Post on 01-Nov-2014
description
W037c.1
Captain David Oliver General Manager Flight TechnicalQantas Airways Limited
Captain David Oliver General Manager Flight TechnicalQantas Airways Limited
Landing Overruns-Human FactorsLanding Overruns-Human Factors
W037c.2Qantas Airways Limited
Landing Overruns - Human FactorsLanding Overruns - Human Factors
A review of the events leading to, and lessons learnt from the over-run of flight QF1 at Bangkok Thailand, September 23, 1999.
A review of the events leading to, and lessons learnt from the over-run of flight QF1 at Bangkok Thailand, September 23, 1999.
W037c.3Qantas Airways Limited
Landing ConfigurationLanding Configuration
• Operating Boeing 747-400 since 1989
• Standard landing configuration up until 1996 was “Flap 30, Full Reverse Thrust”
• Operating Boeing 747-400 since 1989
• Standard landing configuration up until 1996 was “Flap 30, Full Reverse Thrust”
W037c.4Qantas Airways Limited
Landing ConfigurationLanding Configuration
• Review of landing configuration was undertaken due to:– Noise levy at Sydney
Flap 25 chosen for lower noise, better fuel economy
– Carbon Brake WearIdle reverse thrust chosen for less noise and longer, harder brake application
• Review of landing configuration was undertaken due to:– Noise levy at Sydney
Flap 25 chosen for lower noise, better fuel economy
– Carbon Brake WearIdle reverse thrust chosen for less noise and longer, harder brake application
(continued)(continued)
W037c.5Qantas Airways Limited
Landing ConfigurationLanding Configuration
• Landing configuration Policy from late 1996 was:– Flap 25, idle reverse thrust provided the
runway length was not limiting
• Landing configuration Policy from late 1996 was:– Flap 25, idle reverse thrust provided the
runway length was not limiting
(continued)(continued)
W037c.6Qantas Airways Limited
The LandingThe Landing
• F/O was pilot flying
• The runway was wet– The last landing airplane had reported
“good” braking action – The airplane preceding QF1 executed a
Missed Approach due to poor visibility in heavy rain
– This was not relayed to the crew of QF1
• F/O was pilot flying
• The runway was wet– The last landing airplane had reported
“good” braking action – The airplane preceding QF1 executed a
Missed Approach due to poor visibility in heavy rain
– This was not relayed to the crew of QF1
W037c.7Qantas Airways Limited
The LandingThe Landing
• Airplane crossed the threshold high and fast (but within Company limits) and “floated” 10ft above the runway in heavy rain
• Within a period of just a few seconds:– The Captain called for “Go- Around” – The main gear touched down– The rain eased and visibility improved– Captain reached over and took control of
the thrust levers
• Airplane crossed the threshold high and fast (but within Company limits) and “floated” 10ft above the runway in heavy rain
• Within a period of just a few seconds:– The Captain called for “Go- Around” – The main gear touched down– The rain eased and visibility improved– Captain reached over and took control of
the thrust levers
(continued)(continued)
W037c.8Qantas Airways Limited
The LandingThe Landing
• The Captain initially only retarded # 2, 3 and 4 Thrust Levers
• The F/O immediately realized this and retarded #1 to idle, however:– With main gear on the ground and # 1 or
4 T/L advanced, the autobrakes disarmed– Speedbrakes deployed automatically after
#1 T/L was retarded by the F/O
• The Captain initially only retarded # 2, 3 and 4 Thrust Levers
