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Gasman
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QF32 - Could things have been handled differently?

Sun Jun 04, 2017 10:16 pm

The management of the uncontained engine failure on QF32 is nearly always heralded as an unqualified example of magnificent airmanship, teamwork and decision making. Certainly it's hard to be on any kind of downer about an incident where the actions of the crew resulted in the safe return to earth of 466 passengers.

However - the implication then often becomes that nothing could have, or should have been done differently and it is this this that I take issue with.

Most specifically I believe the crew lost an element of situational awareness. Bombarded with an incessant stream of often nonsensical messages from the EFIS, they spent two hours in the skies above SIN attempting to troubleshoot those messages. And they forgot to look at the elephant in the room, which was that they had suffered a catastrophic uncontained engine failure that had caused structural damage to the aircraft resulting - and this is key - into an aircraft with significantly impaired flight control. They had no way of knowing if their aircraft with impaired control would suddenly become an aircraft with *no* control. Surely - if Alaska 261 taught us anything - it's that when an aircraft is having flight control issues; that aircraft gets landed immediately.

In my opinion QF32 should have been landed as soon as it was recognised that the aircraft had suffered structural damage and control was affected. Sure; they got away without doing so - but that doesn't mean that their course of action was the correct one.
Last edited by atcsundevil on Mon Jun 05, 2017 2:50 am, edited 1 time in total.
Reason: Title edited for clarity
 
ChrisKen
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Re: QF32

Sun Jun 04, 2017 10:23 pm

The aircraft was controllable.
The aircraft would have overran if landed earlier.
Job well done.

Lessons will have been learnt.
 
Sydscott
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Re: QF32

Sun Jun 04, 2017 10:34 pm

Before you have an "opinion" it's probably worthwhile reading the report written about it and all of the factual findings and recommendations that were made out of it.

https://www.atsb.gov.au/publications/in ... 0-089.aspx
 
AIRWALK
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Re: QF32

Sun Jun 04, 2017 10:55 pm

Gasman wrote:

However - the implication then often becomes that nothing could have, or should have been done differently and it is this this that I take issue with.


Perhaps by the media, or by other parties who are merely touting their opinions, but remember the accident investigative body certainly doesn't fall prey to that logic. Part of accident analysis is reviewing different possible responses and what their likely outcomes may have been in the interest of flight safety.
I'm sure this thread will take off soon
 
Gemuser
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Re: QF32

Mon Jun 05, 2017 12:06 am

You were not PIC, you were not an ATSB investigator. Unless you are sourcing you opinion from one of those sources your opinion does not matter. What could have been done better is one of the main reason for the ATSB investigation, which is looking back with 20/20 hindsight. Lessons learnt have been disseminated through the appropriate channels. Unless you wish to discuss those lessons your post is irrelevant
Frankly Gasman you disappoint me, I thought you were one of the sane & reasonable posters.

Gemuser
.
 
Gasman
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Re: QF32

Mon Jun 05, 2017 12:25 am

ChrisKen wrote:
The aircraft was controllable.
The aircraft would have overran if landed earlier.
Job well done.

Lessons will have been learnt.

The first two statements here are facile, which is exactly the point I'm making. Yes, the aircraft was controllable but impaired and the crew had insufficient reason to be confident it would remain so. If an aileron had suddenly become locked in a fully deflected position, or an engine separation causing a fireball, or ?, or ?? then it would suddenly have become uncontrollable.

The "aircraft would have overran if landed earlier" is completely fallacious. Every landing is a mixture of risk vs benefit based on some calculations and many assumptions. Pilot factors, braking factors and runway surface factors are not an exact science. As it happened, the aircraft stopped with 150m to spare but they could have stopped earlier. It's all about risk vs benefit and if I'm a passenger on an aircraft with a blown engine, ruptured wing with fuel leaking out and control surfaces damaged and not functioning properly, I want to be put on the ground unless the risk of doing so is utterly reckless.

Job well done/lessons will have been learned - agreed.

Sydscott wrote:
Before you have an "opinion" it's probably worthwhile reading the report written about it and all of the factual findings and recommendations that were made out of it.

https://www.atsb.gov.au/publications/in ... 0-089.aspx


I have done. The report addresses the root cause (Trent 900) and makes recommendations along those lines. It lauds the crew's teamwork but does not specifically critique decision making where those decisions had no adverse outcome.
AIRWALK wrote:
Gasman wrote:

However - the implication then often becomes that nothing could have, or should have been done differently and it is this this that I take issue with.


Perhaps by the media, or by other parties who are merely touting their opinions, but remember the accident investigative body certainly doesn't fall prey to that logic. Part of accident analysis is reviewing different possible responses and what their likely outcomes may have been in the interest of flight safety.



:checkmark:
 
RickNRoll
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Re: QF32

Mon Jun 05, 2017 2:07 am

They pilots were having continual communication in the plane with themselves and also with the check team that happened to be on the flight. In fact the PIC was overruled on some decisions that he wanted to make. The PIC wanted to climb higher in case they had to glide. The others felt that was too risky given all the other problems.
 
catiii
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Re: QF32

Mon Jun 05, 2017 2:13 am

Gasman wrote:
ChrisKen wrote:
The aircraft was controllable.
The aircraft would have overran if landed earlier.
Job well done.

Lessons will have been learnt.

The first two statements here are facile, which is exactly the point I'm making. Yes, the aircraft was controllable but impaired and the crew had insufficient reason to be confident it would remain so. If an aileron had suddenly become locked in a fully deflected position, or an engine separation causing a fireball, or ?, or ?? then it would suddenly have become uncontrollable.

The "aircraft would have overran if landed earlier" is completely fallacious. Every landing is a mixture of risk vs benefit based on some calculations and many assumptions. Pilot factors, braking factors and runway surface factors are not an exact science. As it happened, the aircraft stopped with 150m to spare but they could have stopped earlier. It's all about risk vs benefit and if I'm a passenger on an aircraft with a blown engine, ruptured wing with fuel leaking out and control surfaces damaged and not functioning properly, I want to be put on the ground unless the risk of doing so is utterly reckless.

