Merged: QF 32 Forensic Analysis - 4 Corners

[packrat]

The Four Corners programme on the ABC will provide a forensic analysis of the QF32 event.It will be aired on the 28th March 2011.
It should be much better than the 60 minutes fluff piece aired recently and that is said with the utmost respect and admiration for the pilots involved

[601]

forensic analysis
conducted by whom?

[C441]

Preview here (http://www.abc.net.au/4corners/content/2011/s3172488.htm)

[Mr. Hat]

How about Four Corners do a Forensic Analysis on the entire industry complete with interviews from the Senators.

[The Kelpie]

Mr Hat

I believe it may be on the cards!!!

More to Follow

The Kelpie

[ratso]

FOUR CORNERS ABC Tonight 29Mar11 QF32 A380 INCIDENT

[ratso]

sorry 28th march 11

[breakfastburrito]

8:30pm Monday, March 28 2011
QF32: Sarah Ferguson reports on how a tiny faulty engine part almost brought down the pride of the Qantas fleet. What caused the dramatic mid air engine explosion on board the Qantas super jumbo?
ABC 4 Corners (http://www.abc.net.au/tv/guide/abc1/201103/programs/NC1004H027D2011-03-28T203252.htm?program=Four%20Corners)

Perhaps the mods could change the thread tittle to correct the date.

[ratso]

Rolls-Royce under scrutiny after Qantas explosion - ABC News (Australian Broadcasting Corporation) (http://www.abc.net.au/news/stories/2011/03/28/3175086.htm)

[Just a Grunt]

It should also be on ABC iView (http://www.abc.net.au/iview/#/news) tomorrow, for those without access to the broadcast.

[Waghi Warrior]

Hey moderators you merged the topic and deleted my post. I thought what I said was a kind gesture,obviously you guys didn't agree. I apologize if it was deleted accidentally.

[ejectx3]

Falling out of the sky? I think not...

[no one]

SO "The first officer was working close to his capacity, I would not liked to have had a low experience hours first officer in that situation."

I like it.

[Qantas 787]

Rather predictable - now only 20 minutes of the show is pointing fingers at Rolls Royce........they should spend the whole program doing that.

['holic]

First words out of AJs mouth after hearing about the QF32 were something about the share price taking a dive. WTF? Ok, maybe he was the victim of some unkind editing. But IMHO, the words "share price" should never, ever have been mentioned within whispering distance of anyone with a microphone and/or camera. What was he thinking? :ugh:

[qf 1]

un-bloody believable it's a shame Qanats don't allow 4 corners to go to town on it's current maintenance record when it comes to outsourcing and maintenance standards of contract labour that it uses.Qantas have made much larger mistakes than fitting incorrectly bored stub pipes in resent history.What Hypocrits.You would think there would be a lesson there for Qantas that it doesn't take much to bring down an aircraft be it through manufacturing aircraft or maintaining them.

[Feather #3]

'holic, watch it again!

In fairness to Joyce, the first thing he heard about was the share price falling and when he asked why, was told about QF32.

Bit like doing exams, RTFQ.

G'day ;)

[rodchucker]

Holic,

Agree, but in fairness I think the context was that he was with his investor relations people at the time and this was the first sign that he was given that something was occurring. The markets had picked up the tweeter about the events as they were unfolding.

cheers

[FJ44]

"The first officer was working close to his capacity, I would not liked to have had a low experience hours first officer in that situation."

Now to get the next episode to focus on experience levels...

['holic]

Sorry, gotta disagree .... if he had to share an anecdote about the incident on camera, and it's not like he hasn't had time to think about it, he could have come up with something better than the falling share price.

[The Kelpie]

....and appearing for RR the defendant we have Mr Alan Milne, Head of Maintenance for Qantas. Mr Milne could you tell the court what you meant by the following statements on the 4 corners

ALAN MILNE: Can you design manufacturing errors out, you know, no. You can do a lot, but they couldn't have, I don't think they could've planned for this one.
SARAH FERGUSON: You don't hold them responsible?
[LONG PAUSE TO THINK ON HIS FEET. ABOUT WHAT HE JUST SAID!!]
ALAN MILNE: They still manufactured the engine.
SARAH FERGUSON: So in the end they are responsible?
ALAN MILNE: I think that's being discussed as we speak.

