For the global community of cabin safety specialists, the June 2013 final report1 by the Australian Transport Safety Bureau (ATSB) on the Qantas Flight 32 (QF32) accident provides a missing piece — the official framework and conclusions — needed to interpret the many eyewitness accounts of injury-prevention factors. One such account is a November 2011 AeroSafety World video interview with the flight’s cabin service manager (CSM), Michael von Reth.2,3
For much of the event, he became the principal source of information for the passengers in the aftermath of the uncontained engine failure. The captain and CSM each relied on their backgrounds for extended periods to imagine the likely situation of the other without direct knowledge.
The cabin crew’s alarm-saturated working conditions, imperfect/confusing information, resilient critical thinking and emergency responses had parallels to those of the flight crew, including overriding standard operating procedures (SOPs). Among crewmember attributes credited with influencing the outcome free of any reported injuries were: situational awareness beyond individual duties; attention to their own knowledge state and concern for passing on critical information; active monitoring and control of their own thoughts; and emotional intelligence and skills interacting with passengers. Some anticipated being overwhelmed at times by the complexity and volume of information inputs, and took proactive steps to shed non-essential workload.
Among examples of competent crew behavior, the ATSB report noted von Reth’s assertion of single-point message control, which enabled rapid, thorough communication of necessary information between the flight deck and cabin. “The safe outcome of the accident flight was not only contingent on the primary and supporting flight crew but also on the efforts of the CSM and cabin crew,” the report said. This article highlights some of von Reth’s recollections in the context of a similar video interview with the QF32 captain, Richard de Crespigny, and the captain’s 2012 book, titled QF32, and the ATSB report.
The takeoff was at 09:56:47 local time on Nov. 4, 2010, and the uncontained engine failure occurred at 10:01:07 (see Table 1 in PDF of printed magazine). Visual meteorological conditions prevailed, increasing passengers’ ability to monitor developments. On duty in the cabin in addition to the CSM (functioning as purser) were a customer service supervisor and 22 flight attendants, taking care of 440 passengers.
At about 7,000 ft, during the Airbus A380’s departure climb from Singapore Changi Airport, two explosive, boom-like sounds — the first indication of a problem — apparently were louder to some cabin occupants than to the five pilots on the flight deck, von Reth said. He was seated at the door nearest to the destroyed no. 2 engine.
“When the first explosion occurred, I thought … ‘Something is wrong in a cargo container,’” he said. “It was very audible in the cabin because the aircraft shook. … The second explosion came while I was looking out of the [left] window, and that was when the engine started disintegrating and the wing opened up.” Von Reth felt the aircraft shudder during the second boom.
“Debris was flying with such a velocity out of that wing in all directions [that] you could not see the [individual pieces of] debris,” he said. “I saw debris flying forwards [and] backwards, sparks and fumes.” The disorienting scene was accompanied by a sound he compared to that of marbles rattling against corrugated iron plates. After the flight, he learned that the sound was shrapnel penetrating the wing and fuselage.
The ATSB report said that a large fragment of the engine’s disintegrating turbine disc penetrated the left wing — leaving the hole that von Reth and many left-side passengers could see — and ignited a “short duration, low intensity flash fire inside the wing fuel tank” observed by one passenger-witness.
“There was silence in the cabin, absolute silence,” von Reth said while describing his shift from normal-service operational mode into emergency-procedures mode. The flight attendant manual assumes that this is the time for the cabin crew to quietly review checklist items and await information from the flight deck, he said. “Procedure says you wait until the flight deck has assessed the situation and stabilized everything [before] you get into action. … But then passengers … got out of that shock moment, and they started to get restless.”
QF32 describes von Reth’s first attempts to call the flight deck using the interphone and an additional emergency channel; there was no response. Other cabin crewmembers also received no response. The ATSB report said that the normal overhead panel light had illuminated and the corresponding horn had sounded, but the flight crew inadvertently canceled the horn “without recognising its association with the cabin interphone system emergency contact function” during an ongoing cascade of warning signals. The next event in the cabin was considered pivotal in calming the emotion-laden cabin atmosphere and influencing a robust, enduring level of passenger compliance.