Job well done/lessons will have been learned - agreed.

Sydscott wrote:
Before you have an "opinion" it's probably worthwhile reading the report written about it and all of the factual findings and recommendations that were made out of it.

https://www.atsb.gov.au/publications/in ... 0-089.aspx


I have done. The report addresses the root cause (Trent 900) and makes recommendations along those lines. It lauds the crew's teamwork but does not specifically critique decision making where those decisions had no adverse outcome.
AIRWALK wrote:
Gasman wrote:

However - the implication then often becomes that nothing could have, or should have been done differently and it is this this that I take issue with.


Perhaps by the media, or by other parties who are merely touting their opinions, but remember the accident investigative body certainly doesn't fall prey to that logic. Part of accident analysis is reviewing different possible responses and what their likely outcomes may have been in the interest of flight safety.



:checkmark:


So let's see, the regulator did its investigation, came to its conclusions, passed judgement on the crew's actions...and you think they missed something and were incorrect?

This is going to be fun...
 
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3rdGen
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Re: QF32

Mon Jun 05, 2017 2:15 am

This thread should be locked.

How the heck can you reasonably sit in your arm chair with feet firmly on Terra Firma and make the comment you just did. Seriously leave it. You are shooting way above your weight.

Firstly you've demonstrated your lack of knowledge of Airbus by saying that fault messages are displayed over the EFIS, when in fact the system that displays faults is known as ECAM.

Secondly, no pilot in his right mind would rush into an approach unless he believes that his plane is on the verge of falling apart. To attempt to land while you still have pending ECAM alerts is unacceptable unless you have a critical failure that requires an immediate return. I.e. uncontrollable smoke, fire or an uncontrollable aircraft, of which they had none.

ECAM procedures are designed to ensure that the aircraft is configured properly given the failure that has occured. And that the crew is aware of the aircraft status and any limitations that apply. ESPECIALLY those that would affect landing distance. Airbus has therefore designed a logical way to manage failures that ensures pilots do things step by step to gain a satisfactory outcome.

Yes, sure the pilots have to use their common sense, experience, knowledge and skill to assess the situation and should always be ready to deviate from the procedures. But where there isn't a need to deviate then to do so would be reckless. The guys got the aircraft on the ground safely.

Your arguement is that they should have got the aircraft on the ground sooner. You say
Gasman wrote:
They had no way of knowing if their aircraft with impaired control would suddenly become an aircraft with *no* control. Surely - if Alaska 261 taught us anything - it's that when an aircraft is having flight control issues; that aircraft gets landed immediately.


The reality is that you have to play the situation out as per what you have in front of you. The reality is that they did have control of the aircraft. And your assumption is that they had no way of knowing if they would suddenly lose control? Why would they lose further control of the aircraft? It's simple really. The controls are powered by the hydraulic systems. They might have lost a hydraulic system or two but it's simply a matter of looking at the hydraulic quantity of the other systems to see if they were about to lose the others. If they were..then sure land ASAP. If not they had time to run the checks.

Pilots cannot freak out and believe that everything is about to fall apart on their aircraft when there is absolutely no evidenced to believe so. This kind of mind set doesn't work in the cockpit. You might not like it but the threat of rushing through things and missing key elements that effect safety, especially not completing all checks, is far more dangerous.
لا اله الا الله محمد رسول الله
 
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LAX772LR
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 3:57 am

Gasman wrote:
Could things have been handled differently?

...yeah, the could've crashed.
That's different.

They had no idea the true extent of the damage, and they did what they could with what they knew-- and people LIVED.
I myself, suspect a more prosaic motive... ~Thranduil
 
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RyanairGuru
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 4:02 am

LAX772LR wrote:
Gasman wrote:
Could things have been handled differently?

...yeah, the could've crashed.
That's different.


That's pretty much how I read it as well.

Of course things could have been different, they weren't reading from a script. They got the thing done, so the Monday morning quarterbacking really isn't very helpful.
Worked Hard, Flew Right
 
Gasman
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Re: QF32

Mon Jun 05, 2017 4:19 am

3rdGen wrote:
This thread should be locked.

How the heck can you reasonably sit in your arm chair with feet firmly on Terra Firma and make the comment you just did. Seriously leave it. You are shooting way above your weight.

Firstly you've demonstrated your lack of knowledge of Airbus by saying that fault messages are displayed over the EFIS, when in fact the system that displays faults is known as ECAM.

Secondly, no pilot in his right mind would rush into an approach unless he believes that his plane is on the verge of falling apart. To attempt to land while you still have pending ECAM alerts is unacceptable unless you have a critical failure that requires an immediate return. I.e. uncontrollable smoke, fire or an uncontrollable aircraft, of which they had none.

ECAM procedures are designed to ensure that the aircraft is configured properly given the failure that has occured. And that the crew is aware of the aircraft status and any limitations that apply. ESPECIALLY those that would affect landing distance. Airbus has therefore designed a logical way to manage failures that ensures pilots do things step by step to gain a satisfactory outcome.

Yes, sure the pilots have to use their common sense, experience, knowledge and skill to assess the situation and should always be ready to deviate from the procedures. But where there isn't a need to deviate then to do so would be reckless. The guys got the aircraft on the ground safely.

Your arguement is that they should have got the aircraft on the ground sooner. You say
Gasman wrote:
They had no way of knowing if their aircraft with impaired control would suddenly become an aircraft with *no* control. Surely - if Alaska 261 taught us anything - it's that when an aircraft is having flight control issues; that aircraft gets landed immediately.


