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Kay Ismail

on 23 May 2014

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Presentation by Human Factors Specialist

Accidents involved with Human Factors " Qantas 1,1999(Bangkok,Thailand)Boeing 747-400"
Group 14
Aviation Safety Article Presentaion

Kaicy Guan: Introduction
Ming: sequence of event
Owen: CRM and active errors
Subash: Latent error
Owain: Remedies and how they solved the problem
Jerrick: Conclusion
0457910804 sex call (oral only) very SAFE
Qantas started a Fatigue Risk Management group
Designed to work on recommendations for future flight and duty time imitations
The group worked with CASA, Hoeing, Ansett Australia and the University of South Australia
Became known as Fatigue Risk Management System

Flight and Duty Times

Commenced a review of Qantas’ human factors awareness training in 1999
2 day training course developed to replace existing CRM course
Increased amount of annual CRM training for all flight and cabin crews
Updated the Second Officer CRM, initial cabin crew, and recurrent training courses with regards to CRM

Crew Resource Management

Reviewed the role of second officer with emphasis on training and responsibilities
Greater emphasis on circuit training

Second Officer procedures and training

Issued a Flight Safety Order that reinforced CAR 5.170 requirements (Night Recency)
Addressed the issue of long haul operations and lower performing crew
Enforced CASR Part 121A.970
Not allowed to operate as PIC/Co-pilot during Takeoff/Landing unless he or she has carried out 3 take off and landing in the past 90 days….

Flight Crew Recency

Added discussion of Flap 30 Vs Flap 25, Full reverse vs Idle Reverse Landing Scenarios
Submitted application for approval of contaminated runway landing distances
Issued Flight Standing Order (Landing on Contaminated Runways)
Updated Qantas Flying Manual to include Landing on Contaminated Runways

Contaminated Runway Operations
and Approach/Landing

Qantas implemented several procedural changes and training suggested by the investigation conducted by the ATSB.

Contaminated Runways
Flight Crew Recency
Second Officer Procedures and Training
Crew Resource Management
Flight and Duty Times

Safety Action -Qantas
The most significant incident in fifty years of Jet operations for Qantas!

Possible period of complacency due to the extended time of safety?


Weather Issues

Fig 3

Fig 2

Fig 4

Fig 5

Fig 1


Fig 2

Management issues with runway distance required and wet slippery runways.

Fig 3

Fig 1

Review of the flight, was proper CRM used adequately throughout the incident.
The obvious answer is “NO”
First example, ATC informed Qantas One that that thunderstorms and heavy rain with vis of 4000 or greater were expected. In this situation, the crew should have then decided runway joins, conditions, and expected approach. By showing an adequate amount of CRM in used, the crew would have identified that the runway was indeed “wet” and a slower approach would then be used.
Second example, when the captain decided to reject the go-around without properly informing his crew members. Which clearly shows minimal to none CRM used and was one of the active errors of this entire incident

CRM in used

-crew did not consider the potential of the runway being wet, and did not identify the proper approach. (flaps 25, idle reverse)
First officer did not maintain centerline accurately during the final approach
-The captain aborted go-around, while taking control, captain did not comply with company's proper handover procedure.
The crew did not notice the absence of full reverse thrust.
-The runway surface was affected by water.

Active Errors

effective usage of all available resources and information to achieve safe and efficient flight operation.
CRM has evolved so much over the past decades since it was started my United airlines in 1981.
Helmreich’s and others have distinguish “six generations” of CRM training

Crew Resource Management (CRM)

Estimated Flight to Bangkok Airport was 8hours 23min
VH-OJH Boeing747-438 Departed Sydney-Kingsford Smith International Airport, Australia
Local Time 1647 (23 SEPT 1999)
Thunderstorm was forecast at Bangkok Airport. Approach made to land was bad .
On 23 September 1999, 2247 local time, a Qantas Boeing 747-438 registered VH-OJH overrun the runway while landing at Bangkok International Airport, Thailand.
Event: Qantas flight 1

Aircraft type: Boeing 747-438

Summary: Runway overrun (21R)

Date: 23 September 1999

Location: Bangkok, Thailand

Fatalies: 0

Non-fatalities: 38 (minor injuries)

Flight origin: Sydney Airport

Stopover Don Mueang International Airport (Bangkok Airport)

Destination: London Heathrow Airport
Full transcript