Qantas Flight 32: Crew response to the emergency

by B. N. Sullivan

This is the third in a series of posts about Qantas Flight 32, an Airbus A380 (registration VH-OQA) that experienced an uncontained failure of one of its four Rolls-Royce Trent 900 engines during flight on November 4, 2010.  The information here is based on a preliminary report by the Australian Transport Safety Bureau (ATSB), issued On December 3, 2010.

As mentioned in the previous post, there were five flight crew on board Qantas Flight 32: the Captain (PIC); a First Officer (FO), acting as co-pilot; a Second Officer (SO); a second Captain, who was training as a Check Captain (CC); and a Supervising Check Captain (SCC), who was training the CC.  This post details how they responded to the emergency following the uncontained engine failure that damaged the aircraft and a number of its systems.

Early in the emergency, given that the aircraft was controllable, the crew decided to hold their present altitude while they processed the plethora of ECAM messages that immediately followed the engine failure.  [See previous post.]  They contacted Singapore ATC and asked for an appropriate holding position, ultimately requesting "to remain within 30 NM (56 km) of Changi Airport in case they should need to land quickly."  ATC vectored the aircraft into a holding pattern east of the airport  at 7,400 ft.

As the crew went through procedures associated with the ECAM messages, the SO went into the cabin to try to visually assess the damage to No 2 engine.

As the SO moved through the cabin a passenger, who was also a pilot for the operator, brought the SO’s attention to a view of the aircraft from the vertical fin mounted camera that was displayed on the aircraft’s in-flight entertainment system.  That display appeared to show some form of fluid leak from the left wing.

The SO then went to the left side of the aircraft's lower deck and observed the wing damage and fuel leak.  He saw a fuel trail about 0.5 m wide that appeared to be coming from underneath the wing.

Later, the SCC and SO returned to the cabin "on numerous occasions to visually assess the damage on the left side of the aircraft, and to inspect the right side of the aircraft, and to provide feedback to the cabin crew and passengers."

Meanwhile, up on the flight deck:

The flight crew reported that, during their assessment of subsequent multiple fuel system ECAM messages, they elected not to initiate further fuel transfer in response to a number of those messages, as they were unsure of the integrity of the fuel system.  In addition, the crew could not jettison fuel due to the ECAM fuel jettison fault and they were aware that there was fuel leaking from the left wing.  The crew also recalled an indication that the aircraft’s satellite communications system had failed.  They also received an aircraft communications and automatic reporting system (ACARS)message from the aircraft operator that indicated that multiple failure messages had been received by the operator from the aircraft.

It took about 50 minutes for the crew to complete procedures associated with the many ECAM messages.

They then assessed the aircraft systems to determine those that had been damaged, or that were operating in a degraded mode.  They considered that the status of each system had the potential to affect the calculation of the required parameters for the approach and landing.  The crew also believed that the failure may have damaged the No 1 engine, and they discussed a number of concerns in relation to the lateral and longitudinal fuel imbalances that had been indicated by the ECAM.

The FO and the SCC performed several calculations to determine the landing distance required for their overweight landing.  They determined that landing on Changi's runway 20C  "was feasible, with 100 m of runway remaining," and advised ATC to that effect.

Approach and Landing

Prior to leaving the holding pattern, the crew carried out a number of manual handling checks at holding speed to assess the controllability of the aircraft.

As the crew started to reconfigure the aircraft for the approach by lowering flaps, they conducted further controllability checks at the approach speed and decided that the aircraft remained controllable.  As a result of the landing gear-related ECAM messages, the landing gear was lowered using the emergency extension procedure and a further controllability check was conducted.

The landing performance application indicated a required approach speed of 166 kts.  The flight crew reported being aware that: reverse thrust was only available from the No 3 engine, no leading edge slats were available, there was limited aileron and spoiler control, anti-skid braking was restricted to the body landing gear only, there was limited nosewheel steering and that the nose was likely to pitch up on touchdown.  An ECAM message indicated that they could not apply maximum braking until the nosewheel was on the runway.  The wing flaps were extended to the No 3 position.

Singapore ATC vectored the aircraft to a position 20 NM (37 km) from the threshold of runway 20C and provided for a progressive descent to 4,000 ft.  The PIC was aware that accurate speed control on final would be important to avoid either an aerodynamic stall condition, or a runway overrun. Consequently, the PIC set the thrust levers for Nos 1 and 4 engines to provide symmetric thrust, and controlled the aircraft’s speed with the thrust from No 3 engine.

The autopilot disconnected a couple of times during the early part of the approach as the speed reduced to 1 kt below the approach speed.  The PIC initially acted to reconnect the autopilot but, when it disconnected again at about 1,000 ft, he elected to leave it disconnected and to fly the aircraft manually for the remainder of the approach.  Due to the limited landing margin available, the CC reminded the PIC that the landing would have to be conducted with no flare and that there would be a slightly higher nose attitude on touchdown.

Cabin crew were briefed to prepare the cabin for a possible runway overrun and emergency evacuation.

The aircraft touched down, the PIC applied maximum braking and selected reverse thrust on the No 3 engine.  The aircraft came to a stop with about 150 meters of runway remaining.

After Landing

The crew shut down the remaining engines, however the No 1 engine continued to run.  The crew recycled the engine master switch to OFF, but the engine still did not shut down.  The crew then tried using the emergency shutoff and fire extinguisher bottles to shut down No 1 engine, but to no avail.  Activating a series of circuit breakers in the aircraft's equipment bay, and efforts to starve the No 1 engine of fuel also were unsuccessful.  Ultimately, "the decision was taken to drown the engine with fire-fighting foam from the emergency services fire vehicles," but this did not happen until about 2 hours and 7 minutes after the aircraft landed!

Meanwhile, passengers disembarked on the right side of the aircraft via stairs.

The crew elected to use a single door so that the passengers could be accounted for as they left the aircraft and because they wanted the remainder of the right side of the aircraft to be kept clear in case of the need to deploy the escape slides. They also decided to have the other doors remain armed, with crew members in their positions at those doors ready to activate the escape slides if necessary, until all of the passengers were off the aircraft.

It took about an hour for all passengers and crew to leave the aircraft. There were no injuries reported among the five flight crew, 24 cabin crew and 440 passengers on board Qantas Flight 32.

[Photo Source]

Click here to view all posts about Qantas Flight 32 on Aircrew Buzz.

Qantas Flight 32: Uncontained engine failure and damage to the aircraft

by B. N. Sullivan

This is the second in a series of posts about the events on board Qantas Flight 32, an Airbus A380 (registration VH-OQA) that experienced an uncontained failure of one of its four Rolls-Royce Trent 900 engines during flight on November 4, 2010.  The information here is based on a preliminary report by the Australian Transport Safety Bureau (ATSB), issued On December 3, 2010.

There were five flight crew on board Qantas Flight 32: the Captain (PIC); a First Officer (FO), acting as co-pilot; a Second Officer (SO); a second Captain, who was training as a Check Captain (CC); and a Supervising Check Captain (SCC), who was training the CC.

In a media briefing on the day the preliminary report was released, ATSB Chief Commissioner Martin Dolan praised the crew of Qantas Flight 32, stating that the A380 "would not have arrived safely in Singapore" were it not for the actions of the flight crew.   Reading through the ATSB report, it is clear that the entire crew really had their hands full.

Engine Failure

The ATSB report says that the first sign of trouble came during the climb out of Singapore when the crew heard two "almost coincident" loud bangs.  The PIC immediately selected altitude and heading hold on the autopilot control panel, and the aircraft leveled off, however the autothrust system did not reduce power to the engines as expected.  When it became clear that the autothrust system was no longer active, the PIC manually retarded the thrust levels to control the aircraft's speed.

