Qantas flight flies without emergency oxygen

[B A Lert]

This aircraft is no longer and was not at the time operated by QANTAS but by the cheap/low cost offshoot Jetstar.

So? On whose AOC was the aircraft operating? Don't Qantas crews make mistakes? I thought the Pope was the only infallible human when at work!

[GetAround123]

That should be Jetstar's AOC. Understand the aircraft go to/from MNL for re-paint.

[Few Cloudy]

Correction

Bus 429,

Thanks for the deserved knuckle rapping!

I was convinced that crew O2 OFF had been a contributory factor in the Helios case but having reread the entire thread (took a while...) there is not a single reference to this.

I therefore apologise for the duff gen and will edit my previous post.

FC.

[Capn Bloggs]

My Boeing's a 717. Turn oxy bottle off? Oxy in the line is dumped. Line pressure gauge: on zero. Oxy mask check: no noise. Pretty hard to stuff that up.

It intrigues me that Boeing can continue to make real Boeings without such a simple safety feature.

[Terraplaneblues]

Human Factors

The oxygen bottle tap should have been redesigned/eliminated years ago, there should be a self sealing coupling that allows full flow when connected, no in between. Have seen on a 737 Jurrasic where, with tap open, but only slightly, one crew could breathe with his mask, but when both crew tried the crew oxy gauge descended to zero.
The oxygen bottle is common to both pilots and should not have to rely on anybody remebering anything in order to provide full flow.
Ideally, if a well designed self sealing coupling is disconnected the pressure should read zero and produce an EICAS/ECAM warning. If it is connected it can only supply full flow. Dream on......

[maui]

Would it be prudent to scuba dive without first checking the mask?

Should one be any less prudent when flying?

SOP's in the four airlines I have worked with during the past 30 + years, REQUIRE a mask/oxy system check. I would be surprised if the operator currently under discussion is any different.

What is it that is so difficult about following SOP's, which generally have been developed over many years and through hard won experience, and designed to stop the neophyte falling for the same traps as their predecessors.

When will we learn from others, rather than trying everything bad for ourselves.

I shakes my old head, cos I do not understand the mentality. Rushing is no excuse. MAKE TIME.

Maui

[Bolty McBolt]

If the crew oxy system was pressurised prior to the shutoff valve on the bottle (not the overhead switch) being closed on the A330 you can do the press test several times on the mask assy before the low pressure side of the system drops low enough to give you the ECAM pop up and indication on the SD door page.

Its quite feasable that the crew did thier test in MNL all looked good but when the crew in SYD did their test the pressure dropped to the trigger point and the rest is history.

One good thing came out of this.
We know EBA oxy system does NOT leak

[Bus429]

Thanks for the deserved knuckle rapping!

- not a problem, glad to help.

After maintenance, double check everything. I'm just a low-time PPL but I got my scare on my very first flying lesson. We flew in the back of another plane to a small strip where our plane had been painted, to collect it. Shiny new paint job (shabby jobs, but that's another story) and the paint shop had already removed all the masking tape... Except for the tape on the pitot/static mast.

Backpacker: Although I can understand your concerns, it is not feasible or necessary to double-check everything. We in the UK have had duplicate inspections for years covering stuff like flying controls, engine controls etc focusing on so-called vital points. VPs are those that, if they were to fail, would cause catastrophic loss. Until recently, EASA had no similar requirement.
EASA Part 145.A.65 requires as system for prevent errors due to simultaneous maintenance on safety critical systems. Part M (Continued Airworthiness) requires duplicate systems a la UK BCAR requirement for Part 145 and M. Subpart F organisations. I'm not sure how your certification system works for aircraft such as the 150 flying for hire - is it CAT? Probably is. You can specify a duplicate inspection on whatever you like in addition to VPs (and O2 seems like a good idea!!) but I know organisations that specify dupes for first aid kits and fire axes - not a good idea; you can dilute awareness if you over dupe.

[llondel]

I recall something about human factors, wrong length screws were beside other screws, poorly lit storage and fatigue being a major factor. Was this work duplication checked ?.. curious, that's all.

That time it wasn't, but hopefully once the issue had been highlighted, procedures were changed to make sure it didn't happen again. Checking of safety-critical work should never be left to the person who did the work.

[Bus429]

lightly O/T but on the subject of duplication/checking.....

what about the BA chap that half went out the window when the windscreen blew out becasue the wrong length screws had been used (if memory serves correctly ?).

I recall something about human factors, wrong length screws were beside other screws, poorly lit storage and fatigue being a major factor. Was this work duplication checked ?.. curious, that's all.

That was another factor in the incident; the window had not been identified as a vital point. Aircraft certified before 1986 - the 1-11 500 was certified in 1970 - had to have VPs identified by the operator. Aircraft certified after 1986 had VPs identified by the Type Certificate holder. The 1-11 incident had all the ingredients to make it happen: night shift, working on one's own, a shift supervisor doing a hands-on task, design of the window, no duplicate inspection required (a second set of eyes may have identified unfilled countersink revealed by the use of smaller bolts).

[Sinbad1]

duplicate inspection

I do not know why some of you are going around in circles. The O2 bottle was installed with the SOV closed. There is no residual pressure in the line because the aircraft was on a C check, The ECAM will show ZERO when the SOV is closed. A nice amber MSG on the Door/Oxy page will show ZERO. The maintenance crew F. .ed up and flight crew F.. .ed up. that is the end of it. To avoid this situation from happening again during any maintenance visit is to alter the company procedure and raise a duplicate inspection after such maintenance task is performed.

