As I said in my March article, I am not in the blame game. I also said in that same article that Qantas has the best safety record in the world.
I do admit in December 2007 that I took the information about the incident from Australian news sources after I saw a news item about the incident in the Washington Post, a major newspaper here in Washington, D.C., area. The incident was picked up by all the world’s news sources and published a thousand times over before Christmas. So any potential damage to Qantas’ excellent safety reputation was done way before my article hit the streets in AMT magazine in March 2008.
If you step back and objectively read my article, I used the incident to teach airline and repair stations personnel how to perform a human factors analysis of the incident. If the incident happened to United or American Airlines, I would have used that airline as an example. So I want to assure you that I was not out to “get” Qantas airlines.
You say now that only one aircraft was affected, but no one disputes the fact that Qantas had to inspect 50 aircraft because engineers (mechanics) swapped nitrogen fittings on the nitrogen cart with oxygen fittings and that cart was in service for 10 months according to the media sources. New Zealand airline was also alerted of the incident. In December 2007, Qantas was dealing with a very big unknown, and it was smart of your airline to cover all the bases and inspect all the aircraft that flew out of Melboume Airport.
I do have a side question. Did the “inspection” of the 50 aircraft oxygen bottles include your engineers taking air samples from each of the 50 aircraft oxygen bottles and getting them tested in a lab for nitrogen/oxygen ratio or did the mechanics just vent each of the 50 aircraft bottles and service them with oxygen? If it was the latter, the problem with bad air was solved but Qantas and your Australian Transport Safety Bureau (ATSB) would never really know how many of the 50 aircraft pilot’s oxygen bottles were actually serviced with nitrogen.
But whether it was just one aircraft serviced with bad air or 50 aircraft, this time Qantas and the flying public were very lucky that a mechanic spotted the human factor error prior to the aircraft being released for service. Because that one aircraft in which the pilot’s oxygen bottle was serviced with nitrogen has approximately 350 passenger seats. Since the potential for a major problem existed, I cannot understand how you considered that this human factor error was just a minor incident.
So the discussion we are having really revolves around the fact of whether or not servicing the aircraft(s) with nitrogen was a serious or minor incident.
I will apologize in writing if I offended Qantas. I would even include the statement that I would fly Qantas if I ever get down your way. However, I want to see proof in writing that Qantas and the Australian
Transport Safety Bureau consider this a minor incident.
Please send me Qantas’ actual risk assessment of the incident and your ATSB evaluation for my review. I do not want a Qantas press release. I want to see documented proof and a contact number of the person in Qantas who signed the assessment and a name and a contact number at the ATSB who investigated the incident. If the risk assessment and your ATSB say it is a minor incident that did not affect airworthiness and safety along with the associated factual proof, then sir you will get your apology.
If as I believe, Qantas risk assessment and your ATSB says that the incident if left undiscovered was potentially very serious and in order to prevent it from happening again Qantas had to put in additional safeguards, then my article stands.
I was very interested to read the feature in October 2007 issue of AMT; it was Bert Kinner: The ups and downs, His aircraft and power plants, Part 2 by Giacinta Bradley Koontz. It was a very interesting article and I would love to read Part 1. Unfortunately I missed the AMT issue in which it was published (September 2007). Would it be possible to have a copy of Part 1? I would be so grateful if you could help?
— John Thompson, UK
A human factors case study: Qantas’ nitrogen cart
Vacuum anchor technology I read with interest the article in the March 2008 issue page 32 about the “technology developed to protect mechanics and aircraft” by Tim Maroushek. Although I am...