safety at qantas

[ComeFlyWithMe]

Let Farmer think what he likes.

I personally have the utmost faith in QF safety, and they have a track record to prove it. I don't think QF will miss one farmer's custom. Perhaps he should try Garuda?

 

[anat0l]

Do CEO's know exactly everything that happens within their company? I seriously doubt that. Would the head of QF maintenance know? - yes, that's his job.

Perhaps the problem with this statement is vicarious liability.

If something really does go wrong, especially with respect to safety, ultimately the CEO will bear the responsibility (or a substantial part of it). What the company does internally after the public blame game and resolution is entirely up to them (e.g. dismiss the person who "was really responsible", for whatever that means).

Certainly in the mining industry, a serious incident bites everyone in the chain of command hard and equally. The onus is on every affected person to prove beyond reasonable doubt that they have upheld their obligations of what they should, could and would have done to prevent the accident (in other words, completely - in a legal and logical sense - discharge that they could've not, under any other circumstances, possibly prevented the incident from occurring). Not sure if similar holds for other industries.

 

[simongr]

Perhaps the problem with this statement is vicarious liability.

If something really does go wrong, especially with respect to safety, ultimately the CEO will bear the responsibility (or a substantial part of it). What the company does internally after the public blame game and resolution is entirely up to them (e.g. dismiss the person who "was really responsible", for whatever that means).

Dont forget that all Board members could be liable as well and the CEO would only be liable if on the Board (i.e. is actually a director - there are circumstances where the CEO isnt a Board member - very very rarely).

 

[medhead]

I have an absolute duty of care to ensure subcontractors perfrom their work in a safe manner in accordance with defined safe work methods that are documented and audited continually. This includes maintenance of equipment.Under NSW law there is a reverse onus of proof.

Does not Qantas have the same duty of care to directly supervise its subcontractors particularly those working on the aircraft it operates?

it seems to me that you missing a very important point in what you wrote. It is a duty of care to provide a safe workplace. It does not specify how you have to meet the duty, it does not say you have to directly supervise. As you note safe work methods have to be documented. I would guess that RR probably have a number of ISO certifications including for safety. Simply having those safety certifications would be enough to prove that a safe workplace has been provided.

I'm also not sure how providing a safe workplace is even that relevant for pax. Definitely for the crew. (But that is a totally different discussion). In any case, qantas would have a whole range of documented things about how they safely operate an aircraft and part of that would be that an ISO accredited company uses licensed engineers to maintain our engines. (or whatever the correct technical terms are)

 

[TonyHancock]

it seems to me that you missing a very important point in what you wrote. It is a duty of care to provide a safe workplace. It does not specify how you have to meet the duty, it does not say you have to directly supervise. As you note safe work methods have to be documented. I would guess that RR probably have a number of ISO certifications including for safety. Simply having those safety certifications would be enough to prove that a safe workplace has been provided.

Unfortunately having certification is not enough to prove a safe workplace exists. The certification is the result of demonstrating that documented processes are adhered to and is certainly recommended.

Most accidents occur when processes are not followed correctly and unfortunately if a management culture exists that does not enforce safety procedures and policies it is the board of directors who will be held accountable.

The board is reliant upon it's managers to enforce the code of practices it operates. In a big organisation like Qantas you would want to be certain that this is happening before taking a place on the board. There is a risk associated with being a director and even more so with being the CEO.

My personal view is that Qantas is a safe airline to fly with, with a track record of doing the right thing.

 

[medhead]

Unfortunately having certification is not enough to prove a safe workplace exists. The certification is the result of demonstrating that documented processes are adhered to and is certainly recommended.

Most accidents occur when processes are not followed correctly and unfortunately if a management culture exists that does not enforce safety procedures and policies it is the board of directors who will be held accountable.

The board is reliant upon it's managers to enforce the code of practices it operates. In a big organisation like Qantas you would want to be certain that this is happening before taking a place on the board. There is a risk associated with being a director and even more so with being the CEO.

My personal view is that Qantas is a safe airline to fly with, with a track record of doing the right thing.