• The F/O immediately realized this and retarded #1 to idle, however:– With main gear on the ground and # 1 or
4 T/L advanced, the autobrakes disarmed– Speedbrakes deployed automatically after
#1 T/L was retarded by the F/O
(continued)(continued)
W037c.9Qantas Airways Limited
(continued)(continued)The LandingThe Landing
• The EICAS message “AUTOBRAKES” was not initially noticed by the Flight Crew
• Manual braking was not applied until 8 seconds after touchdown, approx 5000 feet down the runway
• No reverse thrust was applied for the whole of the landing roll
• The EICAS message “AUTOBRAKES” was not initially noticed by the Flight Crew
• Manual braking was not applied until 8 seconds after touchdown, approx 5000 feet down the runway
• No reverse thrust was applied for the whole of the landing roll
W037c.10Qantas Airways Limited
(continued)(continued)The LandingThe Landing
• When manual braking was applied NO deceleration was felt
• Both pilots exerted maximum force on the brake pedals, still with no deceleration– The airplane was aquaplaning
• The airplane only began to decelerate as it entered the last 1000 feet of the runway and the groundspeed reduced below 110kts
• When manual braking was applied NO deceleration was felt
• Both pilots exerted maximum force on the brake pedals, still with no deceleration– The airplane was aquaplaning
• The airplane only began to decelerate as it entered the last 1000 feet of the runway and the groundspeed reduced below 110kts
W037c.11Qantas Airways Limited
DECELERATION
4000ft
5000ft1524m
6000ft1829m
7000ft2134m
8000ft2438m
9000ft2743m
10000ft3048m
3287ft1002m
Distance from Rwy 21L displaced threshold
SWV
Manual braking indicationsCAS 154ktsGS 1 2k
Acft drif ting leftof rw y C/LCAS 158ktsGS 156kts
Nose geartouchdow nCAS 146ktsGS 145kts
Nose gear squatsw itch air modeCAS 143ktsGS 141kts
Nose gear squatsw itch gnd modeCAS 139ktsGS 138kts
Acft returning to rw y C/LCAS 107ktsGS 106kts Acft on rw y C/L
at thresholdCAS 96ktsGS 92kts
Nose gear departs sw yCAS 88ktsGS 87kts
ft /sec2
Acft accelerating due to
residual thrust
Aerodynamic braking
only
Aerodynamic and
w heel braking
Touchdow nAir-gnd logicto gnd modeCAS 156 ktsGS 158 kts
SPLR start deployCAS 160 ktsGS 158 kts
SPLR deployedCAS 160 ktsGS 158 kts
-1.00
-2.00
-3.00
-4.00
-5.00
-6.00
-7.00
Decelerat ion at main gear posit ion
W037c.12Qantas Airways Limited
Comparison of rollout deceleration on various runway surfaces and VH-OJH 23 September 1999
-14
-12
-10
-8
-6
-4
-2
0
2
48090100110120130140150160
Groundspeed (knots)
Dece
lera
tion
(ft/s
ec2)
23 Sep BKK Dry Rwy Contam Rwy (Good brkg) Contam Rwy (Poor brkg)
Acft config for various runw ay surfaces:* 252,000 kg Vref25 + 5 kts* Maximum manual braking* Spoilers deployed, Idle forw ard thrust
Ambient conditions:OAT 25 deg CQNH 1013.2WIND 3.6 kt HWC
Flooded runway* Mu 0.05* Poor braking action
Wet runway* Mu 0.20* Good braking action
Dry runway* Mu 0.35 - 0.41
Spoilers deploy
Autobrakes disarmed
Aircraft drif ting left of centreline 5522ft to rw y end
Manual braking indications 5002ft to rw y end Aircraft passing over
rw y mkgs and abeam tw y W 2536ft to rw y end
Aircraft passing over rw y mkgs and approaching tw y S 1100ft to rw y end
Aircraft returning to rw y centreline 770ft to rw y end
Aircraft on centreline at start of sw y
Aircraft nosegear departs end of sw y
2015ft to rw y end
W037c.13Qantas Airways Limited
Human FactorsHuman Factors
• Why did this happen ?
• Accident analysis showed:– A number of significant active failures and – Significant inadequate defences
• Why did this happen ?
