Workshop: Resilience in Aviation; The Quantas A380 case.

Can we recognize resilience in a major event ? Is it a spontaneous emergent property, is it recovery beyond expectation, is it sheer luck or heroic pilot behaviour? Based on different accounts of a serious aviation incident we invite you to discuss this incident from a resilience perspective. After we have discussed some resilience aspects we will reconstruct the event with video and audio recordings. In an interactive session we search and discuss examples of resilience in the unfolding of the Qantas 32 flight.

Workshop goal

The goal of this workshop is to apply (y)our knowledge about resilience and recognise it in real events. Furthermore we try to operationalize resilience to test if the resilience concepts give us new insights that might be useful for accident investigation and pilot training.
A better understanding of resilience in practice helps us to integrate resilience in our design of systems, organisations and human resources.

Workshop presenters

Prof. John Stoop (Kindunos Safety Consultancy, University of Lund Sweden).
Arthur Dijkstra (Master Human Factors, consultant and airline B777 captain).

Suggestions for workshop preparation

The case we’ve selected is a well-documented accident with Qantas Flight QF 32. Below you find a sort description and some resources. You will benefit from consulting these resources before the workshop.

The accident, at 10:01 am Singapore Standard Time (02:01 UTC), was caused by an uncontained failure of the port inboard (Number 2) engine, while en route over Batam Island,Indonesia.

Shrapnel from the exploding engine punctured part of the wing and damaged the fuel system causing leaks,disabled one hydraulic system and the anti-lock brakes and caused No.1 and No.4 engines to go into a ‘degraded’ mode, damaged landing flaps and the controls for the outer left No.1 engine.

Motor A380 Cockpit A380

The crew, after finding the plane controllable, decided to fly a racetrack holding pattern close to Changi airport while assessing the status of the aircraft. It took 50 minutes to complete this initial assessment. The First Officer (FO) and Supervising Check Captain (SCC) then input the plane’s status to the landing distance performance application (LDPA) for a landing 50 tonnes over maximum landing weight at Changi.Based on these inputs the LDPA could not calculate a landing distance. After discussion the crew elected to remove inputs related to a wet runway, in the knowledge that the runway was dry. The LDPA then returned the information that the landing was feasible with 100 metres of runway remaining.The flight then returned to Singapore Changi Airport, landing safely after the crew extended the landing gear by a gravity drop emergency extension system, at 11:45 am Singapore time. As a result of the aircraft landing 35 knots fasterthan normal, four tyres were blown. 

Upon landing, the crew were unable to shut down the No.1 engine, which had to be doused by emergency crews 3 hours after landing until flameout. The pilots considered whether to evacuate the plane immediately after landing as fuel was leaking from the left wing onto the brakes, which were extremely hot from maximum braking. The SCC pilot, David Evans, noted in an interview, “We’ve got a situation where there is fuel, hot brakes and an engine that we can’t shut down. And really the safest place was on board the aircraft until such time as things changed. So we had the cabin crew with an alert phase the whole time through ready to evacuate, open doors, inflate slides at any moment. As time went by, that danger abated and, thankfully, we were lucky enough to get everybody off very calmly and very methodically through one set of stairs.”The plane was on battery power and had to contend with only one VHF radio to coordinate emergency procedure with the local fire crew.

There were no injuries reported among the 440 passengers and 29 crew on board the plane. Debris also fell on a school and houses, causing structural damage,and on a car.