The Electronic Centralized Aircraft Monitor (ECAM) system displayed an "overheat" warning message for the No 2 engine.  Then all hell broke loose on the flight deck.

Within seconds, the overheat warning changed to a fire for the No 2 engine.  The crew decided to shut down No 2 engine, and "after they had selected the ENG 2 master switch OFF, the ECAM displayed a message indicating that the No 2 engine had failed."

The crew discharged one of the engine's two fire extinguisher bottles, but did not receive a confirmation that it had discharged.  They repeated the procedure and again did not receive the expected confirmation.  They attempted to discharged the second bottle; again they did not receive confirmation that the second bottle had discharged.

The crew reported that they then elected to continue the engine failure procedure, which included initiating an automated process of fuel transfer from the aircraft’s outer wing tanks to the inner tanks.

The crew also noticed that the engine display for the No 2 engine had changed to a failed mode, and that the engine display for Nos 1 and 4 engines had reverted to a degraded mode.  The display for the No 3 engine indicated that the engine was operating in an alternate mode as a result of the crew actioning an ECAM procedure.

Shortly afterward, a flood of ECAM messages began to display.  Quoting from the ATSB report:

The flight crew recalled the following system warnings on the ECAM after the failure of No. 2 engine.

• engines No 1 and 4 operating in a degraded mode
• GREEN hydraulic system -- low system pressure and low fluid level
• YELLOW hydraulic system -- engine No. 4 pump errors
• failure of the alternating current (AC) electrical No. 1 and 2 bus systems
• flight controls operating in alternate law
• wing slats inoperative
• flight controls -- ailerons partial control only
• flight controls -- reduced spoiler control
• landing gear control and indicator warnings
• multiple brake system messages
• engine anti-ice and air data sensor messages
• multiple fuel system messages, including a fuel jettison fault
• center of gravity messages
• autothrust and autoland inoperative
• No. 1 engine generator drive disconnected
• left wing pneumatic bleed leaks
• avionics system overheat

Damage to the Aircraft

Unbeknown to the crew at that time, the No 2 engine's intermediate pressure (IP) turbine had failed.  The turbine disc, blade and nozzle guide vanes separated, ruptured the surrounding casing, and damaged the engine's thrust reverser.  A number of components were ejected, which struck the aircraft.

The leading edge of the left wing was penetrated, resulting in "damage to the leading edge structure, the front wing spar and the upper surface of the wing."

The left wing-to-fuselage fairing also was penetrated, "resulting in damage to numerous system components, the fuselage structure and elements of the aircraft's electrical wiring."

Damaged were "elements of the aircraft's electrical wiring that affected the operation of the hydraulic system, landing gear and flight controls; a number of fuel system components; and the leading edge slat system."

The left wing's lower surface was impacted, "resulting in a fuel leak from the Number 2 engine fuel feed tank and the left wing inner fuel tank."

[Photo Source]

Click here to view all posts about Qantas Flight 32 on Aircrew Buzz.

Qantas Airbus A380 uncontained engine failure: ATSB preliminary report

by B. N. Sullivan

The Australian Transport Safety Bureau (ATSB) has released its preliminary report regarding its investigation of the November 4, 2010 uncontained failure of a Rolls-Royce Trent 900 engine on a Qantas Airbus A380 aircraft over Batam Island, Indonesia.  The aircraft (registration VH-OQA), operating as Qantas Flight QF32, was en route from Changi Airport, Singapore to Sydney with five flight crew, 24 cabin crew and 440 passengers on board.  No one on board was injured, but the aircraft sustained substantial damage.  Two people on the ground sustained minor injuries due to falling debris.

The abstract of the ATSB report provides this brief summary of what happened:

Following a normal takeoff, the crew retracted the landing gear and flaps.  The crew reported that, while maintaining 250 kts in the climb and passing 7,000 ft above mean sea level, they heard two almost coincident ‘loud bangs’, followed shortly after by indications of a failure of the No 2 engine.

The crew advised Singapore Air Traffic Control of the situation and were provided with radar vectors to a holding pattern.  The crew undertook a series of actions before returning the aircraft to land at Singapore.  There were no reported injuries to the crew or passengers on the aircraft.  There were reports of minor injuries to two persons on Batam Island, Indonesia.

A subsequent examination of the aircraft indicated that the No 2 engine had sustained an uncontained failure of the Intermediate Pressure (IP) turbine disc.  Sections of the liberated disc penetrated the left wing and the left wing-to-fuselage fairing, resulting in structural and systems damage to the aircraft.

As a result of this occurrence, a number of safety actions were immediately undertaken by Qantas, Airbus, Rolls-Royce plc and the European Aviation Safety Agency.  On 1 December 2010, the ATSB issued a safety recommendation to Rolls-Royce plc in respect of the Trent 900 series engine high pressure/intermediate pressure bearing structure oil feed stub pipes.  In addition, the Civil Aviation Safety Authority issued a Regulation 38 maintenance direction that addressed the immediate safety of flight concerns in respect of Qantas A380 operations with the Trent 900 series engine.  On 2 December 2010, Qantas advised that the requirements of Rolls-Royce plc Service Bulletin RB211 72 G595 would take place within the next 24 hours on engines in place on A380 aircraft currently in service, and before further flight on engines on aircraft not yet returned to service.

The ATSB report, which was issued today, is lengthy and detailed.  I will present some of the details of particular interest to crew members in the next two posts on Aircrew Buzz.  Stay tuned for that.

Meanwhile, here is the link to the landing page on the ATSB website where you can find links to the full text reports; photos; and safety recommendations pertaining to this accident: ATSB Investigation Number:AO-2010-089

[Photo Source]

ATSB Final Report: July 2008 Qantas Boeing 747 depressurization accident

by B. N. Sullivan

The Australian Transport Safety Bureau (ATSB) has issued a final report on the sudden decompression in flight of a Qantas Boeing 747-400 on July 25, 2008.  The accident happened during the cruise phase of Qantas Flight QF30, which was en route from Hong Kong to Melbourne.  The flight diverted to Ninoy Aquino International Airport, Manila where it landed safely.  There were no serious serious injuries to those on board, however the aircraft's fuselage ruptured over an area measuring approximately 2 x 1.5 m (6.6 x 4.9 ft).

The ATSB investigation determined that the fuselage rupture "had been induced by the forceful bursting of one of a bank of seven oxygen cylinders located along the right side of the cargo hold," i.e.one of the oxygen cylinders that provide the emergency supplementary oxygen supply for passengers.

An analysis of the damage produced by the ruptured cylinder showed that the force of the failure had projected the cylinder vertically upward into the aircraft's cabin, where it had impacted the R2 door frame, handle and the overhead panelling and structure, before presumably falling to the cabin floor and being swept out of the aircraft during the depressurisation. No part of the cylinder body was located within the aircraft, despite a thorough search.

The ATSB investigation "was unable to identify any particular factor or factors that could, with any degree of probability, be associated with the cylinder failure event."

Despite the inconclusive outcome of the investigation as to contributing factors, the associated engineering study did confirm that the cylinder type was fit-for-purpose.  There was no individual or broad characteristic of the cylinders that was felt to be a threat to the safety or airworthiness of the design.  Similarly, there was no aspect of the batch of cylinders produced with the failed item, which deviated from the type specification, or provided any indication of the increased potential for the existence of an injurious flaw or defect within that particular production lot.

