21 years since first AN B747-300 operation
 

Hard to believe it is 21 years. Time does fly !

A rooster one day. feather duster the next.

Feather duster indeed.
The report was valuable reading.

http://www.aussieairliners.org/b-747.../4630.039l.jpg

The Spaceship has landed!!!

The incident and the report are an interesting study in Human Factors and also a good example of the realities of introducing a new compex type into a long standing fleet.

There were heaps of holes in many slices of cheese and they all lined up that day. However, in the end, no one was hurt and the aircraft suffered comparitively minor damage.

Wunwing

onya Willie.wonder if he is still flying:(

catseye,

The PIC would be around 80 now and the F/O mid 50's.

Yes, the PIC is still around! I was delighted to see him at the Antique Aircraft Assoc event at Echuca earlier this year (he has a beautifully restored Aero 145). Very fit and spry for his age.

"BJ" was enormously well-liked and respected in his Cathay days, and I had many enjoyable flights with him. What a very sad way to end your airline career...

Checked the log book. First flight in a 300 series (N118KD) June 25th 1984, Dubai to London. How the years have flown by...

Also checked log book. Last flew N118KD from ASSY (now YSSY) to WSSS early 1991.

Big Trev's baby. It was also a lesson in how not to add an aircraft to your AOC, especially when your plans are over ambitious and you have a timeframe of just a couple of months. Just can't be done, not successfully anyway.
I agree that human factors played a significant role, but you can't blame the pilots. Management were the problem with management putting unrealistic organisational pressure on everyone. It was a classic organisational mismanagemt stuff up because they had dollar signs in their eyes and wanted to cash in on Olympic revenue.
But they are good memories of a great airline filled with a lot of great people.
Do I miss her? Absolutely

https://m.youtube.com/watch?v=jMXQXmeqepo

I think you have your timelines mixed up P377. Big Trev didn't arrive until after the AN888 debacle. If anything it was Big Graham's baby and he wouldn't be told by anyone, particularly pilots, that he was rushing.

Lookleft-

My memory is that TJ was employed to intruduce the B747 & that this was his "baby".:(

It was AN881 that landed in SYD with the nose wheel retracted. VH-INH if I remember correctly. Also 6 years before the SYD Olympics P377. TJ joined AN in 1996.

TANUA-Your timeline is also incorrect. B772 thanks for the correction of the flight number. I knew it had lots of 8s in it as it is considered a lucky number in Asia.

That's a pretty generous statement.

how many greens have you got Who signed off the engineer. Don't blame the pilots.

With a gear horn blaring away at you perhaps a second set of eyes on the down lights would have been appropriate....It was a generous statement indeed.

OzSync:

Enlighten me - have you ever tried to see the gear indicator lights on the aft end of the FE's panel from the captain's seat?

As always, more to it. BJ said, " Have we got all greens"? Uncle Les thought he said, "Have we got four Greens"? The lights were clustered in a way that you could miss the fifth. They painted a little white line around the panel after that.
' Wandering Will' gave up flying years ago. He was also the F/O with that nasty engine failure and fire out of BNE on the 727. I liked him and found him to be a good operator but his confidence was hit after too many people, without the real story, were too critical. You are only remembered by your mishaps, not your achievements in this weird industry. Will was under training at the time and could hardly be expected to 'Ace it'. Unfortunate but the number 1 engine had a few important bits hanging off it. Les was a lovely bloke too and I think it was his first solo trip on the line.

Consider the following:

A three engine approach followed by either a gear or flap failure is a well practiced simulator exercise, something an experienced 747 captain would have been exposed to on numerous occasions.

An experienced captain would also know that extension of the gear, using only the hydraulic ADP takes longer than when the EDP is operating.

Aircraft configuration abnormalities are best dealt with at altitude, and to go around is by far the safest option available when confronted by abnormal conditions, particularly during final approach.

It is the captain’s sole responsibility to support and supervise the actions of the F/E, particularly whilst carrying out abnormal/emergency check lists; otherwise he is left to operate autonomously, leaving both pilots out of the loop.

And yes, the gear lights on the F/Es panel can be viewed from the captain’s position; it just requires the F/E to position his seat accordingly.

So I think to say, that the pilots – and in particular the captain could not be blamed – was indeed a generous statement…

Lookleft, you could be right. Age has taken it's toll on me and I was recently diagnosed with Alzheimer's, for real. I was flying for ANZ at the time, never flew for Ansett although some good mates did. I phoned one earlier and he corrected me about my Olympics comment, Ansett was under the pump to get the 747 flying internationally to coincide with the opening of Kansai airport. At the time a lot of Japanese were travelling to Australia and Qantas had the lions share of the Australian international market. Buggered if I know why the Olympics sprung to mind, perhaps because Ansett sponsored the Sydney Olympics? As for Big Trev I was sure he was part of the project implementation team, but again I could have my years mixed up, who knows.

The incident was an interesting one with numerous causal factors including what I will put politically correct, 'flight deck error', training, manuals, procedures, operational pressure, organisational and management pressure, poor project planning, regulatory issues and so on. But it is now a part of history, nobody died and a lot of lessons were gained and improvements made, particularly within Ansett so that is a good outcome. I still think it was a great airline and will remain a very fond part of Australia's history.

