Landing Overruns- Landing Overruns- Human Factors Human Factors - - PowerPoint PPT Presentation

W037c.1

Captain David Oliver

General Manager Flight Technical Qantas Airways Limited

Captain David Oliver

General Manager Flight Technical Qantas Airways Limited

Landing Overruns- Human Factors Landing Overruns- Human Factors

W037c.2

Qantas Airways Limited

Landing Overruns - Human Factors Landing Overruns - Human Factors

A review of the events leading to, and lessons learnt from the over-run of flight QF1 at Bangkok Thailand, September 23, 1999. A review of the events leading to, and lessons learnt from the over-run of flight QF1 at Bangkok Thailand, September 23, 1999.

W037c.3

Qantas Airways Limited

Landing Configuration Landing Configuration

• Operating Boeing 747-400 since 1989
• Standard landing configuration up until 1996

was “Flap 30, Full Reverse Thrust”

• Operating Boeing 747-400 since 1989
• Standard landing configuration up until 1996

was “Flap 30, Full Reverse Thrust”

W037c.4

Qantas Airways Limited

Landing Configuration Landing Configuration

• Review of landing configuration was

undertaken due to: – Noise levy at Sydney Flap 25 chosen for lower noise, better fuel economy – Carbon Brake Wear Idle reverse thrust chosen for less noise and longer, harder brake application

• Review of landing configuration was

undertaken due to: – Noise levy at Sydney Flap 25 chosen for lower noise, better fuel economy – Carbon Brake Wear Idle reverse thrust chosen for less noise and longer, harder brake application

(continued) (continued)

W037c.5

Qantas Airways Limited

Landing Configuration Landing Configuration

• Landing configuration Policy from late 1996 was:

– Flap 25, idle reverse thrust provided the runway length was not limiting

• Landing configuration Policy from late 1996 was:

– Flap 25, idle reverse thrust provided the runway length was not limiting

(continued) (continued)

W037c.6

Qantas Airways Limited

The Landing The Landing

• F/O was pilot flying
• The runway was wet

– The last landing airplane had reported “good” braking action – The airplane preceding QF1 executed a Missed Approach due to poor visibility in heavy rain – This was not relayed to the crew of QF1

• F/O was pilot flying
• The runway was wet

– The last landing airplane had reported “good” braking action – The airplane preceding QF1 executed a Missed Approach due to poor visibility in heavy rain – This was not relayed to the crew of QF1

W037c.7

Qantas Airways Limited

The Landing The Landing

• Airplane crossed the threshold high and fast

(but within Company limits) and “floated” 10ft above the runway in heavy rain

• Within a period of just a few seconds:

– The Captain called for “Go- Around” – The main gear touched down – The rain eased and visibility improved – Captain reached over and took control of the thrust levers

• Airplane crossed the threshold high and fast

(but within Company limits) and “floated” 10ft above the runway in heavy rain

• Within a period of just a few seconds:

– The Captain called for “Go- Around” – The main gear touched down – The rain eased and visibility improved – Captain reached over and took control of the thrust levers

(continued) (continued)

W037c.8

Qantas Airways Limited

The Landing The Landing

• The Captain initially only retarded # 2, 3 and

4 Thrust Levers

• The F/O immediately realized this and retarded

#1 to idle, however: – With main gear on the ground and # 1 or 4 T/L advanced, the autobrakes disarmed – Speedbrakes deployed automatically after #1 T/L was retarded by the F/O

• The Captain initially only retarded # 2, 3 and

4 Thrust Levers

• The F/O immediately realized this and retarded

#1 to idle, however: – With main gear on the ground and # 1 or 4 T/L advanced, the autobrakes disarmed – Speedbrakes deployed automatically after #1 T/L was retarded by the F/O

(continued) (continued)

W037c.9

Qantas Airways Limited

(continued) (continued)

The Landing The Landing

• The EICAS message “AUTOBRAKES” was not

initially noticed by the Flight Crew

• Manual braking was not applied until 8 seconds

after touchdown, approx 5000 feet down the runway

• No reverse thrust was applied for the whole
• f the landing roll
• The EICAS message “AUTOBRAKES” was not

initially noticed by the Flight Crew

• Manual braking was not applied until 8 seconds

after touchdown, approx 5000 feet down the runway

• No reverse thrust was applied for the whole
• f the landing roll

W037c.10

Qantas Airways Limited

(continued) (continued)