In other words, in the opinion of the ATSB investigators, the rupture of the oxygen cylinder on Qantas Flight 30 was "a unique event and highly unlikely to happen again."

Here is the link to the full report: ATSB: Oxygen cylinder failure and depressurisation - 475 km north-west of Manila, Philippines, 25 July 2008, Boeing 747-438, VH-OJK

The report includes a number of photos showing the extent of the damage to the aircraft.


RELATED: Click here to view all posts about Qantas Flt 30 on Aircrew Buzz.

Qantas Boeing 747 uncontained engine failure near San Francisco

by B. N. Sullivan

A Qantas Boeing 747-400 (registration VH-OJP) experienced an uncontained engine failure last night during climbout from San Francisco.  The aircraft's No. 4 engine, a Rolls-Royce RB-211, was badly damaged and was shut down in flight.  After jettisoning fuel, the aircraft returned to San Francisco International Airport, where the crew made a safe emergency landing.  The aircraft was carrying 212 passengers and a crew of 19; no one was injured.

According to news reports, the accident occurred shortly after midnight on August 31, 2010 as Qantas Flight QF 74 was still climbing after departure from San Francisco, en route to Sydney.   (The aircraft  had departed San Francisco at about 23:30L on August 30, 2010.)  The track log on FlightAware.com suggests that the aircraft was climbing through FL250 at the time of the accident. 

Here is the link to the flight track for Qantas Flt QF 74 on FlightAware.com.

I will post updates here on Aircrew Buzz should more information about this event become available.


UPDATE: Australia's ABC News posted this video clip of their news report about the accident on YouTube. The clip shows some mobile phone video of sparks coming from the engine, and still photos of the damaged engine cowling.



If the video does not play or display properly above, click here to view it on YouTube.

Australian Transport Safety Bureau issues interim reports on two Qantas accidents

by B. N. Sullivan

During the past week, the Australian Transport Safety Bureau (ATSB) released interim updates on the investigations of two separate accidents involving aircraft operated by Qantas.

QF 30 depressurization, January 25, 2008

The ATSB issued an interim factual report on the investigation into the depressurization of a Qantas Boeing 747-400 aircraft, registration VH-OJK, on July 25, 2008. That aircraft, operating as Qantas Flight QF30, was en-route from Hong Kong to Melbourne; it diverted to Manila where it made a safe emergency landing. Once on the ground, a large hole in the fuselage was discovered. The ATSB concluded that the failure of an oxygen cylinder damaged the pressure hull and led the depressurization.

The newest report focused on a series of tests carried out on several oxygen cylinders from the same manufacturing lot as the failed cylinder, intended to replicate the failure. The ATSB reports that the "various tests have not been able to replicate the cylinder failure that initiated the accident." The ATSB says:

To date, all pressure tests of the cylinders met or exceeded the relevant safety specifications, with recorded rupture pressures being over twice the maximum working pressure of the cylinders.

The investigation continues, and a final report is expected in early 2010.

Link: Depressurisation – 475 km north-west of Manila, Philippines – 25 July 2008 - Interim Factual No. 2 - 8-page 'PDF' file 

RELATED: Click here to view all posts about Qantas Flt 30 on Aircrew Buzz.

QF 72 in-flight upset, October 7, 2008

The ATSB also issued a second interim factual report on its investigation into an in-flight upset involving a Qantas Airbus A330-303, registration VH-QPA, on October 7, 2008. The aircraft, operating as Qantas Flight QF 72, was en route from Singapore to Perth when it experienced two uncommanded pitch-down events. The flight diverted to Learmonth, Western Australia, where it landed safely.

The new report describes tests carried out in an attempt to discover what caused anomalous behavior of the aircraft's No. 1 Air Data Inertial Reference Unit (ADIRU), which led to the upset. The tests were inconclusive. The ATSB says:

Despite extensive testing and analysis, the reason why the ADIRU started providing erroneous data (spikes) during the 7 October 2008 flight (or the 27 December 2008 flight) has not been identified to date. Nevertheless, the crew operational procedures that were provided by Airbus in October 2008 (and modified in December 2008 and January 2009) significantly reduced the chance of another in-flight upset by limiting the time that a faulty ADIRU could output angle of attack spikes. Airbus is also modifying the FCPC software used in the A330/A340 fleets to prevent angle of attack spikes leading to an in-flight upset.

The ATSB expects to release a final report into this accident in the second quarter of 2010.

Link: In-flight upset 154 km west of Learmonth, WA, 7 October 2008 - 10-page 'PDF' file

RELATED: Click here to view all posts about Qantas Flt 72 on Aircrew Buzz. 

Several injured during Qantas Airbus A330-300 severe turbulence incident

A number of people on a Qantas flight were injured last night during what has been described as severe turbulence. The Airbus A330-300 aircraft, operating as Qantas Flight QF 68, was en route from Hong Kong to Perth. At the time of the incident, which happened about four hours after departure from Hong Kong, the aircraft was in cruise at 38,000 feet over Borneo.

There were 13 crew members and 206 passengers on board Flight QF 68. Following the incident, the aircraft continued on to Perth, where it landed safely.

Qantas has issued a statement about the incident, saying that the injured included six passengers and one cabin crew member. According to the airline, the seven inured were taken to hospitals after the aircraft landed in Perth, and have since been released.

News reports about the incident, quoting passengers, said the aircraft dropped suddenly causing those who were not restrained to be thrown from their seats. Some passengers reportedly hit their heads on overhead compartments with enough force to crack the plastic. News media described back and neck injuries, and indicated that some of the injured were children.

Mr. David Epstein, speaking to the press on behalf of Qantas, said:

"The aircraft most likely encountered what is known as convective turbulence, which led to it rapidly gaining around 800 feet in altitude before returning to its cruising altitude of 38,000 feet.

"This convective turbulence is not normally visible to weather radar. At top of descent into Perth, the Captain explained this to passengers and also referred to the radar being designed to detect moisture but not ice crystals.

"The flight crew responded quickly to this incident in line with procedure and based on their regular simulator training.

"Some media reports have suggested the aircraft was travelling through thunderstorms at the time of the incident. There may have been thunderstorms in the vicinity, but there is nothing to suggest the aircraft was actually flying through any storm activity."

The incident has been reported to the Australian Transport Safety Bureau.

[Photo Source]

Qantas to park 10 aircraft and cut 1,750 jobs

Big news from Australia: Qantas is planning a major capacity reduction, and will downsize its staff, due to a "rapid and significant deterioration of trading conditions in the past few weeks".  Among the 1,750 jobs cut will be 500 management positions.  

An article about the Qantas capacity reduction plans in The Australian quoted the carrier's CEO, Alan Joyce, who said, "We employ over 34,000 people and we are striving to protect as many of their jobs as possible, but the capacity reductions to protect the long-term viability of the overall Qantas Group mean that up to 1,250 equivalent full-time positions will be affected in addition to the management reductions being made."  

The Australian reports that Qantas "would try to use a range of workforce initiatives to manage the downturn such as annual leave, long service leave, attrition, redeployment, leave without pay, promoting part-time work and exploring job-sharing" in order to mitigate the number of redundancies, but that jobs losses "would be inevitable."

The Australian flag carrier plans to reduce passenger capacity by 5% on both domestic and international routes. A reduction in freight capacity is in the works as well.  To that end, Qantas will park 10 aircraft and put them up for sale.  At least one source mentioned that those aircraft would be widebody planes, including Boeing 747s and Boeing 767s.  Qantas also plans to defer deliveries on new aircraft, including four Airbus A380s and a dozen Boeing 737-800s. 

