We will not accept any kind of lapses

It became public this month that Qatar Airways has fired all four pilots in the cockpit when their Boeing 777 tail broke a set of runway lights during takeoff from Miami International last September. They mistakenly left from an intersection thousands of feet short of the planned full runway length. It was a serious accident, no doubt. There was a visible tear to the aircraft’s skin, the pressure vessel was damaged, and MIA airport needed some new approach lights.

Photos from QCAA report
Damage to aircraft and approach lights. Photo source, QCAA report.

The crew continued with the overwater thirteen plus hour flight uneventfully, apparently unaware of their close brush with disaster. But damage of this kind prompts an investigation. Airport security cameras recorded the airliner’s tail hitting the approach lights. So we know what happened. The real question is why? Was it a hurrying reckless crew? Or should we praise the flying pilot for sensing something was wrong and rotating just in time? And how serious was this?

Bending metal never is good. The damage was all fixable–about 18 square meters of damaged sheet metal, pressure vessel breached behind rear cargo door–but the possibility of a truly serious accident, of real danger to life, was certainly close. A little less performance, a little less runway, and continued flight may have been questionable.

The aircraft started the departure roll from the T1 intersection off a midfield taxiway, leaving less than two-thirds the normal runway length of 13,000 feet available for takeoff. That’s certainly plenty of pavement in a Cessna, or indeed an A320. But a fully loaded B777? Using a reduced takeoff power? Not so much.

Yellow line is aircraft ground roll. Source, QCAA report.
Yellow line is aircraft ground roll. Photo source, QCAA report.

The Qatar Civil Aviation Authority (QCAA) preliminary report clearly details the event, and finds some compelling human factors that shed light on how an experienced captain (over 9,000 hours total time, including almost 1,000 on the B777) and three other pilots could think they were doing everything right. In fact, the report has no suggestion of recklessness, carelessness or intentional violations by the crew.

Zooming in on the taxi chart on a tablet may remove the ‘big picture’ view, leaving you to see a major intersection as close to end of the runway. It was a dark night. Planes landing on the runway were touching down close to the intersection, leading the relief pilots to think it was close to the end of the runway (but actually the landing threshold was displaced 511 meters). And both the captain and first officer thought they had the performance numbers for intersection T1.

Printout of onboard performance tool. Photo source QCAA.
Printout of on-board performance tool data. Photo source QCAA.

Unfortunately 09#T1 refers to “T1” engine performance conditions, not the “T1” intersection on runway 9.

It seems like a normal accident. A variety of engineering and human factors all lining up on a dark night.

So why have all four pilots been fired?

“At Qatar Airways we will not accept any kind of lapses by pilots because they have hundreds of passengers whom they risked.”

Akbar Al Baker
Qatar Airways chief executive
Interview, 3 March 2016, The Sydney Morning Herald

Oh dear. It’s the ‘fire and forget’ philosophy of flight safety (which is one step beyond ‘blame and train’). Stupid pilots. Bad pilots. Dangerous pilots. Now that they have been let go, the head of Qatar has publicly stated that passengers could rest assured the Miami incident was the “first and last” time it would happen at his airline.

The “first and last” time?

PRIDE GOETH BEFORE A FALL

This one accident was a too-close high-energy brush with solid ground. But the message firing the pilots sends to every other pilot, bag loader, dispatcher, flight attendant and gate agent at the airline is a much more dangerous explosive charge. If you make a mistake, however easy due to poor engineering or bad luck or human factors or complex unforeseen interactions, and if you want to keep your job, you best be quiet.

While some media outlets praised the firing decision, “To say, this was the right decision on the part of Qatar is an understatement”, I am saddened. This totally destroys the open sharing of little incidents that lets us all change procedures and behaviors before a large accident happens. This is completely counter to the well-known and proven paths of Just Culture. This is against the philosophy of ASAP and NASA ASRS and UK CHIRP and SMS and just about any open safety system that is conducive to reporting, engagement and safety improvement.

If you “won’t accept any lapses”, on fear of firing, then your employees will not report any. However, I’ll bet you a billion dollars to a bagel that slips and errors and lapses and engineering complexities will happen. And one day, it will be CNN reporting what happened, not the friendly safety department.

cup

It’s scary when management’s response to safety incidents is to offer a big steaming cup of STFU.

Let’s be careful up there. And share our experiences, fun or frightening.

 

 

25 thoughts on “We will not accept any kind of lapses

  1. I’ve been told on many occasions that Qatar is a disaster in the making due to this policy of fear.

    Now I have the proof. I will never recommand friends and family to fly Qatar. Not because of their pilots but because of their lousy management. This management has not learned anything from the past. Terrible.

    And that’s not counting with the obnoxious social and HR way of managing too. This is the 21st century, not god damn middle-age or even industrial revolution !

  2. The error or mistake is human and must be taken in count. It’s a question of safety.
    If you fire a pilot or a ground staff at the first mistake, all people will sut their mouth.

    Qatar and some airlines cannot act like this. I won’t fly with them.

  3. When pilots start worrying about being reported, rather doing the safe thing. It becomes dangerous to everyone.

  4. “Such kind of incidents happen quite often, either it is a tail strike on the runway or it is contact with the landing lights.”

    And:

    Qatar Airways chief Akbar Al Baker says instructions from air traffic controllers resulted in the September runway light collision in Miami, despite evidence of confusion in the cockpit.

