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UCD-STAFFORDBEER  January 2008

UCD-STAFFORDBEER January 2008

Subject:

Re: System failure reply to Stuart

From:

Arthur Dijkstra <[log in to unmask]>

Reply-To:

Forum dedicated to the work of Stafford Beer <[log in to unmask]>

Date:

Tue, 22 Jan 2008 11:43:22 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (1109 lines)

Dear Stuart,
Thanks for your reply. I might mix terms since this is not familiar terrain
for. I am a pilot on the B777 and safety investigator so that is more my cup
of thee.
The matrix (that was how I showed in my mail) was meant as an example of an
accident classification matrix. I am not fully happy with it and one of the
reasons is the mix of genotype and phenotype. Your suggestions to modify the
list have the same mix.
The homeostat is supposed to keep the essential variables within
physiological limits. I regard the pilots with their equipment (autopilot
etc) as the control system of the aircraft. This Joint Cognitive System is
supposed to keep speed, altitude and course within limits or else the
aircraft may crash. 
Now if we take a homestat as principle how can we describe an accident in a
more specified way ? 
I thought that if we take an ontological approach (the highest level of
variety said Roger) how can we then describe an accident (situation where
control is lost) ? I ran into a wall repeating the same thoughts and hope
one of you can give a suggestion ? 

Thanks
Arthur

-----Oorspronkelijk bericht-----
Van: Forum dedicated to the work of Stafford Beer
[mailto:[log in to unmask]] Namens Stuart Umpleby
Verzonden: 22 January 2008 02:01
Aan: [log in to unmask]
Onderwerp: Re: System failure

Arthur, I am struggling with your use of terms, but here are some thoughts.
1.  Add "taxi" after landing?
2.  Add equipment failure?  The tail of a plane broke off climbing out
of NY in recent years.  "Uncontrolled collision with ground"?
3.  Shoot down by military jet or terrorist on ground.  "Uncontrolled
collision with ground"?
4.  You do not mention loading -- passengers, crew, baggage, food,
fuel.  "Uncontrolled collision with ground"?
5.   Where would you put "incorrect computation of needed fuel".  A
famous case in Canada.  "Uncontrolled collision with ground"?
Bad things can happen in the air before the plane encounters the ground.

You say, "If we take the cybernetic approach an accident can be
described as a homeostat out of balance. The critical variables of
speed, altitude and course went out of balance. May I have you
comments on that please !."

The homeostat was a device that demonstrated ultrastability -- the
ability to restructure itself in order to keep a set of variables
within limits.  I believe that autopilots are not ultrastable.  An
ultrastable autopilot would function effectively, though not
immediately, even if it were miswired.  That is, it would change its
parameters, its structure, in order to compensate for miswiring.  I do
not know what "out of balance" means in this case.  "Out of bounds,"
meaning variables outside of acceptable range, would be better.  In a
plane the autopilot provides first level feedback (when circumstances
are normal).  The pilot provides second level feedback, when
overriding routine is needed.  The homeostat did both.  So, the plane
plus pilot is ideally a homeostat (variables are kept within desired
limits).  I would say an accident happens when the homeostat (plane
plus pilot) fails.  Hence the suggestion for additional help --
calling a coach on the ground for help when the plane plus pilot
system seems to be in trouble.  This would be adding an additional
feedback loop.  Of course, there is the possibility that the "helper"
would simply provide additional noise and distract the pilot.  A
machine designed to correct for "pilot error" would be able to
override the pilot.  Similar issues are being discussed in the case of
"driverless" cars.