In late 2008, Qantas reduced its worldwide work force by 1,500.  That round of job cuts included the closure of the Jetstar crew base at Adelaide.  No word yet on how many crew jobs will be lost in the current round of cuts.

Tony Sheldon of the Transport Workers Union of Australia said the union would seek urgent meetings with Qantas to discuss the lay‐offs.

"We will be talking to Qantas about how staff can be retained over this period with preference given to the retention of direct‐hire staff. We will also be talking to them about the recall of affected staff as the situation improves," Sheldon said.

Interim report on the July 2008 Qantas B-747 depressurization accident

The Australian Transport Safety Bureau (ATSB) has just released an Interim Factual Report regarding the sudden decompression in flight of a Qantas Boeing 747-400 on July 25, 2008. The accident happened during the cruise phase of Qantas Flight QF30, which was en route from Hong Kong to Melbourne. The flight diverted to Ninoy Aquino International Airport, Manila where it landed safely, with no serious injuries to the 365 people on board.

After the aircraft landed, a large rupture in the fuselage was discovered.  The ATSB's preliminary factual report about the accident, issued in August of 2008,  stated that one of the cylinders that supplied emergency oxygen to the passenger cabin had "sustained a failure that allowed a sudden and complete release of the pressurised contents," and that "damage to the aircraft's fuselage was consistent with being produced by the energy associated with that release of pressure" from the oxygen cylinder.

Today's interim report elaborated on damage to the aircraft and its systems, with many photos to illustrate. The report also provided detailed descriptions of the engineering tests carried out (and still underway) on components of the accident aircraft's emergency oxygen system, and on similar oxygen cylinders and fittings.

Among the points included in this lengthy interim report:

• there was no evidence of an external explosive event or the use of explosive materials around the rupture area
• no significant maintenance difficulties had been experienced with the passenger oxygen system prior to the accident
• no anomalies in samples of the oxygen gas used to fill the cylinders were identified that would have contributed to this event

Regarding survivability issues, the ATSB said in a media release accompanying the report:

The investigation has determined that, despite the damage to the aircraft's passenger oxygen system caused by the oxygen cylinder failure, the system would have continued to operate for approximately 65 minutes following the depressurisation event. Passenger oxygen was only required for about 5 ½ minutes during the period between the depressurisation event and when the aircraft reached an altitude of 10,000 ft.

The ATSB expects to issue a final report on this accident investigation by the end of 2009.

Here is the link to the report: ATSB Transport Safety Report: Aviation Occurrence Investigation AO-2008-053, Interim Factual - 62-page 'pdf' file

[Photo Source]

Related:

• Qantas Flight QF30 -- Sudden decompression in flight - AircrewBuzz.com, July 25, 2008
• ATSB update on Qantas Flight QF30 accident investigation - AircrewBuzz.com, July 28, 2008
• More information released about the Qantas B747 decompression incident - AircrewBuzz.com, July 30, 2008
• Preliminary factual report issued for Qantas Boeing 747 decompression incident - AircrewBuzz.com, Aug. 29, 2008

...or click here to view all posts about Qantas Flt 30 on Aircrew Buzz.

Qantas Flight QF72 In-flight Upset: What happened inside the cabin

The Australian Transport Safety Bureau (ATSB) has issued a preliminary report about an accident last month involving a Qantas A330-300 aircraft in which a number of people were injured. The aircraft, operating as Qantas Flight QF72, was en route from Singapore to Perth, Australia with 10 crew and 303 passengers on board when it experienced two successive in-flight upsets. The aircraft diverted to Learmonth, Western Australia, where it made an emergency landing. One flight attendant and at least 13 passengers were seriously injured and many others experienced less serious injuries, according to the ATSB. Most of the injuries involved passengers who were seated without their seatbelts fastened.

While the newly released report focuses primarily on what happened on the flight deck, and the results of the ATSB's early examination of systems data from the accident aircraft, the report devotes several pages to what happened in the passenger cabin during the emergency, damage to the cabin, and injuries sustained by crew members and passengers.

The upset happened while the aircraft was cruising at 37,000 feet. In describing the sequence of events, the ATSB report notes that at the time the emergency began, the first officer (F/O) had just left the flight deck for a scheduled rest break. The captain and second officer (S/O) were on the flight deck when things began to go awry. The captain asked the S/O to call the F/O back to the flight deck, and while the S/O was on the interphone asking the flight attendant to send the F/O back to the flight deck, "the aircraft abruptly pitched nose-down."

The aircraft descended 650 ft. The crew described the movement as "very abrupt, but smooth. It did not have the characteristics of a typical turbulence-related event and the aircraft’s movement was solely in the pitching plane."

The seatbelt sign was then illuminated and the S/O made a public address for passengers and crew to return to their seats and fasten their seatbelts immediately. A few minutes after the first event, the aircraft commenced a second uncommanded pitch-down event. This time the aircraft descended about 400 ft.

The ATSB report says [pp. 2-4]:

The captain announced to the cabin for passengers and crew to remain seated with seatbelts fastened. The second officer made another call on the cabin interphone to get the first officer back to the flight deck. The first officer returned to the flight deck at 1248. After discussing the situation, the crew decided that they needed to land the aircraft as soon as possible. They were not confident that further pitch-down events would not occur. They were also aware that there had been some injuries in the cabin, but at that stage they were not aware of the extent of the injuries.

[The crew then made an] emergency broadcast to air traffic control, advising that they had experienced ‘flight control computer problems’ and that some people had been injured. They requested a clearance to divert to and track direct to Learmonth, WA. Clearance to divert and commence descent was received from air traffic control.

...The flight crew spoke to a flight attendant by interphone to get further information on the extent of the injuries. The flight crew advised the cabin crew that, due to the nature of the situation, they did not want them to get out of their seats, but to use the cabin interphones to gather the information.

After the cabin crew advised the flight deck of several serious injuries, the crew declared a MAYDAY and made a emergency landing at Learmonth.

Injuries

Quoting again from the ATSB report [p. 5]:

Initial information provided to the Australian Transport Safety Bureau (ATSB) was that 14 people were taken by air ambulance to Perth. Injuries were considered serious, but not life threatening, and included concussion and broken bones. In addition, up to 30 other people attended hospital with possible concussion, minor lacerations and fractures, with up to a further 30 or so people with minor bruises and stiff necks who did not need to attend hospital.

Subsequent information indicates that one flight attendant and at least 13 passengers were admitted to hospital. The nature and extent of the injuries varied considerably, including injuries listed above and spinal injuries.

At the time of the first in-flight upset event, three flight attendants and the first officer were standing in the forward galley and one flight attendant had just left that galley. The first officer and two of the attendants received minor injuries and the other was uninjured. Four of the flight attendants were preparing to leave the crew rest area (four seats located near the Left 3 door), and all received minor injuries. A flight attendant standing in the rear galley received serious injuries.

Information has been obtained from over 10 per cent of the passengers to date. Based on this information, almost all of the passengers who were seated without seatbelts fastened received either serious or minor injuries during the first in-flight upset. Many of these passengers impacted the ceiling panels. Most of the passengers who had their seatbelts fastened were uninjured, although some received minor injuries. Passengers who were standing at the time of the first in-flight upset received either serious or minor injuries.

Damage

There was no structural damage to the aircraft, however the ATSB report had this to say about the passenger cabin [pp. 5-6]:

Inspection of the aircraft interior revealed damage mainly in the centre and rear sections of the passenger cabin. The level of damage varied significantly. Much of the damage was in the area of the personal service units above each passenger seat, and adjacent panels. The damage was typically consistent with that resulting from an impact by a person or object. There was evidence of damage above approximately 10 per cent of the seats in the centre section of the cabin, and above approximately 20 per cent of the seats in the rear section of the cabin. In addition, some ceiling panels above the cabin aisle-ways had evidence of impact damage, and many had been dislodged from their fixed position.