The reality is that you have to play the situation out as per what you have in front of you. The reality is that they did have control of the aircraft. And your assumption is that they had no way of knowing if they would suddenly lose control? Why would they lose further control of the aircraft? It's simple really. The controls are powered by the hydraulic systems. They might have lost a hydraulic system or two but it's simply a matter of looking at the hydraulic quantity of the other systems to see if they were about to lose the others. If they were..then sure land ASAP. If not they had time to run the checks.

Pilots cannot freak out and believe that everything is about to fall apart on their aircraft when there is absolutely no evidenced to believe so. This kind of mind set doesn't work in the cockpit. You might not like it but the threat of rushing through things and missing key elements that effect safety, especially not completing all checks, is far more dangerous.


Thread should be locked? Punching above my weight? Hmmmm.....

Secondly, no pilot in his right mind would rush into an approach unless he believes that his plane is on the verge of falling apart.

Sorry, but the plane already was falling apart. It had suffered an explosion. That explosion had caused palpable damage to the flight control surfaces and the crew had no reason to believe that the aircraft was stable. And the barrage of ECAM alerts (many of which were nonsensical) should only have served to heighten their awareness that this was not a stable situation.

Pilots cannot freak out and believe that everything is about to fall apart on their aircraft when there is absolutely no evidenced to believe so. This kind of mind set doesn't work in the cockpit. You might not like it but the threat of rushing through things and missing key elements that effect safety, especially not completing all checks, is far more dangerous.

I completely agree. But they landed nearly TWO hours after the initial incident. Think about that. It's a lot of time to be in the air with a disintegrated engine, a hole in the wing and disrupted flight control. They could have landed 60 minutes sooner without being criticised for "rushing through things".

I'm not denying that overall they did a great job. In particular the decision not to hurry the evacuation on the ground, which must have gone against every visceral screaming instinct, was truly professional and inspired. But no crisis is ever handled perfectly, and it does no harm to look at what could/should have been done differently. And I make no apology for stating there is room for debate on the issue as to whether they should have got the aircraft on the ground sooner than what they did.
 
Sydscott
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Re: QF32

Mon Jun 05, 2017 4:46 am

Gasman wrote:
I'm not denying that overall they did a great job. In particular the decision not to hurry the evacuation on the ground, which must have gone against every visceral screaming instinct, was truly professional and inspired. But no crisis is ever handled perfectly, and it does no harm to look at what could/should have been done differently. And I make no apology for stating there is room for debate on the issue as to whether they should have got the aircraft on the ground sooner than what they did.


If you really want to discuss how Qantas, as an airline, train their pilots to deal with a situation where they really had to get their aircraft onto the ground, and not wait in the air to work on systems, then I'd suggest having a browse through this report on QF72 which is probably the closest Qantas has come to losing aircraft.

https://www.atsb.gov.au/publications/in ... 8-070.aspx

and for those that don't want to peruse the ATSB report - the following is a summary along with the first time the crew has ever spoken publicly about what happened less than a month ago.

http://www.smh.com.au/good-weekend/the- ... w26ae.html

It's a lot closer to what happened on Alaska 261 than QF 32 was.
 
Gasman
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Re: QF32

Mon Jun 05, 2017 7:35 am

Sydscott wrote:
Gasman wrote:
I'm not denying that overall they did a great job. In particular the decision not to hurry the evacuation on the ground, which must have gone against every visceral screaming instinct, was truly professional and inspired. But no crisis is ever handled perfectly, and it does no harm to look at what could/should have been done differently. And I make no apology for stating there is room for debate on the issue as to whether they should have got the aircraft on the ground sooner than what they did.


If you really want to discuss how Qantas, as an airline, train their pilots to deal with a situation where they really had to get their aircraft onto the ground, and not wait in the air to work on systems, then I'd suggest having a browse through this report on QF72 which is probably the closest Qantas has come to losing aircraft.

https://www.atsb.gov.au/publications/in ... 8-070.aspx

and for those that don't want to peruse the ATSB report - the following is a summary along with the first time the crew has ever spoken publicly about what happened less than a month ago.

http://www.smh.com.au/good-weekend/the- ... w26ae.html

It's a lot closer to what happened on Alaska 261 than QF 32 was.


Thanks Sydscott. I'd actually suggest that both QF72 and 32 have similarities to Alaska 261. But what absolutely struck me about QF72 was that the pilots reacted to a bamboozling situation that involved impaired flight control by getting the aircraft on the ground as soon as possible.

It's true that the QF32 pilots didn't know just how severe the physical damage to the aircraft was until they were on the ground. But they did know

- they'd had an uncontained engine failure
- there was a hole in the wing
- flight control surfaces were damaged
- the aircraft wasn't handling normally
- there was leaking fuel
- they were receiving an unprecedented barrage of failure messages via the ECAS.

What they did NOT know was that the situation wouldn't suddenly get many many times worse.

Was QF32 an "immediate return/closest runway available" situation? No. But given the points above, it was still one that mandated return to the airport as soon as possible while maintaining a situationally appropriate level of safety. And I'd argue that this should have happened in a time frame earlier than two hours. That's a LONG time.
 
WIederling
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Re: QF32

Mon Jun 05, 2017 8:21 am

Sydscott wrote:


That is a pretty juiced up article, isn't it?
Murphy is an optimist
 
Sydscott
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Re: QF32

Mon Jun 05, 2017 8:37 am

WIederling wrote:
Sydscott wrote:


That is a pretty juiced up article, isn't it?


It's written for the mass media so has to be juicey by nature. However the factual basis for the article is both real and frightening especially given the amount of automation that is onboard aircraft.

Gasman wrote:
But what absolutely struck me about QF72 was that the pilots reacted to a bamboozling situation that involved impaired flight control by getting the aircraft on the ground as soon as possible.


Ah but that is also the key difference between the two as well. In QF72 the crew had absolutely no choice but to get onto the ground immediately as they had a computer that was malfunctioning and causing almost total loss of control. There was literally no time to work on checklists etc because the manuals didn't cover the situation and the computers were pouring out rubbish. So given the situation they had no choice but to get on the ground immediately. QF72 was also mid flight so they didn't have to worry about weight etc.

