Qantas B744 Total electrical failure?
The organisational side of the QF incident is very well addressed by QF insider in the parallel thread running in D&G....
I am very interested in the linkages of minor failure conditions (drip trays etc.) leading to a loss of all generated electical power that did turn out to be survivable after all.
I find it hard to see factual linkages to upper management style in this incident.
Paxing All Over The World
lomapaseo
PRECISELY!! Upper management don't leave factual linkages. It is all about the unspoken. Make sure the documents state that no captain is ever pressurised to X-Y-Z. and then ensure that every Captain knows how they are expected to react!
What I read from the various posters in this thread is that: upper mgmt have spent the past N years saving money. One of the main ways of doing this has been to cut back on maintenance costs leading to the out-sourcing of such. Whether the last check was done in or out, the feeling amongst many (NOT just in QF but numerous airlines) is that maintenance staff are subtly encouraged to cut corners.
Other examples we see of this in other threads are FD crew being encouraged to take a machine that has more faulty items than they would really like/discretion time/etc.
Lastly, in this particular case, it is felt that mgmt have changed the training and working conditions of CC so much that they are also cutting corners. One example: That mgmt specified loose coffee grounds as being cheaper than coffee bags. One of the problems is coffee grounds in drains.
All of this is yet to be substantiated but, for me, having worked in the corporate world for nearly 30 years? I am prepared to believe every word about the attitude of upper mgmt affecting day-to-day working lives, that can bring about a chain of events like this. Not factual but real life.
I find it hard to see factual linkages to upper management style in this incident.
What I read from the various posters in this thread is that: upper mgmt have spent the past N years saving money. One of the main ways of doing this has been to cut back on maintenance costs leading to the out-sourcing of such. Whether the last check was done in or out, the feeling amongst many (NOT just in QF but numerous airlines) is that maintenance staff are subtly encouraged to cut corners.
Other examples we see of this in other threads are FD crew being encouraged to take a machine that has more faulty items than they would really like/discretion time/etc.
Lastly, in this particular case, it is felt that mgmt have changed the training and working conditions of CC so much that they are also cutting corners. One example: That mgmt specified loose coffee grounds as being cheaper than coffee bags. One of the problems is coffee grounds in drains.
All of this is yet to be substantiated but, for me, having worked in the corporate world for nearly 30 years? I am prepared to believe every word about the attitude of upper mgmt affecting day-to-day working lives, that can bring about a chain of events like this. Not factual but real life.
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While this incident had several reasons/factors that 'lined up' to create the right scenario for the incident, the fact remains that if the cabin crew (not just on the flight in question) only put clear liquids ie water down the drains ten they wouldn't block, water wouldn't overflow etc etc. The aircraft drains are designed purely for water like liquids not tea, coffee, vegetable soup etc. If you changed the design and put 3 inch diameter waste pipes in the galley they would still eventually block due to the rubbish that is put down them. Even your waste pipes at home would block with the abuse the aircraft ones get. Suggest that CC get better training in the first instance...and then inpestion of the trays need to be better....
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.... even if only pure water was poured down the drain... you would still get overflows because of Drain Mast Heater failure.
This system was designed to fail. I think we need a better "mousetrap" here.
This system was designed to fail. I think we need a better "mousetrap" here.
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NSEU:
If memory serves the sealed area (which includes a plastic membrane, sealant or wax between floor boards and wax around the feet of galleys and lav's) extends 20 inches fore and aft, inboard and outboard of all defined "wet areas" including MED's, galleys and lav's.
Also keep in mind that a large percentage of equipment in the MEC is aft of the hatch in 'A' zone and the fwd galley area extends to around the fwd edge of #1 MED's.
How far does the sealed area extend? The MEC (using the hatch in "A" Zone as a reference) seems to be well forward of the bench tops/cart stowages.
Also keep in mind that a large percentage of equipment in the MEC is aft of the hatch in 'A' zone and the fwd galley area extends to around the fwd edge of #1 MED's.
While this incident had several reasons/factors that 'lined up' to create the right scenario for the incident, the fact remains that if the cabin crew (not just on the flight in question) only put clear liquids ie water down the drains ten they wouldn't block, water wouldn't overflow etc etc. The aircraft drains are designed purely for water like liquids not tea, coffee, vegetable soup etc.