I would not use the word "ontology" here.  To me what you have
constructed is a "conceptual framework,"  a useful one.  A legal
conceptual framework was suggested earlier in the discussion.
"Ontology" is often a claim of objectivity or certainty.  Does your
client require that?
Regards, Stuart



On Jan 21, 2008 4:21 PM, Arthur Dijkstra <[log in to unmask]> wrote:
>
>
>
>
> Roger et all,
>
> Thanks for your response. Again your reply seems very interesting but I
have
> trouble digesting the full meaning, so we need more iterations. So here I
go
> and hope that you will follow.
>
> My problem with current safety management practices is that it is reactive
> and based on very simple models. The data that is selected is of the type
> that is easy to get. These data points are eg safety reports of a
incorrect
> weight and balance sheet, report of an overspeed, report of a procedure
that
> went wrong, investigation why a crew did not follow the procedure,
> investigation why an airplane wing hit another during taxi, number of to
> fast approaches, etc I hope you get the flavour of the kind of data we
> collect. These event are assigned a risk level , low mid high, and a
> classification, suh as flight management, ground handling etc. This is
done
> by one of the 4 flight safety officers. Risk is severity x probability.
The
> severity is judged on the reported situation, not on what might have
> happened. These data is then put in a management report which shows
> frequency of selected events. These are often the events which contain the
> high risk. The management reports may lead to a further analysis of
specific
> events many management desire so. (I think these reports lack requisite
> variety (RV) but I am unfortunately not able to 'prove' that)
>
> This is normal safety management in airlines. The linking between the
> registered events and accident models is new. So the creation of meaning
out
> of the data is still very immature.
>
> My intention is to design accident models which cover the scope of how you
> can crash an airliner. These models then serve as a basis to collect data.
> Not just that what is easy to report. This data should then via the models
> lead to information that enables the management to take action before
severe
> mishaps occur. One step further is the modelling that allows management to
> see the impact on safety when other (not obvious safety related) decisions
> are made. But that will be later.
>
> Below you find an example of a new classification set of all the possible
> accident that can occur.
>
>
>
>
> Taxi
>
> Take-off
>
> Initial Climb
>
> En-route
>
> Approach
>
> Landing
>
>
> Abrupt manoeuvre
>
>
>
> X
>
> X
>
> X
>
> X
>
>
>
>
> Cabin environment (fire, O2)
>
> X
>
> X
>
> X
>
> X
>
> X
>
> X
>
>
> Uncontrolled collision with ground
>
>
>
> X
>
> X
>
> X
>
> X
>
> X
>
>
> Controlled flight into terrain
>
>
>
>
>
> X
>
> X
>
> X
>
>
>
>
> Forced landing
>
>
>
>
>
>
>
>
>
>
>
> X
>
>
> Mid-air collision
>
>
>
>
>
> X
>
> X
>
> X
>
>
>
>
> Collision on ground
>
> X
>
> X
>
>
>
>
>
>
>
> X
>
>
> Structural overload
>
>
>
> X
>
> X
>
> X
>
> X
>
> X
>
>
> Fire/Explosion
>
> X
>
> X
>
> X
>
> X
>
> X
>
> X
>
>
>
>
>
> Now with classification we must be careful. We can make a pheotypical and
> genotypical description of an accident (event). A description in a
phenotype
> is the description of the manifestation of a system failure without
> inference of how the accident came about, so before the analysis and thus
> without genotypes. Call it a neutral observer (please accept this notion
> which I realise is not without problems) So different observers would
agree
> on the phenotype. An example could be the B777 that crash landed at LHR
last
> week. A phenotype description could be 'distance to short". We all agree
> that he did not make the landing runway. With this description we do not
> make inferences of what went wrong. The list of phenotype description
> contains all the 3 dimensional unities and time. That covers the physical
> descriptions in which a system may fail.
>
>
>
> So far I hope you are following this is where cybernetics rubber meets the
> safety road.
>
>
>
> The genotypes are a collection of 'causes' or better explanations why a
> system has failed. Here the theory in use becomes dominant. Depending on
the
> models used causes are constructed and explanations are made. 'Human
error"
> has for quite some time be a accepted "cause", while we now realise that
> this is more a consequence of the conditions found themselves in than a