• Accident analysis showed:– A number of significant active failures and – Significant inadequate defences
W037c.14Qantas Airways Limited
Active FailuresActive Failures
• The runway was affected by water
• Flight Crew failed to use an appropriate risk management strategy for the approachand landing
• The F/O did not fly the aircraft accurately during final approach
• The Flight Crew were confused over who had control and did not select appropriate level of reverse thrust
• The runway was affected by water
• Flight Crew failed to use an appropriate risk management strategy for the approachand landing
• The F/O did not fly the aircraft accurately during final approach
• The Flight Crew were confused over who had control and did not select appropriate level of reverse thrust
W037c.15Qantas Airways Limited
Inadequate DefencesInadequate Defences
• Company published information, procedures and training for landing on water affected runways was inadequate
• Flight Crew training in evaluating the procedural and configuration options for approach and landing was deficient– The crew may have been “pre-conditioned” to
the use of Flap 25 and idle reverse thrust
• Company published information, procedures and training for landing on water affected runways was inadequate
• Flight Crew training in evaluating the procedural and configuration options for approach and landing was deficient– The crew may have been “pre-conditioned” to
the use of Flap 25 and idle reverse thrust
W037c.16Qantas Airways Limited
Change ManagementChange Management
• Published the Boeing document “Landing on Slippery Runways” (doc D6-44247) in the Qantas Flying Manual
• Provided a flow chart to assist Flight Crew in determining appropriate flap and reverse thrust settings
• Published the Boeing document “Landing on Slippery Runways” (doc D6-44247) in the Qantas Flying Manual
• Provided a flow chart to assist Flight Crew in determining appropriate flap and reverse thrust settings
W037c.17Qantas Airways Limited
Aircraft WeightEnvironmental Conditions
Aircraft WeightEnvironmental Conditions
Evaluate Runway Conditions as Reported
Evaluate Runway Conditions as Reported
Runway DryRunway Dry Runway WetRunway Wet Runway Contaminated or Slippery
Runway Contaminated or Slippery
Determine F25 LandingField Length
Determine F25 LandingField Length
Reported Braking Action
Reported Braking Action
Is F25 Landing Field Length less than
Available Distance?
Is F25 Landing Field Length less than
Available Distance?
Use Flap 25 and Full Reverse Thrust
Use Flap 25 and Full Reverse Thrust
Determine F30 Landing Field Length
Determine F30 Landing Field Length
Is F30 Landing Field Length less than
Available Distance?
Is F30 Landing Field Length less than
Available Distance?
Use Flap 30 and Full Reverse Thrust
Use Flap 30 and Full Reverse Thrust Use another RunwayUse another Runway
MEDIUMMEDIUMGOODGOOD POORPOOR
Determine F30 Landing Field LengthDetermine F30 Landing Field Length Do not land unless a greater emergency exists. Hold until conditions improve or divert
Do not land unless a greater emergency exists. Hold until conditions improve or divert
Is F30 Landing Field Length less than Available Distance?
Is F30 Landing Field Length less than Available Distance?
Use Flap 30 and Full Reverse Thrust
Use Flap 30 and Full Reverse Thrust
YesYes
YesYes NoNo
NoNo
NoNo YesYes
W037c.18Qantas Airways Limited
Change ManagementChange Management
• Flight Crew use max reverse thrust as the “standard” with idle reverse permitted only under stipulated conditions
• Flap 25 is the normal landing flap ondry runways
• Flap 30 used on wet runways (no credit taken for grooving or PFC overlay)
• Flight Crew use max reverse thrust as the “standard” with idle reverse permitted only under stipulated conditions
• Flap 25 is the normal landing flap ondry runways
• Flap 30 used on wet runways (no credit taken for grooving or PFC overlay)
(continued)(continued)
W037c.19Qantas Airways Limited
Change ManagementChange Management
• Produced CBT package summarising performance on slippery and contaminated runways
• Provided detailed stopping distance information for various surface conditions
• Highlighted to crew the importance of using correct techniques for landing on wet, slippery and contaminated runways
