Men Who Killed Qantas - Matthew Benns [8]
The airline staff went into a research and development phase during which no formal risk assessment was undertaken. The Operations Procedures Committee then got involved and noted that using idle reverse thrust and fewer, harder and longer applications of the carbon fibre brakes would have financial benefits. It estimated the airline would make a number of savings, including $700,000 a year on overhauling brakes and $1,640,000 on fuel. The ATSB report critically observed: ‘The cost-benefit analysis for the introduction of flaps 25/idle reverse procedures listed all the benefits of the new procedures in financial terms. It did not consider cost items such as tyre wear and the fact that flaps 25 may not be used on all approaches. It was also not updated after maintenance of the brakes was outsourced.’23
The ATSB report was critical of the organisational structure within Qantas that brought in the cost-cutting measure without ‘a proper risk assessment’. It said: ‘There were also significant deficiencies in the manner in which the company implemented and evaluated the new procedures.’ More specifically it found that Qantas had not sought Boeing’s opinion on the safety impact of the new landing procedure and that its examination of the flaps 25 and idle reverse procedure used by two other airlines was incomplete. Neither did Qantas allow for the fact that the procedures used by the other airlines were more conservative than the ones Qantas was bringing in and had additional safeguards for water-affected runways. Similarly, the performance differences between the two types of landing were not fully examined. ‘Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations,’ said the report.24
Investigators found that the documentation for the project and its history was ‘disorganised and incomplete’. According to the report, there were scant records of conversations or meetings held about the project, or of the timing and reasons for important decisions. It said that the decision to bring in the new landing procedure was based on test flights by a small number of experienced pilots in a flight simulator. This was informal and undocumented. No records were kept of what they thought and there was no evidence that active line pilots flying for Qantas were consulted.
Once the system had been brought in, flight crews were asked in newsletters what they thought. The few pilots who did respond, most critically, either in writing or verbally, were disregarded because they were considered ‘resistant to change’. It noted that many management jobs had been taken by senior pilots with no management training. ‘The management culture was over-reliant on personal experience and did not place adequate emphasis on structured processes, available expertise, management training, and research and development when making strategic decisions.’25
It was this combination of management factors that directly led to QF1 finishing nose-down next to a golf course in Thailand. But why hadn’t the air safety watchdog, the Civil Aviation Safety Authority (CASA), picked up the problem sooner? The ATSB report was damning: ‘The surveillance of airline flight operations was deficient.’26 CASA was actually letting Qantas check on itself. Before the 1990s one per cent of all Qantas operations were monitored. This figure was cut three times by CASA in the decade before the crash in Thailand. In 1993 CASA cut its surveillance by half after Qantas, in consultation with the Civil Aviation Authority, set up its own Flight Standards Department