> "cause".
>
> If we take the cybernetic approach an accident can be described as a
> homeostat out of balance. The critical variables of speed, altitude and
> course went out of balance. May I have you comments on that please !.
>
> The loss of RV is another general description but needs further
> specification, operationalisation, to be useful in safety management.
>
> In safety science the latest generation of accident models describe an
> accident as an unexpected combination of interactions that lead to a
> situation that could not be controlled. The variability of the
environment,
> the context surrounding the work situation of the pilots, results in
> performance variability. The aviation management (as opposed to the
> operators themselves) should in this model try to reduce the variability
of
> the context, design for systems able to cope with the variability and
> design, and maintain variability (risk) control systems. SO via the
control
> of e.g competing goal, operational support ( resources) management can
> influence safe performance. These contextual factors should be monitored
and
> managed.
>
>
>
> So I hope you are still with me.
>
>
>
> An ontological accident model is generic for every domain of application.
It
> should that be made specific for aviation. This would then result in the
> requirements for data, which would then lead to management information
> allowing informed control decisions.
>
> In Stafford's Control and decision I read after page 259 (I think) how he
> describes hat organisation are more or less blind and don't feel their
> environment. I thought that was a very apt description of the simplistic
now
> often used in the already very safe aviation domain. Data collection
should
> allow the organisation to see and feel their context to render that in a
way
> that it makes sense and support survival actions.
>
> He also described the use of short term forecasting in the steel mill to
> prevent iron bars flying through the factory. That technique sounds very
> interesting and might be very useful for aviation safety. But it requires
a
> new way of thinking and I feel I am so 'aviation native" that it is hard
to
> abstract and generalise without help.
>
>
>
> I hope this text gets us in the 'same book' and allow you to apply general
> theory, via me as translator, to the aviation safety management domain.
>
> Thus how can we develop an ontological accident model, that can be
specified
> for aviation and guides the search for data to reduce organisational
> blindness and become proactive ?
>
> How can we make cybernetics applied in aviation safety.
>
> Thanks for you responses !
>
> Regards,
>
> Arthur
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>  ________________________________
>
>
> Van: Forum dedicated to the work of Stafford Beer
> [mailto:[log in to unmask]] Namens Roger Harnden
>  Verzonden: 21 January 2008 15:39
>  Aan: [log in to unmask]
>  Onderwerp: Re: System failure
>
>
>
>
>
> Arthur,
>
>
>
>
>
> Congratulations at exploding the highest degree of variety EVER!!
>
>
>
>
>
> It might be completely irrelevant, but here goes.....
>
>
>
>
>
> There's a guy called William (Bill) Powers who wrote a book called
> 'Behaviour: the Control of Perception'. Both Stafford and Thomas Kuhn (
'The
> Structure of Scientific Revolutions') refer the book.
>
>
>
>
>
> Bill's thesis is that it is our structural coupling with our niche that
> determines our perception, conception and interaction with it  (Of course,
> 'understanding' as a higher level recursion of recurrent coordination of
> language, then becomes a struggle back to that ontology). Basically, the
way
> we 'bump into' things and events through our sense and our total
physiology
> (as in 'bodyhood dynamics' - Maturana), determines the meaningfulness of
> what we 'see'.
>
>
>
>
>
> Hence, to address your original query - not so long ago, but many
iterative
> comments!!!! - I would posit that you consider the 'behaviours' that are
> likely to impact on the design, use and interpretation of data from,
> aviation control processes.  If you consider the range of behaviours that
> might inhibit or increase consideration and openness to the underlying
> issues of 'crash', you will have the shape of a route forward, This way
> forward will include design guidelines,
>
>
>
>
>
> Roger
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
> On 19 Jan 2008, at 15:39, John GI Clarke wrote:
>
>
>
>
>
>
>
>
> At the risk of boring everyone with another South African 'first', read
the
