Qantas fly A330 over the MTOW

[neville_nobody]

Bit of a stuffup on behalf of the ground crew but this sort of thing will get your AOC cancelled if you are a GA operator however Qantas do it and there seems to be no problem. No threat to safety Qantas says.....:hmm:

They were 884kg overweight with the wrong COG and wrong data in the FMC

Qantas overloaded aircraft (http://www.theage.com.au/travel/qantas-overloaded-aircraft-20110323-1c5fg.html)

Qantas overloaded aircraft
Andrew Heasley
March 23, 2011 - 6:10AM

An overloaded Qantas Airbus A330 flying from Sydney to Hong Kong was a risk to flight safety, air investigators have found.

A breakdown in the flow of paperwork controlling pallets of freight loaded on to the passenger aircraft led to it being overloaded, exceeding its maximum structural take-off weight by almost a tonne.

As a consequence, pilots configured the plane's flight computers for take-off based on the wrong data about the aircraft's weight and centre of gravity, which "had the potential to affect the safety of flight", investigators with the the Australian Transport Safety Bureau found.
Advertisement: Story continues below

A delay in notifying the error resulted in the aircraft making another 10 flights before maintenance checks for any damage were undertaken. The delay "presented a risk to the ongoing airworthiness of the aircraft", investigators said.

The safety bureau also trawled its records and found 28 freight load control incidents at Qantas in the 2½ years to last August, with the most recent being on July 8 last year.

The investigation also uncovered a lapse of quality control at the airline.

Qantas had not reviewed its Sydney freight loading centre for quality assurance in the 22 months before the incident on March 6, 2009.

These reviews were supposed to be carried out by senior Qantas management personnel every six months. The last review was conducted in May 2007, investigators found.

"The investigation could not discount that, had those quality assurance reviews been carried out, this occurrence might have been avoided," the bureau's investigators said.

No damage was subsequently found to the aircraft and Qantas has since made changes to the way it loads and checks freight into aircraft, reports incidents and has revamped its staff training, the bureau said.



Investigation: AO-2009-011 - Weight and balance event - Airbus A330-303, VH-QPJ, Sydney Aerodrome, New South Wales, 6 March 2009 (http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-011.aspx)

[blueloo]

884kg? whilst not good, and i don't believe anyone would intentionally do it - in reality it would make 3/5s of 5/8s difference. Of course you wouldnt want an engine failure on the day out of Honkers to test your performance.

I heard a bloke in a certain freight department of an airline reckon that on LAX - SYD flights reckon their 747s were potentially 10-15 tonnes overweight regularly....

[Capn Bloggs]

884kg over 233,000kg (ish). You've gotta be joking. Sure, a stuffup but...

If the ATSB is so worried about weights, it should propose weighing of pax. I wouldn't mind betting that on a fair number of my flights the actual weight of the aeroplane bears no resemblance to what I think it is, based on the size of the blokes getting on.

[MrWooby]

Couldn't agree more Captn Bloggs. I believe average weights would lead to errors of +/- 2t on an A330. On the 747-400 it was funny when taxying out close to MTOW and having to hold prior to takeoff to burn off 100 kg of fuel to get down to MTOW, when you know the actual weight would be +/- 4T.

[swh]

The -300 can be purchased with a 235,000 kg MTOW, and has the single engine performance to handle over 250,000 kg out of SYD.

I wouldn't mind betting that on a fair number of my flights the actual weight of the aeroplane bears no resemblance to what I think it is, based on the size of the blokes getting on.

And the hand carriage items ...

QF should be able to look at their QAR data to see what weight the aircraft calculated it was in flight anyway, the FE computer works that out all the time anyway and uses VS1G calculated by the PRIM for VLS , F, S, and green dot. Alpha prot, Alpha max, and Vsw care calculated from PRIM AoA data. The FE computer also cross checks the imputed CG vs the calculated, and will use a default of 30% if it out of tolerance by too much.

[Ndicho Moja]

Over loading happens more often than we care to admit, especially if when are using generic weights.

[Metro man]

The fly by wire Airbus aircraft aerodynamically "weigh" themselves in flight and it is possible to go into the flight management system and find out what the aircraft thinks it weighs based on angle of attack, altitude and temperature.