“A passenger got up in the cabin, stood up, and was just about to shout at me,” von Reth said. “I thought, ‘This is the moment. … I’ll have to have this cabin under control.’ So I took the PA [public-address handset of the] interphone … system and said, ‘Ladies and gentlemen, obviously, we had some problem with the engine no. 2. Most of you on the left-hand side would’ve seen it out of the window and everybody else would’ve seen it on the in-flight video screen. I can assure [you] the pilots have this all under control. … As soon as they have stabilized everything, we will hear from them. If I get any further information, I’ll pass it on to you.” He emphasized the change to emergency operational mode and issued safety instructions.
The passenger quietly returned to a seat, sat down and followed crewmember instructions. “Then I did a quick run-around of the aircraft, and I sat down again,” von Reth said. “We still hadn’t heard then from the flight deck. … We were not in a situation where were just about to fall down, but we had structural damage. I saw the fuel leak, and obviously hydraulic [fluid leaking] as well.” His next call to the flight crew was answered, and after his report, he was told that a pilot would go to the cabin for a first-hand look.
Mark Johnson, the second officer, examined the damage and leaks, walked through the remainder of the cabin, assessed other conditions, discussed the situation with von Reth on the main deck, and returned to the flight deck. After completing their initial response actions, the flight crew was cleared by Singapore air traffic control to fly a holding pattern east of Changi. “While in the holding pattern, the flight crew worked through the procedures relevant to the messages displayed by the ECAM [electronic centralized aircraft monitor],” the ATSB report said.
Johnson did not plan to talk with passengers during that time, von Reth said, but QF32 notes that several passengers got Johnson’s attention and pointed out exterior anomalies. The second officer reported that the constant stream of droplets seemed to come from underneath the wing near the no. 2 engine, that the trail of fuel was about 0.5 m (1.6 ft) wide and this engine’s turbine was not visible.
“[In] the cabin was dead silence,” von Reth said. “It was like you could cut the air. It was strange, absolutely strange.” Shortly after Johnson left the cabin, David Evans, a captain on the flight deck to supervise a third captain conducting de Crespigny’s annual route check, made the first PA announcement by a pilot, a quick status report with reassurance that the situation was under control.
About an hour into the flight, de Crespigny made his first PA announcement “to explain what’s happened, what we’ve done, that we are safe and how long it will take to configure the aircraft and land.” He spent about 10 minutes on the significance of what passengers already knew, instilling confidence about what had been accomplished and what to expect next. He urged passengers to comply with instructions from “Klaus, the cabin supervisor.” This last statement gave von Reth an idea.
“That PA was done [and there was] silence again, and I thought, ‘No, I can’t run the cabin like that,’” von Reth recalled. “‘I’ll have to break this [tension] somehow.’ … So I took the PA [handset] and said, ‘I want to extrapolate on what the pilot just said … but before I do that, I want to make a few things clear. First of all, my name is Michael and not Klaus, and, secondly, I’m not the supervisor, I am the manager.’ Everybody broke out in laughter and applauded. … It broke the ice, the stifling fear in the cabin was gone, and passengers started to relax.”
Von Reth resolved to keep information flowing to them that would be necessary for the safety of flight, but like the pilots, used discretion to avoid overloading passengers with a few of the facts and plans known to crewmembers. For example, based on his knowledge of normal turnback procedures for jettisoning fuel to reduce the landing weight, he told passengers this was being done. In reality, the flight crew was unable to jettison fuel, and the fuel quantity was being depleted by the consumption by three engines while holding, and by the fuel tank leaks.
“I explained to them in more detail … that the top priority was now to ‘get the aircraft safe onto the ground and you safe into the terminal.’” He told them — also based on his assumptions — that the airline already was aware of the situation and working to take care of the disruptions to their travel plans. “We’ll deal with all that when we are on the ground, not now, because this [emergency] is our priority now, this is the mode we are operating under now, so we need your cooperation,” he said.
Qantas SOPs specify that normally flight attendants be seated with their seat belts fastened when the flight crew illuminates the seat belt signs. Von Reth judged that intentional non-compliance with that SOP was warranted as the holding pattern was entered (see Figure 1 in the PDF and printed magazine). “I got the crew on the right-hand side [and] left-hand side out of their seats,” he said. Meeting with small groups in the galleys, he instructed right-side flight attendants to check all the cabin conditions first, then check all passengers, especially looking for any individual passengers in distress. This meant special attention to mothers with children, elderly people, those who speak a language not being used by crewmembers and people who indicate they do not understand the situation.