The Landing The Landing

• When manual braking was applied

NO deceleration was felt

• Both pilots exerted maximum force on the

brake pedals, still with no deceleration – The airplane was aquaplaning

• The airplane only began to decelerate as it

entered the last 1000 feet of the runway and the groundspeed reduced below 110kts

• When manual braking was applied

NO deceleration was felt

• Both pilots exerted maximum force on the

brake pedals, still with no deceleration – The airplane was aquaplaning

• The airplane only began to decelerate as it

entered the last 1000 feet of the runway and the groundspeed reduced below 110kts

W037c.11

Qantas Airways Limited DECELERATION

4000f t 5000ft 1 524m 6000ft 1 829m 7000ft 21 34m 8000ft 2438m 9000ft 2743m 1 0000ft 3048m 3287ft 1 002m

Distance from Rwy 21L displaced threshold

S W V

Manual braking indications CAS 154kts GS 1 2k Acft drifting left

• f rw y C/L

CAS 158kts GS 156kts Nose gear touchdow n CAS 146kts GS 145kts Nose gear squat sw itch air mode CAS 143kts GS 141kts Nose gear squat sw itch gnd mode CAS 139kts GS 138kts Acft returning to rw y C/L CAS 107kts GS 106kts Acft on rw y C/L at threshold CAS 96kts GS 92kts Nose gear departs sw y CAS 88kts GS 87kts

ft/sec2

Acft accelerating due to residual thrust Aerodynamic braking

• nly

Aerodynamic and w heel braking Touchdow n Air-gnd logic to gnd mode CAS 156 kts GS 158 kts SPLR start deploy CAS 160 kts GS 158 kts SPLR deployed CAS 160 kts GS 158 kts

• 1

.00

• 2.00
• 3.00
• 4.00
• 5.00
• 6.00
• 7.00

Deceleration at main gear position

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Qantas Airways Limited

Comparison of rollout deceleration on various runway surfaces and VH-OJH 23 September 1999

• 14
• 12
• 10
• 8
• 6
• 4
• 2

2 4 80 90 100 110 120 130 140 150 160 Groundspeed (knots) Deceleration (ft/sec2) 23 Sep BKK Dry Rwy Contam Rwy (Good brkg) Contam Rwy (Poor brkg)

Acft config for various runw ay surfaces:

* 252,000 kg Vref25 + 5 kts * Maximum manual braking * Spoilers deployed, Idle forw ard thrust Ambient conditions: OAT 25 deg C QNH 1013.2 WIND 3.6 kt HWC Flooded runway * Mu 0.05 * Poor braking action Wet runway * Mu 0.20 * Good braking action Dry runway * Mu 0.35 - 0.41 Spoilers deploy Autobrakes disarmed Aircraft drifting left of centreline 5522ft to rw y end Manual braking indications 5002ft to rw y end Aircraft passing over rw y mkgs and abeam tw y W 2536ft to rw y end Aircraft passing

• ver rw y mkgs and

approaching tw y S 1100ft to rw y end Aircraft returning to rw y centreline 770ft to rw y end Aircraft on centreline at start of sw y Aircraft nosegear departs end

• f sw y

2015ft to rw y end

W037c.13

Qantas Airways Limited

Human Factors Human Factors

• Why did this happen ?
• Accident analysis showed:

– A number of significant active failures and – Significant inadequate defences

• Why did this happen ?
• Accident analysis showed:

– A number of significant active failures and – Significant inadequate defences

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Qantas Airways Limited

Active Failures Active Failures

• The runway was affected by water
• Flight Crew failed to use an appropriate risk

management strategy for the approach and landing

• The F/O did not fly the aircraft accurately

during final approach

• The Flight Crew were confused over who had

control and did not select appropriate level of reverse thrust

• The runway was affected by water
• Flight Crew failed to use an appropriate risk

management strategy for the approach and landing

• The F/O did not fly the aircraft accurately

during final approach

• The Flight Crew were confused over who had

control and did not select appropriate level of reverse thrust

W037c.15

Qantas Airways Limited

Inadequate Defences Inadequate Defences

• Company published information, procedures and

training for landing on water affected runways was inadequate

• Flight Crew training in evaluating the procedural

and configuration options for approach and landing was deficient – The crew may have been “pre-conditioned” to the use of Flap 25 and idle reverse thrust

• Company published information, procedures and

training for landing on water affected runways was inadequate

• Flight Crew training in evaluating the procedural

and configuration options for approach and landing was deficient – The crew may have been “pre-conditioned” to the use of Flap 25 and idle reverse thrust

