SCENARIO 1 CASE STUDY: NEAR MISS/NEAR HIT INVOLVING QANTAS FLIGHT 32
QF32: How the world's worst air disaster was averted
On 4 November 2010, 469 people on a flight from Singapore to Sydney were in the centre of dramatic events that had the potential to go down as one of the world's worst air disasters. Shortly after leaving Changi Airport, an explosion shattered Engine 2 of Qantas Flight QF32 – an Airbus A380. Hundreds of pieces of shrapnel ripped through the wing and fuselage, creating chaos as vital flight systems and back-ups were destroyed or degraded. The crisis showed every sign of ending tragically. Instead, the plane landed safely a few hours later at Changi Airport in Singapore with all people on board unharmed. At the height of the crisis, the A380's electronic centralised monitoring system ( ECAM ) was spitting out hundreds of alerts on what was wrong with the plane and instructions on what the pilots were required to do to address those defects. It was at this pivotal moment that Captain Richard de Crespigny made a profound decision. As he recalls in his book on the crisis: "I was growing tired of being reactive to the ECAM and I wanted something positive to focus on. There were too many alerts, too many things broken and not much to be achieved by dwelling on them."
Richard de Crespigny, QF32 (McMillan, 2012), p 218.
At that moment, Captain de Crespigny had what he called an epiphany:
"I inverted the logic. I remembered what Gene Kranz, NASA's Flight Director said during the Apollo 13 mission: 'Hold it, gentlemen, hold it! I don’t care what went wrong. I need to know what is still working on that space craft.' We went back to basics and it became easy."
Richard de Crespigny, QF32 (McMillan, 2012), p 198.
Captain de Crespigny's action in focusing on what was right with the plane on that day rather than what was wrong with it, allowed him and his crew to land the plane safely, saving the 469 lives on board.
Source: Case study extracted from Michael Tooma, Due Diligence Series: Incident Notification, Management and Investigation , 2nd Ed, CCH, 2017, see pp 83-84
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