In the QF32 incident the A380 had literally just taken off when the engine issue occurred. The pilots had computer readouts of what has happening, they had visuals from the aircraft windows to somewhat confirm it and they had the advantage of having a Senior Check Caption alongside the Cockpit crew. So they had a base of experience that QF72 didn't have and they also did not have the flight control issues that QF72, or Alaska 261 had. They had manuals and checklists which they followed to secure the aircraft and they had time on their side in terms of locking down the aircraft and reducing aircraft weight for a safe landing. But they other key point here is that at any time if they thought they needed to land immediately the aircraft was easily put into a position to do so. So even though they were working the checklists and securing the aircraft, if the variables had changed or if things had begun to deteriorate they were in a position, and in airspace, where they could land immediately in Singapore. QF72 didn't have this option as they needed to get on the ground immediately.
 
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zeke
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Re: QF32

Mon Jun 05, 2017 8:44 am

Gasman wrote:
Sorry, but the plane already was falling apart. It had suffered an explosion. That explosion had caused palpable damage to the flight control surfaces and the crew had no reason to believe that the aircraft was stable. And the barrage of ECAM alerts (many of which were nonsensical) should only have served to heighten their awareness that this was not a stable situation.


1- There was no explosion, it was an uncontained engine failure, lot of aircraft have had uncontained engine failures. While a serious event, most times are not fatal https://aviation-safety.net/database/db ... Event=ACEU
2- The A380 was the first large airliner built that could keep flying in the event of the loss of all of the engine driven hydraulic systems. The backup actuators have their own self contained hydraulic systems attached to the control surfaces that are electrically powered
3- FBW systems by design automatically reconfigure themselves so the desired input from the pilot is reflected by the correct aircraft response, for roll control it will use ailerons and spoilers.
4- Aircraft are designed to keep flying if an engine detaches, this has happened a number of times in history.
5- The crew knew the handling characteristics and what they had available by reconfiguring the aircraft with flaps etc and speeds before commencing the approach
6- ECAM directs the crew to perform various actions so that systems are reconfigured for abnormal situation, ECAM will direct them for example to monitor the fuel loss, fuel imbalance, start the APU, protect the bleed air, protect hydraulics, protect electrics, push fire extinguishers etc
7- At the end of the ECAM process the STATUS is displayed to provide a summary of the aircraft configuration, the flap position required for approach, monitor fuel imbalance, performance a landing distance assessment, and what will be available for landing, eg types of braking, type of steering, reverses etc
8- The aircraft was not failing apart, there was an uncontained engine failure, parts oif which went into the wing and fuselage. After that teh aircraft did not "fall apart".
9- Aircraft are designed to be "fail safe" structurally, that means in the event of a failure of a load path there is redundant load paths that can take over the role.
10- Could have it been done differently for sure, maybe better, maybe worse. The aim is for a safe outcome, however that is derived, They had a safe outcome.

Sydscott wrote:
If you really want to discuss how Qantas, as an airline, train their pilots to deal with a situation where they really had to get their aircraft onto the ground, and not wait in the air to work on systems, then I'd suggest having a browse through this report on QF72 which is probably the closest Qantas has come to losing aircraft.


As far as I know the ATSB never addressed why the crew did not follow the FCOM procedure for the IR fault to turn it off. They saw the fault light on the IR, it should have been turned off. The ADR 1 should have also been turned off. The external sensors like the pitot, static, TAT, AOA go via the ADIRU, if there is a fault with a sensor or the analogue to digital converter that is attached to them, the only way to isolate those sensors from the aircraft is by turning off the affected ADR.

You can actually dispatch with an ADR/IR and AOA sensor inop under the MEL, it is not a dire emergency.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
WIederling
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Re: QF32

Mon Jun 05, 2017 8:59 am

zeke wrote:
As far as I know the ATSB never addressed why the crew did not follow the FCOM procedure for the IR fault to turn it off. They saw the fault light on the IR, it should have been turned off. The ADR 1 should have also been turned off. The external sensors like the pitot, static, TAT, AOA go via the ADIRU, if there is a fault with a sensor or the analogue to digital converter that is attached to them, the only way to isolate those sensors from the aircraft is by turning off the affected ADR.

You can actually dispatch with an ADR/IR and AOA sensor inop under the MEL, it is not a dire emergency.


Is it (lack of) "introspection capability" that differentiates QF72 ( AF447, ... ) from a case like QF32?

AF447 would have been an unremarkable upset had the crew followed procedures ( and worked as a crew and not as disjunct individuals.).
QF72 ...
Murphy is an optimist
 
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747classic
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 9:01 am

First of all the flight crew performed very good as a team in a multi failure scenario.

However, the basic question that IMHO is missing from the final report :
Would the outcome have been different if only the basic two crew members (capt and co-pilot) would have been in the cockpit. The aircraft has been certified to be operated safely by only two flight crew members.
Would the basic crew of two be overwelmend by the flow of ECAM messages, the decissionmaking would be extremely difficult with one crewmember occupied with the actual flying and the other occupied with all the messages. Cross checking all the actions would be nearly impossible.
Totally missing in the report is : who did what at the flightdeck during the whole operation. The overwritten CVR recording didn't help, but no effort has been made to clearify each flight crew action in detail. What was the input of the two check pilots ?

Note : In this case we had 5 pilots in the cockpit, capt, co-pilot, second officer, check captain and supervising check captain , an ideal situation for evaluations plus assessing the actual outside situation by the second officer after leaving the cockpit (impossible in a two crew situation.).

See : APPENDIX A: ELECTRONIC CENTRALISED AIRCRAFT MONITORING PROCESS WORKFLOW AND TIMELINE
Operating a twin over the ocean, you're always one engine failure from a total emergency.
 