[no one]

Now to get the next episode to focus on experience levels...

FJ44 That's exactly what I am hoping, It was a small mention (thanks to the S.O.) but at least something was mentioned.
Maybe this will have a positive impact on the experience vs 250 Hour FO's debate at the moment.

no one

[Teal]

Two 10 minute excerpts (from the 40 minute program) for those that missed it:

YouTube - Qantas Airbus A380 engine failure over Batam Island - part 1/2

YouTube - Qantas Airbus A380 engine failure over Batam Island - part 2/2

[SgtBundy]

he could have come up with something better than the falling share price.

I find it odd that the CEO first finds out there is a major incident because his investors are telling him the share price is falling. In the story the ground operations teams had indications within 10 minutes of it occurring. Surely someone should have thought to tell management?

[TIMA9X]

Teal,
many thanks for the upload, 4 Cs did a good job!
Nice stuff.:ok:

[Fris B. Fairing]

Even if it's true that he found out via the share price that one of his aeroplanes was in trouble, a CEO with his eye on the main game should be too ashamed to admit it.

[YPJT]

Where was the clip taken where Sarah Ferguson is walking on the concrete apron next to a parked up 380? If it was in Australia, why isn't she displaying an ASIC or VIC?

[1a sound asleep]

http://images.businessday.com.au/2011/02/03/2166094/0302cbd-200x0.jpg

[The Kelpie]

1a - classic!!

But I find it amazing given all of the books that have been written on management, one of the most important lessons can be found in a childrens book. Aesops Fables are famous around the world and you can apply the one quoted below to many situations whether it be the breaking up of a business into many separate businesses (that is your que Alan and Bruce), the shared experience and teamwork on a flight deck or the plight of many people to defend their rights. Here is one such fable and arguably the most famous of all.

Aesop for Children (1919)
13. THE BUNDLE OF STICKS

A certain Father had a family of Sons, who were forever quarreling among themselves. No words he could say did the least good, so he cast about in his mind for some very striking example that should make them see that discord would lead them to misfortune.

One day when the quarreling had been much more violent than usual and each of the Sons was moping in a surly manner, he asked one of them to bring him a bundle of sticks. Then handing the bundle to each of his Sons in turn he told them to try to break it. But although each one tried his best, none was able to do so.

The Father then untied the bundle and gave the sticks to his Sons to break one by one. This they did very easily.

"My Sons," said the Father, "do you not see how certain it is that if you agree with each other and help each other, it will be impossible for your enemies to injure you? But if you are divided among yourselves, you will be no stronger than a single stick in that bundle."

In unity is strength.

[Sunfish]

Kelpie:

ALAN MILNE: Can you design manufacturing errors out, you know, no. You can do a lot, but they couldn't have, I don't think they could've planned for this one.
SARAH FERGUSON: You don't hold them responsible?
[LONG PAUSE TO THINK ON HIS FEET. ABOUT WHAT HE JUST SAID!!]
ALAN MILNE: They still manufactured the engine.
SARAH FERGUSON: So in the end they are responsible?
ALAN MILNE: I think that's being discussed as we speak.

Alan Milne needs to be fired.

"Can you design manufacturing errors out, you know, no. You can do a lot, but they couldn't have, I don't think they could've planned for this one. "

As someone who was taught statistical tolerancing and as a mere student engineer applied it to the manufacture of polarised fittings that deliver oxygen and suction to hospital beds I can tell you that Milnes first opinion is bullsh1t.

As someone who spent Six months in the metrology laboratory of the old Ammo factory at Footscray designing and calibrating "Go" and "No Go" gauges for mortar fuse components, his opinion that the error could not be easily caught by simple inspection is also unsupportable.

I will also bet my left testicle that the business and personal relationship between the Leprechaun and the no doubt frightfully English RR people will be absolutely poisonous.

