ATSB report revisits the QF32 incident with some new surprises
A sample of the voluminous graphical content of the final QF32 accident report

There is one thing that the ATSB final report on the 2010 QF32 A380 incident out earlier today doesn’t  do which is to look widely at how the piloting culture in Qantas had yet again, and on the largest scale ever, saved the airline and a large number of passengers from a disastrous crash.

That is not a criticism of the ATSB, since such a review is not part of its investigative obligation, but the early part of this century has seen Qantas tested by extraordinary circumstances that could so easily have ended very quickly in massive tragedies.

Known by its flight number, QF32, the engine disintegration that occurred to a full A380 soon after departure from Singapore to Sydney on 4 November 2010, is a thoroughly reported accident, and today’s third and final report by the ATSB doesn’t contain too much that would be new to a lay reader, and it is a long, thorough and technical read. Although there are some matters that are new.

We had already learned that the accident was caused by a defect in the manufacture of its inboard No 2 Rolls-Royce Trent 900 engine, as the ATSB reiterates:

The Australian Transport Safety Bureau (ATSB) found that a number of oil feed stub pipes within the High Pressure / Intermediate pressure (HP/IP) hub assembly were manufactured with thin wall sections that did not conform to the design specifications. These non-conforming pipes were fitted to Trent 900 engines, including the No. 2 engine on VH-OQA. The thin wall section significantly reduced the life of the oil feed stub pipe on the No. 2 engine so that a fatigue crack developed, ultimately releasing oil during the flight that resulted in an internal oil fire. That fire led to the separation of the intermediate pressure turbine disc from the drive shaft. The disc accelerated and burst with sufficient force that the engine structure could not contain it, releasing high-energy debris.

But we didn’t know just how badly Rolls-Royce had let its standards slip, and how widespread the danger posed by a deficient safety culture in one of its plants had become.

The HP/IP bearing support assembly was released into service without the non-conforming oil feed stub pipe being reported in accordance with the manufacturer’s non-conformance management procedures. Due to an absence of some of the inspection records for the HP/IP bearing support assembly in the No. 2 engine from VH-OQA, the ATSB could not determine exactly why the non-conformance was not reported.

Similarly, records for HP/IP bearing support assemblies from other Trent 900 engines produced around that time had not been retained by the manufacturer. The ATSB therefore could not determine how they were released without the non-conformances being reported. However, the ATSB identified that a culture existed within the manufacturer’s facility that produced the HP/IP bearing support assemblies where it was considered acceptable to not report what were considered to be ‘minor’ non-conformances.

Numerous other engines within the Trent 900 fleet were also found to contain a critical reduction in the oil feed stub pipe wall thickness.

These findings, about deficient record keeping and a lax safety culture in Rolls-Royce at the time are quite shocking.  This was a time bomb of indifference and incompetence in the manufacture of Rolls-Royce Trent 900 engines at the time which was going to go off on an A380 somewhere someday, and Qantas was the unlucky victim.

Rolls-Royce said today that it has taken steps to ensure the deficiencies identified in the course of investigation will never happen again.

But reading this final report on the matter of its then deficient safety culture and the extent of the problem makes it clear that when Qantas launched an action against the engine maker for damages it was always going to negotiate a settlement (which it did, for $104 million) rather than have the matters go to trial with the attendant massive media exposure of the evidence.

Did Rolls-Royce get off lightly? Perhaps. But through outstanding piloting the travelling public, and Qantas, escaped shaken, but unharmed, other than the financial impact of the accident on Qantas, which rightly grounded its A380 fleet until the risks had been identified and remedied.

The final ATSB report on QF32 clinically describes the actions of the pilots, on the day augmented by a check captain and a supervising check captain, as well as a captain, a first officer and a second officer, and gives them recognition for judgement, team work, focus and the successful return of the A380 with no injury to anyone on board in a jet which showed itself to have an exceptional resistance to an extraordinary range of structural damage caused by debris flung off by the uncontained engine failure.