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neutrino
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 9:15 am

Gasman wrote:
.....Certainly it's hard to be on any kind of downer about an incident where the actions of the crew resulted in the safe return to earth of 466 passengers.


Color me pedantic but if you want to put in figures, please don't pluck them off the ground or from the air for that matter.
Also, don't dump everybody onboard as passengers. Some are cockpit and cabin crews.
How did you get to 466? And all of them passengers???
For the record, the total number of human beings in that flight is *469, comprising 29 crews and 440 passengers. And no, its not rocket maths.

*From the mouth of ATSB: "On board the aircraft were five flight crew, 24 cabin crew and 440 passengers (a total of 469 persons on board)".
https://www.atsb.gov.au/publications/in ... 0-089.aspx
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smi0006
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 9:40 am

I'm not an industry tech expert - what would the consequence be of landing as Gasman suggests immediately, without reducing weight, forgetting the inspired breaking? Are we talking airframe damage, or landing gear come into the cabin?
 
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OA940
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 10:08 am

What if one of the warnings gave them info they needed to know? What if they needed to troubleshoot in order to land? You would be looking at fatalities, whereas the plane landed safely. And if the pilots thought the plane was in immediate risk they would've landed.
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SomebodyInTLS
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Re: QF32

Mon Jun 05, 2017 11:11 am

zeke wrote:
Sydscott wrote:
If you really want to discuss how Qantas, as an airline, train their pilots to deal with a situation where they really had to get their aircraft onto the ground, and not wait in the air to work on systems, then I'd suggest having a browse through this report on QF72 which is probably the closest Qantas has come to losing aircraft.


As far as I know the ATSB never addressed why the crew did not follow the FCOM procedure for the IR fault to turn it off. They saw the fault light on the IR, it should have been turned off. The ADR 1 should have also been turned off. The external sensors like the pitot, static, TAT, AOA go via the ADIRU, if there is a fault with a sensor or the analogue to digital converter that is attached to them, the only way to isolate those sensors from the aircraft is by turning off the affected ADR.

You can actually dispatch with an ADR/IR and AOA sensor inop under the MEL, it is not a dire emergency.


Yeah, I actually found that article to be quite sensationalist - of course what happened was an extremely serious and horrifying event, but it does seem to be written from the "automation is evil" perspective. I too wondered why they didn't just isolate the faulty computer instead of continuing to fly while scared it would all kick off again. The way it's written they seem to have panicked and reacted badly, IMO.
"As with most things related to aircraft design, it's all about the trade-offs and much more nuanced than A.net likes to make out."
 
flipdewaf
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Re: QF32

Mon Jun 05, 2017 11:39 am

Gasman wrote:

It's true that the QF32 pilots didn't know just how severe the physical damage to the aircraft was until they were on the ground. But they did know

- they'd had an uncontained engine failure
- there was a hole in the wing
- flight control surfaces were damaged
- the aircraft wasn't handling normally
- there was leaking fuel
- they were receiving an unprecedented barrage of failure messages via the ECAS.

What they did NOT know was that the situation wouldn't suddenly get many many times worse.

I remember distinctly when I was learning to fly and I would fly in some nice old traumahawks and they kind of had their own personalities. We (the instructor and I) jumped in one day and started hr up for a trip to Carlisle and the oil temp and pressure were both sitting off the end of the green zone and into the yellow, I asked if we should stop and check and he said no, he did the power checks and asked me to watch them both throughout (both stayed at the same place). I took off and we headed north climbed to 3 thousand feet and we checked again and they were still steady in the same place, my instructor said to me "As long as they stable it is fine, it is if they are moving that something is wrong, I would be less concerned about a static needle in the yellow band than one quickly moving in the green". The lesson I learned is that if its flying and stable and controllable and things aren't getting worse use the time you have to prepare yourself and keep ahead of the plane.

- they'd had an uncontained engine failure: Had being operative word, the incident had happened and there was no indications that I was going to keep happening.
- there was a hole in the wing: A hole had been formed and it wasn't growing
- flight control surfaces were damaged But there is a level of redundancy built in that accounts for that such that safe operations can still be conducted.
- the aircraft wasn't handling normallyThey had control, reduced maybe but they had control and there was no reason to expect that the control levels would be reduced.
- there was leaking fuel And likely the amount of fuel that was leaking would either be indicated or relatively easily to calculate the amount of time they have available in the air.
- they were receiving an unprecedented barrage of failure messages via the ECAS. Even more reason to stay in a relatively safe stable and flyable aircraft while the messages are dealt with to ensure that the aircraft is in the safest possible configuration and state given the circumstances, if they don't understand the circumstances then how can they possibly create the best scenario for a safe landing.

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Sydscott
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Re: QF32

Mon Jun 05, 2017 1:01 pm

zeke wrote:
Sydscott wrote:
If you really want to discuss how Qantas, as an airline, train their pilots to deal with a situation where they really had to get their aircraft onto the ground, and not wait in the air to work on systems, then I'd suggest having a browse through this report on QF72 which is probably the closest Qantas has come to losing aircraft.


As far as I know the ATSB never addressed why the crew did not follow the FCOM procedure for the IR fault to turn it off. They saw the fault light on the IR, it should have been turned off. The ADR 1 should have also been turned off. The external sensors like the pitot, static, TAT, AOA go via the ADIRU, if there is a fault with a sensor or the analogue to digital converter that is attached to them, the only way to isolate those sensors from the aircraft is by turning off the affected ADR.

You can actually dispatch with an ADR/IR and AOA sensor inop under the MEL, it is not a dire emergency.


