Today’s Sydney Morning Herald reported that Qantas chief executive Geoff Dixon said “there was no systemic problem behind the three incidents.”This was followed on by CASA spokesman Peter Gibson saying “there is no evidence that safety standards at Qantas are dropping.”
Given the last 10 days of media coverage, is this just spin or do the statements stack up against the publicly released facts?
Root cause analysis theory holds that good governance requires an organisation to maximise all opportunities for corrective action by creating windows that prevent a system failure from escalating to the point where there is an adverse outcome.
It is unrealistic to expect that adverse unexpected changes will not occur in a dynamic and changing environment; airline operations are complex, they have hundreds of airplanes taking off and landing every day. There is a continual dynamic of engineering and human factors in play that are bound to come together at some time in a way that is unexpected.
What is realistic is to expect, from a governance and safety perspective, is that Qantas; and any other organisation, will have pre-planned and taken precautions to ensure that there are many barriers that prevent the failure from escalating to the point that passengers are at risk.
At each moment in time every opportunity to create a window for corrective action needs to be taken.
When the oxygen bottle exploded (theory) on the Boeing 767 last week, the crew are reported to have responded in a well trained way; the 767 dropped to 10,000 feet (breathable air); landed safely at a nearby airport location; all crew and passengers were able to leave the plane safety.
In addition to finding out why the oxygen bottle exploded, the investigation team is sure to explore the reported failure of oxygen delivery to the passengers face masks.
If the 767 had of been flying at a higher altitude, and taken longer to drop to 10,000 feet, the incident may have identified a latent risk where there is only a single source of back-up oxygen for passengers. This may have resulted in an adverse safety outcome occurring. The investigators will also no doubt be looking to ensure that there is more than one source of back up oxygen for the flight deck – even though this was not a reported risk during this incident the consequences are evident.
In relation to the second public incident; QF19 to Manila sprung a hydraulic fluid leak. From the publicly available information, Qantas had appropriate safety precautions in place and responded in a well trained appropriate manner.
To prevent a failure escalating they are reported to have had two (2) back up hydraulic fluid systems; they acted immediately to land and disembark the passengers; they dumped the fuel (in order to reduce landing risk) all in all, from a safety perspective, the reported information indicates that they responded as any responsible organisation could be expected to.
The front page Sun-Herald photograph of QF19 with smoke coming out of the right hand engine did not look that comforting for prospective passengers; but there is nothing in the report to indicate the Qantas response was anything other than appropriate.
Clearly the RCA for this incident will now look at why the hydraulic fluid was leaking and seek to address that in a systemic way i.e. maintenance procedural change, change in schedule for replacement of hydraulic fluid system parts (maybe the age of the aircraft is causing the maintenance schedule to be more frequent).
While Qantas new CEO may have hoped for a more relaxed introduction to his transition from JetStar to Qantas the public reports on the incidents over the last 9 days has not revealed any item that indicates systemic failure, unless something else comes out as part of the investigations Mr Dixon and Mr Gibson appear to be backed up by the reported facts in their safety assurances to the public.
REFERENCES:
http://www.smh.com.au/news/news/qantas-the-safest-airline-probably-says-ceo/2008/08/04/1217701907795.html
http://www.abc.net.au/news/stories/2008/08/03/2322458.htm?section=justin
In relation to the second public incident; QF19 to Manila sprung a hydraulic fluid leak. From the publicly available information, Qantas had appropriate safety precautions in place and responded in a well trained appropriate manner.
To prevent a failure escalating they are reported to have had two (2) back up hydraulic fluid systems; they acted immediately to land and disembark the passengers; they dumped the fuel (in order to reduce landing risk) all in all, from a safety perspective, the reported information indicates that they responded as any responsible organisation could be expected to.
The front page Sun-Herald photograph of QF19 with smoke coming out of the right hand engine did not look that comforting for prospective passengers; but there is nothing in the report to indicate the Qantas response was anything other than appropriate.
Clearly the RCA for this incident will now look at why the hydraulic fluid was leaking and seek to address that in a systemic way i.e. maintenance procedural change, change in schedule for replacement of hydraulic fluid system parts (maybe the age of the aircraft is causing the maintenance schedule to be more frequent).
While Qantas new CEO may have hoped for a more relaxed introduction to his transition from JetStar to Qantas the public reports on the incidents over the last 9 days has not revealed any item that indicates systemic failure, unless something else comes out as part of the investigations Mr Dixon and Mr Gibson appear to be backed up by the reported facts in their safety assurances to the public.
REFERENCES:
http://www.smh.com.au/news/news/qantas-the-safest-airline-probably-says-ceo/2008/08/04/1217701907795.html
http://www.abc.net.au/news/stories/2008/08/03/2322458.htm?section=justin
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