training report podcast host - brent fishlock

Our monthly Training{RE}Port Podcast with Brent Fishlock

Ep 14 – Complex Failures: Qantas 32

In today’s podcast, I’ll be reviewing an occurrence involving an Airbus 380 departing Singapore for Sydney in November of 2010. Qantas Flight 32 is a great example of systems knowledge and crew coordination taking over a complex failure situation, resulting in a positive outcome. I will be taking details of the occurrence from the Australian Transport Safety Bureau’s final report, sometimes word for word.

Due to the sheer number of failures, the crew had to assess and reassess constantly, drawing on a multitude of participants to acquire all the information required to make informed decisions. the crew was kept very busy. Crews assess and reassess in an emergency all the time, but in this case, there were so many failures to deal with that the crew was challenged, and they did a fantastic job.

Briefly:

Shrapnel from the No. 2 engine failure punctured part of the wing and damaged the fuel system, causing leaks and a fuel tank fire. The shrapnel also disabled one hydraulic system and the anti-lock braking system. It caused the No. 1 and No. 4 engines to go into a “degraded” mode, and it damaged landing flaps and the engine controls for the No. 1 engine.

The crew entered a hold and took 50 minutes to complete the initial damage assessment, which included 58 error messages.

My plan is to cover:

  1. The Failure
  2. The Assessment
  3. Preparing for Landing
  4. Post Landing

On board were five flight crew, 24 cabin crew, and 440 passengers.

So, what happened?

Following a normal takeoff, while maintaining 250 kt in the climb and passing 7,000 ft, the crew heard two ‘loud bangs.’ The captain immediately selected altitude and heading hold mode on the auto-flight system control panel.

The electronic centralised aircraft monitoring system, or ECAM, displayed a message indicating a No. 2 engine turbine overheat warning. Soon after, the ECAM began displaying multiple messages. The captain confirmed with the other flight crew that he had control of the aircraft and instructed the first officer to commence the procedures as presented on the ECAM.

What did the crew do?

The procedure for the overheat message was to move the affected engine’s thrust lever to the idle position and to monitor the situation for 30 seconds. During that 30 second monitoring period, the crew transmitted a PAN PAN to Singapore air traffic control. The first officer also reported observing an ECAM warning of a fire in the No. 2 engine that was displayed for about 1 to 2 seconds. The ECAM reverted to the overheat warning and reinitiated the 30 second monitoring period.

A damage assessment as part of the engine failure procedure suggested that the damage to the No. 2 engine was serious, and the flight crew discharged one of the engine’s two fire extinguisher bottles. Contrary to their expectation, the flight crew did not receive confirmation that the fire extinguisher bottle had discharged. They repeated the procedure for discharging the fire extinguisher and again did not receive confirmation that it had discharged. After more discussion, the crew elected to shut down the No. 2 engine.

Crew communication was evident right from the start of this occurrence and continued throughout the procedures.

The engine/warning display indicated that the No. 1 and 4 engines had reverted to a degraded mode and that the No. 3 engine was operating in an alternate mode.

The flight crew discussed the available options to manage the situation, including an immediate return to Singapore, climbing or holding. As the aircraft remained controllable, and there was ample fuel on board, it was decided that the best option would be to hold at the present altitude while they processed the ECAM messages and associated procedures.

The flight crew recalled frequently reviewing this decision and assessing the amount of fuel on board. The fact that decisions had to be revisited and reviewed multiple times is something that pilots don’t often encounter in the scripted, single-failure, and time-compressed simulator environment.

The flight crew contacted ATC and advised that they would need about 30 minutes to process the ECAM messages and associated procedures, and they requested an appropriate holding position in order for that to occur. ATC initially cleared the flight crew to conduct a holding pattern to the east of Singapore. Following further discussion amongst the flight crew, ATC was advised that a holding area within 30 NM of Changi Airport was required. ATC acknowledged that requirement and directed the aircraft to a different area to the east of the airport and provided heading information to maintain the aircraft in a holding pattern at 7,400 ft. ATC also advised of reports that a number of aircraft components had been found by residents of Batam Island, Indonesia.

Let’s talk more about the Assessment Phase

I said earlier the crew entered a hold and took 50 minutes to complete the initial damage assessment, which included 58 error messages.

The second officer went through the cabin trying to get as much visual confirmation of the damage as possible.

The Captain made many PA announcements notifying the cabin crew and passengers of the situation. Passengers could see the damaged engine from the cabin. Fuel was visible leaking from the left wing.

The flight crew assessed and assessed again due to multiple fuel system ECAM messages. They elected not to initiate further fuel transfer as they were unsure of the integrity of the fuel system. Also, the flight crew could not dump fuel due to damage to the fuel management system. This would result in an overweight landing.

The flight crew received an aircraft communications addressing and reporting system, or ACARS, message from the operator Qantas that indicated that multiple failure messages had been received. At the time, the flight crew were busy managing the ECAM messages and procedures, and only had time to acknowledge the ACARS message.

