Qantas A333 at Brisbane on Aug 4th 2016, aircraft dispatched although required equipment unserviceable

Last Update: November 22, 2016 / 18:29:55 GMT/Zulu time

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Incident Facts

Date of incident
Aug 4, 2016

Classification
Incident

Airline
Qantas

Flight number
QF-61

Aircraft Registration
VH-QPC

Aircraft Type
Airbus A330-300

ICAO Type Designator
A333

A Qantas Airbus A330-300, registration VH-QPC performing flight QF-61 from Brisbane,QL (Australia) to Tokyo Narita (Japan), concluded the flight with a safe landing on Narita Airport's runway 16L about 9 hours after departure.

On Aug 11th 2016 the ATSB reported however, that the aircraft had been dispatched "with a component of the required navigation equipment recorded as unserviceable". There were no injuries and no damage. The ATSB rated the occurrence an incident, opened an investigation and is interviewing crew as well as gather additional information.

The occurrence aircraft remained on the ground in Tokyo for just less than 2 hours before departing for the return flight. After landing in Brisbane the aircraft remained on the ground for about 5 hours before departing for the next day's QF-61.

On Nov 22nd 2016 the ATSB released their final report releasing following ATSB comment and safety message:

ATSB comment

The ATSB notes that in large organisations there may be multiple departments with responsibilities for the dispatch of an aircraft. Whereas procedures are normally executed within a department, processes often involve multiple departments. Cross-checks occurred within the IOC and separately among the flight crew during this incident flight, but the cross-checks were not conducted between the departments, where personnel had a different mental model of the situation. The flight dispatcher believed the GPS 2 MEL item would be cleared before flight and the captain believed the flight was planned to be released with the GPS 2 as an unserviceable MEL item.

Safety message

This incident highlights the importance of personnel challenging their own assumptions when something does not appear right in the environment. After the dispatch of QF61 from Brisbane Airport, the captain experienced a ‘gut feeling’ that something was not right. Rather than ignore their sense of unease, the captain reviewed the flight plan and company documents, identified the problem and resolved the issue so that the flight could continue without compromising safety. Throughout the process, they kept the other flight crewmembers informed of the problem they had identified and their decision-making, which enabled the crew to provide feedback to the captain.

The ATSB summarized the sequence of events: "The flight was dispatched with one of the aircraft’s two global positioning systems (GPS) units recorded as unserviceable using Saipan Airport as their enroute alternate. As QF61 travelled north along the east coast of Australia, the captain became uncomfortable with their decision to accept the aircraft with an unserviceable GPS. The captain reviewed the flight plan and the publications, and concluded they needed two serviceable GPS units for their planned flight to use Saipan Airport as an alternate. The captain identified Guam Airport as a suitable alternate airport in lieu of Saipan Airport and the flight continued to Narita Airport and landed without further incident."

The ATSB described the flight preparation: "During the process of building the flight plan, the flight dispatcher noticed one of the aircraft’s two global positioning system (GPS) navigation units was recorded as an unserviceable item on the aircraft minimum equipment list (MEL). The flight dispatcher also identified that two serviceable GPS units were required at dispatch, due to the forecast westerly winds, to allow the use of Saipan Airport runway 25 GPS approach as an alternate airport for destination and EDTO purposes. Therefore, they contacted the section of the IOC responsible for aircraft maintenance (maintenance watch) to check if the unserviceable MEL item (GPS 2) would be cleared before the aircraft’s departure.

Maintenance watch indicated that the unit would be fixed and the unserviceability removed before the aircraft departed. The flight dispatcher completed the flight planning documents with the GPS 2 unit listed as an unserviceable MEL5 item – with the expectation that this would be removed before departure. However, the dispatcher did not make a note in the flight planning documents to advise the flight crew that this MEL item should be cleared before the flight departed. They then sent the documents to the flight crew about 85 minutes prior to the scheduled departure time."

The ATSB described crew actions on receiving the documents for the flight: "The captain for QF61 signed on for work at Brisbane Airport at 0945, after receiving an electronic copy of the flight plan and briefing package. After reviewing the package, the captain requested an additional 1,700 kg of fuel to allow for a second mainland Japan destination alternate airport (Nagoya in addition to Haneda) (Figure 1). They then discussed the implications of the unserviceable GPS 2 unit with the other two flight crewmembers. The captain initially thought that two GPS units were required at dispatch because the Saipan Airport runway 25 approach procedure required GPS. However, after further discussion they decided that they were mistaken as maintenance and flight dispatch were aware one GPS was unserviceable and the captain had very few past experiences of an incorrect serviceability requirement at dispatch. One flight crew member then mentioned that the flight crew operating manual indicated one GPS unit was required."

The ATSB wrote describing the events following departure:

As QF61 travelled north along the east coast of Australia, the captain was uncomfortable with their decision to accept the aircraft with GPS 2 listed as unserviceable. Therefore, the captain reviewed the flight plan and the publications. They concluded they had misinterpreted the MEL operational procedures reference to alternate airport requirements and that their flight plan required two serviceable GPS units to use the Saipan Airport runway 25 GPS approach for destination or EDTO alternate airport purposes.

The captain identified Guam Airport (runway 24R VOR/DME10) as a suitable airport to plan to use instead of Saipan Airport for their EDTO alternate airport and briefed the other two flight crew members. However, one flight crew member queried if Guam could be used for replanning in lieu of Saipan without two serviceable GPS units. The attention of this flight crewmember was drawn to a note on one of the Guam terminal plate pages (Figure 2), which indicated runway 24R required ‘primary means GNSS approval’ for use as an alternate airport. However, the captain considered that this was a reference to the destination alternate (which required two separate approaches) and that the runway 24R VOR/DME approach could be used for EDTO alternate purposes (see Use of Guam Airport as an adequate aerodrome).

The captain entered a new critical point between Tokyo and Guam (in lieu of Saipan) into the aircraft flight management and guidance computer. The computer calculated that an extra 800 kg of fuel was required, which was within the limits of the extra fuel the captain requested before departure. The flight continued to Narita Airport and landed without further incident.

The GPS 2 unit was observed by the crew to be serviceable throughout the flight. It was tested by maintenance at Narita Airport, found to be serviceable, and then removed from the MEL unserviceability list before the next flight.

The ATSB mentioned that dispatch commented, that the comment field in the flight plan would be used in the future to communicate if they expected changes of the MEL status of the aircraft prior to departure.
Aircraft Registration Data New!
Registration mark
VH-QPC
Country of Registration
Australia
Date of Registration
JkiAijdnllicnpmg Subscribe to unlock
Airworthyness Category
Gmbhlcfe Accc emAf Subscribe to unlock
TCDS Ident. No.
Manufacturer
AIRBUS INDUSTRIE
Aircraft Model / Type
A330-303
ICAO Aircraft Type
A333
Year of Manufacture
Serial Number
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine
CAdlfhglqgcjdg nAjqlbhndm pbgnqnqjbekkdln gl Subscribe to unlock
Main Owner
Lqldqcg Akji mhhldpklnfeqmj bbgqAjg igAmqcqndbihlilp g lfileinqbbjbedblbApdppA Subscribe to unlock
Main Operator
Peeihgidflppiln fn AidjcligcjAnifkcpnklpbm jqjlqfcfibeenlqkAcfnjde gcAdqepdcen Subscribe to unlock
Incident Facts

Date of incident
Aug 4, 2016

Classification
Incident

Airline
Qantas

Flight number
QF-61

Aircraft Registration
VH-QPC

Aircraft Type
Airbus A330-300

ICAO Type Designator
A333

This article is published under license from Avherald.com. © of text by Avherald.com.
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