone, the event is under investigation. No one landed with the gear up did they? Was the error found? Yes. Move on with your life.

Why is it, that whenever QF have an incident, everyone jump's up and has their say. And to add, open's another topic to further discuss the point! But Virgin or otherwise have an incident, it only get a one page 'discussion' .....?

Maybe i'm simple, but I dont get it.

[Buster Hyman]

At least they hadn't flown past their airport...

Storm in a teacup really...

[Cactusjack]

It seems that a lot of the posts that have been made in the past few days in relation to the QF incident have been made by people who may have great technical knowledge, but apparently minimal safety knowledge. Thats just a theory.

One valid point that has been left out is that within the work environment there are varying degree's of human factors.In particular Errors vs Violations. Preliminary investigations are showing that the incident is heading down the road of Error.There is a huge difference between an error and a wilful violation, so for the time being lets cut the drivers some slack, let QF conduct their internal investigation, let the ATSB conduct their external investigation and wait for a 'confirmed outcome' before passing judgement upon the Drivers or writing off QF as 'completely unsafe'.

[Old Fella]

Cactusjack I fully endorse your post regarding the need for people to take a deep breath and allow the internal and external investigations into how the Qantas B767 gear was not lowered in sufficient time to allow for a stabilized approach to be completed. The "arm chair critics" who wait in the shadows for any opportunity to bad-mouth either the crew or the company, or both, have likely never sat in the cockpit of an aircraft let alone a large one.

It is all too easy to throw brick-bats or make ill-informed judgement on others from afar. The truth will out and the appropriate action will be taken, when all the facts are known. The one fact we all know is that the aircraft made a missed approach and thereafter landed safely. Whatever else the crew may or may-not have done they averted an embarrassing and potentially dangerous "wheels-up" touchdown.

[nightmode]

Will be interesting to see the sequence of events that lead to the guys missing the initial gear selection. It might help us not make the same mistake some day. They went around, put the gear down and landed.

As for some people sledging the crew - not cool and not required.

Some of you may have seen the link below, but if you havent, it talks about a *near* gear up in a 747 futher down the article among others.

Pelican's Perch #80: Gear-Up Landing In A 747? (http://www.avweb.com/news/pelican/188536-1.html)