About an A380 with one engine on fire and multiple malfunctions, as well as a crew who mastered the emergency landing successfully, also thanks to CRM, you can read here:
1. The Departure after a Stopover in Singapore
1.1. Captain de Crespigny and His Crew
On the flightdeck of the mighty A380 there were five pilots on November 4th 2010, which is unusual. Captain Richard de Crespigny, who was going to undergo a routine check, was assisted by his first officer Matt Hicks. Mark Johnson was going to be his second officer.
Also on board is the pilot who was going to check the captain, Harry Wubben, as well as one more check captain, David Evans who was going to observe the checking pilot.
1.2. The Airliner
A Special Airbus A380 of the Renowned Airline Qantas
Qantas, the renowned Australian airline, which had its last deadly air accident in 1951, christened this A380 Nancy-Bird Walton after the legendary flight pioneer and placed it ceremonially into service in 2008.
Some Figures and Data
A lordly Airbus A380 is 72,73 metres long and has a wingspan of 79,80 metres. The maximum take-off weight is 560 tonnes. In this case, 105 of these were fuel.
More than 500 passengers can be seated on board, the crew can comprise up to 35 persons. On Qantas flight 32, there were 440 passengers and 24 crew on board in addition to the five pilots.
The four engines of an Airbus A380 can be delivered by two different manufacturers. In this case, they were from Rolls Royce, the Trent 900 model.
1.3. The Take-off of the Airbus A380
In Singapore, the weather was perfect for flying on this day in November, with sunshine and a mild wind. The first leg of the route had led here from London. After a stopover of two hours the new crew continued the flight to Sydney.
Immediately before take-off, captain de Crespigny asked his crew: "Everyone happy?". His first officer Matt Hicks replied: "Yeah, just don´t crash."
After an uneventful take-off from runway 20C at Changi Airport in Singapore, the aeroplane climbed into the sky without any difficulties heading South. Initially, it was flying over Indonesian islands.
2. Two Loud Sounds on Board the A380
Only four minutes into the flight, at an altitude of 7000 feet, ca. 2330 metres, two loud sounds in short succession were heard in the cockpit of the A380. At this time, the airliner was flying over the Indonesian island of Batam.
Immediately thereafter, the aeroplane started vibrating. This is also visible on amateur videos taken by passengers (this film worth seeing has been uploaded on YT).
At first, it was totally unclear what had caused the sounds. First of all, captain de Crespigny switched off the autopilot and abandoned the climb of the aircraft in order to level it.
3. Quickly, an Abundance of Occurrences Ensued
3.1. Malfunctions on Board the A380
Engine number two, the inboard engine on the left-hand side of the plane, overheated. The message was conveyed to the crew via ECAM, short for electronic centralised aircraft monitoring.
Right after that, ECAM started to show an abundance of further alarm messages on the respective display in quick succession. These referred to various onboard systems and, initially, there did not seem to be any connection between them.
Then, ECAM reported that engine two was on fire. Quickly, one after another, electronic and hydraulic aeroplane systems failed, amongst them the control over the brakes and slats, flaps and ailerons.
3.2. The Failures Caused Stress
The many acoustic and visual alarms, tied to the error messages, naturally caused stress, as did the at first apparently not interrelated events. Captain de Crespigny: "It was stressful, it was difficult." The crew had to cope with the stress in this very moment.
At the same time, every pilot involved knew that he had to apply everything he had ever learned about flying. Matt Hicks later said during an interview what he told himself after having briefly thought about his family at home: "Better do a decent job, otherwise I won´t come home."
We will elucidate how the crew proceeded in correlation with the following CRM components and concepts:
- use of all resources available, concerning personnel, materials, inside and outside the A380
- Workload Management
- situational awareness
- Decision-Making
- Knowledge, Skills, and Attitude
- appropriate communication
- threat and error management
De Crespigny summarised the quintessence of CRM in the following important sentence:
4. The Crew Applied Important CRM Components
First, it was vital to find the cause of the events, and to gain an overview of the situation as a whole, to stabilise the airliner, and to examine how the failed systems influenced the manoevrability of the plane.
In addition, the crew had to plan further steps, and make decisions, inform the passengers, and prepare them for the emergency landing without causing panic on board.
As you can see, there was a plethora of tasks, which the crew faced so suddenly and which it had to solve in order to bring all souls on board back to the ground safely.