> story on this link.  It tells of a pilot successfully landing a Boeing
B737
> after one of its engines came off on takeoff from Cape TownInternational
> Airport.  The pilot was able to circle, dump the fuel, and land safely, to
> the relief of 107 passengers and crew.
>
>
>
>
>
>
http://www.aviationdimension.com/modules.php?op=modload&name=News&file=artic
le&sid=1548&mode=thread&order=0&thold=0.
>
>
>
>
>
> Vanilla, I am copying it to Simon as I would be grateful for his comments,
> both on the incident and on the way in which Aviation Dimension reports
the
> story, and the assumptions it makes about the working conditions of flight
> crew, etc,etc.
>
>
>
>
>
> The pilot Trevor Arnold and his co-pilot has been feted as heroes, and
have
> received award and endless commendations, which while understandable
rather
> misses the point that a disaster was avoided because of good systems
> principles having been in place - notable the redundancy principle in that
> there were two engines and two pilots.
>
>
>
>
>
> It so happens that the pilot Trevor Arnold, is an old high-school friend.
> Among our peers he was somewhat set apart by the fact that he had bad
asthma
> which affected ability to play sport with the rest of us.  So instead he
> would spend every available hour at the local airfield "hanging around the
> hangars".  He got his pilots licence before his drivers licence.  Having
had
> the privilege of being a passenger with in a four seated Cessna that
Trevor
> co-piloted 34 years ago when he was just 17.
>
>
>
>
>
> This has inspired me to working on a feature to sell to an in flight
> magazine that will try to offer some intelligent insight for passengers,
and
> helps Trevor - actually a shy and modest chap - to explain the episode as
a
> system success story rather than a component failure/ heroic pilot story.
>
>
>
>
>
> As it happens I also happen to have a brother-in-law who is a Qantas
pilot,
> who like Trevor was flying before he could drive.  I hope to get his
> perspective too.
>
>
>
>
>
> So Arthur, thanks for setting off an interesting dynamic of exchange - a
> system of emergent properties, unpredicted and unpredictable. Where will
it
> end?  Maybe to help some passenger reading an article in an in-flight
> magazine shortly, that sets him or her for success in sorting out South
> Africa's electricity crisis.
>
>
>
>
>
> John
>
>
>
>
>
>
>
> John G I Clarke
>
>
> Consultant Social Worker, Development Facilitator, Writer.
>
>
> Blairgowrie, Johannesburg.
>
>
> Tel:  + 27 83 608 0944:    Fax 0866842405
>
>
> Email: [log in to unmask]
>
>
> Post: P.O.Box 2408, Pinegowrie, 2123
>
>
> Skype: johngicskype.
>
>
> Connecting People.... Managing Ideas.....Choosing Life
>
>
>
>
>  ________________________________
>
>
>
> From: Forum dedicated to the work of Stafford Beer
> [mailto:[log in to unmask]] On Behalf Of Vanilla Beer
>  Sent: Friday, January 18, 2008 1:35 PM
>  To: [log in to unmask]
>  Subject: Fw: System failure
>
>
>
>
>
>
> I laughed so much at Steves Quantas jokes that I forwarded them to Simon
> Beer, (Staffords son and my brother) who is a trained pilot - here is his
> contribution to the debate, featuring the Quantas myth and other useful
> info:
>
>
>
>
>
>
>
> ----- Original Message -----
>
>
>
> From: Simon Beer
>
>
>
> To: Vanilla Beer
>
>
>
> Sent: Thursday, January 17, 2008 11:32 PM
>
>
>
> Subject: RE: System failure
>
>
>
>
>
> Hi love,
>
> Thanks for the e-mail which I haven't seen before.  Although I am very
> familiar with the funnies.  Usually there's a lot more but most of them
are
> quite technical.
>
> This list started life as American ground crew response in their military
> aircraft.  I hope it is anyway.  The IFF referred to in the list stands
for
> Identify Friend or Foe.  A useful piece of equipment that identifies you
to
> ground radar before you are shot down by a bloody great guided missile.
> (The actual original written fault was 'IFF does not work in OFF mode'.)
>
> Maybe I'm prejudiced by being plagued with the operational requirements of
> flying. Your friend who wrote the original e-mail seems to have no
> understanding of how flight crews or aviation protocols operate.  For
> instance, any instruction given to an aircraft is read back by the
aircrew.
> So that air traffic are aware that the commander of the aircraft received
> and understood the message.  This works in both directions between the air
> and the ground.  The interaction between the aircrew, (CRM - Cockpit
> Resource Management) is extremely precisely defined down to the actual