Umm your first paragraph contradicts the rest. Certification proves that process are documented and followed. The board/ CEO have to demonstrate that they have taken all steps required to create a safe workplace. If they can show by certification that documented processes are adhered but an accident happens because someone doesn't follow the documented process then the CEO has an out right there, the blame drops to a lower level.

Of course, as you say there could be cultural issues in the workplace and then the blame is going to go back up again. But a safety certification is important to show that the top level have created a safe workplace. The next step is to enforce, by example or otherwise, the require workplace culture. But if someone bypasses the rules and these things have been done then the blame is going to go downhill.

I'm not denying there are risks for people in these positions. But they can not be expected to be there 24/7 watching these things. That is why there are standards and certifications. Further in the case of a sub contractor (which is what my comments were about) the certification is even more important. The board must rely on that certification, RR are not going to let the qantas board in house to oversee their safety systems etc. Instead they prove their standards by being ISO accredited. If these standards didn't constitute proof for the board then every accident would see the CEO and board dragged before the courts.

 

[Smackbum]

Let Farmer think what he likes.

I personally have the utmost faith in QF safety, and they have a track record to prove it. I don't think QF will miss one farmer's custom. Perhaps he should try Garuda?

This debate just gets more and more eloquent, doesn't it?

I am glad you have the utmost faith in an airline that came within a bee's smith of losing a plane full of similarly confident people. Your reward will be in heaven, or whatever other fantasy world you believe in....

Some of us don't wish to be there quite so soon and would like Qantas to review its maintenance arrangements. I know it is easy to be wise after the event and so undue criticism of past decisions would be harsh (unless you are a Qantas engineer who lost their job), but I am confident that this will be done in light of recent events. Best to shut the gate before the horse bolts, wouldn't you think?

 

[nlagalle]

I am glad you have the utmost faith in an airline that came within a bee's smith of losing a plane full of similarly confident people. Your reward will be in heaven, or whatever other fantasy world you believe in....

Some of us don't wish to be there quite so soon and would like Qantas to review its maintenance arrangements. I know it is easy to be wise after the event and so undue criticism of past decisions would be harsh (unless you are a Qantas engineer who lost their job), but I am confident that this will be done in light of recent events. Best to shut the gate before the horse bolts, wouldn't you think?

But again, is there any direct evidence that the QF32 incident had anything to do with maintenance? No.

Do you know what their maintenance arrangements are?

 

[farmer]

But again, is there any direct evidence that the QF32 incident had anything to do with maintenance? No.

Do you know what their maintenance arrangements are?

This is truly ridiculous. Any maintenance regime or operational arrangement that fails to find a flaw in an engine that came with in a whisker of bringing a near new aircaraft down with a very large loss of life, is prima facie "not working". This is unless you are in the Tony Abott school of maintainenace and aircraft manangement i.e *****happens and it will occassionally lead to a large loss of life.

After the accident the CEO of Qantas admitted they were :

1. Not aware of the fault identified in the ATSB report and perhaps RR were not. Ie. This was an accident waiting to happen and probably occurred first on a Qantas plane becuase of the higher takeoff thrust settings used on the Pacific routes. The fault had probably not been previously detected in the maintenance or inspection programme undertaken by RR.

2.Qantas were not aware that other modifications to its engines needed to be undertaken by RR that they were not advised of by RR nor were they aware later builds of the engine had already been modified. Whether these modifications related to the accident is irrelvant. It demonstrates a huge gap in knowledge and communication between the oeprator of the aircraft and the party reponsible for its maintenance.

Please dont tell me this is a satisfactory maintenance and operating regime for any airline , let alone Qantas with its proud record.


farmer

 

[simongr]

This is unless you are in the Tony Abott school of maintainenace and aircraft manangement i.e *****happens and it will occassionally lead to a large loss of life.

And by using similar journalistic techniques as Mark Riley you lost any credibility you had.

I will leave other more qualified people to explain to you about the difference between a design fault and a failure in maintenance.

 

[nlagalle]

This is truly ridiculous. Any maintenance regime or operational arrangement that fails to find a flaw in an engine that came with in a whisker of bringing a near new aircaraft down with a very large loss of life, is prima facie "not working". This is unless you are in the Tony Abott school of maintainenace and aircraft manangement i.e *****happens and it will occassionally lead to a large loss of life.