There is usually a slight difference between between the captains and first officers indications which in turn differ from the load sheet. Usually our aircraft thinks it's lighter because our Asian passengers come in under standard weights.

Any large cargo aircraft which carries fruit and vegetables longhaul and lands with the maximum payload it could have carried on take off with, was overweight on departure. There is a substantial evaporation of water which takes place during the flight.

884kg in a 233 000kg aircraft is an error of less than 0.4%

[jportzer]

Sorry if this is a dumb SLF question, but has anyone ever proposed weighbridges at airports to help resolve this conundrum? Not that every flight would need to be weighed, but just like truck weigh stations, they could spot check a few flights here and there, and see how closely the actual weight matches the pilots' and dispatchers' calculations.

Or would that upset the applecart too much, if a 747 came in e.g. 2 tonnes overweight due to having a couple of rugby teams on board -what would they do? Obviously the airline wouldn't want to go back to the gate and offload some freight...

[ampclamp]

All what you guys say is true the error was small relative to the aircraft weight.
What I am concerned about of the findings of the inquiry.The lack of procedural review despite company policy and the number of stuff ups.
Lining up a few holes in the cheese.

[Captain Sherm]

The key is not the amount of the overload. It doesn't matter whether it is 10 kg or 10 tonnes. The issue is the failure of Qantas' internal quality system to pick up the organisation's ability to make such an error.That is where the real embedding of "Safety First" comes from, not counting the bags on an individual flight per se, but having a system that works to ensure such errors can't happen.

In a case such as this a hypothetical regulator might well take the forensic view that if there is a failure in the quality system in one area then there may well be in others. And that would hypothetically point to a failure of the organisation to run itself according to the required levels of internal oversight and safety management. And that hypothetically would point to the executive management of the organisation and the accountable managers who collectively hold the AOC. A far bigger issue than a few kg here or there.

Just a thought

Quote from the "Age" report:

"The investigation also uncovered a lapse of quality control at the airline.

Qantas had not reviewed its Sydney freight loading centre for quality assurance in the 22 months before the incident on March 6, 2009.

These reviews were supposed to be carried out by senior Qantas management personnel every six months. The last review was conducted in May 2007, investigators found.

"The investigation could not discount that, had those quality assurance reviews been carried out, this occurrence might have been avoided," the bureau's investigators said"

[Prince Niccolo M]

Bloggs,

The issue here is really the integrity of the loading system and trying to control as many of the variables as is practical to do so. The statistical analysis of passenger weights is intended to avoid the issue to which you refer, since the first airline to start weighing our increasingly obese passengers is going to drown in the ensuing PR nightmare.

How good is the procedural control of W&B in your operation? Are systems reviews and QA checks being done on a regular basis? Are crews actively feeding back detected errors or are they working around known deficiencies in the system?

Defence in depth requires system integrity and the parallel tenet of keeping the problem as remote from the aircraft as possible.

However, I was charmed by the QF reference to their "proactive" response - which strangely only came about after they got caught out... := :=

[Toolman101]

Capt Bloggs
' based on the size of the blokes getting on'
Didn't know you where looking that close !!!!!!:E

[Keg]

I agree Sherm. This is not the Qantas of a decade ago. Sacked too many experienced staff (or let them take voluntary redundancy) and promoted too many people into positions that they simply don't have the skills or experience to cope with.

This type of behaviour is rapidly becoming systemic and it comes from the top. Focussing on all the wrong things- getting rid of experience in order to go low cost- and it's starting to come home to roost. This is just the beginning. It's going to get worse. I can not fathom why Qantas are continuing down this road.

[Ken Borough]

Keg is so right! :D The run-down started years ago when Strong, Jackson, Dixon and Gregg did little more than keep the shareholders happy. They invested in neither people nor fleet, and now AJ and his colleagues are paying for their incompetence. The loss of corporate knowledge and expertise has almost been total, and near irreplacable. It can only be recovered over a genration or two. I suggest that a background in domestic aviaition is not a receipe for the successful management of a large international airline and its many complexities.

[Fluke]

Keg & Ken , you are missing the point. Keeping the the share holders happy or providing them with maximum return is the primary role for the CEO of a public company. You can't blame them if they are just following their job description.

