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Merged: QF 32 Forensic Analysis - 4 Corners

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Merged: QF 32 Forensic Analysis - 4 Corners

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Old 28th Mar 2011, 11:22
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....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.
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Old 28th Mar 2011, 11:50
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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.

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Old 28th Mar 2011, 12:10
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Two 10 minute excerpts (from the 40 minute program) for those that missed it:


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Old 28th Mar 2011, 12:17
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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?
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Old 28th Mar 2011, 12:30
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Many thanks

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

Last edited by TIMA9X; 28th Mar 2011 at 14:01.
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Old 28th Mar 2011, 13:11
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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.
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Old 28th Mar 2011, 14:28
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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?
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Old 28th Mar 2011, 15:12
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Old 28th Mar 2011, 17:50
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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.
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Old 28th Mar 2011, 19:47
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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.
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Old 28th Mar 2011, 21:06
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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.
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Old 28th Mar 2011, 21:12
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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.

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Old 28th Mar 2011, 21:36
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So what's it to be Alan?
  • An Own goal
  • An appologist for RR. Mmmm...
  • Out of one's depth!
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Old 28th Mar 2011, 21:46
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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

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Old 28th Mar 2011, 22:15
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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 corners
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Old 29th Mar 2011, 01:50
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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?
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Old 29th Mar 2011, 02:52
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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.
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Old 29th Mar 2011, 03:22
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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.
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Old 29th Mar 2011, 04:07
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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.
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Old 29th Mar 2011, 04:15
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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.
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