18
B737-300 VH-TJD Missing Liferaft
B737-300 VH-TJD Missing Liferaft
Reproduced courtesy of Qantas
Incident Title Missing liferaft
Location Wellington, New Zealand
Date & Time of Incident 18th August 1998 12:10 AEST
Type of Incident Missing safety equipment
Actual Consequence Nil
Potential Consequence Multiple fatalities arising from a water ditching
due missing life raft equipment
Investigation Team Qantas Corporate Safety
Incident Details
• B737-300 Diverted to ADL due fog in MEL
• “Over water return” check performed in ADL overnight
• All 3 life rafts were removed instead of the required 1.
• Operated to ADL-MEL-SYD
• Aircraft prepared for SYD-Wellington service - “over water preparation
check” performed
• One (1) life raft was fitted but the two (2) permanent life rafts were not
checked
• Captain completed pre-flight check which included life raft inspection -
missed the absence of the 2 permanent life rafts.
• Prior to departure CSM received report from L1 and L2 flight attendants
that all emergency equipment was on board
• Aircraft operated over water to Wellington with insufficient life raft
equipment.
What life raft? - sequence of events
Descriptive level outcome
Cause The Crew must have been careless
Recommendations
Counsel the crew to take more care on their pre-flight
checks.
Send out a safety notice.
Is there something more to be learnt from this incident to
prevent recurrence ? We will let the umpire have a go.
Compliance level outcome
CAUSE: Technical and Cabin Crews were supposed to check that all
emergency equipment was on board prior to departure. That risk
control or ‘defence’ failed in this incident due to poor performance by
the Crews
RECOMMENDATION
The crews should be have a written warning put on their files and
given remedial training.
Or is there something more to be learnt from this incident to prevent
recurrence using ICAM?
System level outcome
What is the process
What is an investigation? What do we want from it?
Step Determine Process Tools
1. “What Happened” Data collection PEEPO
2. “Why it Happened” Collected data analysis ICAM
3. “What are we going to do about it?”
Develop recommendations
Hierarchy of control
4. “What did we learn that we can share?”
Key learnings Incident Report
Team briefings
Raw Data Collection
PEOPLE
Aircraft operated over water to Wellington
with insufficient life raft equipment
PROCEDURES EQUIPMENT ENVIRONMENT ORGANISATION
Task
familiarity
Time
pressure
First Officer
Captain
Raw Data Collection
PEOPLE PROCEDURES EQUIPMENT ENVIRONMENT ORGANISATION
Engineering
Instruction
Sheet (EIS)
CSM
Cabin Crew
ADL Line
Engineer
Cabin Crew failed to
check life raft
equipment in place
Crew life raft
inspection
procedures
Over water return
check process
rarely performed
in Adelaide
Training for
air crew
Training for
engineers
Engineers in non
international ports not
familiar with ‘life raft
removal’ procedure –
no formal back up
process
Life raft
inspection hole
Weather
conditions
Inspection hole poorly
designed , small in
size and difficult to
see through.
Fog in Melbourne
resulted in
diversion to
Adelaide – ‘over
water return check’
a non-routine task
in Adelaide
Significant time
pressure on cabin
crew to conduct
pre-departure
checks
Non-standard life
raft checking
procedures and
training for air
crew
Signage
Ambigious and
contradictory
wording of
Engineering
Instruction Sheet
(EIS) – ‘remove all
over water
equipment’.
Lack of line
engineering
resources in
Adelaide resulting
high workload
Policy for life
rafts on B737
Formal Change
Management
procedures not
adhered to by
Engineering
Management for life
raft upgrade program
Aircraft operated over water to Wellington
with insufficient life raft equipment
Head Flight
Training
Captain conducted
pre-flight check but
missed life raft
removal
Errors not picked up
by flight crew
between ADL and
SYD operations
Head
Maintenance SYD Engineers
assumed ‘over water
return check’ done
correctly in ADL
Life rafts
Confusing signage
along side life raft
inspection hole –
‘permanent life raft
inspection’.
Three different and
separate flight crew
training divisions,
SYD, MEL & BNE
Design of EIS task
card poor
Poor contrast
between life raft and
background colour of
roof insulation – same
yellow colour ADL Engineer
misunderstood
Engineering
Instruction Sheet
(EIS) task card
instructions for
‘over water return
check’
Absent / failed defences
• DF5 Awareness – Work
instruction/procedures: Poor Aircrew
safety equipment check procedures.
• DF 3 Awareness –
Competency/knowledge: Unfamiliar work
procedure in ADL.