4.1. Using Resources as a Team Immediately
The team in the cockpit used its members as resources and took advantage of the unusual presence of five pilots. The crew managed the workload wisely, as we will discover under item 4.2. Thus, it was possible to gain an overview over the workload. At the same time, the workload was shared in a manner which allowed the crew to manage it.
Other teams were included as well, amongst them air traffic control, ATC, at Singapore Airport, the cabin crew, but also the passengers. It was crucial that they manage to stay calm.
Contact with ATC in Singapore was made right away, and PAN PAN PAN was declared. This is the international sign that the aeroplane and its occupants are under threat, but the situation is not immediately perilous.
Help is a resource: What help will we be needing? Where do we obtain it? Help should be requested as soon as possible, and all persons involved should be informed as early as possible.
Furthermore, flying a holding pattern was arranged with ATC for about thirty minutes in order to respond to the ECAM messages and to plan the rest of the flight.
Acting anticipatorily: The holding pattern also served to keep the aircraft within gliding range, in case all onboard systems should fail.
4.2. Workload Management in the Cockpit of the A380
The Captain´s and His First Officer´s Tasks
Captain de Crespigny was going to fly the plane manually, which he declared formally using standard phraseology: "I have control."
First officer Matt Hicks took care of the ECAM messages. There were a total of 58 of them, which was unprecedented in aviation history. During training, responding to two or three of such messages in succession is practised.
Whilst Matt Hicks responded to the ECAM messages, he communicated relevant information to the crew and took action. For example, he shut down engine number two and later extinguished the fire using integrated mechanisms.
The Direct View of Engine Number Two
Second officer Mark Johnson took a direct look at the left wing from a window in the passenger cabin, as the wing cannot be seen from the cockpit.
The wing was punctured. One of the holes was so large that a human being could have passed through it. The airliner was leaking fuel in sizeable quantities. The rear part of the nacelle was missing.
Back on the flightdeck, he communicated his observations to his fellow team members. It became clear that the engine had been destroyed, and that parts of it must have been blown apart cutting through various wires and hydraulic systems.
Calculating the Landing
The seasoned check captain David Evans calculated the length of the runway needed at the current weight of the plane, as it up until this point had barely used any fuel. Initially, the software indicated that a landing would be impossible.
After a discussion within the team and alteration of the parameters, there was a margin of 100 metres on a runway that is four kilometres long. The speed during the approach had to be controlled meticulously. If it had been too fast, the runway would have been overshooted, if had been too slow, the plane would have stalled and fallen out of the sky.
Collaboration with the Cabin Crew and the Passengers
In addition, David Evans informed the passengers in several announcements from the cockpit. Michael von Reth, the customer service manager, was involved right from the beginning, as well. His role, as he attended to the passengers, was vital. He helped them to keep calm.
4.3. Decision-Making
After the initial sounds and the dramatic failure of engine number two, the impact of debris on the left wing, and the consecutive destruction of crucial aircraft systems, many decisions had to be made in order to land the aircraft on the safe ground.
Here are some of the decisions, the crew made in a short amount of time:
- to abandon the climb and level the plane
- to maintain a holding pattern for 30 minutes to respond to the ECAM warnings and to plan ahead
- to fly a left turn to see how the aircraft is responding
- who would perform which tasks
- to return to Singapore Airport requesting the longest runway
- requirement of the airport´s fire brigade because of the fuel leak
In the meantime, parts of the A380, belonging to the engine and its nacelle, were found on the Indonesian island of Batam. On the nacelle, the airline´s legendary kangaroo is visible. Indonesia´s ATC informed the ATC in Singapore, which, in turn, passed the information on to the crew on Qantas flight 32.
Captain de Crespigny decided immediately that he could not deal with this message. At that moment, he was unable to do anything about it. Rather, together with his crew, he had to take care of the problems on board and the emergency landing.
4.4. Situational Awareness on the Flightdeck of the A380
As you know, situational awareness encompasses being conscious of the actual surroundings, and the time, as well as all accessible pieces of information, and the personal and material resources.
The crew was aware of the following information and resources and used them actively:
- spatial: distance to Singapore Airport, their altitude, distances and altitudes with respect to the emergency landing
- time: how much time do we allow ourselves to plan ahead, how much is too long and may cause problems
- information: what error messages are there, what is their cause, what has been destroyed, what does still work, the actual weigth of the plane, weather conditions, including wind direction and speed
- resources: the pilots and their expertise, cabin crew, ATC and the possibilities at Singapore Airport, still available computer systems on board (f. ex. landing calculation software), other systems that are still working
5. Knowledge, Skills, and Attitude
Knowledge, skills, and attitude of every team member are essential to the collaboration in order to use resources efficiently.
