Latest Qf Incident,where Will All This End
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The student of the corporation would be well placed to study Q. It is a classic example where operational disconnect and executive management with no operational experience are driving a company into the ground.
Executive management requires a thorough understanding of the operation. Who at executive level posesses that experience? If they do not posess it do they canvass it from the operational experts, be they cabin, pilots, engineering, ramp, check in etc.
In a highly labour oriented business these people are key ASSETS. They are not COST. Ask an experienced cabin crew how to organise the aircraft interior and schedule meals/service they will tell you. Ask engineers how to fix aircraft and what needs to be watched, they will tell you. Ask the performance engineers about the 3 important bits, range, payload and pax-they will tell you. Ask pilots about operating an aircraft, weather etc they will tell you! Ask check in staff about busy times, staff numbers etc they will tell you. More than likely you will reduce cost!
Qantas executive ask nothing! Not only do they not posess the knowledge, they do not seek it. Or if they seek it, they seek it from the yes men. If Dixon was worth $6m, he would not coccoon himself in P class he would talk. His individual illsuited personality and what it engenders and the illsuited people it promotes underscores the problem.
Business segmentation pits normally "objective" focused teams against each other. I cannot get the aircraft to LA if they loaders don't do their job, the engineers don't sign it out, the cabin crew aren't onboard and ready to serve the passengers, the check in staff haven't processed, the fuel isn't loaded etc...A very people intensive business.
Now engineering can duck shove a cost to commercial and the manager generates a $ for himself. The cost borne out in the annual reports meansures nothing of downline disruption, damaged perceptions or OVERALL LONG TERM COST. This does not interest Dixon, nor Gregg nor Jackson, Gosgrove, Cross et al. It is not a tangible cost to the accountant and deserves little attetion. If it can't be measured it isnt important. If they collectively understood the business, they would intuitively know how we are perceived is at the heart of the bottom line.
The end result is clever media, outsourced everything and slick marketing (which is Dixon) substance is little. Substance and tangibility are key in convincing people to fly your aircraft over water to whereever and arrive in one piece. The perception can be manipulated for a time, but for how long?
With an aging fleet, poor route structures, declining market shares, dispatch relaibilities falling, numerous product failures and poor aircraft choices, we see manifest evidence that the executive does not listen nor seek any differing opinion, they know best. The canaries are chirping in the mine, but the company isn't listening. Us canaries be us cabin, engineering or pilot crew will chirp here. The public is getting wind of just how much spin and little substance is Q executive. This latest near miss is a chirp from the mine...
Dixon can't twirl a spanner, Jackson couldn't open a door, Borghetti can't land off an ILS. It is much easier to dismiss their lack of knowledge by fostering a culture where operational people are malaigned and intimidated, particularly if we challenge the process of decisions.
Gordon Bethune could, both twirl spanners and fly 757/767. He encouraged feedback, he was honest and turned around a company that was left with the stain of its Dixon. I hope this occurs before some of the bean counter induced "cost redution" inposes a cost on real operational people that is too big for us all to sustain.
Executive management requires a thorough understanding of the operation. Who at executive level posesses that experience? If they do not posess it do they canvass it from the operational experts, be they cabin, pilots, engineering, ramp, check in etc.
In a highly labour oriented business these people are key ASSETS. They are not COST. Ask an experienced cabin crew how to organise the aircraft interior and schedule meals/service they will tell you. Ask engineers how to fix aircraft and what needs to be watched, they will tell you. Ask the performance engineers about the 3 important bits, range, payload and pax-they will tell you. Ask pilots about operating an aircraft, weather etc they will tell you! Ask check in staff about busy times, staff numbers etc they will tell you. More than likely you will reduce cost!
Qantas executive ask nothing! Not only do they not posess the knowledge, they do not seek it. Or if they seek it, they seek it from the yes men. If Dixon was worth $6m, he would not coccoon himself in P class he would talk. His individual illsuited personality and what it engenders and the illsuited people it promotes underscores the problem.