Fact Check
 

Big Trev had nothing to do with the introduction of the 747 into AN. He was recruited as a result of the accident.

Dora-9, the gear lights are easily visible from the L/H seat; I've used them many times and indeed done two landings with the green bulbs blown on the front panel and 10 greens on the F/E panel!

G'day ;)

Feather #3, with respect, I don't agree - see the next post.

Inspired by this thread, I've just re-read the ATSB report (Investigation: 199403038 - Boeing 747-312, VH-INH, Sydney NSW, 19 October 1994). An awful "read", it certainly was a classic "Swiss Cheese" accident. Despite my readily admitted admiration of the PIC, it's undeniable that the ultimate responsibility for this accident lies with him.

By George:

Had I have thought this, then I would have realized that you'd have known and flown with both of the other "players". I knew the FE to talk to, but never flew with him. I was saddened to read about the FO giving up flying after the peer treatment he received - we do (did) work in an unforgiving industry, don't (didn't) we?

Trail Boss:

Aren't your comments just a little trite and super-critical?


So you're telling me that, placed in the same situation where the operator (rushed introduction/different operating culture), the owner declining to modify the aircraft and a unhelpful crew all combined to "set you up", there's no possibility that you'd have been led into the same error? And, by the way, he DIDN'T have the ADP functioning!


Well I don't claim to have eagle vision, and I always had to stare very hard indeed to see the gear lights at the rear of the panel. That I'm not alone in this is shown by how these lights where subsequently outlined by at least 3 B747 operators I know of.

Notwithstanding where the final responsibility lies, I've always thought the PIC was in particular poorly served by the FE. This gent had spent his previous few years as an FE on the B767, a truly brain-atrophying job if ever there was one, and then he's on his post-training first line trip manning what was a decidedly complex panel. It's easy to imagine him being overloaded and perhaps overwhelmed - this is implied in the report.

One contributing issue was the failure of the ADP to operate as it should have; the possible reasons for this are discussed on p.53 of the report. The only logical conclusion I can reach here is, that despite what the FE subsequently claimed, the ADP was never switched to either AUTO or CONTINUOUS. And, given the way it's laid out, I suspect this is what the ATSB are insinuating too...

There would also be an important cultural issue here - I flew the B727 with Ansett; when I got to Cathay (where BJ spent most of his airline career) it was apparent how much better integrated into the entire operation the FE's were there. They were regarded, and expected to be, an equal third member of the crew (e.g. they monitored all approaches and were expected to call out of tolerance deviations) whereas in Ansett there was an imaginary "chalk line" at the aft end of the pedestal and the FE was expected to stay aft of this, man his panel and leave the rest of the operation to the pilots. Hopefully this changed subsequently; I'd be interested to hear from By George how it was done on the Ansett (and SQ) B743's. I just can't imagine any up-to-speed FE letting the PIC go ahead and land with only "4 greens" displayed and not speaking up assertively.

By George, PM sent....

http://s13.postimg.org/7isvcqel3/INH_Photo.jpg

When the aircraft was towed to the Ansett hangar and the Boeing people started the repairs there was a guard placed on the skip that the scrap was dumped into. The security wasn't all that thorough. This little bit came from the belly skin just of the lower TCAS antenna. Is INH frypans now?

Quote:

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An awful "read", it certainly was a classic "Swiss Cheese" accident. Despite my readily admitted admiration of the PIC, it's undeniable that the ultimate responsibility for this accident lies with him.

---

My thoughts entirely Dora-9! No argument there, what so ever. But even after taking all of the contributing factors into consideration, if there was ever a case for carrying out a missed approach, this was clearly it…


As for the reason for the degraded performance of the #1 Hydraulic System, or the position of the ADP control switch, neither was fully determined.

I do not consider my earlier comments trite, but yes, definitely critical.

Like often is the case, this is an incident that so easily could have been avoided…

I would like to think not...

Thanks for the PM Dora-9. My initial Command was on the 727 and I agree the Engineer was not fully integrated. Once on the 743, in my personal opinion, this was much improved. We were trained by Qantas and our procedures changed quite a bit. SQ were similar.
I then flew the 744 for 11 years and I must say, the best and safest operation was always the one with a Flight Engineer on the old girl. A great loss to the Industry when this 3 man crew configuration was removed.
Ansett received much criticism after the INH incident to the point Qantas called us 'F Troop'. Unfair in my opinion, we were far from perfect, but in operations I have witnessed since, not that bad.
I subsequently flew with both Will and Les on many occasions and would fly with them both anytime, anywhere. Nice guys, just the old 'wrong place at the wrong time'.

P377, very sorry to hear of your diagnosis. The INH accident was a big wakeup call. From memory AN made a video about it with Jeff Radbone playing the part of the Captain.

