Sunday, August 03, 2008

Getting the truth out of Qantas

You try it. The Civil Aviation Safety Authority has pledged to. I found it disturbingly difficult.

Below are two stories I wrote for The Canberra Times last week about a series of air incidents on QantasLink flights between Sydney and Canberra. And below that is the email trail that was created as I attempted to get information for the second story.

Granted, Qantas has had its hands full recently. The least forgivable incident in my view is the failure of elastic in oxygen masks. Why the hell do they spend so long telling us how to put them on when they don't appear to maintain them? How often do they check the masks? How long does it take the rubber attached to a mask to perish?

But their approach to (not) answering questions actually ties up more of their resources than answering them would.

Worse, it suggests a systemic desire to cover up rather than open up when things go wrong... one that one day could make things go really wrong.

Here are two extracts from the emails below:

1. Part of the problem with at least one of the QantasLink flights was that the right landing wheel didn't fully retract. I wanted to know whether there had been other such incidents, so I asked:

Question: Have there been other incidents in which the landing wheel of a QantasLink Dash 8 Q400 has failed to retract?

Qantas reply: The main landing gear retracted fully on each occasion. The only issue was the doors not fully closing.

2. This is a question that I asked in order to clarify an earlier "answer":

Question: What was the effect of the air in the hydraulic system? Your answer says that it led to "landing gear door issues"?

Qantas answer: Correct.

Imagine if Qantas line management treated their senior managers that way...

"Have there been other incidents like this in which the landing wheel of a
Dash 8 Q400 failed to retract?"

"The main landing gear retracted fully on each occasion. The only issue was the doors not fully closing."

"Just give me an answer, will you. And while we are at it, what was the effect of the air in the hydraulic system? You said it led to 'landing gear door issues'?

"Correct."


It's scary. Very.

Here are my two Canberra Times stories and then the email trail:


Monday August 28

A QantasLink Dash 8 flew three times between Canberra and Sydney earlier this year with a landing wheel that was unable to automatically retract.

The Civil Aviation Safety Authority investigated the aircraft and discovered that air had made its way into the hydraulic system that was meant to retract the wheel.

It asked Qantas to change its operations procedure and asked the plane's manufacturer to modify its maintenance manuals.

CASA was alerted to the incidents by a Canberra aviation economist Akis Haralabopoulos who told it that on Monday January 28 he had traveled to Canberra on QF1461 "with a limited but reasonable view to the starboard turbo-propeller and landing gear".

He said after the aircraft took off there was "a strange whirring noise" from the right and the captain announced that the right landing gear was not retracting.

"The landing gear to my amazement and best visual assessment was neither fully extended down nor fully retracted," Mr Haralabopoulos wrote.

The captain announced that the landing gear would be retracted "manually".

"I considered this to be unusual but did not contemplate lodging a complaint," Mr Haralabopoulos wrote to CASA.

"However, on Friday morning February 1, 2008. I was alerted that a colleague of mine also flew on two Dash 8 Q400 flights, also on Monday January 28.

"I was advised by my colleague that the crew retracted the gear manually whilst enroute to Sydney. I presume that this is the same aircraft I had just arrived on."

"On my colleague's afternoon return flight from Sydney to Canberra the starboard landing gear [again] did not
retract. The Captain on this occasion returned to Sydney airport."

Mr Haralabopoulos told CASA that "a reasonable assessment that three separate flights experiencing difficulty retracting landing gear all in one day and all requiring manual intervention strongly indicates that there are underlying problems with the aircraft's airworthiness."

After what it termed an "extensive investigation" covering four months CASA wrote that its Flight Operations and Airworthiness Inspectorate had determined that the hydraulic pump that was meant to retract the wheel had failed, activating the backup power transfer unit.

"It would appear that the same aircraft you traveled upon twice returned to the point of departure due to undercarriage problems caused by air in the hydraulic system," it said.

"The aircraft was subsequently removed from service for inspection. It is important to note that these returns were purely precautionary and the aircraft could have proceeded on to its destination in complete safety."

CASA reported that it had asked Qantas to change its flight operations procedure for operating the power transfer unit and asked Bombardier, the manufacturer of the Dash 8 Q400, to modify its maintenance manuals "so as to prevent the introduction of air into the hydraulic system".

