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July 3, 2013 5:24 pm
Official reports into disasters are seldom seen as great literature. They should be. They combine tragedy, folly, drama, suspense, heroism and, often, redemption.
I have read many well-written US and British disaster reports. The Australian Transport Safety Bureau report into a 2010 aircraft engine explosion, published last week, is exceptionally good.
The incident examined in the Australian report was not, in the end, a disaster. But it could have been a catastrophe.
Four minutes after take-off from Singapore’s Changi airport on November 4 2010, climbing through 7,000 feet, the flight crew on a Qantas Airbus A380 heard two bangs, followed by warnings on their electronic cockpit monitors.
One of the aircraft’s four Rolls-Royce engines had caught fire. Disc fragments had burst through the engine casing, damaging the left wing, penetrating a fuel tank and shearing wiring systems. This knocked out several of the aircraft’s safety fallbacks, including its ability to jettison fuel.
An “uncontained engine failure” is a fear that haunts aerospace manufacturers. I have sat at Rolls-Royce’s factory in Derby, England, watching slow-motion films of what happens, for example, when large birds fly into an engine. The engine casing swells and distorts, but keeps all the components inside. What aerospace engineers want to avoid, at all costs, is pieces bursting through the engine’s exterior and smashing into the aircraft in mid-air.
In this case, the Qantas pilots managed, in spite of the damage, to land back in Singapore, where all 440 passengers were safely evacuated – a process slowed by the inability of one of the other engines to shut down because of the damage to the aircraft’s systems.
Although engine debris fell over 1.5 square kilometres of Batam Island, Indonesia and one disc fragment tore a hole in a building, it appears no one was injured.
What caused the damage? A manufacturing misalignment of less than 1mm meant that an oil pipe that went into the engine had a wall that was thinner than intended. This led, eventually, to the pipe cracking and oil spraying inside the hot engine and igniting.
That tiny mistake, which could have had such devastating consequences, germinated “over a number of years”, the report said, and was caused not just by the then culture of Rolls-Royce but that of many organisations under commercial pressure.
The report said Rolls-Royce had identified a problem before. In 2007, an investigation into its facility at Inchinnan, Scotland, found staff were allowing “minor non-conformances” in manufacturing because experience had taught them that their superiors would do nothing if they referred them upwards.
In the same year, the company carried out two audits at its Hucknall, Nottinghamshire, plant, where the oil pipe was made, and found problems too. “There was not a strong focus on quality within the business,” the company concluded. Staff were retrained.
In 2009, an engineer spotted the misalignment of the oil pipe and the resulting thin wall and looked at what should be done about the pipes that had already entered service. A decision was made to approve the existing pipes retrospectively. This should have been referred to either the chief engineer or the business quality director. For some reason it wasn’t.
“It was likely that a culture existed within the Hucknall facility that considered that not strictly adhering to the nonconformance management procedures . . .was a viable form of behaviour,” the report said.
Complex organisations can take great care over safety, the report said, but “their natural tendency is to regress”. There is pressure to get things done, to get products out the door. “This natural regression can occur due to the pressures applied via global economic forces, the requirement for developing growth, profit and market share for stakeholders and the striving for greater efficiencies regarded as commercially essential in what is a very competitive market.”
What lessons can we draw? First, a drive for financial success can lead to small lapses that can have enormous consequences. Second, you can’t expect workers to care more about the products than their bosses do. Third, the battle for quality has to be fought every day.
Rolls-Royce says it has learnt the lessons. The report agreed.
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