words
> that are used.  The words are deliberately chosen so they do not sound
> similar to other flight safety critical words.  For instance, during the
> war, if the bomb aimer wanted the pilot to fly the aircraft to the right
> would say 'right'.  If he wanted the aircraft moved to the left he would
say
> 'left left'.  This avoided any confusion.
>
> The handling pilot, as a matter of course, briefs the other pilot on the
> takeoff and climb out, as part of the pre-takeoff cockpit checks.  And
again
> before landing.  There are two very famous accidents that were caused by a
> high ranking captain with a low ranking first officer who would not
> contradict his senior colleague..  The first is Tenerife, the worst
aviation
> accident to date (583 fatalities) when two Boeing 747's hit each other on
> the active runway.  The problem arose because the KLM first officer did
not
> contradict his most senior training captain, the handling pilot, when he
> commenced his takeoff without clearance.  The first officer knew they had
> not been cleared to take off and eluded to the fact that another aeroplane
> was coming the other way down the same runway. However he did not actively
> state that they had not been cleared for takeoff nor try to stop his very
> senior captain from commencing his takeoff roll.  The other was a Korean
> airlines Boeing 747 which took off at night from Stansted.  The captains
> attitude indicator (artificial horizon) was faulty.  His instrument showed
> that he was commencing a wings level climb when all the other instruments
on
> the flight deck indicated a rapid descent with an increasing angle of
bank.
> Again, the senior captain was not questioned by his junior first officer.
> The first officer died rather than contradict his captain.  To an extent,
> these are cultural problems, and, it is hoped that they have been stopped.
>
> Twice a year every commercial pilot flies in a simulator.  Part of the
> simulator ride is to assess the crew and their decision-making
capabilities.
> Anybody who has to go through this ordeal will point out that crew
> interaction and decision-making ability is very closely monitored and
> commented upon.  Identifying a fault in a modern aircraft can be extremely
> taxing.  Even more so in a simulator where they may mix two or three
> different faults into the melting pot just for you.  Assumptions are
> constantly questioned by both pilots.  They have to be.  This is not to
say
> that they don't get it wrong.  The famous Boeing 737 crash at Kegworth
> caused by the crew's inability to identify which engine was faulty, was
> hampered by instruments that had been crossed over so that the reading
from
> the right hand engine was being displayed on the left hand engine gauge.
> Under these circumstances a crash is almost inevitable no matter how
skilled
> the crew or what preventative system is in place.  But the accident was a
> one off.  Subsequent investigation found several aircraft had had this
> wiring crossover problem but the system demanded that they all be checked,
> and in checking, the faults were discovered.
>
> By the way the 'gripe sheet' referred to is actually the 'Tech log' a
legal
> document held with every aeroplane. It is a legal requirement to fill in
any
> faults experienced in flight.  It must be completed and signed by every
> pilot on landing.
>
> Here's an interesting one then. There is a well developed urban myth that
> Qantas never have any accidents.  (The same as also said of Aer Lingus)
> Below are a few incidents that show that Qantas make the same cock-ups as
> other airlines.  They are no worse and no better than most professional
> airlines.  Simply put, the premise that one airline is doing something
> different from another airline, and that makes it have less crashes, is
> fallacious.  It just isn't so.  No airline wants a crash and they are all
> learning from each other all the time, after all, they almost all fly the
> same aeroplanes - Boeing or Airbus.  Their crews are all trained by the
same
> training organisations and their SOP's (standard operating procedures) are
> policed by the world's aviation authorities assuming that these aircraft
are
> flying internationally.
>
> It is generally accepted in the aviation industry that aircraft accidents
> are statistically so improbable as to be unpredictable.  Inevitably
> accidents happen.  Look at the number of movements per day and marvel that
> the accident rate is so low.  But we have one aircraft land short at