That way be the case but having 9 out of 12 crew injured plus a number of passengers injured at varying degrees would more than fully justify a diversion and immediate landing for medical treatment if nothing else.
 
kalvado
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 3:31 pm

I am also an armchair expert, who just enjoys reading what aviation professionals write on this forum. And in my armchair capacity I learned 2 things, which are relevant here.
1. "get on the ground ASAP if something is wrong!" is obvious to anyone outside the industry, but often wrong for professionals. Just simple examples: go-around, v1 - sometimes it is safer to get/keep plane in the air... I guess that is mindset newcomers have to develop to become professional.
2. Hindsight is always 20/20, and sometimes you just don't know what is going on. I can see the situation when you would be correct. If primary wing structure would get more damage and wing snapped during those 2 hours, we would be talking a bit differently. But they bet on plane not degrading any further - and they won. Could go any way, IMHO - but see hindsight remark above.
 
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zeke
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Re: QF32

Mon Jun 05, 2017 4:43 pm

Sydscott wrote:
That way be the case but having 9 out of 12 crew injured plus a number of passengers injured at varying degrees would more than fully justify a diversion and immediate landing for medical treatment if nothing else.


I take it you have never dived with the whale sharks in Exmouth ? Learmonth is a mainly disused airbase with only a skeleton caretaker staff. The nearest "hospital" is in Exmouth about 40 minute drive away. The "hospital" only has 9 beds and normally 100% full. Those who were injured off QF72 were flown to Perth by the RFDS which took several hours for the aircraft to reach Learmonth and then a couple of hours to get back to Perth.

From when the autopilot disconnected to landing in Learmonth took 52 minutes. From where they diverted to Learmonth to Perth would have taken an hour to fly in the A330. They could have had ambulances and doctors to take those who were ill to a major trauma centre in Perth. They could have used the extra time available to look the failure up in the FCOM and see what they missed, as well as an opportunity to talk to maintenance control who can see the status of the aircraft in real time.

Everything seems easier with hindsight, just presenting a different way to achieve the same outcome.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
n729pa
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 9:10 pm

Bottom line 4th November, 469 people walked out of Singapore Airport. That is good enough for me.

Easy to criticise in hindsight. Personally I think the the crew did a good job considering.

AS261 is a totally different set of circumstances and not remotely similar in flying control conditions.
 
Sydscott
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Re: QF32

Mon Jun 05, 2017 10:24 pm

zeke wrote:
From when the autopilot disconnected to landing in Learmonth took 52 minutes. From where they diverted to Learmonth to Perth would have taken an hour to fly in the A330. They could have had ambulances and doctors to take those who were ill to a major trauma centre in Perth. They could have used the extra time available to look the failure up in the FCOM and see what they missed, as well as an opportunity to talk to maintenance control who can see the status of the aircraft in real time..


I've actually been there twice. Once voluntarily and the other one as a diversion on a SYD-PER QF 747-300. Learmonth is the only other airport in WA that could handle the aircraft.
 
Gasman
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 10:51 pm

n729pa wrote:
Bottom line 4th November, 469 people walked out of Singapore Airport. That is good enough for me.

Easy to criticise in hindsight. Personally I think the the crew did a good job considering.

AS261 is a totally different set of circumstances and not remotely similar in flying control conditions.


Agree with your first two points. But giving the crew a big "tick" should not preclude us from looking at the errors of judgment they might have made as well. Not to do so would be wrong.

On your third point we part company. There are major similarities with AS261. Both QF32 and AS261 had suffered mechanical failure affecting flight control. Both aircraft were (initially) controllable in spite of that. Surely the crew of AS261, prior to the catastrophic failure, had as much reason to believe their aircraft was stable as QF32 did?
 
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flyingturtle
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Re: QF32 - Could things have been handled differently?

Mon Jun 05, 2017 11:42 pm

kalvado wrote:
I am also an armchair expert, who just enjoys reading what aviation professionals write on this forum.


You're mentioning two crucial things. In most incidents, it's "land as soon as practical", while in really dangerous situations it's "land as soon as possible". Always keep in mind that hurrying is a risk factor in itself. When you HAVE five minutes to discuss a solution, USE these five minutes - it's a real asset! You'll be really happy when these five minutes of cross-checking save you a lot of trouble later.

And yes, you always base your decisions on the information you have, not on the information you wish to have. Also, getting additional information will cost you some time - time you sometimes don't have.

Finally, there's no textbook on how to decide things. People who like to think about their past decisions will be a tad better in future decisions than others. It's also good when you have a habit of getting as much information as possible, and getting other people's opinions on the matter. Then, there are accident reports. Reading them can be a rewarding mental challenge. From the safety of your armchair, you can attempt to make better decisions given the same information.



David
Reading accident reports is what calms me down
 
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zeke
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Re: QF32

Tue Jun 06, 2017 12:20 am

Sydscott wrote:
I've actually been there twice. Once voluntarily and the other one as a diversion on a SYD-PER QF 747-300. Learmonth is the only other airport in WA that could handle the aircraft.


If you mean the only airport that can handle an A330, that is not true, Curtin, Port Headland, Pearce, and Kalgoorlie as well.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
Sydscott
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Re: QF32

Tue Jun 06, 2017 2:27 am

zeke wrote:
Sydscott wrote:
I've actually been there twice. Once voluntarily and the other one as a diversion on a SYD-PER QF 747-300. Learmonth is the only other airport in WA that could handle the aircraft.


If you mean the only airport that can handle an A330, that is not true, Curtin, Port Headland, Pearce, and Kalgoorlie as well.


No I mean the only other airport in Western Australia that can handle a 747 is Learmonth. The other you mention can handle widebodies with Kalgoorlie being the usual diversion point for domestic widebodies.
 
cpd
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 2:33 am

We need to put the OP in this situation in a simulator and then evaluate how the OP performed.

