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]

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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]

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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]

Horizon Air pilots approve new five-year contract

by B. N. Sullivan

The pilots at Horizon Air have approved a new five-year collective bargaining agreement.  Their union, the International Brotherhood of Teamsters APA Local 1224, announced today that the tentative agreement  reached in September of this year  was ratified by the membership.  Ballots were tallied yesterday and the vote passed the membership by 60 percent, according to the union.

A press statement by Teamsters Local 1224 offered these details:

The new contract includes dramatic improvements in work conditions where the pilots will be writing their own schedules and trips.  Also, a progressive scheduling process was agreed to whereby pilots can trade and manage their schedules among each other to accommodate their personal wishes, with improved pay protections for Horizon pilots.  Significant ratification bonuses also were included in the agreement.  The pay rates will be submitted in two separate 'baseball style' arbitrations; a method agreed upon to avoid an impasse on the subject.

Most notable of these is, perhaps, the scheduling improvements in this agreement which demonstrate that Horizon has entrusted the pilot group to build safe, cost-efficient schedules.

"We look forward to implementing this new contract, especially the scheduling portion," says Captain Trevor Bulger. "The scheduling section in and of itself is a major industry improvement in that our pilots now have the ability to essentially build their own schedules. We envision this will provide for a vast improvement in our quality of life."

The new agreement was reached following more than four years of negotiations, and months of federal mediation.

American Airlines Boeing 737-800 runway excursion at Montréal

by B. N. Sullivan

On Tuesday evening, November 30, 2010, an American Airlines Boeing 737-800 aircraft went off the runway at Montréal-Trudeau Airport.  The aircraft, operating as American Airlines Flight AA802, had just arrived at Montréal after a scheduled passenger flight from Dallas-Fort Worth.  No one was injured.

WFAA-TV quoted an American Airlines spokesman, who said that after landing, the plane went off the runway into the grass.  He said only the nose wheel tires went off the runway into the grass and mud.

The American Airlines spokesman said there were six crew members and 105 passengers on board.  They deplaned using stairs.

It was raining at Montréal at the time of the incident.

UPDATE Dec 2, 2010:  The Aviation Herald, quoting NAV Canada, reports that "the airplane exited the runway at a speed of about 70 knots and came to a stop between taxiways E and B2 with all gear off the southern edge of the paved surface. At the time of occurrence there was heavy rain and winds from the south at 15 knots gusting 20 knots."

The incident aircraft's registration number is N901AN.

Ilyushin IL-76 freighter crash at Karachi

by B. N. Sullivan

An Ilyushin IL-76 freighter has crashed shortly after takeoff from Karachi, Pakistan.   The aircraft, operating as Sun Way  flight MGC-4412, had just departed Karachi, bound for Khartoum, Sudan.  It crashed into a residential area and burned. Local authorities say that there were no survivors among the eight crew members on board.  Fatalities and injuries on the ground also have been reported, although the number of casualties has not been determined.

The accident happened just before 02:00 AM local time, on November 28, 2010.  Eyewitness reports suggest an engine may have been on fire prior to the crash, and that the aircraft may have been attempting to return to the airport.   The engine fire has not been confirmed by official sources.

Geo News reports that the accident site is "near Dalmia area in Gulistan-e-Johar locality."  News media say that the aircraft crashed into a building that was under construction, near residential apartments housing Pakistani Navy officers.  The crash sparked what has been described as a massive blaze.

A dramatic photo of the crash site has been posted to the MSNBC.com Photo Blog.  Geo TV aired live streaming video of the burning accident site, some of which was also broadcast by CNN.  RTVCHD posted this video on YouTube:



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

Strike ballot scheduled for Evergreen International Airlines crews

by B. N. Sullivan

Frustrated after six years of contract negotiations, the pilots and flight engineers at Evergreen International Airlines (EIA) have scheduled a strike authorization ballot, to begin on December 1, 2010.  Their union, the Air line Pilots Association (ALPA), says that they are conducting a strike ballot of the membership "to be prepared for all possible contingencies should negotiations fail."

This past April, ALPA reached a tentative contract agreement (TA) with management, but it was voted down by the crews in August.  At that time, ALPA reported that 92% of eligible Evergreen crew members participated in the ratification balloting, and 96% of those voted against accepting the TA.

According to ALPA, Evergreen crew members overwhelmingly turned down the TA in August because it fell substantially short of their goals.

The failed agreement was largely a renewal of the current collective bargaining agreement, which has been in place since 1999.  The crew members concluded that the tentative agreement was not acceptable after more than 10 years without improvements in some areas of working conditions, six years without a pay raise, and no per diem increase since the late ’90s.  After months of waiting to come back to the negotiating table since the crew members voted down a tentative agreement in August, the MEC is taking the necessary measures to secure a fair contract, including sending the ballot to authorize a strike.  The strike ballot will open on December 1 and close January 7.  If it passes, it would authorize the EIA MEC to declare a strike once the pilot group is given permission to do so by the National Mediation Board (NMB).

William Fink, MEC chairman of the Evergreen ALPA unit, said, “We certainly want a contract, not a strike.  That has been our goal since day one more than six years ago — but the new agreement must provide our members with industry-standard wages, work rules, and benefits.  We deserve no less.  This strike authorization vote will give us the means to take all legal actions to attain the goal of a fair contract.”

The union can ask the U.S. National Mediation Board (NMB) for arbitration at any time.  If the NMB issues a proffer of arbitration, either party can reject it.  Should that happen, a 30-day cooling-off period would begin, after which the Evergreen crews would be legally free to call the first-ever pilot strike against the carrier.

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.


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