Well at least Ansett gave the ATSB practise on investigating 747 accidents and the influence of organisational culture on flight operations because a major cockup by an Australian widebody operator was just around the corner!:ok:

By George,
Who is Qantas?
Was it the chairman of the board, CEO, Chief Pilot that allegedly used the FTroop slur. I'd suggest to you that it was one or several loudmouths whose opinions expressed usually after a bit of alcohol were inversely proportional to their professionalism and their skills who were mouthing off.

No need for any intercompany slurs.
I do remember that at the time Qantas had 14 Sims in a 747 endorsement while Ansett went with the CAA (***?) minimum of 8. A few of we mere mortals thought that was a bit light on.:ouch:

When this accident occurred,I was in Jakarta on the Haaj. There were 12 aircraft on our ops, all "classic" B747s sourced from a number of airlines and in turn the ground and flight crews sourced from an even bigger number of organisations. So there was a wide range of experienced people there.

When we heard of the accident, a number of crew who were also in our hotel gave a theoretical scenario based on their intimate knowledege of that particular airframe. It was, engine oil loss due to a long standing problem with studs on (I think) an oil pump, followed by engine shutdown, followed by ADP not coming on in auto for which it was well known.

Couple this with all the other Swiss cheese holes with part of crew with very limited experience on type and long haul, merging of cultures, pressure to get the aircraft back to Sydney and a new aircraft in an established operation which had at the time a very limited appreciation of the role of the FE on long haul ops and I suspect that most of us would have found it overwhelming.

Interestingly, when the domestic pilots and FEs started to filter into QF B747 long haul, some and I specifically say some, were reluctant to understand the integrated crew role of the FE on the B747. So this problem was not an AN problem alone but more a cultural problem of how, no matter how much we think we know, we never know it all.

We can all be wise after the event.

Wunwing

Wunwing:

An interesting post, I find that I agree with most of what you wrote. I think all posters, particularly the super-critical, are deluding themselves if they think this doesn't apply to them:

One small point though - I had 7 years on the B747, and I don't recall this as a "well known" ADP problem. By George - any comment?

Dora-9,
To say that Feather3 has substantial experience on the type would be an gross understatement. Although I don't have such substantial time on type, I can say that the gear lights (the and/and --- and/or lights) are clearly visible from the LHS, and we always turned around and had a look, if the lights by the gear lever were other than normal indications.

"In God we trust, everything else we check" is still a good modus operandi.

I agree with Feather3's statement, but I also do agree that the Captain was poorly served by the F/E.

Tootle pip!!

Dora-9, I think he was taking about that particular airframe not 747s in general.

Who leased it before AN?

All the Ansett 743 aircraft, INJ, INK, INH and the short leased 'N' Tails, N123KJ and N121KG were from SQ.


The 744 aircraft, ANA and ANB were also SQ.


ANA and ANB went to Air Pacific and N123KJ became 9VSKJ


All are now coke cans and saucepans. God, I'm having an ' Anorak moment' .

Indeed I was talking about that particular airframe.
In ref to Feather 3's comments about the FEs gear display, I suspect I was with him when we had to do just that. All that happened was that the FE moved the seat out of the way so the Capt could see the gear display. The FE then sequenced the primary and secondaries so that the Capt could see all 10 lights.
That example of crew teamwork was exactly what I was referring to when working as an integrated 3 person crew.It was 2nd nature in our ops and worked extremely well.
Wunwing

Quote:

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I think all posters, particularly the super-critical

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If that comment is aimed at me Dora-9 all I can say is that I must have deluded myself for forty plus years, 35 as a captain and 25 in a check and training capacity on a variety of aircraft, including 16 years on B-747s.

If anyone is deluding themselves it is a pilot who continues to land in an un-stabilised condition and with a continuous undercarriage warning horn blowing, when he still had the option to go around and sort the problem out…

1.20 Stabilised approach
When the aircraft landed, the ‘landing’ checklist was not complete, the airspeed obtained from the flight data recorder readout was 183 knots (approximately 26 knots above target threshold speed), the inboard flap was moving towards flaps 25, the landing gear warning horn was sounding and the gear unsafe light was illuminated.

1. A go-around was not initiated despite the continuing landing gear warnings, the landing checklist challenge and responses being incomplete, the inner trailing edge flaps remaining in transit and the speed being 26 knots above target speed.

Enough said…

Trail Boss:

On reflection, I shouldn't have used the adjective "trite".

However, please don't let's start a "mine's bigger than yours" argument. I have 36 years' airline experience, holding a range of training, checking and management positions during that period. While I'd like to think it wouldn't happen to me because I've always striven to be cunning and careful enough to avoid this sort of situation - I'm also painfully aware that all humans are fallible, and it could happen to me. You too, I suspect.

Wunwing:

Thanks for clarifying that:

It rather torpedoes my theory that the FE never switched the ADP on in the first place! I've actually learnt something from this thread - thanks again. Typical of BASI not to include this particular aircraft's known foible.

Leady:

Hopefully I've indicated I'm not a complete novice in the LHS of the B747. I know that I always had trouble seeing those lights, I couldn't ascertain the situation back there with only a quick glance. Given that everyone else has contradicted me (fair enough), maybe it's just my crappy eyesight?

Trail Boss:

PM sent....