Business segmentation pits normally "objective" focused teams against each other. I cannot get the aircraft to LA if they loaders don't do their job, the engineers don't sign it out, the cabin crew aren't onboard and ready to serve the passengers, the check in staff haven't processed, the fuel isn't loaded etc...A very people intensive business.
Now engineering can duck shove a cost to commercial and the manager generates a $ for himself. The cost borne out in the annual reports meansures nothing of downline disruption, damaged perceptions or OVERALL LONG TERM COST. This does not interest Dixon, nor Gregg nor Jackson, Gosgrove, Cross et al. It is not a tangible cost to the accountant and deserves little attetion. If it can't be measured it isnt important. If they collectively understood the business, they would intuitively know how we are perceived is at the heart of the bottom line.
The end result is clever media, outsourced everything and slick marketing (which is Dixon) substance is little. Substance and tangibility are key in convincing people to fly your aircraft over water to whereever and arrive in one piece. The perception can be manipulated for a time, but for how long?
With an aging fleet, poor route structures, declining market shares, dispatch relaibilities falling, numerous product failures and poor aircraft choices, we see manifest evidence that the executive does not listen nor seek any differing opinion, they know best. The canaries are chirping in the mine, but the company isn't listening. Us canaries be us cabin, engineering or pilot crew will chirp here. The public is getting wind of just how much spin and little substance is Q executive. This latest near miss is a chirp from the mine...
Dixon can't twirl a spanner, Jackson couldn't open a door, Borghetti can't land off an ILS. It is much easier to dismiss their lack of knowledge by fostering a culture where operational people are malaigned and intimidated, particularly if we challenge the process of decisions.
Gordon Bethune could, both twirl spanners and fly 757/767. He encouraged feedback, he was honest and turned around a company that was left with the stain of its Dixon. I hope this occurs before some of the bean counter induced "cost redution" inposes a cost on real operational people that is too big for us all to sustain.
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Third, who or what organization has been signing off or ignoring cracked drip pans? Were senior management aware of this and what action did they take to rectify or mitigate the situation? Were the supervisors who are supposed to see the big picture aware of the correlation between cracked drip pans and clogged sinks because it sounds like a few LAME's should have known the possible consequences?
As someone mentioned in another thread on this incident.. hindsight provides 20/20 vision. As for all inspections, the depth and frequency varies (depending on the importance). Did the engineers know that the drip trays played such an important role in this particular area before this incident?
For info: The drip trays above the equipment racks in some areas clears the floor cabin floor paneling by only a few inches and requires good, even lighting and inspection mirrors. The only way to truly have a good look at the tray is to remove the floor panels and whatever is on top of them (in some cases, this would be a monumental task). The fact that the drip trays were broken is amazing it itself. How do you break something which is barely accessible? Did someone tread on one the last time the floor panelling was removed and was the pre-panel installation check overlooked or not done thoroughly enough? Or did they simply crack with age? (are they made of the correct material for the job?).
Some detractors are starting to say that Qantas is the "lucky airline" because these incidents have not led to any pax deaths in generations of flying. Seems to me that they are they unlucky to have had chains of events which have led to such bizzare incidents.
QF managers want engineers to follow a "safety before schedule" policy... but would the average engineer (prior to this event) have had the b*lls to delay an aircraft for hours/days simply because the carpet in the forward galley area seemed a little damp (by the time they got to the aircraft)?
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NSEU
I agree operational staff are maligned and intimidated.
Yes men appear to prosper and dissenters sidelined.
That happened with QF1 and the flaps 25 idle reverse rubbish too..
Engineering and pilots are the custodian of the airline. Our signatures are on the paperwork, we fixed the doomed part/aircraft or we piloted it. Qantas was built on operational excellence, by pilots and engineers.
We ought all be much more vigilant slick media spin is no sustitute.
FOG
I agree operational staff are maligned and intimidated.
Yes men appear to prosper and dissenters sidelined.
That happened with QF1 and the flaps 25 idle reverse rubbish too..