Your comments about the health of Qantas are so true, and also valid for many airlines amounst the developed nations. Unfortunately while Qantas remains in its present form the sell off of experince and the relunctance to invest in training and retention of experience will continue. I hate it !

Seriously though a 1 ton stuff up on a A330 is not life threatening. These mistakes happen in all airlines and while regretable and potentially dangerous, Qantas pilots and the Australian public should be grateful for the investigation.

[Capt Claret]

My first twin job was flying folk to Lady Eliott Isl off the coast of Bundy. Islander, Nomad & Twooter were the workhorses, and given the island strip was 600 metres, high water mark to high water mark, every thing, pax included, was weighed before it was loaded. Many a larger person, usually women, squirmed and tried to beg off climbing onto the scales, or admonished their better half not to look at the weight display. :rolleyes:

I recall the Chief Pilot's surprise after some admin work, when over several years he found that the average weight of all the pax carried was 77kg. That was the standard weight of the day (late 80's).

[Ken Borough]

Keg & Ken , you are missing the point.
We are not! Where are the returns to which you refer? And although you didn't mention it, where is the growth? There should have been a return to shareholders but also an investment in staff, fleet etc etc etc which are the lifeline to continued returns.

Seriously though a 1 ton stuff up on a A330 is not life threatening.
Agreed, but mistakes of this nature cam become systemic. What if the EK A340 was only 1 ton underweight instead of 100 tons? We'd be none the wiser. There is no substitute for good training and accuracy for without either, the industry is doomed.

[Chadzat]

A popular NZ CEO once said-

"Look after your staff and they will look after your passengers who will in turn look after the shareholders"

[Captain Sherm]

Fluke

I think the point here is that this is not just a company making Frisbees or manhole covers. It is a hybrid-a commercial no-holds barred business run in a regulatory environment where many promises and demonstrations and compliance checks are necessary to get and maintain the AOC which is at the core of the free-enterprise business whose fares, routes and capacity are completely un-regulated.

Central to the issue of an AOC, before the shareholders see even a dollar change hands, is the operator demonstrating that they can actually control and manage their fleet, people and infrastructure. That is done partly by a robust and capable management structure (with key posts actually approved by CASA) and also through the internal accountability structures including Quality and SMS. If the accountability bit was done solely by CASA Inspectors then there'd have to be thousands of them. It is not done that way. Part of the issuance conditions of an AOC is that the operator shows (and continues to show) that Quality and SMS systems are actually effective and that the Accountable Manager and the other AOC Post Holders fulfill their obligations to the CARs and the Authority.

A systematic failure to manage any part of the business, or failure of any or all parts of the internal "self-test" mechanisms is a threshold event......it is like separation in a marriage, the first step to the divorce court or in the case of an airline or an AMO, the pulling of their licence. Part of the criticism of Qantas after the QF accident at Bangkok was that CASA had failed to adequately address systemic failures in the airline's Risk Management and Training regimes. No doubt the failures saved money (at least in the short term) for both the Regulator and the airline, but the fact is that these failures constitute a failure to fulfill the conditions required to obtain, maintain or oversee an AOC.

Well meaning management folks who have never really got actual airline dirt under their fingernails or seen the flowing of passenger and crew blood may groan and moan about the regulatory system. They might privately feel that life would be better if the pesky rules and inspectors were out of the way. The job of the regulator is (a) to make sure that the airline is not run by too many of such folk and that (b) the airlines internal "self test" structures function well and pick up instances where the rubber band is just being stretched too far.

The job of the regulator is made tougher if across an entire group (with many operations business units, a dozen fleet types, 150 aircraft, 100 ports, thousands of pilots and engineers etc etc) well meaning KPI-driven amateurs are daily stretching that rubber band to near the limit without any overall assessment of where or when it might break and what will be the consequences. That in essence is a dis-functional organism and in the ordinary course of events the operator would be denied an AOC or if they have one, see it suspended. The Regulator is the public's defence against that needing to happen.