• Included call of “AUTOBRAKES” each time this is annunciated on EICAS
• Produced CBT package summarising performance on slippery and contaminated runways
• Provided detailed stopping distance information for various surface conditions
• Highlighted to crew the importance of using correct techniques for landing on wet, slippery and contaminated runways
• Included call of “AUTOBRAKES” each time this is annunciated on EICAS
(continued)(continued)
W037c.20Qantas Airways Limited
(continued)(continued)Change ManagementChange Management
• Monitoring of landing configurations and touchdown points has shown:– Significant trend towards flap 30 irrespective
of runway conditions– Max. reverse thrust used on most occasions– Touchdown points are closer to the “desired”
point. i.e. less “float”
• Monitoring of landing configurations and touchdown points has shown:– Significant trend towards flap 30 irrespective
of runway conditions– Max. reverse thrust used on most occasions– Touchdown points are closer to the “desired”
point. i.e. less “float”
W037c.21Qantas Airways Limited
0%0%
20%20%
40%40%
60%60%
80%80%
100%100%
Trend in Landing Flap SettingTrend in Landing Flap Setting
Percentage of landingsPercentage of landings
Flap 25
Flap 30
Mar-00Mar-00
Apr-00Apr-00May-00May-00
Jun-00Jun-00Jul-00Jul-00
Aug-00Aug-00Sep-00Sep-00
Oct-00Oct-00Nov-00Nov-00
Dec-00Dec-00Mar-01Mar-01
Apr-01Apr-01May-01May-01
Jun-01Jun-01Jul-01Jul-01
Aug-01Aug-01Sep-01Sep-01
Oct-01Oct-01Nov-01Nov-01
Dec-01Dec-01Jan-01Jan-01
Feb-01Feb-01Mar-02Mar-02
Apr-02Apr-02May-02May-02
Jun-02Jun-02Jul-02Jul-02Jan-02Jan-02
Feb-03Feb-03
W037c.22Qantas Airways Limited
0%0%
10%10%
20%20%
30%30%
40%40%
50%50%
60%60%
70%70%
80%80%
90%90%
100%100%
Percentage of landingsPercentage of landings
Trend in Reverse Thrust UseTrend in Reverse Thrust Use
Idle
40 to 81%N1
>82%N1
Mar-00Mar-00
Apr-00Apr-00May-00May-00
Jun-00Jun-00Jul-00Jul-00
Aug-00Aug-00Sep-00Sep-00
Oct-00Oct-00Nov-00Nov-00
Dec-00Dec-00Mar-01Mar-01
Apr-01Apr-01May-01May-01
Jun-01Jun-01Jul-01Jul-01
Aug-01Aug-01Sep-01Sep-01
Oct-01Oct-01Nov-01Nov-01
Dec-01Dec-01Jan-01Jan-01
Feb-01Feb-01Mar-02Mar-02
Apr-02Apr-02May-02May-02
Jun-02Jun-02Jul-02Jul-02Jan-02Jan-02
Feb-03Feb-03
W037c.23Qantas Airways Limited
Trend in Distance From 50’ to TDTrend in Distance From 50’ to TD
Percentage of landingsPercentage of landings
0%0%
10%10%
20%20%
30%30%
40%40%
50%50%
60%60%
70%70%
80%80%
90%90%
100%100%
2000 - 2499ft2500 - 2999ft
3000ft +3000ft +
Under 1000ft
1000 - 1499ft
1500 - 1999ft
Mar-00Mar-00
Apr-00Apr-00May-00May-00
Jun-00Jun-00Jul-00Jul-00
Aug-00Aug-00Sep-00Sep-00
Oct-00Oct-00Nov-00Nov-00
Dec-00Dec-00Mar-01Mar-01
Apr-01Apr-01May-01May-01
Jun-01Jun-01Jul-01Jul-01
Aug-01Aug-01Sep-01Sep-01
Oct-01Oct-01Nov-01Nov-01
Dec-01Dec-01Jan-01Jan-01
Feb-01Feb-01Mar-02Mar-02
Apr-02Apr-02May-02May-02
Jun-02Jun-02Jul-02Jul-02Jan-02Jan-02
Feb-03Feb-03
W037c.24Qantas Airways Limited
Cabin CommunicationsCabin Communications
• Nose gear collapse resulted in loss of all Flight Deck / Cabin communications
• Confusion existed as to need for evacuation
• Co-location of back-up comms equipment in an area prone to damage is considered undesirable
• Provided Flight and Cabin Crew with procedures to use in the event of loss of Cabin Interphoneor PA
• Nose gear collapse resulted in loss of all Flight Deck / Cabin communications
• Confusion existed as to need for evacuation
• Co-location of back-up comms equipment in an area prone to damage is considered undesirable
• Provided Flight and Cabin Crew with procedures to use in the event of loss of Cabin Interphoneor PA
W037c.25Qantas Airways Limited
SummarySummary
• Provide Flight Crew with the appropriate tools to do the job
• Train Flight Crew to analyse each landing separately to determine the appropriate landing configuration
• Ensure procedures for landing on wet, slippery and contaminated runways are in place and thoroughly understood
• ATSB report available at www.atsb.gov.au
• Provide Flight Crew with the appropriate tools to do the job
• Train Flight Crew to analyse each landing separately to determine the appropriate landing configuration
• Ensure procedures for landing on wet, slippery and contaminated runways are in place and thoroughly understood
• ATSB report available at www.atsb.gov.au