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Rag left in two Qantas aircraft in 2013 during maintenance

written by australianaviation.com.au | March 26, 2015
A rag found in a cable drum on a Qantas Boeing 737-800. (NZ TAIC)
A rag found in a cable drum on a Qantas Boeing 737-800. (NZ TAIC)

New Zealand’s Transport Accident Investigation Commission (TAIC) called upon the expertise of the country’s Wool Testing Authority and US National Transportation Safety Board (NTSB) to determine the origin of a rag found in the electronics and equipment compartment area under the flightdeck of a Qantas Boeing 737-800.

The rag was discovered during a routine maintenance check of the 737-800 ZK-ZQG at Auckland Airport on June 7 2013 after metal filings were seen next to the stabiliser trim cable drum, according to the TAIC report published on Thursday.

The rag had been trapped under the cable windings, causing the cables to bulge outwards and rub against the steel bolts that held the cable guide spacers in place.

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“The rag had increased the cable tension of the stabiliser trim system, which resulted in damage to a number of cable pulleys through which it was rigged,” the TAIC said.

“The integrity of the aeroplane’s stabiliser trim system manual control was compromised. Whilst considered unlikely, there was the potential for the stabiliser trim system manual control to become jammed or at worst disabled if a cable severed.”

How the bulging cables had damage the bolts on the cable drum. (NZ TAIC)
How the bulging cables had damage the bolts on the cable drum. (NZ TAIC)
The bulge caused by the rag trapped under the cable drum. (NZ TAIC)
The bulge caused by the rag trapped under the cable drum. (NZ TAIC)

However, the TAIC noted the electric side of the stabiliser trim control would still have operated through independent electric switches on the pilots’ control column.

The rag was sent to the NZ Wool Testing Authority to determine the type of material it was made from and how it had been manufactured.

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The TAIC also obtained samples and photographs of the rags used by companies that did maintenance on the aircraft, which was owned by Qantas but operated by the company’s NZ subsidiary Jetconnect.

Also, it asked the NTSB to help Boeing test the rag to determine if it was introduced into the cable drum during the assembly of the aircraft in 2011.

While that test found the rag was “not consistent with examples used in production” at Boeing, the Wool Testing Authority’s findings showed Qantas’s Sydney base as the most probable origin of the ran.

“It was highly likely that the rag ended up in the aeroplane’s electronics and equipment compartment following cleaning, inspection, or maintenance conducted at the Qantas Sydney maintenance facility,” the report said.

However, it was “not possible to determine when a rag may have been introduced into either the flightdeck or the electronics and equipment compartment, because the use of rags was not required to be controlled or recorded”.

The TAIC also noted a second incident involving a Jetconnect-operated Qantas 737 and a rag on September 11 2013, when the flightcrew of ZK-ZQC reported difficulty raising the right main landing gear after departing Melbourne bound for Wellington.

“The right main landing gear initially retracted but did not stay up, falling back down once the gear selector was moved to the off position,” the report said.

“When the crew reselected the gear lever to the up position, the right main gear retracted and stayed up.

“After the aeroplane landed at Wellington the ground engineers inspected the landing gear and found a rag wrapped around the right main landing gear uplock assembly.”

The report said a Qantas investigation found the rag was “used by an engineer to protect against an accidental head strike on the uplock during a maintenance task”.

“The key lesson learnt from the inquiry into this occurrence was that all personnel must take care not to leave anything behind inside an aircraft after completing maintenance or cleaning tasks, especially in areas or near systems critical to flight safety,” the report said.

“Procedures developed to prevent foreign objects being left behind after maintenance must be adhered to in order to avoid similar incidents occurring in the future.”

A supplied photo of ZK-ZQG. (NZ TAIC/Jetconnect)
A supplied photo of ZK-ZQG. (NZ TAIC/Jetconnect)

Steer your own in-flight experience – available on print and digital Whether our classic glossy magazine in your letterbox, daily news updates in your inbox, peeling back a few layers in the podcast or our monthly current affair reports, you can count on us to keep you up to date. Sign up today for just $99.95 for more exclusive offers here. Subscribe now at australianaviation.com.au.