5.1. The Summarised Knowledge on Board the A380
Captain de Crespigny emphasised the value of the summarised knowledge on board as he said „…to make one massive brain and then use the intelligence to resolve problems…“.
The knowledge on board comprised amongst others:
- general knowlegde of flying
- general data and facts about the aeroplane
- the actual state of the A380
- where electric wires and hydraulic systems are located
- how the failures consecutively could be explained
- how to use the resources still available
- what runway and other resources on the ground were necessary for this kind of emergency landing
- where to find these resources, in this case the next major airport was Singapore
5.2. Flying Skills
In addition to the respective knowledge, also practical skills were of enormous importance to handle the crippled plane and make the emergency landing successfully:
- flying a careful left turn to find out how the plane is responding
- performing a control check to explore the roll control right before the emergency landing
- using thrust wisely to control the speed precisely
- touching the stricken plane down expertly
5.3. The Attitude Is Crucial, Too
The teamwork attracts attention. We recognise that the available skills were combined at once: The knowledge was summoned into one massive brain and CRM was widely used.
6. Communication Inside and Outside the A380
Clear and explicit communication within the crew, as well as with other teams involved, was crucial for this success.
We will first look at the various techniques used here. Then, we will reveal, how many different parties communicated with one another in this case.
6.1. Communication Techniques
Speak up
The following examples can be named. Matt Hicks alerted the captain to the important speed regulation during the approach: "watch your speed." Immediately after touchdown he requested several times that the captain brake maximally: "Brakes, Rich, Brakes."
Closed Communication Loops
Clearly stated and acknowlegded were, for instance, the use of the integrated fire extinguisher in enginge number two, as well as the lowering of the landing gear before the emergency landing.
Standard Phraseology
As mentioned above, pilots clarify amongst themselves, who is flying the plane: Either stating "I have contol", or "you have control", which is acknowledged accordingly.
Sterile Cockpit Rule
During certain parts of a flight, especially during an emergency, the sterile cockpit rule applies. It means that all communication is now solely about the flight, the current situation and the tasks at hand. It is strictly forbidden to talk about private topics.
6.2. Who Communicated With Whom
When concentrating on the events on the flightdeck, one doesn´t notice at first, how many different parties were involved here and communicated with one another.
In detail, the following teams communicated with one another:
- the crew in the cockpit amongst themselves
- the cockpit crew with the cabin crew and the passengers
- the cockpit crew with ATC at Singapore Airport
- Indonesia´s ATC with the ATC in Singapore
- ATC in Singapore with the airport´s fire brigade
- the Qantas operation centre, which monitors the whole fleet live, with ATC in Singapore (communicating with the cockpit was not possible due to the severed wiring)
All of that was important and had to be coordinated in order to make the emergency landing successfully and to support it, respectively.
7. Threat and Error Management in the Cockpit of the A380
In crew resource management training, the avoidance, but also the management of threats and errors that have occurred none the less, is addressed in order to further enhance safety. A threat can also be caused by an error that has been made earlier and cannot be influenced by the crew.
On Qantas flight 32 the crew and everyone on board was severely threatened by the destroyed engine and the subsequent failures, without anyone having made an error during the flight.
Now the crew had to deal with this already existing threat, which due to stress enhanced the risk of consecutive errors.
On the one hand, they achieved this due to preparation, including:
- consequent CRM training
- dealing with stress using CRM
- preparing for an engine failure and engine fire in a simulator
- practising an emergency landing and more in a simulator
- responding to ECAM messages during a simulation
On the other hand, not everything can be prepared. As mentioned above, it was the first time in aviation history that 58 ECAM messages were displayed one after another. It took fifty minutes in total to work through each one of them in order to be able to take the next step.
Also because of that, the management of the given situation was vital. This included:
- Workload Management
- dealing with stress right there and then
- gaining and processing information
- decision-making building on the information obtained
- Communication
- employing the available knowledge, skills, and attitude, as well as all resources
8. The Emergency Landing in Singapore
8.1. Preparing the A380 for the Landing
The hydraulic system of the landing gear was damaged, as well. The crew lowered it manually and could only hope that gravity would pull it into place. This took a whole two minutes, but, luckily, it worked.
The cabin crew and the passengers had to be prepared for a hard and fast landing quickly. Everyone´s collaboration in the cabin was essential.
Shortly before the landing, the roll control was tested using a control check. It was severely limited, especially when the plane was rolled to the right.