But even Regulators are not perfect and how good that Australia has an independent ATSB. That is a valuable safeguard, even if it only seems to be picking up minor errors. They matter! If you read the report of the NTSB into (just for example) the Alaska Airlines MD-80 Stabilizer Failure accident near LA or the Aloha Airlines roof separation in Hawaii you will see damning indictments of what happens when such dis-function in upper management or indeed in the Regulator finally kills people.

It is my understanding that the head of Safety at QF is a well meaning pleasant fellow, from a thinnish but arguably respectable aviation background, who learned what he knows about safety at the management level at Jetstar. So be it. He has a difficult job, even more demanding now after the ATSB report. I wish him well. Enthusiasm and KPIs are wonderful things for a job like his, or his hundred management peers, but care must be taken lest they mask a toxic cocktail of overflowing In-Trays, denial, complacency and ignorance.

Ask the family of Clarabelle "C.B." Lansing what they think of the competence of the airlines’ management, safety systems and the FAA oversight. Clarabelle died when the roof separated from the fuselage of her Aloha 737 years ago. Her body was never found and she rests deep in Hawaiian waters, a rest I am sure that is denied the management people in Aloha at that time, or the FAA inspectors and managers who failed in their duty. The public trusted them and they both failed to live up to that trust.

The NTSB said the following of the Aloha accident’s cause:

• The systematic failure of Aloha Airlines’ maintenance program and its inability to detect serious structure and corrosion problems
• Contributing to the accident were the failure of Aloha Airlines management to properly supervise its maintenance force and:
• The failure of the FAA to adequately evaluate and oversee Aloha’s maintenance, inspection and quality programs.

Or ask the families of the 88 souls who perished in the Alaska Airlines stabilizer failure in an MD-83 near LA. They probably all thought the airlines’ internal quality and safety processes were in place and regularly checked by a vigilant FAA. Not so. The symptom available to any competent QA inspector or FAA PMI was Alaska’s unilateral change (to lengthen) the stabilizer lubrication schedule and to use non-standard tools to measure wear in that area. No doubt saved a few thousand bucks and fed someone’s KPIs. The NTSB noted (of Alaska management and the FAA):

• "This was a maintenance accident. Alaska Airlines' maintenance and inspection of its horizontal stabilizer activation system was poorly conceived and woefully executed. The failure was compounded by poor oversight...
• …had any of the managers, mechanics, inspectors, supervisors or FAA overseers whose job it was to protect this mechanism done their job conscientiously, this accident would not have happened. Poor maintenance will find a way to bite”

Sorry for the rambling length of this….airlines are not and never will be “just another business” and not all the beguilingly attractive ethnic accents, management jargon, acronyms and KPI driven strategies will ever make this different. An airline doesn't even get to be a business unless it daily satisfies the Regulator that it is up to the task and stays that way. Having done that-then it's on for one and all to make money, subject to the rules and Safety First". It can be done, actually costs less than cutting corners and it can be done well.

Safe flying to all readers-and if a tough CASA watching your outfit’s systems and management makes life a little tough, small price to pay. The shareholders only get their slice AFTER the business is run properly. Unless they want Frisbees or manhole covers.

Sherm

[breakfastburrito]

Thanks for the excellent post Sherm.

[haughtney1]

In respect of looking after staff..

Herb Kelleher said it best

If the employees come first, then they're happy, ... A motivated employee treats the customer well. The customer is happy so they keep coming back, which pleases the shareholders. It's not one of the enduring Green mysteries of all time, it is just the way it works

[VBPCGUY]

If the aircraft was overweight how was paperwork generated???

[Keg]

Keg & Ken , you are missing the point. Keeping the the share holders happy or providing them with maximum return is the primary role for the CEO of a public company. You can't blame them if they are just following their job description.

Shareholders aren't going to get any return at all if we don't even meet the basic requirements of the AOC. Things like doing regular reviews of systems and processes form part of that AOC. Perhaps that's the issue. CEOs focussing on maximum return instead of focussing on maintaining the AOC. :ugh:

Sherm. :D

(I'm a little freaked out that Ken and I agree on this! :eek: :ok: )

[HF3000]

Average after several years of compiling data may be 77kg. That is the nature of statistics, it tends closer to the average the more data you collect.

That doesn't mean in any way that a plane load of overweight tourists from the USA will average 77kgs.