Qantas had also put in place a changed procedure for its engineers to follow during maintenance.

Qantas was last night unable to confirm that in January it had continued to fly the Dash 8 Q400 between Sydney and Canberra after being alerted to problems with its landing gear.

It bought seven of the planes from Bombadier during 2006 and continues to use them on the Canberra-Sydney route.

In March this year Bombadier agreed to pay $170 million in compensation to the Swedish airline SAS for problems with its Dash 8 Q400 fleet.

Three of its Bombardier-built Dash 8 Q400 crash-landed within weeks of each other last year.

The airline grounded its Dash 8 Q400 fleet permanently.

Mr Haralabopoulos told the Canberra Times that he was pleased that CASA had taken his complaint seriously and had gone to an extreme in asking Qantas to change its procedures.

"But I don't fly the Dash-8 Q400 between Canberra and Sydney anymore," he said.


Friday August 1:

Fresh details have emerged of a series of incidents on a series of QantasLink flights between Sydney and Canberra in which parts of the hydraulic system that controlled the landing wheels failed.

Qantas has confirmed that the hydraulic pump failed the 11:45 am flight from Canberra to Sydney on the Australia Day January 28 holiday.

The airline’s group general manager for regional services Mr Narendra Kumar told the Canberra Times that the aircraft's backup power unit was activated and that the aircraft landed in Sydney normally.

The hydraulic pump was replaced but on the next flight of the Dash 8 Q400 – from Sydney to Canberra the following morning - air was detected in the hydraulic system, meaning that the landing gear doors could not properly close.

A Canberra aviation economist Mr Akis Haralabopoulos on the flight complained to the Civil Aviation Safety Authority that he heard “a strange whirring noise” from the right and that the captain announced that the right landing gear was not retracting.

Mr Kumar said to the best of its knowledge the right landing gear did retract without intervention and that the only problem was that the landing gear doors did not fully close.

When the plane landed in Canberra efforts were made to clear the clear the air from the hydraulic system, which turned out to be unsuccessful.

On its next flight to Sydney the Dash 8 Q400 still had air in its hydraulic system, meaning that the landing gear doors did not close once again.

A further attempt to remove the air on its arrival in Sydney was apparently successful and the Dash 8 Q400 made several more flights that day without incident, until the 5.20pm flight to Canberra on which the landing gear doors were slow to close and the captain returned the plane to the airport.

The aircraft Dash 8 Q400 was again inspected and cleared to resume service.

It has operated since on the Canberra to Sydney route without incident.

Mr Kumar said the hydraulic pump on Dash 8 Q400 aircraft had failed on four other occasions since their introduction to the fleet in 2006.

There had also been “a small number” of incidents involving air in the Dash 8 Q400 hydraulic system.

In March this year the airline introduced a new routine inspection procedure for all Dash 8 Q400 hydraulic pumps and has since had no failures.

Also in March the plane’s manufacturer Bombadier agreed to pay the Swedish airline SAS compensation of $170 million for problems with its Dash 8 Q400 fleet.

Three SAS Dash 8 Q400 crash-landed within weeks of each other.

The airline grounded its Dash 8 Q400 fleet permanently.


Emails, first first:

from Peter Martin
to Sophia Connelly
date Mon, Jul 28, 2008 at 3:10 PM
subject QantasLink Dash 8 Q400

Hi Sophia,

I am following up today's Canberra Times story about the airworthiness of QantasLink's Dash 8 Q400 fleet.

I spoke to you yesterday - a very busy Sunday - and you were unable to get back to me with a complete reply

I have pasted in the story below, and also extracts from a letter from the Civil Aviation Authority about the incident.

These are my questions:

1. Can QantasLink confirm that hyydrolic pump that was meant to retract the right landing wheel of the Dash 8 Q400 failed on three seperate flights on the Canberra-Sydney route on Monday January 28, 2007?

2. Was the same Dash 8 Q400 involved in all three incidents?

3. Have there been other incidents in which the landing wheel of a QantasLink Dash 8 Q400 has failed to retract?

3. Did QantasLink continue to fly the aircraft which had the problem on QF1461 rather than ground it immediately?

4. What action did Qantas take?

5. Does it still use the Dash 8 Q400 on the Canberra-Sydney service?







Peter Martin
____________________________________________________________

Peter Martin
The Canberra Times
Parliament House
Canberra ACT 2600


from Peter Martin
to Sophia Connelly
date Tue, Jul 29, 2008 at 12:26 PM
subject FW: QantasLink Dash 8 Q400


Hi Sophia,

When do you think you will be able to get me answers?