• DF5 Awareness – Work
instruction/procedures : Ambiguous
wording of EIS job task card.
• DF5 Awareness – Work
instruction/procedures : Lack of final
inspection and checks by SYD
maintenance
Team / individual actions
• IT 12 Work method error or violation:
ADL engineer misunderstood EIS
task card instructions.
• IT 12 Work method error or violation:
SYD engineers assumed job had
been conducted as per task card.
• IT 10 Hazard recognition/perception:
Captain missed the life raft removal.
• IT 6 Procedural compliance: Cabin
crew failed to check equipment.
Task / environmental conditions
• TE 5 Abnormal operational
situation/condition: Abnormal task for
ADL engineer
• TE 10 Weather conditions: Fog in
Melbourne caused diversions to ADL
• HF 6 Time/productivity pressures: Time
pressure to recover schedule.
• TE 1 Task planning/manning: Shortage
of LAME’s.
• HF 5 Situational awareness: Placard
read “permanent life raft installation” –
confirmation bias.
Organisational factors
• TR ADL engineers had not been
trained in “over water removal
procedure”.
• PR Non-standard checking
procedure by aircrew - training
inadequate.
• MC Protracted B737 life raft
modification program.
• DE Poor design of life raft
inspection hole.
Aircraft
operated over
water to
Wellington
with
insufficient life
raft equipment
Absent /
Failed Defences
Individual/ Team
Actions Outcomes
Task/ Environment
Conditions
Organisational
Factors
DF3 - Unfamiliar
procedure in ADL
DF5 - Ambiguous
wording of EIS
job task card.
DF5 - Lack of
final
inspection and
checks in SYD
DF5 - Poor
Aircrew safety
equipment check
procedures.
IT12 - ADL
engineer
misunderstood
EIS task card
instructions
IT12 - SYD
engineers
assumed job had
been conducted
as per task card
IT10 - Captain
missed the life
raft removal
IT6 - Cabin crew
failed to check
equipment
HF6 - Time
pressure.
TE10 - Fog in
Melbourne
TE5 - Abnormal
task for ADL
engineer
TE1 - Shortage
of LAME’s.
HF5 - Placard
read “permanent
life raft
installation”
MC Protracted
B737 life raft
modification
program.
TR ADL
engineers had
not been trained
in “over water
removal
procedure”
PR Non-standard
checking
procedure by
aircrew -training
inadequate
DE Poor design
of life raft
inspection hole
Aircraft
operated over
water to
Wellington
with
insufficient life
raft equipment
Absent /
Failed Defences
Individual/ Team
Actions Outcomes
Task/ Environment
Conditions
Organisational
Factors
DF11 - Unfamiliar
procedure in ADL
DF11 -
Ambiguous
wording of EIS
job task card.
DF6 - Lack of
final
inspection and
checks in SYD
DF1 - Poor
Aircrew safety
equipment check
procedures.
IT12 - ADL
engineer
misunderstood
EIS task card
instructions
IT12 - SYD
engineers
assumed job had
been conducted
as per task card
IT10 - Captain
missed the life
raft removal
IT6 - Cabin crew
failed to check
equipment
HF6 - Time
pressure.
TE10 - Fog in
Melbourne
TE5 - Abnormal
task for ADL
TE1 - Shortage
of LAME’s.
HF5 - Placard
read “permanent
life raft
installation”
MC Protracted
B737 life raft
modification
program.
TR ADL
engineers had
not been trained
in “over water
removal
procedure”
PR Non-standard
checking
procedure by
aircrew -training
inadequate
DE Poor design
of life raft
inspection hole Must be addressed by a
recommendation.
Recommended Corrective Actions
OFT/
Defence
Hierarchy of Control
Corrective Actions Responsible Timeline
PR & DF1 L3: Admin Issue safety alert to crew about life raft inspection procedures
Safety Within 24 hours
TR, DF11 & DF6
L3: Admin
Develop training register to ensure all station engineers are aware and trained in over water removal procedure and training register compliance.
Maintenance 90 days
PR & DF1 L3: Admin Review aircrew check procedures and implement training to ensure consistency with an annual audit/check requirement
Flight Training
90 days
MC & DF11 L3: Admin Expedite the life raft modification program Maintenance 60 days
DE & DF11 L2: Engineering Redesign the life raft inspection hole to ensure better visibility
Maintenance 90 days
DF6 & DF11 L3: Admin
Review EIS instructions for over water equipment and implement a system to regularly review engineering instructions
Maintenance Within 6 months
1. Management of change projects needs to have a formal risk
assessment process
2. Cannot rely on cross checking to manage human error
Key Learning’s