Engineering and pilots are the custodian of the airline. Our signatures are on the paperwork, we fixed the doomed part/aircraft or we piloted it. Qantas was built on operational excellence, by pilots and engineers.
We ought all be much more vigilant slick media spin is no sustitute.
FOG
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There are two sets of contributors to this thread - those whose every utterance on any PPRunNe thread reflects the focus of their hatred and loathing of QF management; and those who seek to make a reasoned, thoughtful and objective contribution to the discussion. What a pity the former outnumber the latter.
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There is a simple choice in relation to aircraft maintenance:
a) Expensive newer aeroplanes allows cheap maintenance.
b) Cheaper older aeroplanes requires expensive maintenance.
They are both valid options, and both safe, QF in the past has proven this because generally they have always used option b) with success, hence the deserved reputation for engineering excellence.
The current Brain Surgeons in QF Management are trying to invent a third option:
Cheap old Aeroplanes AND cheap maintenance - this will spell disaster and people at the QF coal face have been seeing it, and warning against it for quite a few years now.
a) Expensive newer aeroplanes allows cheap maintenance.
b) Cheaper older aeroplanes requires expensive maintenance.
They are both valid options, and both safe, QF in the past has proven this because generally they have always used option b) with success, hence the deserved reputation for engineering excellence.
The current Brain Surgeons in QF Management are trying to invent a third option:
Cheap old Aeroplanes AND cheap maintenance - this will spell disaster and people at the QF coal face have been seeing it, and warning against it for quite a few years now.
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one of dixon's actions of late was to "compartmentalize" Qantas into five separate divisions, each one responsible for maintaining/containing their own profits/costs.
It reminds me very much of my airline (not QF).
Interesting post (#172) on the thread on the main board on this same topic asking what part maximum use of automation might have played in the outcome of this incident had it occurred in some other airline that demands this practice.
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Borghetti is called Il Duce for a reason............
An assembled group of 500 Qantas staff at the Sydney Conservatorium Of Music for a "Roadshow" where senior management spell out the company's plans and seek [??
] to inspire the troops..............
Only to hear John Borghetti rant and rave that, and I quote " I don't care about any EBAs, if I hear anyone say anything negative about qantas i'll sack them."
------------------
Willi B,
at least there is no doubt why QF management are so routinely hated, eh?
] to inspire the troops..............Only to hear John Borghetti rant and rave that, and I quote " I don't care about any EBAs, if I hear anyone say anything negative about qantas i'll sack them."
------------------
Willi B,
at least there is no doubt why QF management are so routinely hated, eh?
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So, answer my original question: Couldn't you just turn off the battery to conserve power AFTER you've 1/ descended 2/ depressurized 3/Advised ATC and 4/ worked out Navigation .
I'll have to hand this question over to the aerodynamicists... As previously asked.. Can the 747-400 fly without any Yaw Damper whatsover? (Does it simply make the flight uncomfortable for the passengers in E Zone or perhaps waste a little fuel... or will it make the aircraft wobble about until it shakes itself to death
After a brief study of the wiring schematics, it looks like at least one of the YD systems will be operating using Standby Power (with half the rudder authority than two systems.. and much less if you switch off one of the two functioning IRU's). "worked out Navigation"
Not for the faint hearted, either... following a great circle route using a wobbly magnetic compass
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NSEU: yes the 400 would fly ok at lower altitudes without the yaw damper.
Navigation may be a problem depending on where you were and the cloud cover.
BUT..........that aside.
Answer my question. Could you turn off the battery to save power?
remember this is a last ditch effort to conserve remaining power for landing.
Navigation may be a problem depending on where you were and the cloud cover.
BUT..........that aside.
Answer my question. Could you turn off the battery to save power?
remember this is a last ditch effort to conserve remaining power for landing.
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Answer my question. Could you turn off the battery to save power?
remember this is a last ditch effort to conserve remaining power for landing
remember this is a last ditch effort to conserve remaining power for landing
It worked for Jim Lovell, Jack Swigert and Fred Haise on Apollo 13 !
