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Qantas Link 717 hard landing Darwin

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Qantas Link 717 hard landing Darwin

Old 5th Mar 2008, 03:48
  #101 (permalink)  
 
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Quoted cost is a few million USD
There goes my pay rise....
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Old 5th Mar 2008, 10:24
  #102 (permalink)  
 
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Reminds me of those guys who buy WWII fighters etc, all they get is a mass of corroded twisted metal , find the manufacturers plate in amongst it somewhere and then proceed to remanufacture an entire aeroplane around that plate. Just another simple repair really!
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Old 6th Mar 2008, 02:08
  #103 (permalink)  

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QANTAS PRANGS. Fatal and Aircraft Destroyed.

In days of Olde when Pilotes were Bolde, QANTAS did experience a few fatal accidents as well as non-fatal with hull destroyed. Critics can say that these were in the early days but the aircraft were registered as QANTAS aircraft and flown by QANTAS crew.

To name a few.

26 November 1943. Lockheed Lodestar VH-CAB. Capt. G.Campbell. Wards Strip Port Moresby. Crashed on landing. All crew and 14 pax killed.

July 1949. DH84 VH-BAF. Capt. R. Crabbe. Near Zenag. non-fatal. Aircraft destroyed.

May 1949. Avro Anson VH-BBZ. Capt N. Mitchell. Kerowagi. Non fatal. Aircraft destroyed.

July 1951. Drover. VH-EBQ. Capt. J. Spiers. Near Lae in water. Capt and six pax killed.

Sept. 1951 DH Dragon. VH-AXL. Capt F. Barlogie. Near Karanka. Capt. killed.

Dec. 1951 DH 84. VH- URV. Capt. S Peebles. Near Yaramunda. Capt and two pax killed.

Dec. 1951. DH 84. VH-URD. Capt.R. Davis. Non fatal. Aircraft destroyed.

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Old 6th Mar 2008, 09:38
  #104 (permalink)  
 
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Quoted cost is a few million USD.

How many million $$$ is a 'few'? Is it in excess of the replacement cost of $35M to preserve the 'written off' record, which seems to be the rumour (but unconfirmed by the big Q).

Is there any news on when/ if QANTAS will release any official information regarding damages, costs and injuries incurred?
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Old 6th Mar 2008, 13:24
  #105 (permalink)  
 
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The estimated repair cost is nowhere near the $35miliion replacement cost. It is a single digit number.
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Old 6th Mar 2008, 20:44
  #106 (permalink)  
 
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Aaaahh Gove.... the memories come flooding back, I've done a few landings there I'd rather forget about. Tell me, is my big paper fish still in the control tower? Is the control tower still there?!!
PM me if you know who I am because I will probably know you................
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Old 7th Mar 2008, 05:46
  #107 (permalink)  
 
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Pilots did good job on QF1 at BKK

I noted during my reading of posts on this thread that the comment was made in relation to the QF1 over-run at BKK that the pilots did a good job in keeping QF1 under control on a rain soaked runway.

Having had access to the full accicent report, via a relative who was a pax on that flight, it made for very interesting reading. The "accident", which Qantas tried to have described as an "incident", was the result of a totally inadequate appreciation of the problems likely to be encountered and no thought, apparently, to the use of Full flap and Max reverse on landing. (Rather than 25 Flap and Idle Reverse as was SOP)

My recollection of the report is that there was no discussion regarding the use of reverse thrust or full 30 degree flap for the landing. The F/O was the handling pilot. The approach was consistently flown above bug speeds, above glide slope and in addition to these points landed long. The F/O had initiated a missed approach too late to prevent touchdown, at which point the Capt took control without advising the F/O and endeavoured to complete the landing. In so doing, he retarded only three throttle to idle, leaving one engine (No 1 I believe) still developing around 1.50 EPR. The AutoBrake system would have been disengaged, the ground spoiler deployment cancelled when the throttles were advanced and all in all the situation on the flightdeck was chaotic. At no stage was full reverse selected and only 25 flap was used.