3 Comments

  • MauriceDee

    says:

    Many, many years ago (about 1955) I was the pilot of a Meteor NF14 landing in a strong cross-wind. At the critical moment of straightening up immediately before touch-down, I found the rudder jammed. I kicked the rudder-bar frantically and the control came free – thankfully.
    The cause was found to be the cap of a Rozellex tube (skin protector). The ground-crew procedure was to check off against a list of all tools taken inside the aircraft but, of course, the list did not include the separate cap. This had become wedged between control cable and pulley.
    It appears that similar mistakes are still taking place.

  • Jaime A Sotelo

    says:

    A few years ago, I was on a routine, Qantas morning-flight from Sydney to Adelaide via Melbourne. It was a breezy warm day in late January 2011. I had a window seat, starboard side, in Business Class, and was looking out the window just before the aircraft pulled out of its parking bay, on the tarmac, before the flight from Sydney.

    After the ground crew & baggage handlers finished their assortment of tasks on the ground, in the vicinity of the forward part of the aircraft, I noticed a very large, white, stiff cardboard or plastic sheet flapping around, aimlessly floating in the breeze, precisely in front of the engine air intakes!

    I quickly alerted a flight stewardess to advise the pilots of what I discovered. She promptly told the pilots, who were already in the cockpit, getting the aircraft ready to “rock-and-roll”. Within a few minutes, I noted that one of the ground crew showed up in front of the engine, was looking up at the cockpit, and taking some instruction from the pilot. He then removed the large sheet, which if it had remained on the tarmac, could have resulted in catastrophic consequences – i.e., it could have been sucked into the jet engine, and choked it badly, especially as it would have started to increase in power and RPMs!

    This would have “killed” the engine, or even caused it to ignite or explode; what with all the fuel led into the engine, at the start of a flight!

    (I did not receive a thank you from any of the pilots, nor from Alan Joyce; although at least, I feel that I saved many lives (including my own) and an expensive Qantas asset (a Boeing 737-800), on that day.

    Note by the way, that Boeing 737s have very low-lying jets. Their intakes are very close to the ground. As a result, they can easily suck any manner of debris left lose on the ground, especially in their vicinity; as when they get going, they are like very large vacuum cleaners.

  • Pete

    says:

    @Jaime Sotelo: while I think your surmising that you saved an aircraft and many lives somewhat of an exaggeration (the circumstances that would have led to a catastrophic engine failure are pretty unlikely given the sequence of events that would have had to occur), it was a bit slack of the pilots to at least not thank you for identifying the FOD. What’s more concerning is that none of the myriad of ramp workers did not pay more attention to the FOD…they’re hardly the world’s hardest workers out at the QF Ramp, but they are meant to be trained to recognise and deal with FOD immediately.

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Your email address will not be published. Required fields are marked *

Rag left in two Qantas aircraft in 2013 during maintenance

written by australianaviation.com.au | March 26, 2015
A rag found in a cable drum on a Qantas Boeing 737-800. (NZ TAIC)
A rag found in a cable drum on a Qantas Boeing 737-800. (NZ TAIC)

New Zealand’s Transport Accident Investigation Commission (TAIC) called upon the expertise of the country’s Wool Testing Authority and US National Transportation Safety Board (NTSB) to determine the origin of a rag found in the electronics and equipment compartment area under the flightdeck of a Qantas Boeing 737-800.

The rag was discovered during a routine maintenance check of the 737-800 ZK-ZQG at Auckland Airport on June 7 2013 after metal filings were seen next to the stabiliser trim cable drum, according to the TAIC report published on Thursday.

The rag had been trapped under the cable windings, causing the cables to bulge outwards and rub against the steel bolts that held the cable guide spacers in place.

Advertisement
Advertisement

“The rag had increased the cable tension of the stabiliser trim system, which resulted in damage to a number of cable pulleys through which it was rigged,” the TAIC said.

“The integrity of the aeroplane’s stabiliser trim system manual control was compromised. Whilst considered unlikely, there was the potential for the stabiliser trim system manual control to become jammed or at worst disabled if a cable severed.”