Okay, let’s talk about the Landing Preparation

The crew had to calculate a landing distance. This was a challenge since the list of inoperative equipment was long. Generally, the list included:

  1. Inoperative wing leading edge lift devices;
  2. Reduced braking function;
  3. Reduced number of operational spoilers; and
  4. Disabled left engine thrust reverser.

I looked at the landing distance charts for the aircraft I fly, which is a 737, and it was a challenge to come up with a landing distance based on the Qantas crew’s list of failures. What I did was take each non-normal landing distance number from the chart for EACH failure, which gave me fou different landing distances. Then the interpolation started: would these failures combined affect the other landing distance numbers, or could I safely average the numbers and add a cushion? Individually, these numbers are valid but combined there is less certainty. How about taking the normal landing distance number, figure out how much MORE distance is required for each failure, and add that to the normal distance?

Also, the Airbus 380 aircraft was 50 tonnes overweight for the Qantas crew. The 737 checklist provides a landing distance factor so you can add landing distance over and above the maximum landing weight. The experience of the Qantas crew probably played a major role here.

The first time the crew entered the information into the landing distance calculator, the software would not calculate a landing distance. I’m not familiar with that software, but the aircraft was 50 tonnes overweight.

After much discussion, the crew determined that a landing within the distance available on runway TWO ZERO Centre at Changi Airport was achievable.

The aircraft had been holding for almost an hour, and controllability of the aircraft for the landing was again questioned and discussed. Many systems were affected, and who knows if other systems were slowly failing? The crew decided to perform a few controllability checks prior to initiating the approach. The aircraft was determined to be controllable enough to fly the approach, and the crew requested a long final. This is an excellent idea since it would probably take extra time to configure the aircraft for landing.

The flight crew advised ATC that, on landing, they required emergency services, and that the aircraft was leaking fuel from the left wing. The Captain called the lead flight attendant or cabin manager on the interphone to advise him of the potential for a runway overrun and evacuation. The cabin crew prepared the cabin for this possibility.

In the News

Okay aviation professionals, let’s change gears for a moment. In the News is a segment of the podcast where I talk about other happenings in business aviation.

In the non-radar environment of the North Atlantic, collision risk is significantly reduced by the application of “Strategic Lateral Offset Procedures, or SLOP.”

According to ICAO’s North Atlantic Operations and Airspace Manual, SLOP has been implemented as a standard operating procedure in the NAT Region since 2004. ADS-C position reports data shows that during 2012, more than 40% of aircraft flying in the NAT MNPS Airspace selected the 1NM Right option and about 20% chose the 2NM Right option.

SLOP guidelines are as follows:

  1. Along a route or track, there will be three positions that an aircraft may fly: centreline, or one mile right, or two miles right;
  2. Offsets will not exceed 2 NM right of centreline; and
  3. Offsets LEFT of centreline must not be made.

Other SLOP related considerations include:

  1. Aircraft without automatic offset programming capability must fly the centreline.
  2. Pilots of aircraft capable of programming automatic offsets should preferably not fly the centreline but rather elect to fly an offset one or two nautical miles to the right of the centreline in order to obtain lateral spacing from nearby aircraft. Pilots should use whatever means are available such as ACAS/TCAS, communications, visual acquisition, GPWS, etc. to determine the best flight path to fly.
  3. An aircraft overtaking another aircraft should offset within the confines of this procedure, if capable, so as to create the least amount of wake turbulence for the aircraft being overtaken.
  4. For wake turbulence purposes, pilots should fly one of the three positions available. Pilots may contact other aircraft on the air-to-air channel, 123.45 MHz, as necessary, to coordinate the best wake turbulence offset option.
  5. Pilots may apply an offset outbound at the oceanic entry point and must return to centreline prior to the oceanic exit point unless otherwise authorized.
  6. Aircraft transiting ATS Surveillance-controlled airspace mid-ocean should remain on their already established offset positions.
  7. There is no ATC clearance required for this procedure and it is not necessary that ATC be advised.
  8. Voice Position reports should be based on the waypoints of the current ATC clearance and not the offset positions.
  9. Pilots should attempt to determine the offsets being flown by aircraft immediately ahead on the same track one flight level above and one flight level below. And then they should select an offset which differs from those. If this is not possible or practical, then pilots should randomly choose one of the three flight path options.

The following text was taken from a Track message:

CREWS ARE REMINDED THAT, WITHIN THE NAT REGION, THE STRATEGIC LATERAL OFFSET PROCEDURES, SLOP, SHOULD BE USED AS A STANDARD OPERATING PROCEDURE TO REDUCE THE RISK OF COLLISION AND NOT SOLELY FOR TURBULENCE OR WEATHER.

A quick shout-out to TrainingPort.net, who produces this podcast.

Let’s get back to it.

Okay, let’s talk about the Approach and Landing

The flight crew progressively configured the aircraft for the approach and landing and conducted controllability checks after each new configuration change. Due to the damage to the aircraft, extending the landing gear required use of the emergency extension procedure.

Singapore ATC radar vectored the aircraft to a position 20 NM from the threshold of Runway 20 centre and provided for a progressive descent to 4,000 ft. The captain set engines No. 1 and 4 to provide symmetrical thrust and controlled the aircraft’s speed with thrust from the No. 3 engine. I’d like to mention here that reversers are only installed on the inboard engines on the Airbus 380; therefore, only one reverser was available for the landing. The No. 2 engine with the thrust reverser had been shut down.