The aircraft left the end of the runway at 88 kts (101 MPH) and, fortunately, came to rest several hundred metres into the over-run which was very boggy. Approx $100 Million repair bill. In addition, it took more than 20 minutes to disembark the crew and pax. Qantas most certainly does have an enviable record, but not so good as is commonly perceived by the general public.
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Old 7th Mar 2008, 07:43
  #108 (permalink)  
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VH-OJH at Bangkok

Old Fella,

For others who might wish to read it, the report is public domain and can be downloaded from the ATSB WWW site. I know the senior aviation psychologist on that investigation (the ATSB does not identify "leads", as some other organisations do).

You say
Originally Posted by Old Fella
The "accident" .... was the result of a totally inadequate appreciation of the problems likely to be encountered and no thought, apparently, to the use of Full flap and Max reverse on landing
I think that it is fair to point out that that list of active failures and latent failures identified in the report is rather longer than your two. They have seven "significant active failures" relating to crew behavior, one relating to runway condition and one technical (PA system failure). In addition, there were nine "significant latent failures" associated with Quantas Flight Operations Branch activities, three associated with CASA's oversight activity, and one with the design of the aircraft itself (placement of components of the PA system).

So I think your summary understates the complexity of the causal factors leading to the accident, as identified by the ATSB. You focus exclusively on the pilots, whereas the ATSB spends considerable space on the context in which the pilots did what they did.

Your "totally inadequate appreciation of the problems" corresponds to the ATSB's first active failure, "The flight crew did not use an adequate risk management strategy for the approach and landing". However, your "no one thought" about flaps Full and Max Reverse, is for me somewhat more problematic. The report does say that the crew neither selected nor noticed the absence of either idle or full reverse thrust, but there is no mention of flap setting in the list of active failures. [Edit: I now understand that Old Fella was referring to the choice during the approach of Flaps 25/idle reverse, which the ATSB characterised as "not appropriate for operations on to water-affected runways", Report p vi, but which was Qantas standard at the time. In contrast, the ATSB considers Flaps 30/full reverse thrust as "appropriate". Below, I refer to deciding about use of reverse thrust when on the runway itself and it becomes apparent that decel is not what it should be.]

Sometimes it is very hard to understand exactly why people did what they did. The crew undertook substantial interviews with the ATSB HF people, who are world-leading, and the results of those interviews do not appear to have yielded a definitive answer to the "why", otherwise it would have been in the report.

It does seem to me odd to suggest that, in a large jet, "no one thought" about reverse thrust. I think it more likely that at the point of landing they fixated on other things: one pilot was in a go-around mind set; the other decided to continue with the landing, and at that point of opposing conceptions of the situation they probably "lost the bubble" in a number of ways.

"Having the bubble"/"losing the bubble" are concepts highlighted by Gene Rochlin in his study of the shootdown of Iran Air 655 by the Aegis cruiser USS Vincennes (Iran Air Flight 655 and the USS Vincennes, in Todd R, La Porte, ed., Social Responses to Large Technical Systems, Kluwer Academic Publishers 1991.) The closest I can come to it on-line is a precis in Rochlin's book "Trapped in the Net", of which the relevant Chapter 9 is on-line. There is no mention of the "bubble".

Here is what Rochlin says:
Originally Posted by Gene Rochlin, Iran Air Flight 655 and the USS Vincennes, 1991, pp116-7

Past and present TAOs [Tactical Action Officers] have characterized their sense of having proper command and integration of the information flows as "having the bubble." When you've got the bubble, all of the charts, the radar displays, the information from console operators, and the inputs from others and from the senior staff fall into place as part of a large, coherent picture. Given the large amount of information, and the critical nature of the task, keeping the bubble is a significant strain. On many ships, TAO shifts are held to no more than two hours. When for one reason or other the TAO loses the sense of coherence, or cannot integrate the data, he announces loudly to all that he has "lost the bubble" and needs either replacement or time to rebuild it. Losing the bubble is a serious, and ever-present, threat, and has become incorporated into the general conversation of TAOs as representing a state of incomprehension or misunderstanding even in an ambience of good information.