I'm fairly certain the crew did all they could in the situation, managing the problems and not rushing things. If the plane is heavy, then you have no option but to reduce the weight of it or otherwise run off the runway. In this case, the plane was able to be flown on its backup hydraulic systems, so the choices taken seem perfectly reasonable.
 
jimatkins
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 3:02 am

Read QF32 by the captain, available for Kindle. I don't know how they got that plane on the ground with alarms going off for two hours straight. They couldn't dump fuel and couldn't transfer fuel because of the numerous cable cuts caused by the debris. I'm not an expert, but that crew managed about the least manageable disaster possible with skill and cool heads.
 
Gasman
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 3:08 am

cpd wrote:
We need to put the OP in this situation in a simulator and then evaluate how the OP performed.

I'm fairly certain the crew did all they could in the situation, managing the problems and not rushing things. If the plane is heavy, then you have no option but to reduce the weight of it or otherwise run off the runway. In this case, the plane was able to be flown on its backup hydraulic systems, so the choices taken seem perfectly reasonable.


No. The *control surfaces* were affected. You don't have backups of those. They remained affected and the aircraft did not fly normally for the whole two hours after the uncontained failure. This wasn't just a case of a hydraulic failure with backup systems coming on-line and remedying the problem. Do your research please.

Thanks for your offer of a go in an A380 simulator, I'm sure it'll be fun.
 
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zeke
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 3:28 am

Gasman wrote:
No. The *control surfaces* were affected. You don't have backups of those. They remained affected and the aircraft did not fly normally for the whole two hours after the uncontained failure. This wasn't just a case of a hydraulic failure with backup systems coming on-line and remedying the problem. Do your research please.


Some control surfaces were impacted, however the controllability was not, in fact they had the autopilot engaged.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
Balaguru
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 3:51 am

The pilot in command of the aircraft, Captain Richard Champion de Crespigny participated in a interview a few years ago and he said this about the decision making process in the flight deck that day. I am not quoting, I am typing what I remember. ..... When the flight controls of the aircraft are impaired because of an uncontained failure as had happened, it was important for him and the first officer to certify for themselves the flying characteristics of the aircraft at that time. They could not go ahead flying the aircraft as they had before. They had to relearn the aircraft's reactions to their control inputs to even attempt a safe landing. In addition to this, they had to sift through all the ECAM messages to make sure that, among all the information they were getting, there was nothing that could ruin a safe landing attempt. The FADEC links to one of the engines were severed (if I remember right, it was engine no. 1), and therefore could not throttle that engine up or down. With all this information, they landed, knowing that they could not idle 1 of the engines after landing, and therefore had to prepare for that as well (in terms of differential braking, loss of reverse thrust on 1 side, etc.).
All in all, "if things were handled differently, could all the passengers and crew have safely walked off the aircraft?" That is the more important question, rather than, "could it have been done differently?"
 
cpd
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 10:50 am

Gasman wrote:
cpd wrote:
We need to put the OP in this situation in a simulator and then evaluate how the OP performed.

I'm fairly certain the crew did all they could in the situation, managing the problems and not rushing things. If the plane is heavy, then you have no option but to reduce the weight of it or otherwise run off the runway. In this case, the plane was able to be flown on its backup hydraulic systems, so the choices taken seem perfectly reasonable.


No. The *control surfaces* were affected. You don't have backups of those. They remained affected and the aircraft did not fly normally for the whole two hours after the uncontained failure. This wasn't just a case of a hydraulic failure with backup systems coming on-line and remedying the problem. Do your research please.

Thanks for your offer of a go in an A380 simulator, I'm sure it'll be fun.


I actually did attend a lecture of a fairly well known and old aeronautical organisation with one of the crew members on that plane who explained what was going on to us. He went into a large amount of detail. Zeke I think has it right.

I also didn't say if it flew normally or not, you said that, not me.
 
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zeke
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Re: QF32 - Could things have been handled differently?

Tue Jun 06, 2017 11:02 am

This is the RAeS interview with one of the people up front https://www.aerosociety.com/news/exclus ... e-cockpit/
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
GinoDownUnder
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 3:21 am

Gasman it's fine to be an armchair quarterback, but have you read:

    1. QF32 book
    2. The ECAM workflow in the ATSB report - look at the SD pages called by the aircrew. This chart provides an accurate workflow of the crew, showing their activities including the flight control checks
    3. https://qf32.aero/lessons-learned-from-qf32


Other notes:
    Have you asked the captain at his web site QF32.com?
    QF32 is a classic story of risk management and threat and error management,
    The flight to compare with QF32 in relation to flight controls is El Al Flight 1862. The crew actions are obvious when put into this context.
    You cannot be impetuous in electric networked FBW aircraft - Rule #1 - don't presume or assume. Get your facts - to as many significant digits as possible.

Questions are fine, but they were all answered years ago in these references.
 
Gasman
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 5:35 am

GinoDownUnder wrote:
Gasman it's fine to be an armchair quarterback, but have you read:

    1. QF32 book
    2. The ECAM workflow in the ATSB report - look at the SD pages called by the aircrew. This chart provides an accurate workflow of the crew, showing their activities including the flight control checks
    3. https://qf32.aero/lessons-learned-from-qf32


Other notes:
    Have you asked the captain at his web site QF32.com?
    QF32 is a classic story of risk management and threat and error management,
    The flight to compare with QF32 in relation to flight controls is El Al Flight 1862. The crew actions are obvious when put into this context.
    You cannot be impetuous in electric networked FBW aircraft - Rule #1 - don't presume or assume. Get your facts - to as many significant digits as possible.

Questions are fine, but they were all answered years ago in these references.


Thanks Gino

To answer your questions, I've read Richard de Crespigny's book, read the ATSB report (which rightly focuses mainly on the fuel pipe, not so much on what the crew theoretically should or should have done differently) and seen just about every - if not actually every - media release, most of which are superficial to the extreme "Modern aircraft have many REDUNDANT SYSTEMS which take over in an emergency, and the highly trained crew............. blah blah...........aircraft can fly on 3 engines quite safely........".

No, I've not contacted the Captain directly and you're right - perhaps I should.

