Qantas: Oxygen cylinder explosion

In November 2010 a Qantas Boeing 747, enroute from Hong Kong to Melbourne, experienced an explosion of an oxygen cylinder.  Qantas’ performance before, during and after the incident was exemplary at all times, but the media was never going to pass up the opportunity for some aero-sensationalism.  Here were some thoughts of my younger self about this circus at the time – specifically, the difference between the way a pilot or engineer might describe events, and how the media portrayed it:

This engineering maintenance business with Qantas gets more preposterous by the minute.

It all started with the oxygen bottle explosion over the Pacific.  A serious incident, no doubt.  An industry professional might have observed there was a cabin depressurisation, following which the aircraft descended to a suitable altitude, and diverted to the nearest suitable airfield where is made an uneventful landing.  However, in the hands of the media, this became a “terrifying plunge” in which passengers were only too happy to line up and say how they “thought they were going to die.” 

Next on the scene were the Australian aircraft maintenance technicians, ready to push their agenda that this showed why their jobs needed to stay in Australia.

It now seems not a day goes by without another breathless account of a delay somewhere as some minor item was repaired, a defective component was changed or some paperwork was fixed up.

How is it possible that a situation where nothing bad happens to anyone – no-one gets killed or even injured, becomes front-page headline news story?  Where faults are identified, corrective actions are taken, items are repaired or replaced, and inspections are carried out, all with the desired effect of assuring the safety of passengers and crew?  Where aircraft land normally, never leave the ground or don’t even start up when a problem is detected?  Where the very worst thing that has happened to anyone has been some inconvenience for passengers?

It seems that ever since the initial trigger event, the media pack has descended en masse upon Qantas so that all the normal, minor faults that occur all the time in every aviation operation, whether it be an airline, a squadron, or a flying school have become major news.

What have we seen in the last few days?   A range of incidents including a missing insignificant panel, some hydraulic leaks, some minor component failures, some trouble with paperwork, and yes, a small number of quite significant equipment failures.

And what was the result of these incidents for passengers?  Nothing.  No-one was killed, injured, or in most cases even aware there was a problem.

But what do we see reported?  Qantas was “in turmoil”….”embarrassed”…”troubled.”

In every case we have had the same beat-up involving passengers (if they actually boarded the aircraft at all) who were sure they were going to die, and the inevitable union rep suggesting that this showed why maintenance should stay in Australia (although it could equally well be demonstrating the opposite).

And why did nothing happen?  Here is the real story.  The answer is because the aircraft are so well designed, built, and operated; maintenance procedures are so rigorous, flight procedures are so meticulous, pilots are so well trained, quality assurance and the whole safety management system is so effective, and the company safety culture so pervasive that faults, failures and mistakes, when they occur (as they always will), are detected and addressed.  The key element of the systems safety approach is to ensure that these problems never link together into a causal chain that might otherwise lead to an accident, and this is exactly what we see.

It is total nonsense to suggest that Qantas should be “in turmoil”….”embarrassed”…or even ”troubled.” How is it embarrassing that the airline is so safety-conscious it won’t allow its aircraft to fly when there is merely some doubt as to whether an inspection was carried out years ago? 

All of the incidents to date, and the follow-up actions initiated by Qantas itself and the regulator, demonstrate nothing more than how well the system is working.

People need to understand that Qantas is not International Rescue.  A Boeing 747 is not like Thunderbird 2.  Despite the incredible level of overall system reliability, little things go wrong all the time. Instruments fail, hydraulics leak, warning lights illuminate, and sometimes things break. 

Aircrew are not infallible either.  Mistakes are made, people forget things, and the full range of human fallibility is present, as in any other field of endeavour.

None of this should be surprising to anyone.  We live in a world of imperfect machinery, systems, procedures, and people.  Aircraft are far more carefully designed and built than almost any other artefact, but they are structures and machines nevertheless.  Pilots and aircraft maintenance technicians are some of the most highly skilled and disciplined tradesmen there are, but they are nevertheless human and capable of making mistakes, as are we all.

What is important about safety management systems, and air safety in particular, is the manner in which systems, processes, and people work together to identify equipment failures and personal errors, and to manage them so that the consequences of all the stuff which happens all the time remain minor, if they are noticed at all.

Compared to other activities like driving in the car, or going skiing for the weekend, it shouldn’t be hard for most people to figure out which is by far the safest activity.