Oxygen masks had deployed from above nine of the seats where there had been damage to overhead personal service units or adjacent panels. Some of the cabin portable oxygen cylinders and some of the aircraft first aid kits had been deployed.

The report includes photos of damage to the ceiling panels above passenger seats, and in the aisle.

Here is the link to the entire document, which is worth reading: AO-2008-070: Preliminary Report - ATSB, Nov. 14, 2008 (43-page 'pdf' file)

RELATED: Click here to view all posts about Qantas Flt QF 72 on Aircrew Buzz.

 

ATSB Preliminary Report on the In-Flight Upset of Qantas Flight QF72 in October

A Preliminary Report has just been released by the Australian Transport Safety Bureau (ATSB) in regard to the in-flight upset of Qantas Flight QF72 on October 7, 2008. Readers will recall that on that date the Airbus A330-300 aircraft was en route from Singapore to Perth, Australia with 10 crew and 303 passengers on board, when it experienced two successive uncommanded pitch-down events. A number of individuals in the passenger cabin were seriously injured. The aircraft diverted to Learmonth, Western Australia, where it made an emergency landing.

About a week after the accident, the ATSB reported that early analysis of the accident aircraft's Flight Data Recorder data, Post Flight Report data and Built-in Test Equipment revealed that an Inertial Reference System fault had occurred within the Number-1 Air Data Inertial Reference Unit (ADIRU 1). Today's report elaborates further on that finding, and also reports on the overall progress of the investigation, which is ongoing.

A summary of important points is contained in a media release issued by the ATSB in conjunction with the publication of the Preliminary Report. Here is a part of that summary:

Examination of flight data recorder information indicates that, at the time the autopilot disconnected, there was a fault in a flight computer system component known as the air data inertial reference unit number 1 (ADIRU 1) which resulted in a number of spurious spikes in ADIRU parameter values. Further spurious parameter spikes continued to influence a number of system failure indications throughout the flight, resulting in frequent failure messages being provided to the crew. The crew completed required actions in response to the messages, but these actions were not effective in removing the spikes or failure indications. The investigation team is continuing to examine the influence of the spikes in ADIRU parameters on the performance of the flight controls.

Most components on modern aircraft, including ADIRUs, are highly reliable and there has only been a small number of occasions where ADIRUs of different types made by varying manufacturers have had some form of failure. It is extremely rare for any such failures to have an effect on an aircrafts flight controls. The ATSB has previously investigated an in-flight upset related to ADIRU failure from a different manufacturer in a Boeing 777 which occurred in 2005 and was traced to a software fault. While a software fault has not been ruled out in the current investigation, it seems unlikely that the two events are linked.

Still ongoing:

• The three ADIRUs will be subject to comprehensive testing at the manufacturer's facilities in the US.
• Review of the ADIRUs' data monitoring capability and management of anomolous ADIRU data, including flight deck indications.
• Review of records of previous occurrences involving ADIRU failures (which did not result in in-flight upsets) and any occurrences where large numbers of spurious messages were generated.
• Subject to the results of the ADIRU testing, examination of other aircraft components may be conducted such as the three flight control primary computers and their software in order to understand why the fault in the ADIRU was able to be translated to flight control movements.

The report goes on to say that, although this is unlikely, possible external sources of electromagnetic interference are being explored and assessed, "including from the Harold E. Holt very low frequency transmitter near Exmouth, WA and from portable electronic devices on board the aircraft."

The investigation of cabin safety issues related to this accident also is still underway. This includes interviews with the cabin crew and seriously injured passengers, and responses to questionnaires "seeking passenger observations during the upset events and asking questions in relation to the use of seatbelts, injuries and the use of personal electronic devices."

The ATSB also noted that a number of important safety actions have already been implemented arising from the investigation to date.

Here is the link to the entire document: AO-2008-070: Preliminary Report - ATSB, Nov. 14, 2008 (43-page 'pdf' file)

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Qantas Airbus A380 inaugural commercial flight arrives at Los Angeles

Aviation history was made today as Qantas became the first airline to operate a commercial passenger flight on the Airbus A380 between Australia and the US West Coast. The new A380 'superjumbo' aircraft, operating as Qantas Flight QF 93 landed on Runway 25L at Los Angeles International Airport (LAX) early this morning, October 20, 2008, after a scheduled flight from Melbourne, Australia. The flight was met at LAX by celebrities and government officials, including actor John Travolta, Australian singer Olivia Newton-John and Los Angeles Mayor Antonio Villaraigosa, among others.

Qantas took delivery of its first A380 (registration number VH-OQA) last month. The aircraft is powered by four Rolls-Royce Trent 900 engines, and is configured with 450 seats in four cabins. On the main deck are 14 first class suites, and 332 economy seats. The upper deck has 72 business class seats, plus 32 premium economy seats.

Today's flight was the Qantas A380's first scheduled passenger service. Later this week, on October 24, 2008, the new aircraft will be used for the first time on the Sydney-Los Angeles route.

[Photo Source]

Systems fault identified in Qantas Flight QF72 in-flight upset accident

The Australian Transport Safety Bureau (ATSB) held another media conference earlier today to provide new details in the progress of its investigation of the Qantas Flight QF72 in-flight upset. In today's media conference, the ATSB described the role a faulty Air Data Inertial Reference Unit played in the accident involving the Airbus A330-300 aircraft.

To review briefly, the accident occurred on October 7, 2008, while Qantas Flight QF72 was en route from Singapore to Perth, Australia with 303 passengers and 10 crew on board. While in cruise at 37,000 ft., the pilots received electronic centralized aircraft monitoring messages in the cockpit relating to some irregularity with the aircraft's elevator control system, and the aircraft departed level flight. According to the ATSB, "the aircraft climbed about 200 feet from its cruising level of 37,000 feet, the aircraft then pitched nose-down and descended about 650 feet in about 20 seconds, before returning to the cruising level. This was closely followed by a further nose-down pitch where the aircraft descended about 400 feet in about 16 seconds before returning once again to the cruising level."

The in-flight upset injured dozens of people in the aircraft's cabin. The crew ultimately declared a MAYDAY and diverted to Learmonth, Australia where they made an emergency landing.

Systems Fault Identified

Today the ATSB update reported a preliminary sequence of events based on further analysis of the accident aircraft's Flight Data Recorder data, Post Flight Report data and Built-in Test Equipment. Quoting from the ATSB's October 14, 2008 statement:

The aircraft was flying at FL 370 or 37, 000 feet with Autopilot and Auto-thrust system engaged, when an Inertial Reference System fault occurred within the Number-1 Air Data Inertial Reference Unit (ADIRU 1), which resulted in the Autopilot automatically disconnecting. From this moment, the crew flew the aircraft manually to the end of the flight, except for a short duration of a few seconds, when the Autopilot was reengaged. However, it is important to note that in fly by wire aircraft such as the Airbus, even when being flown with the Autopilot off, in normal operation, the aircrafts flight control computers will still command control surfaces to protect the aircraft from unsafe conditions such as a stall.

The faulty Air Data Inertial Reference Unit continued to feed erroneous and spike values for various aircraft parameters to the aircrafts Flight Control Primary Computers which led to several consequences including:

• false stall and overspeed warnings
• loss of attitude information on the Captain's Primary Flight Display
• several Electronic Centralised Aircraft Monitoring system warnings.