Kind regards,


Peter
____________________________________________________________

Peter Martin
The Canberra Times
Parliament House
Canberra ACT 2600

from Holly Williams
to Peter Martin
date Tue, Jul 29, 2008 at 2:11 PM
subject Fw: QantasLink Dash 8 Q400



Peter,

I am looking after this request - am seeking clarification and will get back to you asap this afternoon.

Kind regards, Holly.

Holly Williams
Senior Corporate Communication Adviser I Qantas Airways Limited
Qantas building A, Level 7, 203 Coward St
Mascot NSW 2020 Australia


from Holly Williams
to Peter Martin
date Tue, Jul 29, 2008 at 6:10 PM
subject Qantas response



Peter,

Response below, attributable to Qantas Group General Manager Regional
Airlines, Mr Narendra Kumar:

1. Can QantasLink confirm that the hyydraulic pump that was meant to
retract the right landing wheel of the Dash 8 Q400 failed on three seperate
flights on the Canberra-Sydney route on Monday January 28, 2007?


This is incorrect. The hydraulic pump failed on one occasion only and the
aircraft's back up power unit was immediately activated to aid the
hydraulic system. The landing gear was retracted fully, but the doors did
not fully close.

The pump was replaced before the aircraft's next scheduled flight.
The subsequent landing gear door issues were due to air in the hydraulic
system, not any component failure.


2. Was the same Dash 8 Q400 involved in all three incidents?


Yes. On each occasion, the aircraft was inspected in accordance with
QantasLink and manufacturer requirements and cleared to resume service.

3. Have there been other incidents in which the landing wheel of a
QantasLink Dash 8 Q400 has failed to retract?

The main landing gear retracted fully on each occasion. The only issue was
the doors not fully closing.

4. Did QantasLink continue to fly the aircraft which had the problem on
QF1461 rather than ground it immediately?


After the landing gear doors initially did not close completely, the crew
responded in accordance with their training and standard procedure which
immediately resolved the situation inflight. The aircraft then landed in
Canberra with the landing gear and doors fully operational.

5. What action did Qantas take?

We immediately began working with the aircraft manufacturer to develop
several enhanced hydraulic system operating and maintenance procedures.
Since then, we have not experienced any further issues with Q400 landing
gear doors.

6. Does it still use the Dash 8 Q400 on the Canberra-Sydney service?

Yes. Qantas also operates B737 aircraft on the route.

7. Does it regard the plane as safe?

Absolutely. Safety is our highest priority. This was not a safety issue in
any way.


from Peter Martin
to Holly Williams
date Wed, Jul 30, 2008 at 11:36 AM
subject RE: Qantas response


Hi Holly,

Thanks.

As I mentioned, these answers raise follow-up questions:

In Question 3 I asked whether there had been other been other incidents in which the landing wheel of a QantasLink Dash 8 Q400 has failed to retract.

Narendra Kumar's answer corrected me as to the nature of the incidents.

So the follow up question is - has QantasLink had other such incidents with Dash 8 Q400 flights in which the hydraulic pump that is meant to retract the landing wheel failed, or air found its way into the hydraulic system, or the doors did not fully close,

If the answer is yes - how many? And when?

I am trying to get an idea of whether the incidents on Monday January 28, 2008 were isolated.

Question 4 asked whether QantasLink continued to fly the aircraft which had the problem on QF1461 rather than ground it immediately.

Is the answer "yes"?

And can I get clarification as to the sequence:

It reads as if the hydraulic pump failed on QF1461, then the landing gear was fully retracted by the backup power unit, and then the doors either "did
not fully close" or were "fully operational".

Which was the case?

Then when QF1461 arrived in Canberra the pump was replaced before the aircraft's next scheduled flight.

Is that when air was introduced into the hydraulic system?

What was the effect of the air in the hydraulic system? Your answer says that it led to "landing gear door issues".