This notional "bubble" is one of the key elements in obtaining high and reliable systemic performance in [critical , complex, high-risk settings].....
Mathematicians, computer scientists and others in the UK sometimes speak of "grocking" something, which means something similar. The idea is that there is a distinct mental state in which you intuitively understand all the relevant features and phenomena in an active situation, and equally its opposite is a mental state in which you don't have such an understanding. The point of singling this out with a special word or phrase is to indicate that the mind can switch rather rapidly between the two. I think ATCOs know about this quite well. They come to a radar screen to start a shift, and spend a while "grocking" what could be a complex situation. When they "have" it, then they can take over. And when they think that they are in danger of "losing" it in the middle of a shift, there is a second person there to offload some of the work. I hope that gives some idea of what I am getting at. It means you do/don't have a complete cognitive grasp of all relevant features of the situation at a given time.

I think all of us have experienced this phemonenon at some point, when a situation we thought we cognitively understood suddenly feels foreign, strange, and we instinctively look for clues to help us regain our cognitive grasp.

It seems to me that in a state of indecision, in which one pilot is set on go-around and the other on continuing a landing, that both pilots could easily "lose the bubble", a crew could collectively fail to "grock" the situation. Some relevant phenomena become absent from attention, and it seems use of reverse thrust may well have been one of these.

I think "losing the bubble", or failing to grock, decribes a different cognitive phenomenon than that signified by "not giving thought to" something. I hope you will agree.

Seaching for the reasons why such a lack of understanding of the actual situation developed during the landing led the ATSB to their "significant latent failures", most of which were associated with Qantas Flight Ops, so I think it is fairer to mention this along with active failures of the crew. Causally, the latent failures are just as significant as the active failures.

PBL

Last edited by PBL; 7th Mar 2008 at 12:17. Reason: Clarification of a misunderstanding; correct reference to Rochlin
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Old 7th Mar 2008, 08:24
  #109 (permalink)  
 
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Factors contributing to QF1 Accident

PBL, my comments regarding the performance of the cockpit crew on QF1 were made in response to the previous comment on their performance by an earlier contributor. Of course I realize that many factors were in play. May I recommend to all who wish to take the time to read the 8 page coverage in the CASA Flight Safety magazine summary that you go to WWW.casa.gov.au/fsa/2002/nov/24-31.pdf and view that report. In it it mentions flap settings and the use of reverse thrust. Qantas policy was, at the time of the accident, to use 25 Flap/Idle Reverse as the preferred configuration for landing.
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Old 7th Mar 2008, 08:39
  #110 (permalink)  
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Old Fella,

Understood that your comments were focused.

The point about the flaps 25/idle reverse versus flaps 30/max reverse is of course pertinent; the ATSB found that the former configuration was "not appropriate for operations onto water-affected runways" and the other configuration was "appropriate". However, they say that inter alia the inappropriate selection of flaps 25/idle reverse (which selection was made before landing) was an error "primarily due to the absence of appropriate company procedures and training", and I would rather point the finger where the ATSB says it should be pointed.

PBL
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Old 7th Mar 2008, 10:17
  #111 (permalink)  
 
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PBL, absolutely no arguement from me on that score. In fact, QF training was found inadequate and the company now uses 30 Flap and Full Reverse as SOP, just as Boeing intended.
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Old 7th Mar 2008, 10:28
  #112 (permalink)  
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Old Fella,

on second thoughts, I think I misinterpreted you when you said "no thought to" use of Flaps 30 and Max Reverse. My comments were addressed to what one might do when barrelling along a runway much faster than one wants to be, and more flap and max reverse are two of the things one could do in a hurry. Whereas you meant the selection of landing config at the appropriate time on the approach. Sorry.