About 2 minutes after the initial fault, ADIRU 1 generated very high, random and incorrect values for the aircrafts angle of attack.

These very high, random and incorrect values of the angle attack led to:

• the flight control computers commanding a nose-down aircraft movement, which resulted in the aircraft pitching down to a maximum of about 8.5 degrees,
• the triggering of a Flight Control Primary Computer pitch fault.

The crew's timely response led to the recovery of the aircraft trajectory within seconds. During the recovery the maximum altitude loss was 650 ft.

The Digital Flight Data Recorder data show that ADIRU 1 continued to generate random spikes and a second nose-down aircraft movement was encountered later on, but with less significant values in terms of aircraft's trajectory.

At this stage of the investigation, the analysis of available data indicates that the ADIRU 1 abnormal behaviour is likely as the origin of the event.

The ATSB officials went on to say that as far as they can understand, this appears to be a unique event and Airbus has advised that it is not aware of any similar event over the many years of operation of the Airbus.

Action by Airbus

Airbus has issued an Operators Information Telex reflecting the preliminary findings of the ATSB investigation of this accident. The ATSB anticipates that Airbus also will issue Operational Engineering Bulletins and provide "information relating to operational recommendations to operators of A330 and A340 aircraft fitted with the type of ADIRU fitted to the accident aircraft. Those recommended practices are aimed at minimising risk in the unlikely event of a similar occurrence. That includes guidance and checklists for crew response in the event of an Inertial Reference System failure."

ATSB Investigation Continues

The ATSB reported that its investigation is ongoing and will include:

• Download of data from the aircraft's three ADIRUs and detailed examination and analysis of that data. Arrangements are currently being made for the units to be sent to the component manufacturer's facilities in the US as soon as possible and for ATSB investigators to attend and help with that testing, along with representatives from the US National Transportation Safety Board, The French Bureau d'Enquêtes et dAnalyses (BEA) and Airbus.
• In addition, investigators have been conducting a detailed review of the aircraft's maintenance history, including checking on compliance with relevant Airworthiness Directives, although initial indications are that the aircraft met the relevant airworthiness requirements.
• Work is also ongoing to progress interviews, which will include with injured passengers to understand what occurred in the aircraft cabin. The ATSB plans to distribute a survey to all passengers.

The ATSB expects to publish a Preliminary Factual report in about 30 days from the date of the accident.

[Photo Source]

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Qantas Flight QF72 Emergency Landing at Learmonth, Australia

Earlier today, the Australian Transport Safety Bureau (ATSB) held a media conference regarding an in-flight incident on board a Qantas Airbus A330-300 aircraft that caused injuries to dozens of people. The incident occurred yesterday, October 7, 2008, as Qantas Flight QF72 was en route from Singapore to Perth with 303 passengers and 10 crew on board.

Here is what happened, according to the ATSB media statement about Qantas Flight QF72:

The aircraft, which had 303 passengers and 10 crew on board, was in normal level flight at 37,000 ft about 110 nautical miles north of Carnarvon and 80 nautical miles from Learmonth near Exmouth in north-western Australia, when the pilots received electronic centralised aircraft monitoring messages in the cockpit relating to some irregularity with the aircraft's elevator control system.

The aircraft is reported to have departed level flight and climbed approximately 300 ft, during which time the crew had initiated non-normal checklist/response actions. The aircraft is then reported to have abruptly pitched nose-down.

During this sudden and significant nose-down pitch, a number of passengers, cabin crew and loose objects were thrown about the aircraft cabin, primarily in the rear of the aircraft, resulting in a range of injuries to some cabin crew and passengers.

The crew made a PAN PAN emergency broadcast to air traffic control, advising that they had experienced flight control computer problems and that some people had been injured, and they requested a clearance to divert to and track direct to Learmonth.

A few minutes later the crew declared a MAYDAY and advised ATC of multiple injures including broken bones and lacerations. The aircraft landed at about 1530 local time, about 40 minutes after the start of the event.

The ATSB understand that there were 14 people with serious but not life threatening injuries, which included concussion and broken bones who were taken by air ambulance to Perth. In addition, up to 30 other people attended hospital with possible concussion, minor lacerations and fractures, with up to a further 30 or so people with minor bruises and stiff necks etc who did not need to attend hospital. However, these casualty figures are subject to further clarification and confirmation.

All passengers have been now been transported to Perth. Given the nature of injuries, the occurrence is defined as an accident in accordance with the International Civil Aviation Organization definition.

The aircraft's Flight Data Recorder and Cockpit Voice Recorder have been retrieved by investigators and sent to Canberra for examination. In addition, ATSB is carrying out an on-site investigation at Learmonth, where the aircraft remains.

Qantas also issued a statement today with similar information. The Chief Executive Officer of Qantas, Geoff Dixon, also said, "We commend the professionalism of our crew, who ensured the aircraft landed safely in Learmonth."

UPDATE Oct. 9, 2008: The ATSB has issued an update on the Qantas Flight QF72 accident. Today's ATSB media release says, in part:

The aircraft's Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) arrived in Canberra late on Wednesday evening. Downloading and preliminary analysis overnight has revealed good data from both recorders. Data from the FDR has been provided to Qantas, the French Bureau d'Enquêtes et d'Analyses (BEA) and Airbus as parties to the investigation.

While the full interpretation and analysis of the recorded data will take some time, preliminary review of the data indicates that after the aircraft climbed about 200 feet from its cruising level of 37,000 feet, the aircraft then pitched nose-down and descended about 650 feet in about 20 seconds, before returning to the cruising level. This was closely followed by a further nose-down pitch where the aircraft descended about 400 feet in about 16 seconds before returning once again to the cruising level. Detailed review and analysis of FDR data is ongoing to assist in identifying the reasons for the events.

Click here to view the Oct. 9 ATSB media release.

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Dozens injured in Qantas Airbus A330 'sudden in-flight upset'

Dozens of people were injured earlier today, October 7, 2008, when a Qantas A330-300 aircraft experienced what the Australian Transport Safety Bureau (ATSB) referred to as a sudden in-flight upset. Qantas described the event as a sudden change of altitude. According to the ATSB, the crew declared a MAYDAY and diverted to Learmonth, near Exmouth, in Western Australia, where they made an emergency landing at about 13:45 local time.

The aircraft (registration VH-QPA), operating as Qantas Flight QF72, was cruising in level flight en route from Singapore to Perth with 303 passengers and 10 crew on board at the time of the incident. An ATSB media release said that the event resulted in injuries to a number of cabin crew and passengers, primarily in the rear of the aircraft. The ATSB said: "Early reports indicate that three cabin crew and approximately 30 passengers sustained injuries, including about 15 with serious injuries, namely broken bones and lacerations."

The injured were taken to Exmouth Hospital for treatment. Several news media reports said that some of the more seriously injured were later flown to Royal Perth Hospital by the Royal Flying Doctor Service.

Qantas sent two aircraft -- a Boeing 767 and a Boeing 717 -- to Learmonth from Perth to collect passengers and crew.

Best wishes for a speedy and full recovery to all those who were injured.

UPDATE Oct. 8, 2008: Both the Qantas and the Australian Transport Safety Bureau (ATSB) issued statements today with a few more details about the events on Qantas Flight QF72, which the ATSB has now officially classified as an accident: ATSB statement; Qantas statement.

Qantas takes delivery of its first Airbus A380

In a ceremony at the Airbus facility in Toulouse, France, on September 19, 2008, Australian airline Qantas took delivery of its first Airbus A380 'superjumbo' aircraft. The new aircraft (registration number VH-OQA) will become the Qantas flagship.