[TBM-Legend]

Re Alan Milne you have to remember that there is a giant lawsuit vs. RR and he has to be very careful what he says.

[standard unit]

Yes, and yet he said this about RR -

ALAN MILNE: Can you design manufacturing errors out, you know, no. You can do a lot, but they couldn't have, I don't think they could've planned for this one.


:}

[KRUSTY 34]

So what's it to be Alan?

An Own goal
An appologist for RR. Mmmm...
Out of one's depth!
:suspect:

[The Kelpie]

A simple 'given the ongoing legal case between Qantas and Rolls Royce it is not appropriate to comment on that' would have served you much better Alan.

Or perhaps this is the considered opinion of the Qantas camp and this whole case against RR is just a game of bluff!!

More to Follow

The Kelpie

[Capt Chambo]

The following is a link to the programme on the ABC. You can watch the show again.

(I have only looked at it briefly and it seems to show everything that was in the original programme. I guess like a lot of these shows though it will only be available on the 'net for a short while and may not be available to you unless you have an Australian ISP)

ABC iview (http://www.abc.net.au/iview/#/series/four) corners

[Motorola]

Not very forensic.

No mention of longitudinal imbalance motivating a landing.

No clear pursuit of the engine maintenance outsourcing. Why weren't the engines modded earlier?

[Beer Baron]

In defence of Alan Milne, I believe he was differentiating between a design error and a manufacturing error. And saying that RR can't design an engine that would withstand any/every possible manufacturing fault.

When pressed as to whether it was still RR's fault he essentially says, Yes as They still manufactured the engine. Hence a manufacturing fault is still the responsibility of RR.

I don't think he is defending RR as some seem to be suggesting.

But that's just how I saw it.

[Ex FSO GRIFFO]

As discussed on Perth Radio this morning.....

'Pure Luck'....or Good Fortune.....or Fate...(as in the 'Hunter').....was riding on this flight.

The crew on board at the time - Top Notch.
2 very experienced Check Capts, one of whom took over the various calculations prior to the landing to determine the landing config / parameters -thus leaving the pilot flying to actually concentrate on flying the damaged aircraft, and the FO to handle his duties in assisting.....Luck.

Again the crew on board at the time - possibly the world's most experienced A-380 crew available - anywhere....Luck.
Which enabled them collectively to exercise their combined Skills.

When the engine disc, weighing in at over 200kg, disintegrated into 3 pieces -

- One presumably went up and over the fuselage after exiting the top of the wing. Imagine the consequences of that piece of flailing hardware penetrating thru the fuselage at say FL250,......In one side and out the other(?)......Explosive decompression (?).....Luck

- Managing the imbalance of the fuel loads etc, and landing with an engine still producing power that the crew had thought they HAD control of, and HAD shut down on landing - Skill and Luck

- With brakes at 900+ deg C and fuel spilling to the ground in close proximity from the ruptured tank(s) in the left wing, and NOT igniting - Luck (?)
(The crew and pax were in this aircraft for an hour or so after landing...)

I'm sure that there is much 'reflection' out of this incident.

Not only from RR, whose engine caused the problem in the first place, but also from QANTAS, and all of the other airlines using the same RR 'Trent's.

Not to mention the considerations if that engine had exploded at a higher level and penetrated the fuselage......PURE Luck..(?)

Cheers, and Congrats to all of the crew concerned.

[Sunfish]

Beer baron:

In defence of Alan Milne, I believe he was differentiating between a design error and a manufacturing error. And saying that RR can't design an engine that would withstand any/every possible manufacturing fault.

Totally wrong.

You design an engine where every component can be tested to ensure fitness for purpose, it's called quality control, and for an engine like the Trent, it's 100% inspection. If it can't be tested or its reliability insured some other way, then it doesn't go in the engine.

Blind Freddy could have seen that eccentric counterbore - if Freddy had bothered to look. My Toyota has better engineered joints than that arrangement.