> Heathrow and it hogged the news all day here.  Listening to the aviation
> 'experts' wheeled out on the radio is frankly sick making.  Soon, the AAIB
> (Air Accident Investigation Branch) will issue their report which will be
> incredibly detailed.  If there is a systemic problem it will immediately
be
> recognized and measures will be immediately put in place to guarantee that
> the same thing couldn't happen again.  More probably, it will identify a
> series of minute detailed faults or errors that culminated in this problem
> and the probability of this chain ever happening again in the next
thousand
> years is nil.
>
> Operational Research (preceding Cybernetics) played a huge part in
aircraft
> development during the 40s and 50s which resulted in the incredible levels
> of safety achieved to date.  One of the best stories that introduced
> Operational Research to aviation concern the air ministry who divided a
> specific type of aircraft into tiny little squares and numbered each
square.
> Using this 'map', they insisted that every time a battle damaged aircraft
> landed, the exact detail of the damage should be plotted using the
numbered
> squares to form a mosaic of the damage.  This is all right so far.
>
> Once they had a detailed assessment from many aircraft that had been
damaged
> before returning to their bases, they set out to design armour plating
that
> exactly matched the battle damage identified by the 'maps'.  It took and
> Operational Research scientist to point out that they should be armouring
> all the places on the aeroplane, that were not identified on the map.
> Because the aircraft with the identified battle damage had come back.  It
> was the aircraft that had been hit in the other places and that didn't
come
> back that needed protecting.
>
> There are many excellent books concerning the analysis of aviation
> incidents.
>
> A very famous crash was the Chinook helicopter on the Mull of Kintyre.
> Stuart Campbell's book, 'Chinook Crash' gives a superb analysis of crash
> investigation from all sides.  It rather horrifyingly details the systemic
> failures of both the military investigative abilities and the failures of
> the inquest system to identify the cause of the crash.  The military had a
> vested interest in the outcome of the enquiry and so prejudiced it's
> outcome.  The AAIB who investigate civil aircraft crashes, operate above
> everybody.  They are free to criticise the Civil Aviation Authority, the
> aircraft manufacturers, the aircraft operators, the government and their
air
> traffic controllers or the pilots, with no interference.  Their job is to
> clearly identify the cause of the accident and offer, where appropriate,
> ideas on how to stop it happening again.  They do not apportion blame.  By
> and large this is an extremely successful solution and rarely does the
same
> accident happen twice.
>
> Other books such as 'The Naked Pilot' by David Beaty go into the
psychology
> of flying accidents.  Whilst 'The Killing Zone' by Paul Craig looks at
pilot
> assumptions and inexperience.  'Pilot Error' by Ronald and Leslie Hurst
> examines the human factors in aviation crashes.  I discovered to my horror
> that I have 47 books on aircraft crashes, they cause, analysis, and
> recommendations on how to stop it happening again.
>
> If the CAA (Civil Aviation Authority or Campaign Against Aviation) had
their
> way, they would ground all pilots.  For this surely is the best way of
> avoiding accidents.
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>   Having worked on aircraft accident investigation and analysis at the
> British Aircraft Corporation, I think perhaps a more interesting form of
> research that could produce some very useful information when applied to
> other disciplines, might be how the aircraft industry has developed such
> incredibly safe aircraft containing so many individual components and
> trained ordinary people to work within such tightly defined flight
> parameters.  For instance, are their parallels that could be employed in
the
> automotive industry?  which, by comparison, has a dreadful safety record.
>
>
>
> Some Qantas incidents:
>
> The full name is QANTAS: Queensland And Northern Territory Aerial Services
>
>
>
> QANTAS accident at Bangkok's Dom Muang International Airport
>
> The case involved a Qantas B747-400 that attempted to land during a heavy
> rainstorm September 23, 1999, at Bangkok's Dom Muang International
Airport.
> In the terse wording of the Australian Transport Safety Bureau (ATSB)
> report, "The overrun occurred after the aircraft landed long and