On landing, the aircraft was "inspected in accordance with QantasLink and manufacturer requirements and cleared to resume service".

Did this fix the problem on the next flight, or did air get back into the hydraulic system on that very next flight?

When was the aircraft "removed from service to ensure serviceability" as CASA says.

In other words, I want to know the sequence.

It might help for Mr Narendra Kumar or one of his staff to phone me and talk me through what happened.

Thanks.

Kind regards,


Peter

____________________________________________________________

Peter Martin
The Canberra Times
Parliament House
Canberra ACT 2600


from Holly Williams
to Peter Martin
date Wed, Jul 30, 2008 at 5:08 PM
subject QantasLink response



Peter,

Response below, attributable to Qantas Group General Manager Regional Airlines, Mr Narendra Kumar:

A Q400 aircraft operating a flight from Canberra to Sydney on Monday 28 January experienced a hydraulic pump failure.

The aircraft's back up power unit was immediately activated to aid the hydraulic system. The landing gear was retracted fully. The aircraft was removed from service immediately upon arrival in Sydney (as referenced by CASA) and a thorough investigation was undertaken.

The hydraulic pump was replaced before the aircraft's next scheduled flight, which was on Tuesday 29 January.

The subsequent landing gear door issues on Tuesday 29 January and Wednesday 30 January were due to air in the hydraulic system, not any component failure. On each occasion, air in the system caused the gear doors to not fully retract. Engineers inspected the aircraft and removed air from the system.

Additional responses:

QantasLink has experienced four other incidents of hydraulic pump failures since the introduction of the aircraft to our fleet in 2006. On each occasion, the back-up systems operated as required and the undercarriage retracted fully.

We have thoroughly investigated the causes, in conjunction with the manufacturer. As a result, in March 2008 we introduced a new routine inspection procedure for all Q400 hydraulic pumps. Since then, we have had no pump failures.

What was the effect of the air in the hydraulic system? Your answer says that it led to "landing gear door issues"?

Correct.


Qantas Airways Limited
ABN 16 009 661 901


from Peter Martin
to Holly Williams
date Wed, Jul 30, 2008 at 6:02 PM
subject Re: QantasLink response



Dear Holly,

Thanks.

But I had better hold the story over for another day yet again.

The answer has me more confused than before.

For one thing, QF1461 was (and is) a flight from Sydney to Canberra, not the other way around.

The only way that I will get a handle on what did happen - and the order in which it happened - is for Narendra Kumar or another Qantas officer to go through it with me.

Can we do this tomorrow?

Thanks.

Kind regards,


Peter Martin
____________________________________________________________

Peter Martin

The Canberra Times
Parliament House
Canberra ACT 2600


from Holly Williams
to Peter Martin
date Thu, Jul 31, 2008 at 9:09 AM
subject Re: QantasLink response


Peter,

According to our records, the passenger flew on Tuesday 29 January.

QF1474 CAN-SYD on Monday 28 January was when the aircraft experienced a
hydraulic pump failure.

Subsequent issues - on Tuesday 29 January and Wednesday 30 January - were
due to air in the hydraulic system.

Kind regards, Holly.

from Peter Martin
to Holly Williams
date Thu, Jul 31, 2008 at 4:11 PM
subject QantasLink Dash 8 Q400 Chronology



Hi Holly,

I have set down what I understand that Qantas understands happened.

Can you let me know if I have any of it wrong?

And could you clarify the questions I have posed in brackets?

Thanks.

Peter



QF1474 Monday 28 January, Canberra to Sydney, departing 11:45 am, due 12:38 pm

The hydraulic pump failed and the aircraft's back up power unit was immediately activated to aid the hydraulic system. The landing gear was retracted fully, but the doors did not fully close.

The aircraft was removed from service immediately upon arrival in Sydney (as referenced by CASA) and a thorough investigation was undertaken.

The hydraulic pump was replaced before the aircraft's next scheduled flight, which was on Tuesday 29 January.

*(Is this correct? Was the plane that arrived in Sydney at 12.38 pm really not scheduled to fly again until 6.45am the following day?)

QF1461, Tuesday 29 January, Canberra to Sydney, departing 6.45am, due 7.35am.

