Two safety critical issues arose today, in Crikey reports about a Qantas 767 descending too low with its wheels up as it approached Sydney last Monday, and about the informal relationship between Qantas and CASA and shoddy foreign maintenance.
They raise again the question as to whether the public administration of air safety in Australia is going to be reformed promptly, or after a major crash?
The Cityflyer incident , which occurred on a Melbourne-Sydney 767 appears to be unprecedented in a modern jet airliner in terms of triggering a Ground Proximity Warning System alert telling the pilots, who have been stood down, that they were flying the jet too close to the ground without the wheels down.
The pilots realised what was happening before the warning went off, and had firewalled the throttles and commanded flap changes in a go-around procedure, but at 700 feet and dropping, the jet continued to descend before responding to their inputs.
Just how low it descended will be determined by the ATSB, which is investigating the event as a ’serious incident.’
There is an interesting clue about the sequence of events in this statement issued by Qantas this morning:
This was an extremely rare occurrence but one we have taken seriously. The flight crew knew all required procedures but there was a brief communications breakdown. They responded quickly to the situation and instigated a go around. The cockpit alert coincided with their actions. There was no flight safety issue.
The incident was reported to the ATSB and the pilots were stood down. We are supporting the ATSB’s investigation and our own investigations will determine what further action might be warranted.
The reference to a ‘brief communications breakdown’ in intriguing. What the hell was going on in the cockpit of a 254 seat jet flying the premier domestic route in Australia to cause it to end up sinking toward the tarmac, wheels up and engines screaming, seconds from what could have been an extremely ugly crash?
Qantas is responsible for the flying standards and culture of the airline. No ‘ifs’ or ‘buts’. Why has this failure of standards occurred? Was it mechanical, or was it in the piloting? Qantas management and its directors are responsible for both.
It can be argued that standards at Qantas, and the degradation of its once unquestionable safety culture, became apparent in 1999 when the QF 1 service to London ploughed into a golf course off the end of a runway at Bangkok.
The use of full reverse thrust had been ‘trained out of’ pilots in order to save money through reduced wear and tear on the braking systems and wasted fuel. It was insanely stupid. Not even the lowliest carriers in the Asia Pacific hemisphere did such a wilfully dumb thing. The jet flew a crappy approach in bad visibility to the shorter runway at the Don Muang airport then in use, the captain told the co-pilot to go around, but then reached over and retarded three of the four engine throttles without telling him, resulting in a jet that didn’t know if it was landing or going around hurtling off the end of the runway at 89 knots.
What happened inside the jet in the next half hour was also a dismal farce, culminating in the appearance of the then CEO of Qantas, James Strong, on the Channel 9 Today show assuring the viewers that this was ‘a safety enhancing experience.’
It can be argued that since then Qantas has just been dead lucky, as necessary changes in work place practices and the emphasis on efficiency created a management culture that unfortunately seems to have also assigned lesser value to safety and standards.
Yes, the safety rhetoric remained. And CASA’s oversight of the airline deteriorated into the sort of informal relationships touched on by licensed engineers union federal secretary Steve Purvinas in the other Crikey story today.
Is there any room for informal reporting of safety matters between any airline and CASA? Given that there are formal procedures related to its obligations and processes, perhaps it is time to end the corporate capture of the safety regulator and enforce the rules, to the letter.
9 Comments
Ben why do you feel the need to sensationalise these issues? Of course the aircraft would continue to sink after go around power was applied. Maintaining nose down or level attitude is essential until the engines spool up to full power and positive rate of climb is commenced. This does not happen instantly. I bet the aircraft was never in any danger of colliding with terrain.
Paul,
If I wished to sensationalise the analysis the ATSB has to carry out I’d describe a number of critical actions and alerts that would normally occur on a properly flown final approach to the runway. For the aircraft to get into the position it was at the altitude is was passing is of great concern to 767 pilots as well as Qantas. That is why it is being investigated.