The new Qantas double-decker A380, which is powered by Rolls-Royce Trent 900 engines, is configured with 450 seats. On the main deck are 14 first class suites, and 332 economy seats. The upper deck has 72 business class seats, plus 32 premium economy seats.

According to Qantas, features of the new A380 include:

• 14 single private suites in First Class featuring a 17 inch LCD wide screen video monitor, a unique touch screen control unit, and a seat (manufactured by B/E Aerospaces's VIP jet group) that swivels into a comfortable armchair and a fully flat, extra long and wide bed
• the next generation of Qantas' award-winning sleeper seat Skybed in Business Class, which now offers an extra long and fully flat bed with ergonomically enhanced cushioning, a larger in-arm entertainment screen, additional storage options and more privacy
• a private lounge area in the upper deck Business Class cabin featuring leather sofas, a self-service bar, large video monitor with laptop connectivity and a feature display cabinet
• Premium Economy seats by Recaro, with fully adjustable, in-arm, digital wide screen television monitors, and a self service bar dedicated to the upper deck Premium Economy cabin
• Recaro seats in Economy Class featuring a sliding base that moves with the seat back to create a more comfortable, ergonomically tested position to aid sleep and eliminate pressure points and a foot net to stop sliding during sleep
• four self-service bars in Economy Class
• state-of-the-art Panasonic inflight entertainment system with more than 100 on demand movies, 350 television selections, 500 audio CDs, 30 PC style games, and a selection of audio books, language tutorials, destination information, business education and radio channels
• in-seat laptop power and connectivity in every class allowing passengers to send and receive emails directly from their personal webmail and hotmail accounts via laptop or seat monitor

The first Qantas A380, named after Australian pioneer aviatrix Nancy-Bird Walton, aged 92, was scheduled to depart Toulouse at 23:55 and operate via Singapore to touch down in Sydney at 09:00 (AEST) on Sunday, September 21, 2008.

Nancy-Bird Walton will attend the official naming ceremony for the aircraft in Sydney on 30 September.

The new Qantas A380 will enter commercial service in October with an inaugural flight to Los Angeles.

In a Qantas news release about the delivery of the aircraft, the airline's Chief Executive Officer, Mr. Geoff Dixon, said the A380 symbolized a new era of travel for Qantas.

"No other airline has flown as far as Qantas for as long as Qantas, so we know very well the value of a well designed inflight product for long haul flights," said Dixon. "The A380, with its extra space, new materials and advanced technology, has given us the ideal platform to reinvent the inflight experience."

Qantas is the third airline to take delivery of an A380 for commercial passenger service. Singapore Airlines flew the first commercial A380 flight last October. In July of this year, Dubai-based Emirates Airline took delivery of its first A380, which made its inaugural flight on August 1.

[Photo Source]

Preliminary factual report issued for Qantas Boeing 747 depressurization incident

The Australian Transport Safety Bureau (ATSB) has issued a preliminary factual report regarding the in-flight decompression of a Qantas Boeing 747-400 last month. Readers will recall that on July 25, 2008, Qantas Flight QF30 experienced a rapid decompression while en route from Hong Kong to Melbourne. The aircraft (registration number VH-OJK) diverted to Manila, where it made a safe emergency landing. Once on the ground, a large hole in the fuselage was discovered. No one among the passengers and crew on board the flight were injured.

The preliminary factual report issued today by the ATSB reviews the course of events on Flight QF30 and confirms that "the fuselage rupture was aligned with the nominal position of the number-4 passenger emergency oxygen cylinder" in the aircraft's forward cargo hold, and that the oxygen cylinder - one of seven in the bank of cylinders that provided emergency oxygen to the passenger cabin - was missing.

Today's report made clear that one oxygen cylinder had ruptured, and was believed to have caused the breach in the aircraft's pressure hull. How or why the cylinder ruptured has not yet been determined.

The ATSB media release accompanying the report says:

On the basis of the physical damage to the aircraft's forward cargo hold and cabin, it was evident that the number-4 passenger oxygen cylinder sustained a failure that allowed a sudden and complete release of the pressurised contents. The rupture and damage to the aircraft's fuselage was consistent with being produced by the energy associated with that release of pressure. Furthermore, it was evident that as a result of the cylinder failure, the vessel was propelled upward, through the cabin floor and into the cabin space. Damage and impact witness marks found on the structure and fittings around the R2 cabin door showed the trajectory of the cylinder after the failure.

The report includes a number of graphics that illustrate the likely trajectory of the cylinder, based on the observed damage (links below).

The ATSB media release goes on to say:

The investigation to date has also identified other damage to the aircraft, including severing and damage to numerous electrical cables and cable bundles, routed through the lower aircraft fuselage near the point of rupture. In addition, both right side (first officer's) aileron control cables, routed along the right side of the fuselage above the passenger oxygen cylinders, were fractured during the rupture event. However, the aircraft control systems have a redundancy arrangement whereby the first officer's aileron control cables are duplicated by the captain's system, the cables from which were routed along the opposite (left) side of the forward cargo hold. Interlinks between the aileron systems provided the necessary redundancy in this instance, ensuring the continued safety of flight after the event.

Another aspect of the investigation entails cabin safety issues, especially the status of the passenger oxygen masks and equipment. The investigation found that 476 passenger oxygen masks had deployed, and 426 of those had been activated. (Days after the incident, the ATSB had reported that "In all, 484 masks had deployed. Of those, 418 had been activated by pulling on the mask to activate the flow of oxygen.") Of note, the report says that forward crew rest and customer support manager station masks had not deployed.

The investigation is ongoing. Still underway are an engineering investigation into the apparent oxygen cylinder failure; examination of cockpit voice recorder, flight data recorder and quick access recorder information; and a survey of all passengers on the flight.

Links to information released today by the ATSB:

• Depressurisation, 475 km north-west of Manila, Philippines, 25 July 2008, Boeing Company 747-438, VH-OJK - Media Release 2008/33, Aug. 29, 2008
• ATSB Transport Safety Report: Aviation Occurrence Investigation AO-2008-053, Preliminary - Aug. 29, 2008 (38-page 'pdf' file)
• Slides used in the media conference - Aug. 29, 2008 (11-page 'pdf' file)
• Audio of the ATSB Media Conference - Aug. 29, 2008 (28MB)

Previous articles on Aircrew Buzz about this incident and the investigation:

• Qantas Flight QF30 -- Sudden decompression in flight - July 25, 2008
• ATSB update on Qantas Flight QF30 accident investigation - July 28, 2008
• More information released about the Qantas B747 decompression incident - July 30, 2008

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More information released about the Qantas B747 decompression incident

The Australian Transport Safety Bureau (ATSB) has released new information regarding their investigation into the recent Qantas Boeing 747-400 depressurization accident. Readers will recall that the aircraft, operating as Qantas Flight QF30, experienced a rapid depressurization at 29,000 feet while en route from Hong Kong to Melbourne on July 25, 2008. The aircraft diverted to Manila where it made a safe emergency landing. No injuries were reported, however the aircraft was found to have a large hole in its fuselage.

First the good news. Today's ATSB news release stated that, "From the evidence gathered to date it appears that the flight crew have responded to and managed the emergency situation extremely well. It is apparent that they followed the procedures they have trained for in simulators, which ensured the best possible outcome for the aircraft, the passengers and crew."

Earlier this week the ATSB reported on the initial inspection of the damaged aircraft, noting (among other things) that one oxygen cylinder, which had been located near the site of the hull breach, was missing. Today the ATSB confirmed that pieces of the missing oxygen cylinder were found in the passenger cabin.