How the bulging cables had damage the bolts on the cable drum. (NZ TAIC)
How the bulging cables had damage the bolts on the cable drum. (NZ TAIC)
The bulge caused by the rag trapped under the cable drum. (NZ TAIC)
The bulge caused by the rag trapped under the cable drum. (NZ TAIC)

However, the TAIC noted the electric side of the stabiliser trim control would still have operated through independent electric switches on the pilots’ control column.

The rag was sent to the NZ Wool Testing Authority to determine the type of material it was made from and how it had been manufactured.

PROMOTED CONTENT

The TAIC also obtained samples and photographs of the rags used by companies that did maintenance on the aircraft, which was owned by Qantas but operated by the company’s NZ subsidiary Jetconnect.

Also, it asked the NTSB to help Boeing test the rag to determine if it was introduced into the cable drum during the assembly of the aircraft in 2011.

While that test found the rag was “not consistent with examples used in production” at Boeing, the Wool Testing Authority’s findings showed Qantas’s Sydney base as the most probable origin of the ran.

“It was highly likely that the rag ended up in the aeroplane’s electronics and equipment compartment following cleaning, inspection, or maintenance conducted at the Qantas Sydney maintenance facility,” the report said.

However, it was “not possible to determine when a rag may have been introduced into either the flightdeck or the electronics and equipment compartment, because the use of rags was not required to be controlled or recorded”.

The TAIC also noted a second incident involving a Jetconnect-operated Qantas 737 and a rag on September 11 2013, when the flightcrew of ZK-ZQC reported difficulty raising the right main landing gear after departing Melbourne bound for Wellington.

“The right main landing gear initially retracted but did not stay up, falling back down once the gear selector was moved to the off position,” the report said.

“When the crew reselected the gear lever to the up position, the right main gear retracted and stayed up.

“After the aeroplane landed at Wellington the ground engineers inspected the landing gear and found a rag wrapped around the right main landing gear uplock assembly.”

The report said a Qantas investigation found the rag was “used by an engineer to protect against an accidental head strike on the uplock during a maintenance task”.

“The key lesson learnt from the inquiry into this occurrence was that all personnel must take care not to leave anything behind inside an aircraft after completing maintenance or cleaning tasks, especially in areas or near systems critical to flight safety,” the report said.

“Procedures developed to prevent foreign objects being left behind after maintenance must be adhered to in order to avoid similar incidents occurring in the future.”

A supplied photo of ZK-ZQG. (NZ TAIC/Jetconnect)
A supplied photo of ZK-ZQG. (NZ TAIC/Jetconnect)

Steer your own in-flight experience – available on print and digital Whether our classic glossy magazine in your letterbox, daily news updates in your inbox, peeling back a few layers in the podcast or our monthly current affair reports, you can count on us to keep you up to date. Sign up today for just $99.95 for more exclusive offers here. Subscribe now at australianaviation.com.au.

3 Comments

  • MauriceDee

    says:

    Many, many years ago (about 1955) I was the pilot of a Meteor NF14 landing in a strong cross-wind. At the critical moment of straightening up immediately before touch-down, I found the rudder jammed. I kicked the rudder-bar frantically and the control came free – thankfully.
    The cause was found to be the cap of a Rozellex tube (skin protector). The ground-crew procedure was to check off against a list of all tools taken inside the aircraft but, of course, the list did not include the separate cap. This had become wedged between control cable and pulley.
    It appears that similar mistakes are still taking place.

  • Jaime A Sotelo

    says:

    A few years ago, I was on a routine, Qantas morning-flight from Sydney to Adelaide via Melbourne. It was a breezy warm day in late January 2011. I had a window seat, starboard side, in Business Class, and was looking out the window just before the aircraft pulled out of its parking bay, on the tarmac, before the flight from Sydney.

    After the ground crew & baggage handlers finished their assortment of tasks on the ground, in the vicinity of the forward part of the aircraft, I noticed a very large, white, stiff cardboard or plastic sheet flapping around, aimlessly floating in the breeze, precisely in front of the engine air intakes!

    I quickly alerted a flight stewardess to advise the pilots of what I discovered. She promptly told the pilots, who were already in the cockpit, getting the aircraft ready to “rock-and-roll”. Within a few minutes, I noted that one of the ground crew showed up in front of the engine, was looking up at the cockpit, and taking some instruction from the pilot. He then removed the large sheet, which if it had remained on the tarmac, could have resulted in catastrophic consequences – i.e., it could have been sucked into the jet engine, and choked it badly, especially as it would have started to increase in power and RPMs!