“The crew on the left-hand side [took their] primary positions,” von Reth said. “I told them, ‘You stay where you are, you are not moving. You watch the outside. [If you see] any changes on the outside, you report that immediately.’”
A cascade of cabin equipment malfunctions made these tasks difficult. The in-flight entertainment system operated intermittently, and the cabin emergency lighting repeatedly illuminated, then turned off. Half the cabin had no normal interior lighting but had daylight through windows.
Observing their oblong circuits within gliding range of the airport, in an approximately 20-nm (37-km) long racetrack holding pattern at 7,400 ft, the passengers showed signs of better understanding the risks and reasons for the actions of the flight crew and cabin crew.
“The ambient noise in our work environment — with all these whistles, bells, lights and whatever — was just incredible,” von Reth said. He decided to implement a decision-making rule for everyone: If the cabin crew could not see that an anomaly indicated was real, still present and significant, the assumption would be, “It’s not happening to us,” he said.
The CSM began walking throughout the main deck and upper deck in a figure-8 pattern. But the number of people seeking his attention, warning systems, and other sights and sounds started to become overwhelming. “Maybe for a half an hour, I was in overdrive, [but] you can’t handle it. … It’s too much,” he said. He considered options that could very quickly make him more situationally aware, able to keep focusing and concentrating.
The best option came to mind when the cabin supervisor from the upper deck accosted him and began to deliver a lengthy report. “I stopped him in his place and said, ‘Listen very carefully now,’” von Reth said. “‘You are 2IC [second-in-command]. The crew will report through you to me. From now on, the upper deck is yours, you are responsible, you make the decisions. I will support you, and when you make a wrong decision, reassess and make the right decision.’”
Von Reth then told himself, “[Flight crew now] are the only people I have to talk to. … The rest are not relevant for the time being.” He deliberately “tuned into” PA announcements, signals of incoming interphone calls, engine sounds and voices of flight attendants and successfully ignored non-safety-critical signals and passenger voices, he said.
Around this time, flight attendants told him that a large group of German passengers, filling an entire section of the cabin, was getting restless and concerned. Some had not understood the PA announcements in English. Von Reth spoke with them in German, the information calmed them, and he agreed to repeat subsequent PA announcements in German. Others requested PA announcements in Spanish and French, but after updating them in those languages, he declined.
One exception to his self-imposed narrow focus was attending to an elderly female passenger who had collapsed onto the floor, and was receiving oxygen from a flight attendant. The passenger showed signs of a possible panic attack — fainting, lying down and shaking. Coincidentally, when she spoke, von Reth realized that she only spoke a dialect similar to his own first language, a German dialect. “She thought we were just about to crash,” he said. Speaking this language, he told her, “No, no, no. Everything is under control [and explained the situation]. … Ten minutes later, she was good as gold, in her seat, calm, quiet.”
As plans were finalized on the flight deck to exit the holding pattern and to conduct checks of manual control of the aircraft during a 20-nm approach, von Reth received an in-person briefing from Johnson about the state of the aircraft, the expectation of stopping near the end of the runway, and the best/worst possibilities of a runway overrun and/or an evacuation.
To brief the entire cabin crew with these details, “I went from galley to galley because the interphone system was useless,” he said. “I told them, ‘Guys, this is it. We’ve been trained for this.’’’ The cabin crew was diverse in age range from 19 to 61, with many different nationalities, languages spoken and levels of professional experience.
Von Reth directed them to secure the cabin for landing, stow loose objects, secure themselves into their jump seats, mentally rehearse the ABC (able-bodied passengers, brace position, and commands to passengers during an evacuation) impact drill and perform their silent review of memorized emergency checklist items.
Von Reth described this landing phase as a very tense time for passengers, yet they complied with crewmember instructions as the aircraft stopped. “It was quiet,” he said. “None got out of their seats. … They were all relieved. … … I made our standard PA [beginning with]: ‘Welcome to Singapore where the local time is [five minutes to mid-day on Thursday 4 November].’
