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Case Studies

Case Study 4.1 - International collaboration on Qantas flight QF30

The Australian Transport Safety Bureau (ATSB) has a proven track record of highly developed capabilities in the technical and operational aspects of transport safety investigations. Many major investigations, however, are the product of collaboration with external parties. Under international standards and recommended practices, different organisations and agencies are able to share a wide variety of expertise, allowing for a far better understanding of the circumstances that led to accidents and incidents.

On 25 July 2008, a Boeing Company 747-438 aircraft operating as flight number QF30, with 365 persons on board, departed Hong Kong International Airport on a scheduled passenger transport flight to Melbourne, Australia. Approximately 55 minutes into the flight, while the aircraft was cruising at 29,000 ft, a loud bang was heard by passengers and crew, followed by rapid depressurisation of the cabin. Oxygen masks were deployed for the passengers and crew, and the aircraft commenced descent to a safe altitude where supplemental oxygen would no longer be necessary. The flight was then diverted to Ninoy Aquino International Airport, Manila, the Philippines, where an uneventful approach and landing was made. The subsequent ATSB investigation saw important contributions from a number of external parties, including international regulatory agencies, manufacturers and the operator, as well as investigative colleagues such as the Australian Federal Police and the Philippines National Bureau of Investigation.

The initial inspection of the aircraft by the operator's personnel and ATSB investigators revealed a rupture in the lower right side of the fuselage. Upon further inspection, it was discovered that an oxygen cylinder on board had sustained a sudden failure and the forceful discharge of its pressurised contents ruptured the fuselage. The subsequent investigation into the cause of this accident was extensive, and has involved more than 10 cooperating parties from several different countries. The first collaboration involved the Australian Federal Police and the Philippines' National Bureau of Investigation, which together screened the aircraft for explosives residue, confirming that a bomb had not caused the accident.

As the cylinder in question was ejected from the aircraft at the time of the incident, ATSB investigators worked with Qantas officials and other international operators to obtain 'sibling' cylinders from the same batch, with which to study. These cylinders were quickly and efficiently supplied to ATSB investigators, for testing and evaluation. Several cylinders that were filled at the same time as the failed item were also sent to the Defence Science and Technology Organisation for analysis of the oxygen contents. Further assistance has been received from Air Liquide, (an international manufacturer of gases and equipment), the US's National Transportation Safety Board and Federal Aviation Administration, Airbus and Boeing, bringing about a more comprehensive analysis of the accident. As the investigation into flight QF30 progresses, this level of cooperation is proving increasingly valuable.

Damaged fuselage as a result of a malfunction involving an oxygen cylinder.

Damaged fuselage as a result of a malfunction involving an oxygen cylinder.

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