The captain asked once more, whether nothing had been overlooked. After the acknowledgement, he started the final approach. Now he had to control the airspeed precisely down to a few knots (1 knot equals 1,852km/h).
8.2. The Actual Landing
After touching down on the runway, de Crespigny pushed the nose down as quickly as possible in order to avoid that tyres would explode when braking due to lacking contact with the ground. Such an explosion is only a question of split seconds.
Due to the failure of the braking system, only manual braking was possible. Matt Hicks reminded the captain several times to brake hard, because the plane didn´t seem to slow down. The latter replieed that he was braking maximally already, which could be confirmed by looking down onto the brake pedal.
Captain de Crespigny saw the fire brigade as it was standing by, he aimed at joining them: "they were my friends." The huge A380 came to a halt one hundred metres within the end of the runway right next to the fire engines.
8.3. The Danger Was Not Over Yet
Already in this moment, the crew and the passengers were incredibly happy. However, the danger was far from over after this superb emergency landing. Fuel was leaking from the left wing in large quantities, the brakes directly under it were 900 degrees Celsius hot. It goes without saying what consequences this could have had.
Using a coded message directed to the cabin crew, everything was prepared for an emergency evacuation. During such an evacuation everyone on board has to leave the aircraft within ninety seconds.
The outboard engine on the left-hand side, number one, could only be shut down after several hours. For this, fire extinguishing foam was applied.
Only after two hours, the passengers could be evacuated from the right-hand side of the plane. Their relief was boundless. As one passenger later recalled: "I was thinking of kissing the ground."
In the chaos of this first-time event in aviation, well stuctured CRM, efficient communication, as well as knowledge, skills, and attitude aided the crew to manage their stress levels and to master the emergency landing.
9. Are the A380 and Its Engines Safe? - The Investigation
9.1. Assessing the Damage Directly After the Landing
Having left the airliner, the pilots took a look at the engine. They were shocked by the view. The rear part of the nacelle was missing, the aft section of the engine was held in place solely by the turboshaft. The traces of the fire were visible, as was the damage to the wing and its joint to the fuselage.
9.2. Inspection of the A380 Parts in Indonesia
Immediately after the engine parts had been found on the island of Batam, specialists of the Australian Transport Safety Bureau, ATSB, were dispatched to start the investigation there. Luckily, no one on the ground had been hit by the falling debris.
One part of the turbine disc, which weighs more than two hundred kilogrammes in total, was found in the detritus. A blue tinge on it suggested that a leaking lubricant might have caused the engine explosion.
The discovery of the parts confirmed a so-called uncontained engine rotor failure, UERF, i. e. a destruction during which debris flew out of the engine, hit the wing and its joint to the fuselage, severing the control systems.
Luckily, the upper section of the fuselage was not hit by the part of the turbine disc that had punctured the wing. The fuselage is not constructed to withstand such an impact.
9.3. Examination of the Engine in Singapore
The airliner was towed to hangar six. There, the engine was dismantled until the technicians could see the spot where the fire had started.
An untight oil pipe was discovered from which a lubricant had leaked onto hot parts of the engine and, subsequently, had caught fire. Consecutively, parts of the turbine structure had overheated, the turbine disc had started to spin at uncontrollable speed and, finally, had exploded.
9.4. The Root Cause of the Leakage
The cause of the leakage was a stub pipe which was sitting in a borehole which had not been drilled in a straight fashion. Besides, the wall of the stub pipe was too thin. Due to the strain during take-offs on short runways, cracks had formed in that stub pipe over time. On flight 32, the pipe became totally untight.
So this was the error, which developed into a threat to the crew and all the passengers during the flight.
9.5. Consequences for the Refitting and Maintenance of the Rolls Royce Engines
The stub pipe, which is only five centimetres long, had not been suitable for the engine. All the engines of the same kind have been refitted accordingly. Besides, Rolls Royce has taken measures to prevent uncontained engine failures. The company has improved its quality management system, as well.
Also after this incidence, the painstaking investigation of the cause has contributed to avoid another event of this kind. Thus, it has made flying even safer.
10. In My Next Blog Article You Can Read About:
In this article, we have already taken a brief look at how to manage threats and errors successfully. We will explore this topic further in the next article.
In addition, we will elucidate what an undesired aircraft state, UAS, is. How does it happen? What are the consequences? What learning points can we transfer to our own lines of business?
You can find more blog articles at the bottom of my blog page.
Author: Eva-Maria Schottdorf
Date: June 8th 2021