Complaint: "There was a strange "whirring" noise from the starboard of the aircraft.
The noise was not typical of the turbo-propellers operation and from observing only the propeller there was nothing wrong with the propeller's operation.

The Captain made an announcement that there was "a technical problem" with the right landing gear. Inter alia the Captain said that the landing gear was not retracting.

To the best of my knowledge and visibility the starboard landing gear had indeed not retracted.

The landing gear to my amazement and best visual assessment was not fully extended down NOR fully retracted.

The Captain also announced that the gear would be retracted "manually" and this would be "cycled through" as a part of "procedures".

Qantas: There were "landing door issues due to air in the hydraulic system and not to any component failure". "Air caused the gear doors not to fully retract."

"After the landing gear doors initially did not close completely, the crew responded in accordance with their training and standard procedure which immediately resolved the situation inflight. The aircraft then landed in Canberra with the landing gear and doors fully operational."

*(Was the landing gear itself stuck for a time, as observed by the complainant? Was the aircraft's back up power unit activated, as apparently heard by the complainant and apparently advised by the Captain? How is this different from component failure?)

The aircraft was inspected in accordance with QantasLink and manufacturer requirements and cleared to resume service.

The same aircraft - QF1462 departing Canberra for Sydney at 0800, minutes later.

Complainant: "The aircraft had difficulty retracting the starboard landing
gear. The crew retracted the gear manually whilst enroute to Sydney."

The aircraft was inspected in accordance with QantasLink and manufacturer requirements and cleared to resume service.

*(There may have been subsequent flights with air in the hydraulic system on Tuesday 29. Were there? How many?)

QF1489 Tuesday 29 January, Sydney to Canberra, departing 1720.

Complainant: "The starboard landing gear did not retract. The Captain on this occasion returned to Sydney airport."

The aircraft was inspected in accordance with QantasLink and manufacturer requirements and cleared to resume service.

Wednesday 30 January
Issues with air in the system.

(*How many flights?)

(*What was the last flight on which there was trouble with air in the system. In other words - when was it fixed for good.)


Other instances:

QantasLink has experienced four other incidents of hydraulic pump failures since the introduction of the aircraft to our fleet in 2006. On each occasion, the back-up systems operated as required and the undercarriage retracted fully.

We have thoroughly investigated the causes, in conjunction with the manufacturer. As a result, in March 2008 we introduced a new routine inspection procedure for all Q400 hydraulic pumps. Since then, we have had no pump failures.

(*How many other incidents has the Dash 8 Q400 had of air in the hydraulic system? Is it a continuing problem or did it also stop as a result of the new routine inspection procedures instigated in March.)

(*Can I check about the landing wheel doors on each occasion.? Were they "fully operational" or did they "did not fully close" during the flight?)

(*If the doors did not close during the flight - on how many occasions has this happened with Dash 8 Q400 flights?)

Thanks.


Peter
____________________________________________________________

Peter Martin
The Canberra Times
Parliament House
Canberra ACT 2600

from Holly Williams
to Peter Martin
date Thu, Jul 31, 2008 at 6:25 PM
subject Fw: QantasLink Dash 8 Q400 Chronology



Peter,

Response below, attributable to Narendra Kumar.


QF1474 Monday 28 January, Canberra to Sydney, departing 11:45 am, due 12:38 pm

The hydraulic pump failed during descent into Sydney and the aircraft's

back up power unit was immediately activated to aid the hydraulic system.

The landing gear extended fully and the aircraft landed normally.

The aircraft was removed from service immediately upon arrival in Sydney (as referenced by CASA) and a thorough investigation was undertaken.

The hydraulic pump was replaced before the aircraft's next scheduled
flight, which was on Tuesday 29 January.

*(Is this correct? Was the plane that arrived in Sydney at 12.38 pm really
not scheduled to fly again until 6.45am the following day?)


CORRECT

QF1461, Tuesday 29 January, Canberra to Sydney, departing 6.45am, due 7.35 am.

Complaint: "There was a strange "whirring" noise from the starboard of the aircraft.
The noise was not typical of the turbo-propellers operation and from observing only the propeller there was nothing wrong with the propeller's operation.

The Captain made an announcement that there was "a technical problem" with the right landing gear. Inter alia the Captain said that the landing gear was not retracting.

To the best of my knowledge and visibility the starboard landing gear had indeed not retracted.