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Bravo
QFInsider,
I think you should send a copy of that MOST erudite, intelligent and superbly-crafted post of yours (#203) to each secretary of upper management in QF and have them sit their respective boss down, tie them to the chair and READ IT to them! That's the only way they'll hear your most brilliant 'take' on the situation that is before all of us. But I'm not naive enough to expect them to do anything else but yawn, then immediately get back to smiling at their latest personal bank statement.
In one awesome post you've very accurately summarised the peril we face.
Well said, sir. I hope one day I can buy you several beers up the track.
I think you should send a copy of that MOST erudite, intelligent and superbly-crafted post of yours (#203) to each secretary of upper management in QF and have them sit their respective boss down, tie them to the chair and READ IT to them! That's the only way they'll hear your most brilliant 'take' on the situation that is before all of us. But I'm not naive enough to expect them to do anything else but yawn, then immediately get back to smiling at their latest personal bank statement.
In one awesome post you've very accurately summarised the peril we face.
Well said, sir. I hope one day I can buy you several beers up the track.
Last edited by captaindejavu; 13th Jan 2008 at 02:37.
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On time departures
Do cabin crew have MEL's?
After reading about aircraft departing with sinks "taped off" so they don't use them due to blocked drains, I have to wonder about the effect of the "on time departure" performance measurement, and how this affected this incident.
It also surprises me that there are no air driven backup instruments. Maybe Boeing should talk to Piper. The PA31 can get home and lower its gear without electric power.
After reading about aircraft departing with sinks "taped off" so they don't use them due to blocked drains, I have to wonder about the effect of the "on time departure" performance measurement, and how this affected this incident.
It also surprises me that there are no air driven backup instruments. Maybe Boeing should talk to Piper. The PA31 can get home and lower its gear without electric power.
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Captaindejavu,
I was just printing QFinsider's post to send to our management and airport section heads for discussion, as it with clarity and precision identifies a corporate syndrome which must be avoided in the aviation business.
I do not know wether QF is or is not in this position, however the syndrome is plausable and dangerous and company senoir management and Boards should be on their guard.
QFinsider very well done.
I was just printing QFinsider's post to send to our management and airport section heads for discussion, as it with clarity and precision identifies a corporate syndrome which must be avoided in the aviation business.
I do not know wether QF is or is not in this position, however the syndrome is plausable and dangerous and company senoir management and Boards should be on their guard.
QFinsider very well done.
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MELs
bushy,
No MELs of their own. Any cabin condition entries that impact the operation have an MEL but are included in the master Tech Log, after transcription from (and being referenced to) the Cabin Condition Log. (e.g. blocked sink, locked-off toilet, galley chiller inop, GWDU failure, O2 bottle used; seats recline u/s, etc). MELs are applied by the Ginger Beers/Flight Crew for applicable items.
No MELs of their own. Any cabin condition entries that impact the operation have an MEL but are included in the master Tech Log, after transcription from (and being referenced to) the Cabin Condition Log. (e.g. blocked sink, locked-off toilet, galley chiller inop, GWDU failure, O2 bottle used; seats recline u/s, etc). MELs are applied by the Ginger Beers/Flight Crew for applicable items.
captaindejavu;
Fully agree with all you said in re QFInsider's comments. I know another airline that these comments should be sent to - same procedure for reading it to them - they don't believe flight data so maybe this will work.
Fully agree with all you said in re QFInsider's comments. I know another airline that these comments should be sent to - same procedure for reading it to them - they don't believe flight data so maybe this will work.
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Answer my question. Could you turn off the battery to save power?
remember this is a last ditch effort to conserve remaining power for landing.
remember this is a last ditch effort to conserve remaining power for landing.
Note that the outflow valves (in Manual) would need the Battery Switch to be ON for control, but at 10,000', you could set them open and forget them.