I have to agree with you Ben, that since the QF1 incident in Bangkok in 1999 there have been a number of incidents to cause concern with Qantas and unfortunately there appears to be still a significant chasm between operations and engineering. There is little doubt the divisive “Red” and “Blue” team culture from the time QF took over a Australian Airlines / TAA is still alive and well and I can still remember numerous old blue TAA binders being proudly displayed containing Qantas technical data during my audits of the maintenance divisions based in Melbourne. Also a majority of labour being used at Avalon for B747 heavy inspection checks is sourced from the local contractor Forstaff, which has created another cultural division between the QF supervisors in white shirts overseeing almost a 1,000 Forstaff contractors in blue overalls.
This reminds me of Ansett flight 881, a Boeing 747-300 that crash landed at Sydney Airport in 1994. The pilots failed to lower the nose gear, despite audible alarms going off in the cockpit. The aircraft had 274 people on board (all survived the crash). In the aftermath, Prime Minster Paul Keating defended criticism of Australia’s air safety standards.
Anyway, congratulations, Ben, for bringing the latest Qantas incident to light. The mainstream media (eg the ABC) are just catching on to the story now, probably after reading your report on Crikey. Even Qantas and the investigators agree it was a serious incident, so it’s not at all sensationalist to reveal it to the public.
It has long been the view of CASA’s airworthiness surveyors that formally reporting QANTAS safety problems was a waste of time and likely to and likely to get you labelled a trouble maker
Ben – well done on scooping this one – and the mainstream media have now picked up on it I note. However, could you please leave emotive expressions such as “engines screaming” and “seconds from….an ugly crash” to the tabloids and their uninformed reporters?
It’s incredible that the pilots could overlook such a basic action. Fortunately technology in the form of the jet’s GPWS saved the day on this occasion. Thank God it didn’t end up like Eastern Airlines Flight 401 which slowly descended into the ground when the flight deck crew were distracted trying to fix a faulty cockpit light.
Ben, the problem was Qantas has gone to a cheaper reminder sticky pad and the’ don’t forget to lower the wheels’ sticker fell off the dash. Don’t you worry about it,we didn’t crash. Being a qualified Upholsterer who worked at Mack Trucks for years in P/delivery and did quality control knows about putting washers in the right way and right size. The last time i flew O/S was with Qantas 20 years ago and paid $50 more than Garuda airlines to fly to Bali. Is Garuda my safer bet now ? or a leaky boat ?
A second serious incident seemed to go unnoticed by the Australian media, this time with Qantas subsidiary Jetstar.
On October 28, Jetstar flight JQ-12, an Airbus A330 en route from Narita to Gold Coast. Over Guam, the ECAM central computer began issuing the error message “NAV ADR DISAGREE”. The autopilot then disengaged itself, and the central flight computer changed to ‘Alternate Law’, the same spooky error message that appeared just before Air France Flight 447 plunged into the Atlantic.
This must be at least the third spooky A330 incident that the Australian Transport Safety Board is investigating concurrently. I guess a computer error message is hard for a newspaper to interest the public in. That’s why some colourful and descriptive language helps the public to absorb the subject. The language of the ASTB will naturally be dry, but when relaying it to the public it must be worded in an interesting way. We need the public to be interested in air safety or nothing will improve.
Quite a relevant comment Comet and I’m glad you mentioned the ATSB. Unfortunately, similar to CASA, government funds have been significantly reduced to both Air Safety entities over many years since the jet fuel levy was removed to pay for their services and we have been stuck with compromised resources ever since. Unless there is a fatality many of the ATSB accident investigations are conducted from the Canberra office and their copybook was seriously blemished with a fanciful final investigation report following the Whyalla Airlines fatal accident in South Australia. Perhaps the Federal government should consider introducing the jet fuel levy again to restore resources for both entities to realistic levels for air safety oversight and I would guess a mere two cents a litre levy would see them both awash with funds.
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