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Some further random thoughts on lessons that may or may not be being learned.
Loss of generators means total loss of CVR and DFDR, which are not powered by battery. Investigators have been campaigning for some time now to get this rectified, so there’s a few minutes recording time after power loss (too much, and the recorders could be overwriting the initial incident). SR 111 was one of just several where this was a major issue. Others included Egyptair 990, Air Transat at the Azores, and several others.
Since investigations have come up, fact is, their purpose is not to find out why, but to prevent the incident in question recurring. There are occasions when you know what to do to stop it happening again without being clear on the immediate cause.
Co-location of redundant systems where they can be stopped by a common fault is a clear and obvious contradiction of the philosophy of redundancy. If the systems can be stopped by one thing all together, then they are not redundant. What about JAL 123 in 1985: all four hydraulic pipes went through the same hole in the rear bulkhead. Why does this happen? Because (pace Vortsa) the risk assessment has been done and relied on instead of “systems safety” philosophy. RA asks: How likely is it that these things would happen? Answer: Almost unbelievably unlikely. Ergo, nothing needs to be done. (This kind of reasoning may also explain the absence of a RAT on 747s.)
The more conservative, systems safety approach asks: “suppose that failed, what would then happen?” That way, you prevent systems failures having a domino effect on other systems.
BTW, the 747 cargo doors should probably have cleaner windows for inspecting the latch, but that was not the issue with UAL 811 at Honolulu. NTSB got it wrong at first, and then had to issue a new report when they found out the real reason. The latch was properly locked on the ground, but at 23,000ft a short in the latch motor caused it to operate, turn and release the door, which then blew off, taking nine pax with it.
Cargo doors are another good example of RA versus systems safety. Under the latter approach you would have plug cargo doors (remember the DC10). Under RA you just calculate an acceptable level of disaster by factoring the event against total fleet hours, supposedly making sure it is one in a billion or less.
Loss of generators means total loss of CVR and DFDR, which are not powered by battery. Investigators have been campaigning for some time now to get this rectified, so there’s a few minutes recording time after power loss (too much, and the recorders could be overwriting the initial incident). SR 111 was one of just several where this was a major issue. Others included Egyptair 990, Air Transat at the Azores, and several others.
Since investigations have come up, fact is, their purpose is not to find out why, but to prevent the incident in question recurring. There are occasions when you know what to do to stop it happening again without being clear on the immediate cause.
Co-location of redundant systems where they can be stopped by a common fault is a clear and obvious contradiction of the philosophy of redundancy. If the systems can be stopped by one thing all together, then they are not redundant. What about JAL 123 in 1985: all four hydraulic pipes went through the same hole in the rear bulkhead. Why does this happen? Because (pace Vortsa) the risk assessment has been done and relied on instead of “systems safety” philosophy. RA asks: How likely is it that these things would happen? Answer: Almost unbelievably unlikely. Ergo, nothing needs to be done. (This kind of reasoning may also explain the absence of a RAT on 747s.)
The more conservative, systems safety approach asks: “suppose that failed, what would then happen?” That way, you prevent systems failures having a domino effect on other systems.
BTW, the 747 cargo doors should probably have cleaner windows for inspecting the latch, but that was not the issue with UAL 811 at Honolulu. NTSB got it wrong at first, and then had to issue a new report when they found out the real reason. The latch was properly locked on the ground, but at 23,000ft a short in the latch motor caused it to operate, turn and release the door, which then blew off, taking nine pax with it.
Cargo doors are another good example of RA versus systems safety. Under the latter approach you would have plug cargo doors (remember the DC10). Under RA you just calculate an acceptable level of disaster by factoring the event against total fleet hours, supposedly making sure it is one in a billion or less.
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Quote:
While this incident had several reasons/factors that 'lined up' to create the right scenario for the incident, the fact remains that if the cabin crew (not just on the flight in question) only put clear liquids ie water down the drains ten they wouldn't block, water wouldn't overflow etc etc. The aircraft drains are designed purely for water like liquids not tea, coffee, vegetable soup etc.
and just where should the other than clear liquids go?