The captain, as the pilot flying, continued to fly the aircraft using the autopilot during the time that the crew managed the ECAM procedures. The captain disconnected the autopilot to conduct control checks to assess the handling qualities of the aircraft before re-engaging it. During the approach, the autopilot disconnected at about 800 ft due to autopilot presets, and the captain elected to leave it disconnected and manually fly the aircraft for the remainder of the approach.

The aircraft touched down, and the captain applied the brakes and selected reverse thrust on the No. 3 engine. The flight crew observed that the deceleration appeared to be ‘slow’ in the initial landing roll. The captain recalled feeling confident that, as the speed approached 60 kt, the aircraft would be able to stop in the remaining runway. The No. 3 engine was gradually moved out of maximum reverse thrust and manual braking was continued until the aircraft came to a stop about 500 feet from the end of the runway. Emergency services approached the aircraft.

So, what happened next?

The flight crew commenced shutting down the remaining engines and, when the final engine master switch was selected OFF, the aircraft’s electrical system went into a configuration similar to the emergency electrical power mode. That rendered all but one of the aircraft’s cockpit displays blank and meant that there was only one VHF radio available to the crew.

A number of the flight crew noticed that the left body landing gear brake temperature was indicating 900 °C and rising.

After some initial confusion about which radio was functioning, the first officer contacted the emergency services fire commander, who asked for the No. 1 engine to be shut down. The first officer responded that they had done so already, but was advised again by the fire commander that the engine continued to run.

The flight crew briefly discussed the still-running No. 1 engine and recycled the engine master switch to OFF, but the engine did not shut down. In response, the flight crew decided to press the engine fire push button and then fire extinguisher bottles in an attempt to shut down the engine. This was also ineffective.

Then, the fire commander indicated that there appeared to be fuel leaking from the aircraft’s left wing.

Okay, so we have hot brakes and a fuel leak in the same area and an engine that will not shut down. I’m sure that the anxious passengers are wanting to de-plane.

The first officer advised the commander of the hot brakes and requested that fire retardant foam be applied over the leaking fuel. The firefighters had already commenced laying a foam blanket over the fuel leak in accordance with the airport emergency services standard operating procedures.

The flight crew then discussed the options for disembarking the 440 passengers. The captain made a PA announcement to the cabin crew and passengers to advise them of the situation, and that the emergency services were dealing with a fluid leak from the left side of the aircraft.

After this discussion, the crew decided that a precautionary disembarkation via stairs on the right side of the aircraft would be the safest course of action.

The flight crew elected to use a single door for the disembarkation so that the passengers could be accounted for as they left the aircraft and to keep the remainder of the right side of the aircraft clear in case of the need to deploy the escape slides. They also decided to leave the remaining doors armed, with cabin crew members at those doors ready to activate the respective escape slides until all of the passengers were off the aircraft.

About 13 minutes after the aircraft landed, the flight crew asked for stairs to be brought to the right of the aircraft and to arrange for buses to move the passengers to the terminal. Consideration of how to shut down the No. 1 engine continued, with some flight crew members contacting the operator via mobile phone to seek further assistance.

Stairs arrived at the aircraft about 35 minutes after landing, and the first bus arrived about 10 minutes later. Passengers commenced disembarking from the aircraft via the No. 2 main deck forward door about 50 minutes after the aircraft touched down. The last passengers disembarked the aircraft about 1 hour later.

Throughout the disembarkation, the flight crew, under advice from the operator’s maintenance personnel, attempted to shut down the No. 1 engine through various alternative means. That included activating a series of circuit breakers in the aircraft’s equipment bay and reconfiguring the transfer valves in the aircraft’s external refuelling panel to transfer fuel away from the engine. All of these attempts failed.

Maintenance personnel at the aircraft also attempted a number of methods to shut down the engine, each without success. Finally, the decision was taken by the operator to ‘drown’ the engine, initially with water and then with fire fighting foam from the airport emergency services fire vehicles. The No. 1 engine was finally shut down about three hours after the aircraft landed.

The list of Crew Resource Management successes here is amazing. Threat and error management, communication, situational awareness, pressure and stress, workload management, leadership and team building, decision making, automation and technology management, and on and on. Flight crew, cabin crew, Air Traffic Control, maintenance personnel at the aircraft and at the operator’s home base, and emergency personnel worked together to achieve a positive outcome. This is also a great example of a complex failure being expertly handled by a well-trained crew. Time and time again, the crew had to reassess the situation before proceeding with the next step to solve the next problem. Once on the ground, there were countless more factors and participants to help. The engine ran on the ground for three hours after landing! That is amazing to me.

I’ll leave a link in the show notes to the Australian report. Lastly, check out the new TrainingPort.net website. Thanks for listening.

Australian Transport Safety Bureau Report: http://www.atsb.gov.au/publications/investigation_reports/2010/aair/ao-2010-089.aspx

 

 

 

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