[rodchucker]

Yep an awful lot of luck helped save that flight, but at the end of the day it was the experience of the crew that brought it home. The aircraft was unable to fly itself and the SO view of a less experienced crew was very pointed and completely valid.

The hull cost and passenger pay outs buy a hell of a lot of experience in my view should it all go pear shape.

I am still at a complete loss as to how the Rat management cost justify their drive to lower pilot costs by compromising experience up the front.

Complete BS in my simple mind and singularly short sighted strategy at the cost of a great company.

As has been pointed out before, which is the better investment...securing long term experience or Executive bonuses.

No brainer even before assessing performance of the latter and even worse if you do.

[airtags]

Overall the story missed despite great camera and editing.
Certainly again proves 4 Corners has lost the journalistic edge it had in the Chris Masters era. As one journo commented - it was as forensic as pathology without results!!

Re Milne's comments:
Milne hinted at the nexus between the two which in risk terms are not mutually exclusive. In other words there was an awkward mid sentence pause that I'm sure will later prove to be significant.

That said however the question of "who knew what" is unanswered.

Still find it hard to believe that Milne and Co did not know what was happening on the Airbus production line with RR replacing engines, the AD's and the test bed failure and not even thinking to ask the question about the engines on the QF 380 wings. Single contract responsibility does not negate the need for due diligence.

End of the day RR knew there was an issue and a resultant risk and did NOTHING hoping to lay low and change the rented engines over quietly during heavy.

Noted the absence of CASA in the 4 Corners story although CASA was very quick to issue letters of praise coincidently as QF talked up the market with resumption of 380 services. Dolan for the ATSB was ineffectual and highlighted why both Regulatory bodies need a shake up.

Also thankful for the noted absence of Olivia's Worth-less efforts.

Did however like the AIPA lanyard.

AT :E

[The Kelpie]

Question:

If QF lease their engines on a per hour basis, is it incumbent on RR to keep Qantas appraised about 'non operational' issues with the engines since they are only buying a service?

Qantas seem effectively on a pay as you go deal and this in itself, if my question is valid reduces the layers of swiss cheese from what used to be two layers (manufacturer and owner both with a vested interest) to just one layer where RR are the only party interested in looking for issues.

The old addage two sets of eyes are better than one!!

More to Follow

The Kelpie

[airtags]

Kelpie,

the overlay to your question also involves the State Based OHS Acts particularly the Victorian Act which has clear obligations associated with Designers, Manufacturers and Operators of Plant (plant as in a/c & engines).

While Q belives Mascot is the centre of the universe, the placement of crew from Victoria on the 380 means that the Victorian OHS legislative provisions also apply.

Under such it is incumbent upon the Designer and Manufacturer (ie RR) and Operator (QF) to not only inform but more significantly 'ensure'!!

Not that State WorkCover/Safe Agencies have a passion for prosecution, it is none the less a clear underscore to RR's obligations to tell and QF's obligations to ask.

Moreover Airbus by its own admissions knew of RR's replacement of prod line engines - Still can't quite buy Joyce's line that Q knew nothing and certainly can't buy the line that Q did not have to ask the questions.

The Q action against RR would make the detail of those agreements to some degree, discoverable but reality is there is no way on earth that RR would risk the precident of an unfavourable judgement.

AT

[Ken Borough]

SO view of a less experienced crew was very pointed and completely valid.

And totally inappropriate. How many people watching this program would realise that because of seniority, only the most experienced of Qantas' pilots would occupy the front seats during the critical phases of flight?

[Chadzat]

Your point being Ken? Do you disagree with the SO's statement?

[rodchucker]

Sorry Ken but does the same apply to Jetstar?

Might at the moment but for how long?

[Ken Borough]

I've made my point but I can't help you if you are either unable or unwilling to understand it! :ugh::ugh::ugh:

[Jimothy]

Ken
Actually I don't think the answer was inappropriate, because I believe the question asked by the interviewer (not shown/heard on tv) was: how do you think an inexperienced F/O would have handled the emergency?

[Chadzat]

Nice sidestep Ken, spoken like a true politician. I understood your statement clearly and think that the SO was simply trying to state that the FO was at his limits in a high workload situation.

