Anna Wilson - HEAnet

Flying is safer than any other way of getting around. There’s a reason for that, and it’s not superhuman pilots. The entire industry has worked hard to reach this state, and has done so in some very mundane, understandable ways.

Qantas flight QF32 took off from Singapore on 4 November 2010. It was an Airbus A380, an enormous aircraft that has safety and resilience built into its core design. It had, very unusually, five crew members in the cockpit.

Shortly after takeoff, at 10:01, undetected cracking in engine number 2 finally broke. Oil leaked into the engine and exploded. The turbine came apart and pieces flew off in all directions. Shrapnel from the explosion damaged the wings (useful for flying), flaps (useful for landing) and both sides of redundant systems (useful for controlling the plane.)

So crucial redundant systems were down, the plane had a limited amount of altitude, the controls weren’t working right, and alarms had lit up like a Christmas tree. And there were five people in the cockpit.

This is a stressful situation.

The air incidents that we hear about are almost invariably the bad news ones. For examples of where poor communication caused accidents, other presentations are available. QF32 had perhaps the most experienced flight crew in the world, and was a model in how to recover from what seemed like an unrecoverable situation.

Preparedness in a situation like this goes beyond the technology of flight. Cockpit Resource Management (CRM) is a technique for communication and decision making in a situation just like this. Even before takeoff, the Captain had briefed the crew to ensure that the chain of command was clear.

During the flight, the Captain managed the situation by using the vast experience around him, with clear communication, carefully delegated duties, and listening to the crew. They kept in close contact with the cabin crew, who made sure that the passengers were prepared.

Even when they made it to the ground, the incident wasn’t over. Fuel was leaking, the brakes were white-hot, and one of the engines wouldn’t shut down. And there were still 469 people on board. It took two hours to get everyone off the aircraft safely. (They could have evacuated the plane quickly, but this would definitely lead to injuries.)

And after all this, the Captain spoke to the passengers who had disembarked, and said “Write down this number. It’s my personal number. If Qantas doesn’t take care of you, call me.”

No one called. But what could have been a true disaster turned into a public relations coup for Qantas, because it was handled so well.

We don’t fly planes, but we do manage complex, redundant systems and, when they fail, we have teams of people involved in their restoration. Many of our incidents can be lengthened or shortened by applying some of the same lessons that airlines learned decades ago. This talk will look at how we operate through the lessons of QF32, and see what we can learn.