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Qantas Airways Limited

Change Management Change Management

• Published the Boeing document “Landing
• n Slippery Runways” (doc D6-44247) in

the Qantas Flying Manual

• Provided a flow chart to assist Flight Crew

in determining appropriate flap and reverse thrust settings

• Published the Boeing document “Landing
• n Slippery Runways” (doc D6-44247) in

the Qantas Flying Manual

• Provided a flow chart to assist Flight Crew

in determining appropriate flap and reverse thrust settings

W037c.17

Qantas Airways Limited

Aircraft Weight Environmental Conditions Aircraft Weight Environmental Conditions Evaluate Runway Conditions as Reported Evaluate Runway Conditions as Reported Runway Dry Runway Dry Runway Wet Runway Wet Runway Contaminated

• r Slippery

Runway Contaminated

• r Slippery

Determine F25 Landing Field Length Determine F25 Landing Field Length Reported Braking Action Reported Braking Action Is F25 Landing Field Length less than Available Distance? Is F25 Landing Field Length less than Available Distance? Use Flap 25 and Full Reverse Thrust Use Flap 25 and Full Reverse Thrust Determine F30 Landing Field Length Determine F30 Landing Field Length Is F30 Landing Field Length less than Available Distance? Is F30 Landing Field Length less than Available Distance? Use Flap 30 and Full Reverse Thrust Use Flap 30 and Full Reverse Thrust Use another Runway Use another Runway MEDIUM MEDIUM GOOD GOOD POOR POOR Determine F30 Landing Field Length Determine F30 Landing Field Length Do not land unless a greater emergency exists. Hold until conditions improve or divert Do not land unless a greater emergency exists. Hold until conditions improve or divert Is F30 Landing Field Length less than Available Distance? Is F30 Landing Field Length less than Available Distance? Use Flap 30 and Full Reverse Thrust Use Flap 30 and Full Reverse Thrust

Yes Yes Yes Yes No No No No No No Yes Yes

W037c.18

Qantas Airways Limited

Change Management Change Management

• Flight Crew use max reverse thrust as the

“standard” with idle reverse permitted only under stipulated conditions

• Flap 25 is the normal landing flap on

dry runways

• Flap 30 used on wet runways (no credit taken

for grooving or PFC overlay)

• Flight Crew use max reverse thrust as the

“standard” with idle reverse permitted only under stipulated conditions

• Flap 25 is the normal landing flap on

dry runways

• Flap 30 used on wet runways (no credit taken

for grooving or PFC overlay)

(continued) (continued)

W037c.19

Qantas Airways Limited

Change Management Change Management

• Produced CBT package summarising

performance on slippery and contaminated runways

• Provided detailed stopping distance information

for various surface conditions

• Highlighted to crew the importance of using

correct techniques for landing on wet, slippery and contaminated runways

• Included call of “AUTOBRAKES” each time

this is annunciated on EICAS

• Produced CBT package summarising

performance on slippery and contaminated runways

• Provided detailed stopping distance information

for various surface conditions

• Highlighted to crew the importance of using

correct techniques for landing on wet, slippery and contaminated runways

• Included call of “AUTOBRAKES” each time

this is annunciated on EICAS

(continued) (continued)

W037c.20

Qantas Airways Limited

(continued) (continued)

Change Management Change Management

• Monitoring of landing configurations and

touchdown points has shown: – Significant trend towards flap 30 irrespective

• f runway conditions

– Max. reverse thrust used on most occasions – Touchdown points are closer to the “desired”

• point. i.e. less “float”
• Monitoring of landing configurations and

touchdown points has shown: – Significant trend towards flap 30 irrespective

• f runway conditions

– Max. reverse thrust used on most occasions – Touchdown points are closer to the “desired”

• point. i.e. less “float”

W037c.21

Qantas Airways Limited

0% 0% 20% 20% 40% 40% 60% 60% 80% 80% 100% 100%

Trend in Landing Flap Setting Trend in Landing Flap Setting

Percentage

• f landings

Percentage

• f landings

Flap 25 Flap 30

Mar-00 Mar-00 Apr-00 Apr-00 May-00 May-00 Jun-00 Jun-00 Jul-00 Jul-00 Aug-00 Aug-00 Sep-00 Sep-00 Oct-00 Oct-00 Nov-00 Nov-00 Dec-00 Dec-00 Mar-01 Mar-01 Apr-01 Apr-01 May-01 May-01 Jun-01 Jun-01 Jul-01 Jul-01 Aug-01 Aug-01 Sep-01 Sep-01 Oct-01 Oct-01 Nov-01 Nov-01 Dec-01 Dec-01 Jan-01 Jan-01 Feb-01 Feb-01 Mar-02 Mar-02 Apr-02 Apr-02 May-02 May-02 Jun-02 Jun-02 Jul-02 Jul-02 Jan-02 Jan-02 Feb-03 Feb-03