Or that any particular flight on any particular day may not be overweight. Certain sectors eg peak MEL-SYD weekday flights most business travelers bring carryon and don't check their luggage. The carryon is certainly not within weight limits (rarely weighed and enforced). Multiply an extra 5-10kg per pax by 250.

I remember once carrying a large bunch of Japanese Sumo wrestlers. They had to block out adjacent seats just so they could sit down. But they were boarded using standard weights. And those standard weights were used for takeoff performance data. There should have been an extra couple of tone in that for sure.

The reason standard weights are permitted is that there is enough fat in the performance limits that a small overweight which WILL occur from time to time using standard weights will not have any material impact. Even WITH an engine failure.

The article is correct about internal systems being inadequate, but not correct in its suggestion that this particular incident possibly posed a danger to flight safety. I would suggest that you would have to go at least 10-20 tonne over before you would really start to worry about flight safety.

Having said that, if they hope to ensure a fix to internal systems to prevent future recurrences of possibly larger magnitudes, they probably feel the need to play the safety card, and I don't have a problem with that at all.

[Fluke]

Sherm

I hear what you say.

I just think most shareholders are not really interested in the costs of maintaining a healthy AOC. To them, it is simply bottom line either in the form of dividens or share value. Partly for this reason I think airlines should be represented on the stock market in a different class or form of share holding. (Perhaps Nuclear Power companies could fall into this bracket as well )

I don't know the answers ! Except that nobody wants "Frisbees or manhole covers".

Sorry for the thread creep, I enjoyed the read.

[Fris B. Fairing]

VBPCGUY

If the aircraft was overweight how was paperwork generated???

The weight shown in the system was for the lighter substitute pallet so as far as the DC system was concerned the aircraft was under MTOW and there would have been no problem producing a loadsheet.

(I got drawn to this thread by burning ears with all this talk of Frisbees)

[aveng]

The fact is a fly by wire aircraft will cope better than most to CofG issues. Lets not forget that the ramp staff are not working their way through Medical school - you get what you pay for!:ok:

[Howard Hughes]

Certain sectors eg peak MEL-SYD weekday flights most business travelers bring carryon and don't check their luggage. The carryon is certainly not within weight limits (rarely weighed and enforced). Multiply an extra 5-10kg per pax by 250.
Am always surprised at the size/weight of some peoples 'hand' luggage when I fly. Can't understand why nobody is tackling this issue, or at the very least researching it, after all the required equipment is already at the check in counters/gates.

PS: Won't be long until they wake up to hand luggage being another source of revenue...;)

[Metro man]

PS: Won't be long until they wake up to hand luggage being another source of revenue...

And when they do that will be another reason less to fly QF versus the opposition. Just look at the USA would you rather go on a good low cost, or a poor full service at a higher fare ?

[Howard Hughes]

Didn't necessarily mean QF Metro!

[arkmark]

Couldn't have said it better myself metro man.

Last year my spend was $ 30K with QF for myself and my staff.

This year that spend is with Virgin for domestic and Air Asia for international.

You already stated the reason. At least with these I get what I paid for.

If your so called full service airline is deliberately busting weight limits, skimping on maintenance, training, and customer service, and forcing you to check your own baggage, then why not fly a low cost carrier that does none of this ????

[Metro man]

Agreed, there has to be a noticable difference for the extra money. I fly a mixture of low cost and full service. When I fly full service my expectations are higher. If my hold baggage is a couple of kilos over I don't expect to be charged, I expect better on time performance, better seat pitch and a reasonable meal. If I'm not getting a better product, why pay a higher fare ?

When travelling low cost I expect to be charged for everything and plan around it, also I much more tolerant of small delays and less convenient times.

As long as I got what I paid for I'm happy. Having flown domestically in America, out of my own pocket I'd opt for low cost. Full service standards have come down so far it's not worth paying extra for.

[Popgun]

Having flown domestically in America, out of my own pocket I'd opt for low cost.

I totally agree. I use Virgin America and Jet Blue in strong preference to AA, DL and UA even though I miss out on the Business Class lounge with both of them...