Farmer please tell me how any engineer would find such a fault? do you even know the part that failed? do you know it didn't have anything to do with the AD that was issued a few months prior that's been mentioned? If it was due to poor maintenance don't you think the engineers union would be jumping up and down? They aren't because they know it was virtually undetectable. please tell me how an engineer is supposed to discover a bore hole was mis-aligned when being made?

I seriously suggest you read up on some past aviation incidents/accidents and see that even with strict maintenance regimes, there are scenarios that won't be accommodated for.

After the accident the CEO of Qantas admitted they were :

1. Not aware of the fault identified in the ATSB report and perhaps RR were not. Ie. This was an accident waiting to happen and probably occurred first on a Qantas plane becuase of the higher takeoff thrust settings used on the Pacific routes. The fault had probably not been previously detected in the maintenance or inspection programme undertaken by RR.

2.Qantas were not aware that other modifications to its engines needed to be undertaken by RR that they were not advised of by RR nor were they aware later builds of the engine had already been modified. Whether these modifications related to the accident is irrelvant. It demonstrates a huge gap in knowledge and communication between the oeprator of the aircraft and the party reponsible for its maintenance.

Please dont tell me this is a satisfactory maintenance and operating regime for any airline , let alone Qantas with its proud record.


farmer

And of course the fault hadn't been detected. Not probably farmer, hadn't been. If it was there would have been an AD released and engines fixed then.

Got the link to the AD that states there were modifications required to the engines they were running? I'm yet to read it. And why a newer engines (which are of course by nature going to have modifications) irrelevant??

I'll give you another scenario. QF buys the engines off RR. They own them and service them. RR releases version B of their engine. You can't modify version A easily so have to buy Version B if you want the "new" engine. So QF either sticks with version A or stumps up and has to buy new engines? Are they less safe with version A? Just because there is a newer engine out, doesn't mean there is anything wrong with Version A does there?

Do you update the engine in your car whenever Holden/ford/Toyota etc brings out an updated engine?

 

[farmer]

And by using similar journalistic techniques as Mark Riley you lost any credibility you had.

I will leave other more qualified people to explain to you about the difference between a design fault and a failure in maintenance.

Should not a fault of this magnitude have either been detected in the testing of the engine prior to certification for passenger flight or in the regular inspection and maintenance programme undertaken by RR?

It appears to be a manufcturing fault which should have been detected. Either way Qantas was in the dark!!

 

[simongr]

This is truly ridiculous. Any maintenance regime or operational arrangement that fails to find a flaw in an engine that came with in a whisker of bringing a near new aircaraft down with a very large loss of life, is prima facie "not working". This is unless you are in the Tony Abott school

Should not a fault of this magnitude have either been detected in the testing of the engine prior to certification for passenger flight or in the regular inspection and maintenance programme undertaken by RR?

It appears to be a manufcturing fault which should have been detected. Either way Qantas was in the dark!!

Pick one - either it was a maintenance problem or a manufacturing problem.

 

[farmer]

Pick one - either it was a maintenance problem or a manufacturing problem.

It appears to be a manufaturing fault by RR that was not detected by RR's regular inspections or maintenance programmes. This is the purpose of these inspections particularly early in the operation of a new engine type. The regular inspections are designed to detect design, manufacture or operational issues.

This was not a minor failure. An uncontained engine failure is the most catastrohpic event that can happen to an engine in flight. As RR had control of design, testing, certification, manufacturing, inspection and maintenance the responsbility in the current contract arrangements rests with them. The problem for Qantas as the operator is they are responsible for passenger safety but had little involvement or control of the process. Qantas may have detected the fault but were not in a position to undertake its own detailed inspections under the Power by the Hour arrangements.

 

[nlagalle]

Should not a fault of this magnitude have either been detected in the testing of the engine prior to certification for passenger flight or in the regular inspection and maintenance programme undertaken by RR?

It appears to be a manufcturing fault which should have been detected. Either way Qantas was in the dark!!

I don't know how I can explain it to you any simpler. Some things don't always get picked up during manufacturing. Look at car recalls etc. It happens in aviation too.