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Qantas Airways Limited

0% 0% 10% 10% 20% 20% 30% 30% 40% 40% 50% 50% 60% 60% 70% 70% 80% 80% 90% 90% 100% 100%

Percentage

• f landings

Percentage

• f landings

Trend in Reverse Thrust Use Trend in Reverse Thrust Use

Idle 40 to 81%N1 >82%N1

Mar-00 Mar-00 Apr-00 Apr-00 May-00 May-00 Jun-00 Jun-00 Jul-00 Jul-00 Aug-00 Aug-00 Sep-00 Sep-00 Oct-00 Oct-00 Nov-00 Nov-00 Dec-00 Dec-00 Mar-01 Mar-01 Apr-01 Apr-01 May-01 May-01 Jun-01 Jun-01 Jul-01 Jul-01 Aug-01 Aug-01 Sep-01 Sep-01 Oct-01 Oct-01 Nov-01 Nov-01 Dec-01 Dec-01 Jan-01 Jan-01 Feb-01 Feb-01 Mar-02 Mar-02 Apr-02 Apr-02 May-02 May-02 Jun-02 Jun-02 Jul-02 Jul-02 Jan-02 Jan-02 Feb-03 Feb-03

W037c.23

Qantas Airways Limited

Trend in Distance From 50’ to TD Trend in Distance From 50’ to TD

Percentage

• f landings

Percentage

• f landings

0% 0% 10% 10% 20% 20% 30% 30% 40% 40% 50% 50% 60% 60% 70% 70% 80% 80% 90% 90% 100% 100%

2000 - 2499ft 2500 - 2999ft 3000ft + 3000ft + Under 1000ft 1000 - 1499ft 1500 - 1999ft

Mar-00 Mar-00 Apr-00 Apr-00 May-00 May-00 Jun-00 Jun-00 Jul-00 Jul-00 Aug-00 Aug-00 Sep-00 Sep-00 Oct-00 Oct-00 Nov-00 Nov-00 Dec-00 Dec-00 Mar-01 Mar-01 Apr-01 Apr-01 May-01 May-01 Jun-01 Jun-01 Jul-01 Jul-01 Aug-01 Aug-01 Sep-01 Sep-01 Oct-01 Oct-01 Nov-01 Nov-01 Dec-01 Dec-01 Jan-01 Jan-01 Feb-01 Feb-01 Mar-02 Mar-02 Apr-02 Apr-02 May-02 May-02 Jun-02 Jun-02 Jul-02 Jul-02 Jan-02 Jan-02 Feb-03 Feb-03

W037c.24

Qantas Airways Limited

Cabin Communications Cabin Communications

• Nose gear collapse resulted in loss of all Flight

Deck / Cabin communications

• Confusion existed as to need for evacuation
• Co-location of back-up comms equipment in an

area prone to damage is considered undesirable

• Provided Flight and Cabin Crew with procedures

to use in the event of loss of Cabin Interphone

• r PA
• Nose gear collapse resulted in loss of all Flight

Deck / Cabin communications

• Confusion existed as to need for evacuation
• Co-location of back-up comms equipment in an

area prone to damage is considered undesirable

• Provided Flight and Cabin Crew with procedures

to use in the event of loss of Cabin Interphone

• r PA

W037c.25

Qantas Airways Limited

Summary Summary

• Provide Flight Crew with the appropriate tools

to do the job

• Train Flight Crew to analyse each landing

separately to determine the appropriate landing configuration

• Ensure procedures for landing on wet, slippery

and contaminated runways are in place and thoroughly understood

• ATSB report available at www.atsb.gov.au
• Provide Flight Crew with the appropriate tools

to do the job

• Train Flight Crew to analyse each landing

separately to determine the appropriate landing configuration

• Ensure procedures for landing on wet, slippery

and contaminated runways are in place and thoroughly understood

• ATSB report available at www.atsb.gov.au