[MrWooby]

Arkmak, you realy believe that Airasia, doesn't bust weight limits, skimp on maintenance, training, etc. Just look at the current news articles on Indigo Air pilots and you will see how low Asian LCC's will go to save a dollar. The main pilot concerned landed the aircraft nosewheel first, not just once but many times. Look at the airasia incident that nearly crashed into the hills at Coolangatta. What price do you put on the lives of your staff and yourself.
In Australia, LCC's pilot standards are high, not so overseas.

[breakfastburrito]

Look at the airasia incident that nearly crashed into the hills at Coolangatta.
Twice actually, in less than a month.

During an approach in Instrument Meteorological Conditions (IMC), the aircraft went below the radar lowest safe altitude. On the previous day, a similar occurrence in Visual Meteorological Conditions (VMC) occurred involving the same aircraft type. Subsequently the ATSB was notified of another similar occurrence involving the same aircraft type on 29 May 2010. The investigation is continuing.
A report has not yet been released for this investigation.
Source: Airbus A330-343E, 9M-XXB, Gold Coast Aerodrome, 4 May 2010 (http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-027.aspx)

[Captain Sherm]

Just a further thought or two to get this back on track.....

Do not ever make the mistake of using anecdotes or one-off events to justify a point of view or to condemn an operation. This is exactly the strategy used by amateur managers who've never been near the pointy end of things whether on the ramp, the cabin or the cockpit.

The whole point of having black letter rules is that someone will always have an anecdote or dodgy "data" to justify what they want to do. For example let's say that a carrier were to have notoriously non-compliant crew rest facilities on a long haul type and were to use the existence of that non-compliant facility to justify horrible duty schedule with long back of the clock operations. And lets say that the safety and ops managers were to get very very defensive when questioned about the fact that other than being better than standing-up, the facilities provided for "rest" meet no other requirement of the FOM or the CARs or even the exemption to the CARs. Let's say their response were to be "we're developing a fatigue management system and in any case we've had very very few written complaints". Are they off the hook because on any given day the system vaguely seems to work? NOT AT ALL. The regulations for crew rest are stark and easily understood. Management (and crews) are required to follow the law, not "whatever works on any given day".

If the Quality system cannot pick up a 10kg overload who's to say that it could pick up 100 kg or 10,000 kg? Not possible. That's why it is a condition of getting and maintaining an AOC that the Quality system works. Otherwise it's like flying an approach with either 4 reds or 4 whites on the PAPI. You no longer have any guidance as to your glide-slope and are reduced to guessing.

Take-home message is that having a safety and quality system that works some of the time for some of the operation is like using a contaminated syringe. You have no idea at all what might happen next.

Sorry for the sermon....this stuff can cost lives and the fact that it didn't in the case of the 330 doesn't in any way diminish the significance of the lapse in quality assurance.

Safe flying

Sherm

[ALAEA Fed Sec]

Why don't those in Qantas Management understand this?

Why does CASA sit back and allow it to happen?

[SpannerTwister]

The article is correct about internal systems being inadequate, but not correct in its suggestion that this particular incident possibly posed a danger to flight safety. I would suggest that you would have to go at least 10-20 tonne over before you would really start to worry about flight safety.
I'd suggest you (and others who are correctly pointing out that this amount of overweight doesn't matter) are about as wrong as it is possible to be.

As Donald Rumsfeld said "because as we know, there are known knowns; there are things we know we know. ... But there are also unknown unknowns -- the ones we don't know we don't know."

In this instance, we know that any given passenger does not weigh 77Kg, 83Kg, 16 Kg or any other specified figure, and this is allowed and calculated by the aircraft manufacturer.

However, it is assumed that we DO KNOW how much the freight weighs, and it matters not if it is 1 Kg out or 25 tonnes out, if the "system" can get it wrong on this flight by 1 Kg, then on the next flight it can just as easily get it wrong by 10 Kg / 100 Kg / 1000 Kg / 10,000 Kg.

THAT IS WHAT CAUSES THE DANGER TO FLIGHT SAFETY, NOT THE 884 KG THIS FLIGHT WAS OVERWEIGHT.

Why don't those in Qantas Management understand this?

Why does CASA sit back and allow it to happen?

ALAEA Fed Sec, Have you heard of the phrase, "The tail wagging the dog" :ugh: :ugh: :ugh:

ST