If you left the battery on for descent to control the outflow valves, you would waste a lot of power however (with everything else running on Battery/Standby power). Maybe if you turned off Standby Power and left the battery switch on (only), this would be a compromise. On the other hand, you might decide to put your faith in the mechanical underpressure/overpressure control devices (positive/negative pressure relief valves).
Engine fire extinguishing is available on the Hot Battery Bus, but detection requires the Battery Switch to be on. You may need the Battery Switch to be ON to configure your Equipment Cooling to Override (maybe in this scenario, differential pressure, at least during descent, may assist the drying process of the waterlogged components).
In the cabin, the emergency lights would be on but power will be coming from individual battery packs, not the main batteries. You could manually select these off, if you thought you might need them later on for evacuation on landing.
Other things to consider in the cabin:
Cabin temp might be troublesome.
There will be no PA with the Battery Switch off. Hopefully good person to person communication between the pilots, cabin crew and passengers will reduce the panic. I'm sure the fact that the engines would still be running would put many minds at ease
Hope this helps.
Cheers.
NSEU
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Out of interest - when you've got FADEC engines, will the thrust levers and/or fuel control switches still do anything when there's no electric power?
Fuel Control switch relays relax to the RUN position with loss of power. This means that without power (on the 747-400), you won't be able to switch them OFF.. at least not until ground power has been established after landing. Later aircraft types, such as 777's and 737NG's, have a separate rechargeable battery source for switching off the engines (I think it was mandatory in new aircraft design after a certain date due to the problems it has caused previously)
The EEC's/ECU's may run in a semi-degraded, but non life-threatening, mode however, because of lack of anti-icing for the engine sensors and lack of Air Data from the aircraft (especially with Battery/Standby Power turned off completely).
Hope this helps.
Rgds.
Q>
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Some one may wish to pass this onto the good Mr Dixon as well
http://www.casa.gov.au/fsa/2007/dec/18-25.pdf
An extract
CEO legal responsibilities for safety
For a CEO of a business that operates through an AOC – that is, an airline or charter business – the legal obligations for managing safety are up front in Section 28BE of the Civil Aviation Act 1988. It’s probably worth repeating the detail here: Section 28BE Duty to Exercise care and diligence
(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.
(2) If the holder is a body having legal personality, each of its directors must also take steps specified in subsection (1).
There are some useful observations to make. Firstly, the issue of duty of care is quite clear, and places the ultimate responsibility for safety with the operator. Secondly, it is the ‘holder’ of an AOC who carries that responsibility. The vast majority of AOCs are held by legal entities (a company), so CASA places the practical responsibility on the office holders or ‘key personnel’ of the company as listed in S28 (3) of the Act.
The CEO is at the top of the list of those key personnel, so although day-to-day responsibility may be delegated to other officers, should a serious safety issue develop, CASA ’s main port of call will be to the CEO. The third point to note is that the scope of that duty of care is very broad. ‘Every activity covered by the AOC’ and ‘everything done in connection with such an activity’ includes everything from flying the aircraft and maintaining it to loading, training, dangerous goods management and so on.
Subsection (2) highlights the responsibility that each director of a company operating under an AOC carries with respect to safety. A CEO will, in most cases, also be a director of the company; however CASA could consider it necessary to approach non-executive directors to resolve a safety issue.
Although Section 28BE highlights the duty of care regarding safety for companies (and their CEOs) holding an AOC, CEOs of companies operating under other certificates issued by CASA under the Civil Aviation Act, such as a maintenance organisation or an airport, in reality have the same duty of care. Risks associated with flying operations are more obvious, so the Act gives appropriate focus to AOC holders.
However, as we know from experience, some accidents can result from a multitude of factors, including ones associated with maintenance or airport design and operations; hence, CEOs of these types of aviation businesses could be held accountable for safety outcomes under common law.
There is a practical reason for a CEO to be involved in safety
Not many years ago, safety problems in larger organisations were seen by many as purely technical problems that involved pilots, engineers and so on. It was quite common for safety managers to operate exclusively in the technical parts of a business and for discussions on how to fix safety issues to be conducted amongst only the technical people.