    This would have “killed” the engine, or even caused it to ignite or explode; what with all the fuel led into the engine, at the start of a flight!

    (I did not receive a thank you from any of the pilots, nor from Alan Joyce; although at least, I feel that I saved many lives (including my own) and an expensive Qantas asset (a Boeing 737-800), on that day.

    Note by the way, that Boeing 737s have very low-lying jets. Their intakes are very close to the ground. As a result, they can easily suck any manner of debris left lose on the ground, especially in their vicinity; as when they get going, they are like very large vacuum cleaners.

  • Pete

    says:

    @Jaime Sotelo: while I think your surmising that you saved an aircraft and many lives somewhat of an exaggeration (the circumstances that would have led to a catastrophic engine failure are pretty unlikely given the sequence of events that would have had to occur), it was a bit slack of the pilots to at least not thank you for identifying the FOD. What’s more concerning is that none of the myriad of ramp workers did not pay more attention to the FOD…they’re hardly the world’s hardest workers out at the QF Ramp, but they are meant to be trained to recognise and deal with FOD immediately.

Leave a Comment

Your email address will not be published. Required fields are marked *

Rag left in two Qantas aircraft in 2013 during maintenance

written by australianaviation.com.au | March 26, 2015
A rag found in a cable drum on a Qantas Boeing 737-800. (NZ TAIC)
A rag found in a cable drum on a Qantas Boeing 737-800. (NZ TAIC)

New Zealand’s Transport Accident Investigation Commission (TAIC) called upon the expertise of the country’s Wool Testing Authority and US National Transportation Safety Board (NTSB) to determine the origin of a rag found in the electronics and equipment compartment area under the flightdeck of a Qantas Boeing 737-800.

The rag was discovered during a routine maintenance check of the 737-800 ZK-ZQG at Auckland Airport on June 7 2013 after metal filings were seen next to the stabiliser trim cable drum, according to the TAIC report published on Thursday.

The rag had been trapped under the cable windings, causing the cables to bulge outwards and rub against the steel bolts that held the cable guide spacers in place.

Advertisement
Advertisement

“The rag had increased the cable tension of the stabiliser trim system, which resulted in damage to a number of cable pulleys through which it was rigged,” the TAIC said.

“The integrity of the aeroplane’s stabiliser trim system manual control was compromised. Whilst considered unlikely, there was the potential for the stabiliser trim system manual control to become jammed or at worst disabled if a cable severed.”

How the bulging cables had damage the bolts on the cable drum. (NZ TAIC)
How the bulging cables had damage the bolts on the cable drum. (NZ TAIC)
The bulge caused by the rag trapped under the cable drum. (NZ TAIC)
The bulge caused by the rag trapped under the cable drum. (NZ TAIC)

However, the TAIC noted the electric side of the stabiliser trim control would still have operated through independent electric switches on the pilots’ control column.

The rag was sent to the NZ Wool Testing Authority to determine the type of material it was made from and how it had been manufactured.

PROMOTED CONTENT

The TAIC also obtained samples and photographs of the rags used by companies that did maintenance on the aircraft, which was owned by Qantas but operated by the company’s NZ subsidiary Jetconnect.

Also, it asked the NTSB to help Boeing test the rag to determine if it was introduced into the cable drum during the assembly of the aircraft in 2011.

While that test found the rag was “not consistent with examples used in production” at Boeing, the Wool Testing Authority’s findings showed Qantas’s Sydney base as the most probable origin of the ran.

“It was highly likely that the rag ended up in the aeroplane’s electronics and equipment compartment following cleaning, inspection, or maintenance conducted at the Qantas Sydney maintenance facility,” the report said.

However, it was “not possible to determine when a rag may have been introduced into either the flightdeck or the electronics and equipment compartment, because the use of rags was not required to be controlled or recorded”.

The TAIC also noted a second incident involving a Jetconnect-operated Qantas 737 and a rag on September 11 2013, when the flightcrew of ZK-ZQC reported difficulty raising the right main landing gear after departing Melbourne bound for Wellington.