aquaplaned"
> down Runway 21L. Because the crew did not apply reverse thrust (per
company
> policy to rely on the carbon brakes instead), and because the captain
called
> for a go-around and then almost immediately reversed this decision, the
> airplane roared off the end of the runway at a speed of about 88 knots
(100
> mph.), continuing through wet, "boggy" soil before grinding to a stop with
> the nose resting on the airport perimeter road. A precautionary evacuation
> using the escape slides was initiated about 20 minutes later. None of the
> three flight crew, the 16 flight attendants, or the 391 passengers abroad
> the flight fromSydney reported any serious injuries. The airplane was
> damaged to the tune of some $100 million.
>
>
>
> QANTAS accident at JFK
>
>
> On Sunday, 28 May 2006, Qantas flight QF107 hit the blast fence at
Terminal
> 7 while taxiing to its gate. As a result, the starboard side wingtip was
> damaged. The aircraft was VH-OEE, a Boeing 747-400 ER, named the Spirit of
> Australia. The aircraft was in the hangar at John F. Kennedy (JFK) for
three
> days before emerging with only one winglet. On 11 June, the outer 3-4' of
> the wing were removed and replaced by Boeing employees. The plane finally
> made the trip back to Australia on 18 June, a full three weeks after the
> incident occurred. Below are some pictures showing the damage to the
> aircraft.
>
>
>
>
>
>
>
>
>
>
>  Qantas 747 has Landing Gear Incident in Rome
>
>
> 23 April 2000: A Qantas airlines 747-300, with 303 passengers on board,
had
> a landing gear strut collapse while taxiing for takeoff from Rome. One of
> the engines was damaged, but there were no injuries among the passengers
and
> crew. This is the second serious incident involving Qantas in less than a
> year..
>
>
>
>
>
> A Qantas 747 was also involved in a minor landing incident in Perth the
same
> month.
>
>
>
>
>
>
>
>
>
>
>
> Qantas Flight 1 overran runway Bangkok
>
>
>
>
>
> Qantas Flight 1, arriving at Bangkok from Sydney, overran runway 15L while
> landing in a rainstorm. Passengers reported that the aircraft landed long,
> followed by the sound of increasing engine noise from the thrust
reversers.
> The aircraft came to rest on a golf course.
>
>
>
>
>
>
>
>
>
>
>
>
> Qantas runway overshoot 24 AUG 1960
>
>
> During takeoff from runway 13, engine number 3 lost power just before
> reaching the V1 speed of 115 knots. The captain pulled off the power,
braked
> hard, and pulled selected reverse thrust. The aircraft however, did not
> decelerate as expected. The flight engineer feathered the number 3 engine
> and pulled its emergency shut-off valve. The Super Constellation, named
> "Southern Wave", could not be brought to a stop on the remaining runway
and
> overran the runway at a speed of 40 knots. The airplane bounced over a low
> embankment, crashed into a gulley and caught fire.
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
> Qantas Wing clip February 2006
>
>
>
>
>
> A minor collision occurred on Thursday (2 February) at Melbourne Airport
in
> Australia between aircraft operated by United Airlines and Qantas Airways.
>
>
> According to a statement released by Qantas, a Boeing 767 operated by the
> carrier was clipped by a Boeing 747 operated by another airline on the
> taxiway
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
> For more information go to: www.metaphorum.org For the Metaphorum
> Collaborative Working Environment (MCWE) go to: www.platformforchange.org
>
>
>
>
>
>
>
> For more information go to: www.metaphorum.org For the Metaphorum
> Collaborative Working Environment (MCWE) go to: www.platformforchange.org
>
>
>
>
>
>
>
>
>
>  For more information go to: www.metaphorum.org For the Metaphorum
> Collaborative Working Environment (MCWE) go to: www.platformforchange.org
>
>
>
>
>
>  For more information go to: www.metaphorum.org For the Metaphorum
> Collaborative Working Environment (MCWE) go to: www.platformforchange.org
>
>
>
>
>
>



-- 
Stuart Umpleby, Research Program in Social and Organizational Learning
2033 K Street NW, Suite 230, The George Washington University,
Washington, DC 20052
www.gwu.edu/~umpleby, tel. 202-994-1642, fax 202-994-5284

For more information go to: www.metaphorum.org
For the Metaphorum Collaborative Working Environment (MCWE) go to:
www.platformforchange.org

For more information go to: www.metaphorum.org
For the Metaphorum Collaborative Working Environment (MCWE) go to:  www.platformforchange.org

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