I disagree that my questions were answered "years ago". The question on whether they could and/or should have landed earlier has been raised before; but not in an official context - and perhaps that's appropriate. Timing wasn't a sentinel event (the oil pipe was) and the outcome of QF32 could not have been better. The crew did a good job, and whether or not I believe they "should" have returned the aircraft to terra firma earlier is largely irrelevant to understanding the cause and effect of the incident.

However, obviously when an aircraft has structural damage affecting flight control, you want it on the ground as soon as it is practical with the appropriate level of safety. If this can be achieved, nothing is to be gained by remaining in the air. In my opinion, QF32 was in the air beyond this point.
 
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zeke
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 6:12 am

Gasman wrote:
However, obviously when an aircraft has structural damage affecting flight control, you want it on the ground as soon as it is practical with the appropriate level of safety. If this can be achieved, nothing is to be gained by remaining in the air. In my opinion, QF32 was in the air beyond this point.


Can we all get an understanding of your expertise to come to such a personal opinion?

Every account produced stated there were benifits staying airborne, what is the factual basis to make such a claim ? The control of the aircraft was not impacted as you have incorrectly stated numerous times, nor were they in danger of falling apart or hitting the ground. For the most part the flight including most of the approach was flown with the autopilot on.

Even at the weight they landed they didn't have a lot of margin in the landing distance, staying airborne and burning off fuel made for a safer approach and landing.

I don't agree with your opinion, but that's just me, with over 10,000 hrs flying Airbus widebodies.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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77west
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 6:52 am

I agree with Zeke. In the air with options is far safer than a fast, heavy landing with half the brakes inoperative. I mean the fact the autopilot was still available shows you that there was not a completely critical flight control breakdown. If half the wing was missing like that Cargo A300 that got hit by a missile, or a major fire, then yes, landing ASAP would be better. QF32 was not in this situation.

With hindsight, many accidents / incidents "could have been handled differently" but thats just it, hindsight.
77West - AW109S - BE90 - JS31 - B1900 - Q300 - ATR72 - DC9-30 - MD80 - B733 - A320 - B738 - A300-B4 - B773 - B77W
 
ltbewr
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 6:59 am

Clearly serious problems with major engine failures in the past, like UA292, led to changes in the control systems of aircraft and flying procedures that led to the decisions or the ability to do so as made with QF32. Sometimes it just takes some good CRM and sound basic airmanship to prevent a major problem from becoming a disaster.
What may be learned from QF32 may include changes in ECAM message systems and how these pilots made their decisions. ECAM message systems may have to be reprogrammed to prioritize more critical messages in certain severe circumstances so pilots are not overwhelmed with info so can make decisions easier, quicker and right. Improvements in training including to better prepare pilots in such major failures including what was done right or not so right in this situation.
 
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77west
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 7:17 am

ltbewr wrote:
Clearly serious problems with major engine failures in the past, like UA292, led to changes in the control systems of aircraft and flying procedures that led to the decisions or the ability to do so as made with QF32. Sometimes it just takes some good CRM and sound basic airmanship to prevent a major problem from becoming a disaster.
What may be learned from QF32 may include changes in ECAM message systems and how these pilots made their decisions. ECAM message systems may have to be reprogrammed to prioritize more critical messages in certain severe circumstances so pilots are not overwhelmed with info so can make decisions easier, quicker and right. Improvements in training including to better prepare pilots in such major failures including what was done right or not so right in this situation.


True. Why warn about failed window heat when 2 of 3 HYD systems are offline?
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zeke
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 7:56 am

77west wrote:
True. Why warn about failed window heat when 2 of 3 HYD systems are offline?


What do you means by 2 out of 3, the A380 only has two.
Human rights lawyers are "ambulance chasers of the very worst kind.'" - Sky News
 
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airmagnac
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 11:36 am

Gasman wrote:
However, obviously when an aircraft has structural damage affecting flight control, you want it on the ground as soon as it is practical with the appropriate level of safety. If this can be achieved, nothing is to be gained by remaining in the air. In my opinion, QF32 was in the air beyond this point.


Speaking as a systems engineer, not a pilot.

The function (= finality) of a flight control system is to reach a target attitude by rotating the aircraft around its axes without taking the aircraft beyond its design limits. Latter limits include stuctural static loads and also buffeting & vibration modes induced by the excitation of various forces around the machine.
The physical control surfaces are only a means to this end, therefore their exact status is not very relevant as long as the aircraft responds correctly to a rotation command sent through the sidestick. Even more so in a FBW aircraft where this whole process is made transparent to the pilot.
Yes, performance may have been degraded, but the primary function of the flight controls remained fulfilled....at least in flight, at altitude and at speed. And this was apparent to the crew.

What could not be immediately known is whether this control function would remain fulfilled at lower speeds and lower altitude, as required for an approach to land.
As variations of speed, altitude and flap/slat/gear configuration will change the force distribution around the aircraft and therefore the loads and vibration excitations, it could very well be that the structurally and "systemally" damaged aircraft might not behave as expected. The last place I'd want to discover that is on approach, at low alititude and low speed, with reduced available thrust.

So no, it is not obvious to me that rushing down to land is an appropriate reaction.
My goal as an engineer is to fill my soul with coffee and become immortal
 
WIederling
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 1:09 pm

77west wrote:
If half the wing was missing like that Cargo A300 that got hit by a missile, or a major fire, then yes, landing ASAP would be better. QF32 was not in this situation.


Even those pilots did the "cortical thing". First access the damage, think about how you can fit your objectives into the damaged plane.
Test your solution .... then land.
Murphy is an optimist
 
cpd
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Re: QF32 - Could things have been handled differently?

Wed Jun 07, 2017 1:21 pm

zeke wrote:
This is the RAeS interview with one of the people up front https://www.aerosociety.com/news/exclus ... e-cockpit/


Thanks for posting that, I forgot it was online. If only the presentation slides were on there too.

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