PBL
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Old 7th Mar 2008, 11:28
  #113 (permalink)  
 
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The Non Accident accident

The non accident accident at BKK was the result of the simplest of human factors - changing the mindset of a missed approach to a landing after the missed approach was initiated.
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Old 7th Mar 2008, 11:57
  #114 (permalink)  
 
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Old Fella/PBI:

Why would Qantas change the recommended Boeing configuration of 30 flap and full reverse to 25/idle reverse? Supposed cost savings?
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Old 7th Mar 2008, 12:19
  #115 (permalink)  
 
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The non accident accident at BKK was the result of the simplest of human factors - changing the mindset of a missed approach to a landing after the missed approach was initiated.
Not that simplistic Spaz. Get hold of the full report on CASA's website and digest. Many, many lessons to be learnt, and the source of the smell doe's not necessarily eminate from the cockpit.
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Old 7th Mar 2008, 12:51
  #116 (permalink)  
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Teal,

Originally Posted by Teal
Why would Qantas change the recommended Boeing configuration of 30 flap and full reverse to 25/idle reverse? Supposed cost savings?
No, it doesn't appear to have been that at all. It appears to have been that the info on operations into wet and contaminated runways were filed off under "Cold Weather Operations" in the Supplementary Procedures section of the Ops Manual, so people didn't think they applied in the tropics (see the quote below). The procedures do include an instruction to use max reverse. They were issued by Boeing in 1975, but then limited the amount of info provided for two-crew aircraft and they were never in the B744 Ops Manual. However, Qantas included them in the "Cold Weather Ops" section when the introduced the B744 in 1989. All this in Section 1.6.1, p31 of the Report. Further,

Originally Posted by VH-OJH Report, 1.6.1, p31
It became evident during the investigation that many Qantas pilots (including the crew of Qantas One) viewed this section of the ... Operations Manual as relevant only to cold weather operations, such as those encountered in winter in Europe or Japan, or when strong crosswind conditions existed. They did not associate the information with water-affected runways in warmer climatic areas.
There were no definitions of the meanings of the relevant terms "wet", "icy", "slippery", "water patches", "flooded" or "contaminated" referring to runway condition in either the Qantas B744 Performance Limitations Manual or any other publication which formed part of the company ops manual. So apparently people didn't realise that wet was what "wet" meant. They thought "wet" meant "cold and wet" (if they had been Brits, I could understand it )

PBL
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Old 7th Mar 2008, 23:36
  #117 (permalink)  
 
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PBL - thanks for the explanation. Puzzling though given that wet runways (hot or cold) have always been around and operating procedures would have been honed over decades of jet operations in all weather conditions.

I could be imagining it but I do seem to vaguely recall reading a report at the time of the BKK incident which referred to maintenance savings Qantas could achieve through less frequent/extreme use of flaps/reverse thrust on landings. I stand corrected if this is not true.
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Old 8th Mar 2008, 00:14
  #118 (permalink)  
 
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PBL said

Teal,

Quote:
Originally Posted by Teal
Why would Qantas change the recommended Boeing configuration of 30 flap and full reverse to 25/idle reverse? Supposed cost savings?
No, it doesn't appear to have been that at all.
Please. Lets actually read the report and get facts straight before posting this time. Accuracy is important. Of course it was for cost savings. Read page 149 of the report. There were a whole bunch of changes in procedures with the intention of cutting costs as outlined in memos. Flaps 25 landings and idle reverse with certain exceptions and this statement....."any situation where airmanship considerations dictate otherwise."

Last edited by punkalouver; 8th Mar 2008 at 13:03. Reason: punctuation
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Old 8th Mar 2008, 00:15
  #119 (permalink)  
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PBL

As you may be aware, "grocking" (sic) relates to a novel by Heinlein, "Stranger in a Strange Land". The author spells it "grok" (king). It describes a state of mind that inhabits the realm of complete awareness.
John Boyd, the noted combat theoretician and combat pilot calls it "In The (OODA) Loop". It has been described in many ways over time: "Swordlessness", the Eye, the "Zone", etc. Not new, it surprises many people when they first "grok" the description. Some call it focus, that is incorrect, it is awareness cubed; focus is a narrowing, awareness is a dilation. It is a concept that is being applied in many ways in many new areas of endeavor.

Last edited by airfoilmod; 8th Mar 2008 at 00:27. Reason: punctuation
 
Old 8th Mar 2008, 05:53
  #120 (permalink)  
 
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airfoilmod

What some in aviation would refer to as "situational awareness".
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