There was probably an element of ‘turf protection’ behind this practice, but it was largely driven by the simple fact that the vast majority of bad safety outcomes involved technical people of some sort.
Although analysis over the years has highlighted the dominance of human factors involving technical people in accidents, it is clear that organisational factors in many cases play a major part.
Organisational factors are clearly the responsibility of management in the broadest sense, not necessarily just technical management such as a chief pilot.
Indeed, in some cases technical managers such as a chief pilot could use the support of the business owner/CEO to see the system problems and identify system fixes.
Someone once said ‘If you think the cost of safety is high, just wait till you’ve had an accident!’ It is a sobering fact that of the three fatal accidents involving Australian airlines (all small regionals) since 1990, none are still in business.
Question: Is Qantas an accident looking for a place to happen - Or headed in that direction?
http://www.casa.gov.au/fsa/2007/dec/18-25.pdf
An extract
CEO legal responsibilities for safety
For a CEO of a business that operates through an AOC – that is, an airline or charter business – the legal obligations for managing safety are up front in Section 28BE of the Civil Aviation Act 1988. It’s probably worth repeating the detail here: Section 28BE Duty to Exercise care and diligence
(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.
(2) If the holder is a body having legal personality, each of its directors must also take steps specified in subsection (1).
There are some useful observations to make. Firstly, the issue of duty of care is quite clear, and places the ultimate responsibility for safety with the operator. Secondly, it is the ‘holder’ of an AOC who carries that responsibility. The vast majority of AOCs are held by legal entities (a company), so CASA places the practical responsibility on the office holders or ‘key personnel’ of the company as listed in S28 (3) of the Act.
The CEO is at the top of the list of those key personnel, so although day-to-day responsibility may be delegated to other officers, should a serious safety issue develop, CASA ’s main port of call will be to the CEO. The third point to note is that the scope of that duty of care is very broad. ‘Every activity covered by the AOC’ and ‘everything done in connection with such an activity’ includes everything from flying the aircraft and maintaining it to loading, training, dangerous goods management and so on.
Subsection (2) highlights the responsibility that each director of a company operating under an AOC carries with respect to safety. A CEO will, in most cases, also be a director of the company; however CASA could consider it necessary to approach non-executive directors to resolve a safety issue.
Although Section 28BE highlights the duty of care regarding safety for companies (and their CEOs) holding an AOC, CEOs of companies operating under other certificates issued by CASA under the Civil Aviation Act, such as a maintenance organisation or an airport, in reality have the same duty of care. Risks associated with flying operations are more obvious, so the Act gives appropriate focus to AOC holders.
However, as we know from experience, some accidents can result from a multitude of factors, including ones associated with maintenance or airport design and operations; hence, CEOs of these types of aviation businesses could be held accountable for safety outcomes under common law.
There is a practical reason for a CEO to be involved in safety
Not many years ago, safety problems in larger organisations were seen by many as purely technical problems that involved pilots, engineers and so on. It was quite common for safety managers to operate exclusively in the technical parts of a business and for discussions on how to fix safety issues to be conducted amongst only the technical people.
There was probably an element of ‘turf protection’ behind this practice, but it was largely driven by the simple fact that the vast majority of bad safety outcomes involved technical people of some sort.
Although analysis over the years has highlighted the dominance of human factors involving technical people in accidents, it is clear that organisational factors in many cases play a major part.
Organisational factors are clearly the responsibility of management in the broadest sense, not necessarily just technical management such as a chief pilot.
Indeed, in some cases technical managers such as a chief pilot could use the support of the business owner/CEO to see the system problems and identify system fixes.
Someone once said ‘If you think the cost of safety is high, just wait till you’ve had an accident!’ It is a sobering fact that of the three fatal accidents involving Australian airlines (all small regionals) since 1990, none are still in business.
Question: Is Qantas an accident looking for a place to happen - Or headed in that direction?