“The right main landing gear initially retracted but did not stay up, falling back down once the gear selector was moved to the off position,” the report said.

“When the crew reselected the gear lever to the up position, the right main gear retracted and stayed up.

“After the aeroplane landed at Wellington the ground engineers inspected the landing gear and found a rag wrapped around the right main landing gear uplock assembly.”

The report said a Qantas investigation found the rag was “used by an engineer to protect against an accidental head strike on the uplock during a maintenance task”.

“The key lesson learnt from the inquiry into this occurrence was that all personnel must take care not to leave anything behind inside an aircraft after completing maintenance or cleaning tasks, especially in areas or near systems critical to flight safety,” the report said.

“Procedures developed to prevent foreign objects being left behind after maintenance must be adhered to in order to avoid similar incidents occurring in the future.”

A supplied photo of ZK-ZQG. (NZ TAIC/Jetconnect)
A supplied photo of ZK-ZQG. (NZ TAIC/Jetconnect)

Steer your own in-flight experience – available on print and digital Whether our classic glossy magazine in your letterbox, daily news updates in your inbox, peeling back a few layers in the podcast or our monthly current affair reports, you can count on us to keep you up to date. Sign up today for just $99.95 for more exclusive offers here. Subscribe now at australianaviation.com.au.

3 Comments

  • MauriceDee

    says:

    Many, many years ago (about 1955) I was the pilot of a Meteor NF14 landing in a strong cross-wind. At the critical moment of straightening up immediately before touch-down, I found the rudder jammed. I kicked the rudder-bar frantically and the control came free – thankfully.
    The cause was found to be the cap of a Rozellex tube (skin protector). The ground-crew procedure was to check off against a list of all tools taken inside the aircraft but, of course, the list did not include the separate cap. This had become wedged between control cable and pulley.
    It appears that similar mistakes are still taking place.

  • Jaime A Sotelo

    says:

    A few years ago, I was on a routine, Qantas morning-flight from Sydney to Adelaide via Melbourne. It was a breezy warm day in late January 2011. I had a window seat, starboard side, in Business Class, and was looking out the window just before the aircraft pulled out of its parking bay, on the tarmac, before the flight from Sydney.

    After the ground crew & baggage handlers finished their assortment of tasks on the ground, in the vicinity of the forward part of the aircraft, I noticed a very large, white, stiff cardboard or plastic sheet flapping around, aimlessly floating in the breeze, precisely in front of the engine air intakes!

    I quickly alerted a flight stewardess to advise the pilots of what I discovered. She promptly told the pilots, who were already in the cockpit, getting the aircraft ready to “rock-and-roll”. Within a few minutes, I noted that one of the ground crew showed up in front of the engine, was looking up at the cockpit, and taking some instruction from the pilot. He then removed the large sheet, which if it had remained on the tarmac, could have resulted in catastrophic consequences – i.e., it could have been sucked into the jet engine, and choked it badly, especially as it would have started to increase in power and RPMs!

    This would have “killed” the engine, or even caused it to ignite or explode; what with all the fuel led into the engine, at the start of a flight!

    (I did not receive a thank you from any of the pilots, nor from Alan Joyce; although at least, I feel that I saved many lives (including my own) and an expensive Qantas asset (a Boeing 737-800), on that day.

    Note by the way, that Boeing 737s have very low-lying jets. Their intakes are very close to the ground. As a result, they can easily suck any manner of debris left lose on the ground, especially in their vicinity; as when they get going, they are like very large vacuum cleaners.

  • Pete

    says:

    @Jaime Sotelo: while I think your surmising that you saved an aircraft and many lives somewhat of an exaggeration (the circumstances that would have led to a catastrophic engine failure are pretty unlikely given the sequence of events that would have had to occur), it was a bit slack of the pilots to at least not thank you for identifying the FOD. What’s more concerning is that none of the myriad of ramp workers did not pay more attention to the FOD…they’re hardly the world’s hardest workers out at the QF Ramp, but they are meant to be trained to recognise and deal with FOD immediately.

Leave a Comment

Your email address will not be published. Required fields are marked *

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