I'm still wondering how you think the failed part would be detected during maintenance? We are talking about a few millimeters in a boring process.

And so how would QF been not "in the dark"? I still fail to see where you are getting to this. Had RR known about the fault, then yes, but they would be lying to the authorities too, by not sending out an AD advising of the issue. That is criminal action in multiple countries.

 

[nlagalle]

This was not a minor failure. An uncontained engine failure is the most catastrohpic event that can happen to an engine in flight. As RR had control of design, testing, certification, manufacturing, inspection and maintenance the responsbility in the current contract arrangements rests with them. The problem for Qantas as the operator is they are responsible for passenger safety but had little involvement or control of the process. Qantas may have detected the fault but were not in a position to undertake its own detailed inspections under the Power by the Hour arrangements.

farmer, you last comment truly shows you don't have a clue on what you are posting. had your guess above been the case, the union here would be bleating about it daily. They're not because they know they wouldn't have found the fault. Again, I would like to know how you think they would have detected the fault? Do you know the affected part and which bit of it failed?

It has nothing to do with "power by the hour" arrangements.

 

[anat0l]

I'm still wondering how you think the failed part would be detected during maintenance? We are talking about a few millimeters in a boring process.

It's interesting that it is only after an incident that they discover that it was due to such minuscule but critical detail.

 

[nlagalle]

It's interesting that it is only after an incident that they discover that it was due to such minuscule but critical detail.

Well that could be said for many of the incidents/accidents that happen. For example the A330 dive over NW Australia was due to a programming fault that wasn't discovered until then.

 

[farmer]

The question was riased " how was a manufacturing fault detectable prior to the incident."

In the quote below Airbus notes that when an inspection was undertaken of all the A380 engines after the QF 32 accident, a oil was found at a place in the many engines which was an indicator of the manfacturing problem. The oil was found in 40 out of 80engines. Clearly if after the event a precursor of the problem can be found, it shoud have been detected by RR regular inspections before in the accident That is their purpose particularly at the early stages of a new engine types introduction.

"Airbus Chrief Operating Office- John Leahy ....As many as 40 of the 80 Trent 900s delivered to A380 operators Singapore Airlines, Qantas and Lufthansa are understood to be affected by the oil leak issue to some degree, with 14 of those engines on Qantas’s six A380s, 24 in service with Singapore Airlines and two with Lufthansa."

 

[nlagalle]

The question was riased " how was a manufacturing fault detectable prior to the incident."

In the quote below Airbus notes that when an inspection was undertaken of all the A380 engines after the QF 32 accident, a oil was found at a place in the many engines which was an indicator of the manfacturing problem. The oil was found in 40 out of 80engines. Clearly if after the event a precursor of the problem can be found, it shoud have been detected by RR regular inspections before in the accident That is their purpose particularly at the early stages of a new engine types introduction.

"Airbus Chrief Operating Office- John Leahy ....As many as 40 of the 80 Trent 900s delivered to A380 operators Singapore Airlines, Qantas and Lufthansa are understood to be affected by the oil leak issue to some degree, with 14 of those engines on Qantas’s six A380s, 24 in service with Singapore Airlines and two with Lufthansa."

I think perhaps you should become a LAME. You clearly know a lot about how it all works. You have come to the conclusion that because there is oil there it's immediately known where it came from?

Here is the ATSB quote:

A recent key finding from those examinations was the presence of an area of fatigue cracking within a stub pipe that feeds oil to the HP/IP bearing structure. That cracking was associated with a misaligned region of counter-boring within the stub pipe outlet. The misaligned counter-boring had produced a localised thinning of one side of the pipe wall (Figure 9).

If you go to the report and read page 16 again, you'll see the picture of the part in question.

here is a copy of the Rolls Royce AD:

http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/4b846c8b3d5675ba8625726d006e3668/bd36c747996b02d78625777e00523051/$FILE/2010-16-07.pdf

Which explains what they believe at the time to be causing issues and what to do to address it.

Again I'm asking, if you think that QF engineers could have done a better job, why aren't they jumping up and down? they know full well it would have been near impossible to spot unless you had x-ray vision.