    “It was an instruction given to our pilot by the air traffic control, which he should have refused to accept,” says Al Baker at a media event in New York today. “However, he had enough runway for getting airborne and it was only an unfortunate incident. At no time was the aircraft or the passengers put in any harms way.”

    So when did this become a “serious risk”?

  5. Yes a highly undesirable old time “knee jerk” reaction from management, going against current safety environments of just culture. Looking at the photo of the Miami airport layout, you don’t have to be a qualified investigator to see those taxiways could very easily become very confusing. What a classic also, the engine performance parameters “T1” with the taxiway having the same number “T1” as I understand it. I know not everything could be in this short relating of the events, but to me the most challenging airmanship/management potential decisions occurred after the event, did the crew suspect a strike, apparently not…the most interesting scenarios are, had the captain suspected a strike, dumped fuel and landed back, only to find no damage, and a huge cost to the company, what would managements reaction have been? Had they aborted landed back and found the subsequent damage, what would managements reaction have been? These to me are the interesting questions regards to safety culture. I can see that continuing the flight with a damaged pressure hull, which could have resulted in a catastrophic rupture of the hull under the pressure differential at high altitude, was a big factor for management, but to me not the true safety issues/errors here. Have to admit I think I will avoid flying with this airline, after this reaction to the crews mistake.

  6. So now you just cause people not to disclose . This will result in silence in fear of being fired. So how do you improve to make for a safer environment . We can all learn from others….

  7. I guess the CEO must also lead by example. Should he fail or perform poorly, does he not face his own sacking…

  8. Nik says
    To all airlines in the world.STOP LETTING YOUR CREWS TAKING OFF FROM INTERSECTIONS SPECIAL ON ER FLIGHTS THERE IS NO NEED.FUEL BENEFITS ARE NEGLIGIBLE.
    IT IS AN UNNESSASERY PRESURE IN THE COCKPIT DURING CRITICAL FACE OF DEPARTURE.
    To have a long runway in front of you is a benefit for many unexpected reasons
    don’t through it away for 200 or 300 kilos of fuel.

  9. I have flown wide body aircraft for 21 years and have never left runway behind me by doing a intersection takeoff. That is a very poor decision especially when starting a long haul flight at night on a wet runway. Maybe a suspension and more training would be a more acceptable punishment rather than dismissal, after all these are experienced pilots and are hard to replace. Captain Edward Grell. (Retired with 17000 Jet time)

    1. What would be the purpose of the suspension / more training? If this was an error, then it was unintentional and a deterrent cannot therefore be effective.

      If a proper investigation was completed and the incident was as a result of a reckless act, then this is a different matter. Even if the event was due to a violation, or deliberate non-compliance with established procedures, we have to understand the performance influencing factors before the correct response is identified.

      Our free to download FAiR tool mat stimulate some further thought on this – bear in mind that this is only effective if a proper investigation has been completed.

      http://www.bainessimmons.com/aviation-consulting-services/smarrt-tools/fair-system/fair-system-download/

  10. Decisions like this are the result of a Tribal/Authoritarian social structure in Qatar, and how the brains of the execs there are programmed to think like this. Commercial aviation (both execution and construction of the planes) requires more sophisticated, empathetic development. Needless to say, Qatar is not exactly an empathetic background culture.

    To understand and explore how this works, I’ve actually put up a video on my blog about the China Airlines fire and remediation. It was a TED talk. You might take a look here:

    http://empathy.guru/a-short-video-on-empathetic-organization/

    Chuck Pezeshki

  11. Hi There, I really enjoy reading the article on this blog. Its interesting and eye opener to many areas of flying. Thank you.

    Skipper David

  12. Couple of true stories about Qatar Airways.
    One Engineer was sacked because, paint on aircraft was slightly different in shades. Which was not his fault. He did aircraft acceptance from another country.

    One Pilot was sacked as he was drinking water onboard during exhaustive summer. He was return after a long flight and after passenger disembarkation.

    One cabin crew was demoted as she forgot on dish exact name.

    Culture of fear is common.

    1. Boeing 777 is two person cockpit( Pilot and Co-Pilot). Why he fire other two pilots. They were resting in rest area untill first two pilots relieve from duty after certain hours of flying duty on long haul flight.

  13. Qatar is notorious for it’s sacking culture. I wouldn’t want to work for them no matter how much they pay.

  14. Right up front, I am not an aviation expert. I do know something about safety. I agree with everything that has already been said about the culture of Qatar, but additionally I am disturbed that (apparently) MIA has made no changes. Why is a departure roll from the intersection off a midfield taxiway ever acceptable? A protocol that all take offs start from the established point at the beginning of the runway with appropriate coding (green line, lighting, etc.) would go a long way to preventing similar incidents across airlines and aircraft.

  15. To ban all intersection departures would be a knee jerk reaction. When properly planned, there is no inherent danger in this practice. To force a high performance light jet to taxi to the end of a 9000 ft runway when they only need 4000 ft makes no sense and could increase congestion and taxi times for all operators. In this case it appears the crew were confused about their exact location on the runway. I wouldn’t normally expect a long haul heavy to accept an intersection departure, but that presumes we know the incident aircraft’s loading. Perhapps even a lightly loaded long haul heavy could safely perform intersection departures in some cases.
    I’m in complete agreement that firing the entire crew without evidence of negligence or willful non compliance is detrimental to safety. As a manager, I have always made it a point to thank those who have come forward to admit making a mistake. It is also crucial to perform and complete proper incident investigation before deciding what remedial actions are appropriate.

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