[Joetom]

Sinbad1, nail on the head, two inspections should be reqd and system should be tested.
.
These oxygen systems fitted to aircraft can have Left and Right thread parts in the system, SOV's can be fitted in any location or orientation, very very easy for things to be fitted wrong.
.
As a general rule, Pilots can re-check each others work/functions, Cabin Crew even cross check doors man/auto modes, Engineers often work alone, work it out.
.
Another point to mention, parts/systems are often fitted wrong for long long periods of time, if they are never needed during service they will not come to light, even during parts/systems maint at a later time, incorrect fitting may not come to light, but the poss of new parts/systems being fitted in the same incorrect fashion can be increased.

[AerocatS2A]

...except for the tape on the pitot/static mast.

Pitot/static? pffft! She'll fly when she's ready and once airborne ya judge your speed by listening to the singing of the flying wires .

[Sinbad1]

bizarre situation

The thing I found surprising is not the fact that the O2 bottle has been installed with the SOV left in the closed position or having right or left hand thread, but the series of the events that have taken place following the installation of the bottle. For example, why the engineer did not check the ECAM and carry out verification of the QTY displayed?? was the installation procedure carried out as per the MM?? normally it requires functional check and the MM reference to complete the paper work.
After the aircraft left the hangar was the Daily check carried out?? That would have been required either in the hangar or on the line. I am sure the O2 check is on the daily sheet and I am even more than sure it is on the pre-departure check list which has to be performed by the flight crew prior to departure. Also, what baffled me the most is how could the Capt and the FO miss looking at the Door/Oxy page??? I think QAN.. ..TAS airline should carry out their own investigation to find out what had lead to this unusual error. I would be very interested to read the flight crew version. My comments are obviously based on what has been posted on this forum. If it is true of course and not rumours......

[bubbers44]

We all know that when an aircraft has a lot of maintenance done on it that the plane will end up at the gate with nonstandard positions on switches and maybe a few circuit breakers pulled and forgotten, especially the TO warning CB annoying them everytime they add power. Pressurization left in manual, TO warning horn CB's pulled, dozens of other things too. Always look at everything when taking an aircraft maintenance has been working on. They have a different checklist than we do and sometimes don't follow that one. I had one experience when I got a 737 in Burbank in the afternoon, flew it until late at night, got the same AC the next morning, did the normal crew oxygen test and when I pushed the flow switch oxygen pressure dropped to zero. Just before I picked up the AC the previous crew at a down station had the bottle replaced because of marginal pressure. Even though it showed normal pressure when I got it, it was trapped pressure because the valve was off. Had to take a delay because the bottle was in the fwd baggage compartment and I couldn't get to it because of bags. Chief pilot asked me why I didn't write it up giving maintenance the delay because maintenance said it was our problem because it wasn't written up. Asked him how much the FAA would fine us knowing the bottle was installed noon the day before and we flew it all day until the preflight checks the next morning with the valve shut off.

[Sinbad1]

O2 confusion

bubbers44

The airbus system (A330) is different from the Boeing 737, If you read my previous first post, I did explained the O2 system on the Airbus. On the Airbus when the SOV is off the ECAM shows Zero plus it has low pressure system warning as well, the ECAM Door /Oxy page will display the MSG in Amber When the pressure is less than 50 psi in the system.the first low pressure warning comes on when the pressure drop below the required acceptable level it will show on the ECAM the Numbers in green with Boxed amber, I am not sure but I think around 1500 psi, and when it drops below that, the whole Numbers go Amber, Surely you can not miss that. In a very good airlines when an aircraft complete a check usually the airline engineering has pre hangar departure check list which has to be signed off before it leaves the hangar. Malaysia airline is one of them.The condition you describe the aircraft after a hangar check is unbelievable ( I am not doubting you at all) but I think they must have quite a bad QA department. as for engineering trying to blame the flight crew for not writing it in the book, well I just do not find that answer acceptable at all.There is something seriously wrong with that airliner engineering department to deliver the aircraft in the conditions you described.

[bubbers44]

Actually, I wasn't upset, I knew maintenance screwed up and was trying to fix the problem without them getting into trouble with the FAA. When they threw their screw up back at me it irritated me a bit. I always think everybody is trying their best and once in a while you screw up. Why not let them learn from their mistakes so it doesn't happen again instead of frying them?

[F/O Bloggs]

As Sinbad says you get the indications on the door page.

Additionally with my company, you are supposed to do an oxy test with the normal and emergency setting before every flight. If you push the emerg button and no oxy comes out- something is wrong. Seems like a crew stuff up.

(Capn Bloggs- Your beloved 146s had the "leave the residual pressure indication in the line" system)

[Capn Bloggs]

Sinbad,

I think QAN.. ..TAS airline should carry out their own investigation to find out what had lead to this unusual error.

It wasn't Qantas, it was Jetstar. see the top of this page.

Back in your box, BLOGGS!

[Sinbad1]

Red Kangaroo....

Capn Bloggs

Apology for the mis quote but the title of this thread was referring to QAN...TAS , I wonder how JE::T::::STA::::R got mixed-up with the RED KANGAROO....