Well I think they should all go down the toilets. Aircraft drains have too much "thick" liquids, i.e. orange juice, coffee, milk, wine and not enough water flowing through them The thick fluids mix together on the way and congeal. There is not enough water to flush them out.
The worst case I see is the drain pan below the coffee makers on the A320. This is quite a large drain tube (by aircraft drain standards), but the only liquid it ever sees is spilt coffee. The coffee dries in the drain and it gets blocked. Impossible to clear on the ramp.
Galley drains are just simply designed too small. A large galley drain is one cm diam. They are always blocking up.
If any cabin crew read this, please pour a coffee pot of hot water down each sink every flight. It really helps.
While this incident had several reasons/factors that 'lined up' to create the right scenario for the incident, the fact remains that if the cabin crew (not just on the flight in question) only put clear liquids ie water down the drains ten they wouldn't block, water wouldn't overflow etc etc. The aircraft drains are designed purely for water like liquids not tea, coffee, vegetable soup etc.
and just where should the other than clear liquids go?
Well I think they should all go down the toilets. Aircraft drains have too much "thick" liquids, i.e. orange juice, coffee, milk, wine and not enough water flowing through them The thick fluids mix together on the way and congeal. There is not enough water to flush them out.
The worst case I see is the drain pan below the coffee makers on the A320. This is quite a large drain tube (by aircraft drain standards), but the only liquid it ever sees is spilt coffee. The coffee dries in the drain and it gets blocked. Impossible to clear on the ramp.
Galley drains are just simply designed too small. A large galley drain is one cm diam. They are always blocking up.
If any cabin crew read this, please pour a coffee pot of hot water down each sink every flight. It really helps.
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Originally Posted by Swedish Steve
A large galley drain is one cm diam.
My home sink drain is 4 cm diam (just checked...) and that gets only 'home' usage, even so it can get clogged.
A galley drain gets 'industrial' usage. At the size you mention the first olive pip dropped into it by mistake would be enough to clog it!
One cm diam is the internal diameter of domestic water pipes, not drains (just dealt with a leak, so checked that too....).
...Some further random thoughts on lessons that may or may not be being learned ...
I might add that I have seen cases where the assumptions of redundancy were faulted by latency e.g. a completely missing layer of prevention because it was either incorrectly installed or failed for in a hidden manner.
This kind of fault stacking often is missed in the original design/certifcation assumption because it is assumed to be 90% reliable when in fact there is no maintenance or quality control approach that verifies or ensures the assumption.
I still await any facts of what really happened in this event
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Quote:
Originally Posted by Swedish Steve
A large galley drain is one cm diam.
You can't be serious.
Originally Posted by Swedish Steve
A large galley drain is one cm diam.
You can't be serious.
One more time for the dummies. Coffee grinds will find their way into drains wet or dry,
from spills putting grinds in & out of pots, same for the LOOSE LEAF TEA we now have
instead of pot bags used successfully for the past 15 years.
Yes wine, milk, ice creams etc are better off in the bins (plastic lined & checked by catering for no tears????) Mmmmm.
Last edited by Short_Circuit; 15th Jan 2008 at 22:39. Reason: spell check and smiley
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Since blockage of galley drains seems to be a chronic problem, the system (i.e. gravity only) is inadequate. Seems to me a vacuum scavanging system ought to be used, perhaps utilising the existing system used for toilet waste...
Octane
Octane
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There is one on 744ER's. It is connected to the vacuum system. You pour your liquids in there, close the lid, press the button and shazam the offending articles are gone. It is called the GWAD. (Galley waste..........something). Its like a little dunny in the galley.
Pity there are only six ER's flying around.
Pity there are only six ER's flying around.
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Octane
The drains connect to the drain masts which are outside the aero,
therefore, cabin differential pressure acts as a vacuum at some 8 PSI in
flight. This still does not overcome the blockages as the volume of airflow
is kept low by small diameter drain lines. This keeps the noise level &
potential hazards low.
The drains connect to the drain masts which are outside the aero,
therefore, cabin differential pressure acts as a vacuum at some 8 PSI in
flight. This still does not overcome the blockages as the volume of airflow
is kept low by small diameter drain lines. This keeps the noise level &
potential hazards low.
