QF1 Runway Overrun_1

QF1 Runway Overrun_1

1. People

   • Captain
     • 49 years age
     • Hold a senior management position in the Qantas Operations Training Department
     • A B-747-400 senior check captain
     • He had 15,881 flight hours.
     • Durng 30 days preceding the accident, he flew four flight segment and conducted two day landings.
       • People/ competency issue
     • The captain awoke at 5am Sydney time and reported for duty at 3pm.
     • He had a 30 minutes rest period and a two-hour rest period during the flight.
     • He received recurrent crew resource management training
     • The captain had been awake almost 21 hours prior to accident
       • Fatigue management failure
   • Frist officer
     • 36 years of age.
     • He had 8,973 flight hours
     • He completed two sectors and ond day landing in the 30 days prior to the accident.
     • He often feels a little tired on such trips as the Sydney to Bangkok sector.
     • He did not believe he was fatigued at the time of the accident.
     • He received recurrent crew resource management training
     • He had been awake almost 19 hours prior to accident.
       • Fatigue management failure
   • Second officer
     • 35 years of age
     • A former Royal Australian Air Force poilot.
     • He had 6,685 flight hours.
     • He received recurrent crew resource management training
   • Cabin crews
     • 16 cabin crews on the aircraft
     • The crews did not getting safety training regularly.
       • Management failure
   • Controller
   • Passengers
     • The passengers did not given appropriate direction after eiting the airplane.
       • Operational and communication failure
     • Some passengers carried their carrier.

2. Workplace

   • Environments
     • Very poor visibillity
     • Heavy raining
     • Windshear
     • Thunderstorms with rain.
   • Workplace factors
     • Runway 21R was not grooved
       • Runway design failure
     • Runway 21R was not coated with porous friction concrete.
       • Runway esign failure
     • Runway was very wet and heavy raining
     • Runway light was not visible for the pilots.
     • The runway is slippery when wet.
   • Equipment design
     • The cabin-interphone and public-address system in B747-400 wereco-located in the same relatively damage-prone position in the lower fuselage aft of the nosewheel.
       • Design failure

3. Management

   • Organisational factors
     • The captain did not take leadership.
     • The company manuals contained procedures and checklists for various emergency situations but did not contain definitions for or guidance for choosing, an emergency evacuation or a precautionarly disembarkation.
     • Decision makin processs was poor because flight crew did not consider all relevant factors.
       • People / competency issue
     • Some cabin crewmembers did not enforce the company's requirement that passengers not carry baggage during disembarkation.
       • Operational failure
     • Qantas B747-438 Operations Manual about conducting landings on wet runways, slippery runways and icy runways in a section titled 'Cold Weather Operations.'
       • This confused the pilots
     • Qants pilot training in the 1960s and 1970s included ontamnated-runway issues but had not been covered in training since then.
   • Job design
     • The captain was not control of the aircraft, he did not show the ownership of the aircraft.
       • Leadership failure
     • The captain was awake 21 hours. He should have some sleep while his brake but he was feeling fatigue.
     • The Qantas B747-400 Performance Limitations Manual
       • Flaps-25 landings were preferred because they maximized carbon-brake life and reduced fuel, time and noise.
         • Precedure failure
       • Flaps-30 setting reduces landing speed and landing distance.
       • Flaps-30 should be used when landing field length requirements are critical also contaminated runway.
       • Idle reverse thrust should be used in normal conditions and that maximum reverse thrust should be used in abnormal conditions.
         • Policy failure
     • B747-400 pilots were to use a flaps-30 setting and maximum reverse thrust.
       • Procedure failure
   • Information transfer
     • There were no communication between captain and cabin crews after impact.
       • Design failure
     • Communication with control room was not efficient.
       • Control room could not understand wether QF1 need emergency vehicle.
         • Communication failure
     • The captain's delay decision for fully evacuate airplain.
       • Operational failure
     • Did not hear control room said go- around
       • Communication failure
     • The first and second officer had not considered the possible runway-surface condition
       • Operational failure

4. System parts

   • Crew members
     • Flight crews
     • Cabin crews
     • Roles and responsibilities
       • People /competency failure
     • Training
       • Managament failure
   • Aircraft
     • Fire protection
     • Communication
     • Navigation
     • Fuel
     • Flight controls
     • Landing gear
     • Electrical system
     • Bleeding ystem
     • Hydraulics
     • Avionics system
   • Passengers
     • 391 passengers on board
   • Organisational system / management
     • Policies
     • Procedures
     • Leadership
     • Commitment
     • Risk and change management
     • Training
     • Document and data control
     • Operational control
     • Emergency preparation and response
     • Monitoring audits and reviews
       • Organisational failure

5. Event Sequence

   • 16:47 23rd September 1999, VH-OJH Boeing 747-439 Departed Sydney international airport Australia
   • Estamated flight to Bangkok airport 8hours 23 min
   • 22:47 Local time 23rd September 1999 Qantas Boeing 747-438 overran runway while landing Bankok International Airport
   • Aircraft was still moving at 163km/h at the end f the runway.
   • Aircraft stopped 220m later on soft turf with nose of aircraft down.
   • Disembarkation commenced at 23:07
   • Disembarkation completed at 23:30