[Peetwo]

Why are we (ATPs) paying for the ATCB?

(ATP - Australian Taxpayer, ATCB - Australian Topcover Bureau)

Just read the ATCB AO-2017-044 investigation Final Report -  : 

What happened

On 7 April 2017, a Qantas Airways Boeing 747-438, registered VH-OJU, was operated as scheduled passenger flight QF29 from Melbourne, Victoria, to Hong Kong International Airport, in the Hong Kong Special Administrative Region of the People's Republic of China. On board were 17 crew and 347 passengers.

While descending toward Hong Kong International Airport, air traffic control instructed the flight crew to hold at waypoint BETTY.

When entering the holding pattern, the aircraft’s aerodynamic stall warning stick shaker activated a number of times and the aircraft experienced multiple oscillations of pitch angle and vertical acceleration. During the upset, passengers and cabin crewmembers struck the cabin ceiling and furnishings.

A lavatory smoke alarm later activated, however, the cabin crew determined the smoke alarm to be false and silenced the alarm. The aircraft landed at Hong Kong International Airport without further incident. Four cabin crewmembers and two passengers suffered minor injuries during the incident and the aircraft cabin sustained minor damage.

What the ATSB found

The ATSB found that while planning for the descent, the flight crew overwrote the flight management computer provided hold speed. After receiving a higher than expected hold level, the flight crew did not identify the need to re-evaluate the hold speed. This was likely because they were not aware of a need to do so, nor were they aware that there was a higher hold speed requirement above FL 200. Prior to entering the hold, the speed reduced below both the selected and minimum manoeuvring speeds. The crew did not identify the low speed as their focus was on other operational matters.

The ATSB also found that due to a desire to remain within the holding pattern and a concern regarding the pitch up moment of a large engine power increase, the pilot flying attempted to arrest the rate of descent prior to completing the approach to stall actions. In addition, the pilot monitoring did not identify and call out the incomplete actions. This resulted in further stall warning stick shaker activations and pilot induced oscillations that resulted in minor injuries to cabin crewmembers and passengers.

Additionally, the operator provided limited guidance for hold speed calculation and stall recovery techniques at high altitudes or with engine power above idle. This in turn limited the ability of crew to retain the necessary manual handling skills for the recovery.

Stall prevention and recovery at high altitudes

The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.

Safety issue details

Issue number: AO-2017-044-SI-01
Who it affects: Qantas Airways Boeing 747 flight crew
Status: Adequately addressed

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Re-evaluating hold speeds for a change in altitude

The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude.
Safety issue details

Issue number: AO-2017-044-SI-02
Who it affects: Qantas Airways Boeing 747 flight crew
Status: Adequately addressed

& via the Oz:

Pilots’ role in 2017 Qantas in-flight incident which injured six


MARCH 27, 2019
By ROBYN IRONSIDE

Qantas has been forced to amend training for its pilots following an incident on a Melbourne-Hong Kong flight in which six people were injured in-flight.

The four cabin crew and two passengers, one of whom was in a toilet at the time, hit the ceiling, when the Boeing 747 underwent rapid changes in movement during a flight in April, 2017.

A two-year Australian Transport Safety Bureau investigation found a technical miscalculation by the pilots resulted in the “upset” after flight QF29 was placed into a higher than expected holding pattern (of 22,000 feet) over Hong Kong.

Although the altitude change was entered into the flight management computer, the pilots did not re-evaluate the hold speed.

That meant as the 747 turned to enter the holding pattern, the speed dropped below what was needed, putting the aircraft at risk of aerodynamic stall.

The pilots initially failed to notice until the stall warning stick shaker activated, alerting them to the problem.

The pilot flying responded by starting the stall recovery process but this was not completed, resulting in more stick shaker activations and for a few brief seconds, a very bumpy ride.

A Qantas spokesman said what occurred was essentially a “mismatch between the holding speed and altitude entered into the flight management computer”.

“In correcting the aircraft’s path, the crew was very conscious they were operating in congested airspace and had limited room to manoeuvre, which added to the sense of turbulence in the cabin,” the spokesman said.

The ATSB report said “when entering the holding pattern, the aircraft’s aerodynamic stall warning stick shaker activated a number of times”.

As the pilot went about the stall recovery process, “the aircraft experienced multiple oscillations of pitch angle and vertical acceleration”, the report said.

“During the pilot-induced oscillations, passengers and cabin crew members struck the cabin ceiling and furnishings.”

In the course of the investigation, the ATSB found the Qantas crew had undergone stall recovery training on multiple occasions exposing them to various scenarios, in line with Civil Aviation Safety Authority requirements and industry best practice.

But the ATSB could find no scenarios of stick shaker activation while manoeuvring at altitude, such as that experienced by QF29.

As a result, the ATSB identified the need for specific training which Qantas promptly addressed for not only 747 crews, but those operating 737 and 787 aircraft as well.

“(Qantas) also updated ground school lesson plans and information to ensure standardised flight crew training and ensure holding pattern training was adequately addressed during flight crew training,” the report said.

Now although it reads as a fairly comprehensive report, I have to ask why did this investigation take nearly 2 years to complete for safety issues that were more than likely identified within days and addressed internally, with a proper safety management action plan through the Qantas SMS, within weeks? 

Is this merely just another case of the ATCB providing topcover for in this case our national airline? If we have come to the point where all the ATCB is doing is regurgitating major airline internal investigation reports, then perhaps the Aviation should be omitted from the ATCB's remit -   

MTF...P2