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As I alluded to on another thread on D&G, the issue is NOT about whether the check was done. It is not who it was done by. It is not about the size or absence of a drain/s. It is not about the Cabin Crew, their training poor rumeration or even as some implied laziness. These are all but symptoms.
The problem rests fairly at the feet of management. They have ensured an operational disconnect. By this I mean operational staff are sidelined, particularly those who question a normalised deviation of operating practice.
As such the pursuit of cost reduction bears no foreseeable penalty. Budgets are reduced aircraft dispatched, all the managers are shovelling cash due to their ability to save money. The genesis of this problem lies in the reckless pursuit of COST reduction, it shows how little senior management know about the the dangers of treating the sea or the sky with contempt.
We operational folk, who sign out aircraft or fly them are acutely aware or the risk, we live with them in our daily lives.
Those reducing costs do not.
We were lucky this time....
Those students of history will remember the QF1..
That aircraft was operated by a well trained crew. I won't comment further n the individuals, suffice to say the procedure of Flaps 25 and idle reverse was instituted to save MONEY (brake wear etc) Experienced operational Captains and indeed Boeing themselves mentioned that teaching pilots to use less than maximum stopping ability was setting up a scenario where the pilot would not apply maximum stopping capability...The ATSB report is available and mentions in italics the points raised above.
Guess what..That aircraft rebuild cost in excess of $100million
You may surmise that experienced operational staff should therefore have done something to remedy this flawed policy. Many did. The Captains/pilots who put their name to paper and voiced concern were labelled "resistent to change"
This incident is no different, fortunately the outcome is different. Many are stating that the hijack of business by cost driven administrators may in short term generate savings, however in the longer term the cost imposed on the business and to those operational staff caught up far exceeds any financial bewnefit obtained in the short term.
It is the pursuits of cost reduction at any price without understanding the need of dilligence and multiple defences that could have generated the big one.
These administrators/accountants have no place in operational decisions where people can be killed.
The problem rests fairly at the feet of management. They have ensured an operational disconnect. By this I mean operational staff are sidelined, particularly those who question a normalised deviation of operating practice.
As such the pursuit of cost reduction bears no foreseeable penalty. Budgets are reduced aircraft dispatched, all the managers are shovelling cash due to their ability to save money. The genesis of this problem lies in the reckless pursuit of COST reduction, it shows how little senior management know about the the dangers of treating the sea or the sky with contempt.
We operational folk, who sign out aircraft or fly them are acutely aware or the risk, we live with them in our daily lives.
Those reducing costs do not.
We were lucky this time....
Those students of history will remember the QF1..
That aircraft was operated by a well trained crew. I won't comment further n the individuals, suffice to say the procedure of Flaps 25 and idle reverse was instituted to save MONEY (brake wear etc) Experienced operational Captains and indeed Boeing themselves mentioned that teaching pilots to use less than maximum stopping ability was setting up a scenario where the pilot would not apply maximum stopping capability...The ATSB report is available and mentions in italics the points raised above.
Guess what..That aircraft rebuild cost in excess of $100million
You may surmise that experienced operational staff should therefore have done something to remedy this flawed policy. Many did. The Captains/pilots who put their name to paper and voiced concern were labelled "resistent to change"
This incident is no different, fortunately the outcome is different. Many are stating that the hijack of business by cost driven administrators may in short term generate savings, however in the longer term the cost imposed on the business and to those operational staff caught up far exceeds any financial bewnefit obtained in the short term.
It is the pursuits of cost reduction at any price without understanding the need of dilligence and multiple defences that could have generated the big one.
These administrators/accountants have no place in operational decisions where people can be killed.
AlwaysOnFire
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Interesting turn of events, http://www.theage.com.au/news/nation...159455322.html
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Nepotism,
You're right, someone's already thought of it. The GWAD (galley waste disposal system) is described as a custom option suitable for Boeing and Airbus aircraft. Looks a nice unit, weighs 6 kg and uses existing vacuum and waste tanks.
Maybe the price just went up!
Octane
You're right, someone's already thought of it. The GWAD (galley waste disposal system) is described as a custom option suitable for Boeing and Airbus aircraft. Looks a nice unit, weighs 6 kg and uses existing vacuum and waste tanks.
Maybe the price just went up!
Octane