The landing gear to my amazement and best visual assessment was not fully extended down nor fully retracted.

The Captain also announced that the gear would be retracted"manually" and this would be "cycled through" as a part of "procedures".


We cannot comment on what the passenger has reported, however we can confirm that the gears were not retracted manually. The aircraft has no systems for retracting landing gear manually - it can only extend landing gear manually.

We can confirm that the landing gear was not operated manually at any stage during this flight.

Qantas: There were "landing door issues due to air in the hydraulic system and not to any component failure". "Air caused the gear doors not to fully retract."

"After the landing gear doors initially did not close completely, the crew responded in accordance with their training and standard procedure which immediately resolved the situation inflight. The aircraft then landed in Canberra with the landing gear and doors fully operational."

*(Was the landing gear itself stuck for a time, as observed by the complainant?


NO

Was the aircraft's back up power unit activated, as apparently heard by thcomplainant and apparently advised by the Captain? How is this different
from component failure?)


NO - the gear was fully retracted by the hydraulic system.

The aircraft was inspected in accordance with QantasLink and manufacturer's requirements and cleared to resume service.

The same aircraft - QF1462 departing Canberra for Sydney at 0800, minutes later.

Complainant: "The aircraft had difficulty retracting the starboard landing gear. The crew retracted the gear manually whilst enroute to Sydney."


Not correct - it is not possible for the landing gear to be manually retracted.

The aircraft was inspected in accordance with QantasLink and manufacturer
requirements and cleared to resume service.

*(There may have been subsequent flights with air in the hydraulic system on Tuesday 29. Were there? How many?)


Yes - Engineers carried out a procedure to remove air from the system after QF1462.

The aircraft operated QF1471 SYD-CBR without incident.

During QF1472 CBR-SYD, the landing gear doors were slow to close, due to air in the system. Another procedure to remove air from the system was conducted in Sydney.

The aircraft subsequently operated QF1485 and QF1486 with no technical issues.

QF1489 Tuesday 29 January, Sydney to Canberra, departing 1720.

Complainant: "The starboard landing gear did not retract. The Captain on this occasion returned to Sydney airport."


The landing gear doors were slow to close. At no point did the aircraft receive indication that the landing gear failed to retract properly, however the crew did receive an indication that the landing gear doors had failed to close, at which point the crew elected to return to Sydney.

The aircraft was inspected in accordance with QantasLink and manufacturer requirements and cleared to resume service.

Wednesday 30 January
- no flights affected.

(*What was the last flight on which there was trouble with air in the system. In other words - when was it fixed for good.)

QF1489 Tuesday 29 January was the last flight that experienced any issues with the hydraulic system.

Other instances:

(*How many other incidents has the Dash 8 Q400 had of air in the hydraulic system? Is it a continuing problem or did it also stop as a result of the
new routine inspection procedures instigated in March.)


QantasLink has experienced four other incidents of hydraulic pump failures and a small number of instances involving air in the hydraulic system.

As discussed, in March 2008 we introduced a new routine inspection procedure for all Q400 hydraulic pumps. Our maintenance department also reviewed and enhanced the procedures used to remove air from the aircraft's hydraulic system. Since then, we have had no pump failures nor any issues with air entering the hydraulic system.

(*Can I check about the landing wheel doors on each occasion.? Were they
"fully operational" or did they "did not fully close" during the flight?)


The landing gear doors did not fully close on two other occasions.

(*If the doors did not close during the flight - on how many occasions has
this happened with Dash 8 Q400 flights?)


Refer above

How does a hydraulic pump failure differ to air in the hydraulic pump?

If a hydraulic pump fails, the aircraft is designed with two separate back up systems to provide hydraulic power to ensure the landing gear can be retracted or extended fully. As a further safeguard, if no hydraulics are available, the landing gear can be extended manually.

When the hydraulic pump failed on 28 January, the aircraft's back up power unit was immediately activated to aid the hydraulic system as required. In other words, there was no effect to the aircraft.

When air entered the hydraulic system on the other occasion, it had the effect of preventing the gear doors from being fully closed.

***

Peter - we have now provided you with full clarification on all relevant details regarding this issue, including the sequence of events.

We have nothing further to add.

Kind regards, Holly