But consider for a moment the scale and depth of the experienced pilot asset Qantas has, and hope, very strongly, that it retains and nurtures it forever.

The QF72 incident in which an A330 dived out of control twice with little warning near Learmonth in 2008 remains one of the most difficult investigations the ATSB has ever undertaken, and it was intuitive and rational piloting, initially with only one of two pilots actually in the cockpit on the onset of the crisis, that saved that flight.

This is part of the Plane Talking’s coverage of that incident.

The ATSB has found a dormant fault in the software installed on all Airbus A330s sent a Qantas flight berserk in a set of dives that injured 119 people in 2008.

After considering everything from electromagnetic interference from a defence signalling facility at Exmouth to cosmic ray damage, the air safety investigator found that Qantas flight QF72, an A330-300, dived out of control on a flight from Singapore to Perth on 7 October 2008 after a software fault in its flight control primary computers was triggered by their being fed false flight parameters from another device.

The two upsets or losses of control that resulted were promptly brought under control by the pilots, but threw many passengers who were not wearing seat belts about the cabin, some smashing through overhead panels with their heads. QF72 then made an emergency landing at Learmonth, where it was found that 119 out of the 315 passengers and crew on board had suffering injuries, 12 of them having been seriously injured and a further 39 requiring hospital treatment.

There were also two 747-400 incidents in which the pilots were not just confronted by serious mechanical or electrical failures, but a barrage of error messages as occurred in the A380 and A330 incidents.

Both were in 2008, the first, fortunately, occurring in a flight that was close to Bangkok airport and not over Antarctica where it has been performing a scenic charter shortly before then.

A week before a Qantas 747-400 suffered a series of electrical failures while fortuitously close to Bangkok Airport on January 7, 2008, it had been above Antarctica, on a scenic charter flight, and many hours away from Australia.

Three of the jet’s four GCUs or generator control units had been flooded and knocked out by water from a blocked, and probably partly frozen waste pipe draining a galley where coffee grounds often clogged the sinks.

As detailed in today’s final ATSB report into the serious incident, the electrical failures caused by the plumbing problems took down a range of important controls and systems, and confronted the pilots with a mass of error messages on their cockpit displays. Rather like a vanilla version of the far more severe issues that confronted the crew of a Qantas Airbus A380 on November 4 near Singapore.

But there was a really nasty side to this incident, on flight QF2 from London, with 346 passengers and 19 crew on board, compared to the structural challenges faced by the A380.  The Boeing 747-400 was running out of electricity. When it pulled up at the terminal there was only 14 minutes of 30 minutes of emergency battery power remaining.

Without that power, fuel transfers between the 747s tanks would have been compromised, and the crew would have needed to fly and navigate using a basic set of stand by instruments, no better in many respects than the instrumentation of a light plane.

That incident was followed later in the year by the extraordinary malfunctioning of an oxygen bottle under the forward section of a Qantas 747 shortly after it had taken off from Hong Kong, resulting in a badly damaged jet making a successful emergency landing in Manila.

There are several parallels with the Qantas QF32 A380 incident earlier this month and the accident in which a ruptured oxygen bottle forced one of its Boeing 744ER jets to make a forced landing at Manila on July 25, 2008 and which is the subject of a final report by the ATSB this morning.

They are the saving of a large number of lives by highly experienced, but undervalued pilots, in an airliner stricken by a massive structural crisis.

But while the A380 crisis was the most serious Qantas incident since the Bangkok crash of 1999, and the trigger is known to have been a design fault in its Rolls-Royce engines, the ATSB finds the Manila incident was a ‘freak accident’ unlikely ever to occur again.

In each aircraft, the airliner suffered significant systems and control damage never anticipated in any emergency scenarios, which the pilots had to identify and respond to out of the blue.

If there is a bigger safety message to be drawn from these incidents than the technical analysis done by the ATSB, it is that a perforce costly and continuing and renewing investment in pilots trained to deal with the unexpected upset situations that stalk all airliners comes with incalculable safety benefits for airlines .

Your people are your best and most vital asset.

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