Thread drift, but valid to my argument- do the passengers realise that their "most experienced" pilot up in the RHS on a Jetconnect or Jetstar service is actually far from it? :hmm:

[adsyj]

Ken proves once again he has NFC

[Jabawocky]

I think for not only handling the incident brilliantly, but for handling the media attention superbly Richard deserves a knighthood. :D

That man is the face of Qantas, not some actor. He and his crew (tech and cabin) replicated the Sully / Skiles crew. What more can you say. Brilliant.

As for the phorensic study....well.:rolleyes:

[Clipped]

Alan Milne needs to be fired.


Nope. Just got promoted. Head of IOC.

[teresa green]

Please qualify Chadzat why any of the current F/Os in JQ are not up to standards and why?

[1a sound asleep]

But, I agree with all the comments regarding the quality of the 4 corners reporting

You must admit it was 10 times better than the 60 minutes PR show:rolleyes:

[training wheels]

Just wondering what's the flying background of the F/O? Military, GA, Instructing etc?

[Icarus53]

It actually stated in the show that the FO came into QF via the cadet program.:ooh:

[teresa green]

Training wheels, am pretty sure he is GA. Having been on the wrong end of a few rather alarming problems over the years, you really don't know how you will react until the **** happens. It is highly likely 99% of you, would react in the same way as this crew. You would not be in the job you are in, you most likely would not have slipped thru the net, if you were incompetent. I found after losing a donk, on rotate, out of CBR in a DC9, full pax, full fuel, on nightfall, and the ATC advising me of a "roman candle" coming out of the port side donk, was not the way to start a sector. The F/O and I had a quick chat, the training kicked in, no other thought patterns intruded, just calm, calculated reasoning to get out of the problem, which we obviously did, and got her back on the ground. It was not till a quiet time later over a beer with the F/O, we both said "What the :mad: happened? I thought about my reaction, the F/O's reaction, and realised how much our backgrounds, our experiences, our training over the years had paid such a part in a successful outcome. That was only one of three serious problems I had in my flying career, and I found each time I reacted the same way, as did the three separate F/O's. I took that into my check and training career for years to come, and did not hesitate to fail those who showed they were not coping for whatever reason. Obviously I am deadset against any pilot, who has not put in the hard yards to occupy a RH seat, communication is a huge thing when the **** hits the fan, and the reliance of a competent F/O is paramount, which showed up in the A380, and in all three of my own experiences, that were potentially disastrous.

[FoxtrotAlpha18]

I think one of the most telling statements in the whole story was that of the check captain at the end where he spoke of his son going in for shoulder surgery and the doctor telling him he'd get the "Rolls-Royce treatment", to which he replied 'No thanks!" :ooh:

[Jimothy]

Matt was NOT a Cadet. He came through the GA system, as did the two Check Captains. Richard and the S/O ex-Military.

[spikeflyer]

I joined the same day as Matt. He was GA, not a cadet.

Well done mate.
G.

[Stationair8]

Just think if it had been a couple of well known GA operaters in Australia.
The following scenario would have taken place:

1. The aircraft would have have been operating VFR and been climbing
OCTA to avoid enroute charges,

2. Nothing put on the M/R for at least a week or two,

3. The aicraft would have been at least 10% overloaded,

4. The pilot in the LHS would be on an ICUS paying program,

5. The pilot in the RHS would be employed on a casual basis and only paid for the hours flown.

But back to the serious side, shows the value of a well trained crew, lets see the bean counters put a costing index on that!

The CSM comment was interseting about keeping the passengers calm and in the loop.

Training is expensive, but try putting a cost on an accident.

[Jack Ranga]

Training is expensive, but try putting a cost on an accident.


I reckon they would and if it's covered by insurance they wouldn't give a sh!t if people were killed and a hull lost. I was going to say that an Australian would care more about the company's reputation..........but then I remember Dixon :yuk:

[gobbledock]

Ken proves once again he has NFC
I 'second' that assessment.
Ken Borough the armchair expert = tosspot...........