PDA

View Full Version : ATSB report on QantasLink B717 Canberra


Preemo
1st Oct 2016, 20:55
Investigation: AO-2016-065 - Incorrect configuration involving Boeing 717, VH-YQV, Canberra Airport, ACT, on 20 June 2016 (http://www.atsb.gov.au/publications/investigation_reports/2016/aair/ao-2016-065/)

After late change in passenger numbers revised flex temperature figures not entered into FMS. Thrust levers manually moved forward to increase EPR but after 4 seconds thrust automatically reverted back to lower settings in FMS.

Mail-man
1st Oct 2016, 23:49
http://www.dailymail.co.uk/news/article-3817682/Qantas-flight-leaving-Canberra-incorrect-data-pilot-forgets-update-passenger-numbers.html?login#article-3817682

I think you'll find it was a flux temperature....

hotnhigh
2nd Oct 2016, 01:04
If you put the wrong flux temp into the flux capacitor, there's bound to be issues.

drpixie
2nd Oct 2016, 01:41
Daily Mail - ATTACK of the Deadly SPELL CHEQUERS - When Good Spell Checkers Go Bad.

Lookleft
2nd Oct 2016, 02:33
Seems like an overly complex auto thrust system that is just waiting to catch you out. Some interesting sub-text to the report. The crew were feeling tired but ok to fly. Had they been given an option to off load themselves in Sydney without any risk of management backlash would they have? The companies response was to institute another layer of procedures by requiring a new TOLD card.:ugh: Nothing about flight deck interruptions or the casual way 22 passengers are dumped on their lap. This is not the first time a QF badged aircraft has had an issue with extra passengers loaded and a consequent mishandling of performance figures.

Capn Bloggs
2nd Oct 2016, 03:06
Just an "overly complex" way of describing it, LL. ;)

Agent86
2nd Oct 2016, 09:37
If you don't get the required thrust on Flex ..just press TOGA and go rated.
Pushing the throttles below 80kts does nothing (long term) as the autothrottle fights back :p
Pushing them up after 80 works ...but they come back again at 200ft.
A New TOLD card won't fix an incorrect entry, just makes it easier to read the correct target :E

framer
2nd Oct 2016, 10:18
Normally by the time they are getting to the third set of amended numbers, the first officer would start a new TOLD card. However, as it was approaching the scheduled departure time, the first officer elected to overwrite the existing figures.
To all the Captains out there: Actively go about setting an environment where there is no rushing on your flight deck to achieve OTP. To all the F/O's, don't worry about OTP, there is one speed that is both efficient and safe, find it, tick along at it, things work out just fine even if you are three minutes behind schedule. YSSY probably would have slowed them up anyway.

Keg
3rd Oct 2016, 00:33
Where are the TOLD cards stored? Is it easy to get/ reach a new one or is it a bit of a pain?

maggot
3rd Oct 2016, 00:39
Everythings close on a 717 flight deck

Slippery_Pete
3rd Oct 2016, 02:56
The crew were feeling tired but ok to fly. Had they been given an option to off load themselves in Sydney without any risk of management backlash would they have? The companies response was to institute another layer of procedures by requiring a new TOLD card. Nothing about flight deck interruptions or the casual way 22 passengers are dumped on their lap.

Well dissected. Pity you aren't working at the ATSB or Qantas management.

This "tired does not equal fatigue" thing is bullshit, and I'm sick of hearing it pedalled. Who knows where it started, but CASA and Company management (and even the AFAP) have jumped on board. It's a convenient get out of jail free card, where the reality is there's no set distinction between the two. The symptoms are the same, and the dangers posed are the same - and operating "tired" should not be pedalled as an acceptable safety outcome just because it's not as severe as "fatigue".

As for the TOLD card response - more of the same crap. Australian airline management are such reactive, predictable sheep - when presented with an error which was related to late changes and PILOT WORKLOAD, the solution offered involves MORE WORK. Tired, overworked pilots - with more work and procedures piled on to solve.

The stupidity is mind boggling.

What should have happened:
Ops call the tech crew - "if we delay the flight and give you plenty of time, can you accept 22 more pax and start your pre-departure tasks from scratch. Do you need to stretch you legs or can we get you some food?" Then the desire to rush is released, Pilots relieve some tiredness and get some food/coffee into them - and flight departs safely.

Will it ever happen - not on your life. The financial penalties placed by the mothership on Cobham for off time departures will always place schedule before safety.

josephfeatherweight
3rd Oct 2016, 03:21
As for the TOLD card response - more of the same crap. Australian airline management are such reactive, predictable sheep - when presented with an error which was related to late changes and PILOT WORKLOAD, the solution offered involves MORE WORK. Tired, overworked pilots - with more work and procedures piled on to solve.
Well said - too true! CASA seem to love this approach to problems, also. More lines in the OPS manual, more duties...

travelator
3rd Oct 2016, 06:11
Pushing them up after 80 works ...but they come back again at 200ft.
CLAMP is the active mode until all engine accel alt so they will stay there until at least 1,000'AGL.

Square Bear
3rd Oct 2016, 10:27
So no override or declutch on the B717 autothrottle system?

Anyway, some "gotcha" points come to mind...there but for the grace etc etc.

There in lies the value of a published report.