The ATSB can confirm that it appears that part of an oxygen cylinder and valve entered the passenger cabin and impacted the number 2 right door frame handle, thereby moving the handle part way towards the open position. However, the door handle mechanism has been sheared as it is designed to do if an attempt is made to open the door in flight, so the position of the door handle is not representative of the position of the door lock mechanism or the security of the door.

Thus, there seems to be little doubt that the oxygen cylinder exploded inside the cargo bay. The question is, how and why did that happen? And did the exploding oxygen cylinder cause the hull breach and subsequent depressurization, or was it incidental to another causal event?

Here is a rundown of other important points made public today by the ATSB:

• Descent rate - Initial analysis of data from the Flight Data Recorder showed that that immediately following the decompression event at 29,000 feet, the aircraft descended to an altitude of 10,000 feet. The emergency descent took about five and a half minutes, with an average descent rate of about 4,000 fpm.
• ILS - The ATSB confirmed that the aircraft's three Instrument Landing Systems (ILS) and the anti-skid system were not available for the arrival and landing at Manila. However, evidence to date indicates that all of the aircraft's main systems, including engines and hydraulics were functioning normally
• Cabin Oxygen Masks - The team found that most of the oxygen masks had deployed correctly from the passenger modules and had been pulled to activate the flow of oxygen to the mask. In all, 484 masks had deployed. Of those, 418 had been activated by pulling on the mask to activate the flow of oxygen. Only a small number of masks appeared to have had the elastic retaining strap adjusted by the passengers. It also appears that a small number of masks did not deploy from the passenger modules.

Also relevant to the oxygen issue, the ATSB says they are in the process of establishing whether or not "the flow of oxygen was adequate for the five and a half minute descent to 10,000 feet, where the masks were no longer required." Some news reports had mentioned some passenger complaints about malfunctioning masks or sub-optimal oxygen flow.

The ATSB expects to issue a preliminary factual report about this accident within the next 30 days.

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ATSB update on Qantas Flight QF30 accident investigation

As often happens following a widely publicized aircraft accident or safety incident involving a major international carrier, there are a lot of rumors and speculation surrounding the July 25, 2008 depressurization in flight of Qantas Flight QF30. With this in mind, I thought it would be useful to post some official (though preliminary) information released today by the Australian Transport Safety Bureau (ATSB), the agency leading the investigation regarding this event.

Here is the text of today's ATSB Media Release:

The ATSB was advised on Friday 25 July of a serious occurrence involving a Qantas aircraft.

The aircraft, a Boeing 747-400 was operating a scheduled passenger service from Hong Kong to Melbourne Australia. At approximately 29,000 feet, the crew were forced to conduct an emergency descent after a section of the fuselage separated and resulted in a rapid decompression of the cabin. The crew descended the aircraft to 10,000 feet in accordance with established procedures and diverted the aircraft to Manila where a safe landing was carried out. The aircraft taxied to the terminal unassisted, where the passengers and crew disembarked. There were no reported injuries.

The ATSB is leading this safety investigation with the assistance of a number of other organisations and agencies, including the Civil Aviation Authority of the Philippines, The National Transportation Safety Board and the Federal Aviation Administration of the USA, the Civil Aviation Safety Authority of Australia and Qantas and Boeing.

The ongoing investigation has confirmed that there is one unaccounted for oxygen cylinder from the bank of cylinders that are located in the area of the breech. There are 13 oxygen cylinders in the bank that are responsible for supplying oxygen to the passenger masks and cabin crew.

Also recovered are a number of parts of components including part of a valve in the vicinity of the breech. However, it is yet to be determined whether these components are part of the aircraft system.

A number of passengers have reported that some of the oxygen masks appeared not to function correctly when they deployed from the overhead modules. The ATSB intends to examine the oxygen system including the oxygen masks.

The ATSB is also intending to interview the aircraft crew including the cabin crew and make contact with all passengers on the flight. All passengers will be surveyed, while those that had reported problems with mask deployment will be interviewed.

The passenger survey should be available in about two weeks.

The ATSB would like to request that any passengers that experienced issues during the flight, or those who photographed or videoed the incident contacts us via email at atsbinfo@atsb.gov.au.

The ATSB would also like to encourage passengers to write down their recollection of events that occurred. This will aid them with the completion of the passenger survey.

The aircraft flight data recorder and the cockpit voice recorder have arrived in Australia. The ATSB will download the recorders at its Canberra facilities over the next few days.

The ATSB will also be examining maintenance records for the aircraft. This will include any airworthiness directives or alert bulletins that may have been issued by the regulators or the manufacturers.

Additional factual information about Qantas Flight QF30 and the investigation into the cause of the accident will be posted here on Aircrew Buzz as it becomes available.

UPDATE July 29, 2008: Today the ATSB released another statement, indicating that the accident aircraft had been moved to a hangar, and that the "remainder of the freight on the aircraft has been progressively examined and removed from around the area of the rupture."

The team has removed the outer panels around the ruptured area and they are examining the interior of the cabin including the onboard oxygen system, the passenger masks and portable crew oxygen cylinders.

The aircraft's flight data recorder (FDR) and cockpit voice recorder (CVR) have been removed and sent to Canberra for analysis. The two hour CVR recording was found to commence after the descent and diversion into Manila. The FDR, which nominally records 25 hours of data, is being downloaded at the ATSB facilities. Interviews with both flight crew and cabin crew are being conducted today in Melbourne.

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Qantas Flight QF30 -- Sudden decompression in flight

A Qantas Boeing 747-400 made an emergency landing at Manila today, July 25, 2008, after experiencing a sudden decompression in flight. Qantas Flight QF30 had been en route from Hong Kong to Melbourne. A Qantas press release about the incident said that "all 346 passengers and 19 crew disembarked normally and there were no reports of any injuries to passengers or crew."

The aircraft was said to be at an altitude of about 29,000 ft when the crew reportedly heard a loud bang, followed by a rapid depressurization of the cabin. Oxygen masks deployed in the passenger cabin, and various news reports quoted passengers who said a "wind" passed through the cabin carrying with it loose papers and bits of debris. The crew immediately executed an emergency descent to 10,000 ft and diverted to Manila where the aircraft landed safely at about 11:15 AM local time.

Upon landing, a large hole in the fuselage was discovered, just forward of the starboard wing. The U.S. National Transportation Safety Board (NTSB), which is sending a team to assist with the accident investigation, said in an advisory that the aircraft has a 5 foot hole in the cargo area forward of the right wing leading edge and there is also some wing damage.

News photos taken of the aircraft after it was parked on the ramp at Manila, such as this one from Reuters, show that a panel of the fairing between the wing and the body had separated, revealing substantial structural damage inside. A piece of the aircraft's pressure hull is missing, as well as sections of the fuselage frame. What appears to be baggage or cargo is visible through the gaping hole. In all, not a very pretty sight!

The accident investigation team will include representatives of the Australian Transportation Safety Bureau (ATSB); Qantas Airways; the U.S. NTSB and Federal Aviation Administration (FAA); Boeing; and possibly others.

In a second Qantas press release, the airline's CEO, Geoff Dixon, praised the pilots and cabin crew for the way they handled the incident. I would like to join in extending congratulations to the entire crew of Flight QF30 for a job well done.

[Photo Source]

Related:

• ATSB update on Qantas Flight QF30 accident investigation - AircrewBuzz.com, July 28, 2008
• More information released about the Qantas B747 decompression incident - AircrewBuzz.com, July 30, 2008