“But then I looked out of the window, and I really got tense … the most intense moment for me throughout this entire episode. When I … looked at the fuel leak and realized it was a fuel leak — how it was gushing down onto the tarmac and then flowing off — I thought … this can’t be true. There was not one firefighter in sight, no rescue personnel, nothing.” He said he felt “desperate” to get everyone off the aircraft as the cabin became hot and cabin alarms continued.
The captain’s next PA announcement, however, only began the alert phase: “Attention! All passengers remain seated and await further instructions.” The ATSB report said, “During the alert phase, all cabin crew were to remain at their assigned stations, with all doors armed. This allows the crew to immediately activate the escape slides should they be needed.”
The threats presented by the fuel leak prompted von Reth to immediately try again to call the captain but each call attempt failed, so he considered going to the flight deck. “But then, again, my inner voice said to me, ‘No, you can’t go to the flight deck because they are in overload … so it’s a waste of time [a distraction, and] would take too long to [gain entry],” he recalled. “What finally stopped me was that if anything happens I have to be in the cabin.”
At about the same time, de Crespigny called him and said that airport emergency service (AES) firefighters already were positioned out of sight behind the aircraft, assessing the situation while applying aqueous film-forming foam and washing away the leaked fuel from the runway underneath the aircraft. This reduced the CSM’s stress level.
Von Reth repeated the essence of this information to passengers. “Some of them had started to take their cameras and mobile phones and everything else out,” von Reth recalled. “So I made a very terse statement: ‘We are in a very difficult situation right now, and it’s not over, as you can see out there. No electronics. Switch it all off immediately. Put it away.’ They did. Because I was so tense, they got the message.” Very shortly, he saw firefighters moving around the aircraft exterior applying foam and talking on handheld radios. He said he finally felt his own stress level begin to “notch down again.”
The flight crew was acutely aware of risks of deploying the high, steep slides, but they also considered evacuation — only from the right side — an acceptable Plan B from knowledge of the 78-second evacuation time of 873 occupants from half the exits, according to required conditions of the A380’s certification demonstration (ASW, 1/07, p. 46). Moreover, evacuating 440 QF32 passengers with the aircraft crew remaining inside, given the threats outside the aircraft, was not an ideal situation.
De Crespigny told ASW the key concerns. “Let’s say we have a fire with the fuel, and then people delay at the top of the slide; we will push them out,” he said. “If they got to the bottom of the slide and didn’t break their hips, they might slip on the fuel. If they didn’t slip on the fuel, they might slip on the foam. If they didn’t slip on the foam, they might get sucked into engine no. 1.”4 In contrast, the precautionary disembarkation would be “done very slowly, very methodically, very carefully,” he said.
The ATSB report said, “The flight crew elected to use a single door for the [precautionary] disembarkation so that the passengers could be accounted for as they left the aircraft and to keep the remainder of the right side of the aircraft clear in case of the need to deploy the escape slides. They also decided to leave the remaining doors armed, with cabin crewmembers at those doors ready to activate the respective escape slides until all of the passengers were off the aircraft.”
Contrary to Qantas procedures for selection of the precautionary evacuation door, the AES commander selected the main-deck, two-right (2R) door, von Reth said. The ATSB report said, “There were hurried communications between the cabin and flight crew to ensure that there was no accidental deployment of a door slide when main deck 2R door was opened. The flight crew also instructed the cabin crew to prevent any subsequent evacuation from the left side of the aircraft while the no. 1 engine continued to run.”
However, von Reth realized that the flight attendant stationed at this door would not be able to operate the door as usual. He asked the captain to inform the AES commander to open this door from the outside, and firefighters did this.
The AES commander then took command and instructed von Reth to assist in the precautionary disembarkation by keeping all passengers seated except for one group of 20 passengers, one busload, to be deplaned at a time. Von Reth made the associated PA announcement and added that only airline tickets, passports and vital medication could be removed from the airplane.
“Again, there was almost 100 percent compliance, bar one passenger,” von Reth said. De Crespigny elaborated that von Reth grabbed the rolling carry-on bag from this passenger, forcefully threw it into an aisle on the opposite side of the cabin and commanded the passenger to exit, which persuaded others to comply.
Part way through this sweltering egress, de Crespigny ruled against the cabin crew’s request to open another right-side door for ventilation because that door then would become unavailable for evacuation, and would add a risk of people falling out that door.
Later, under Evans’ command — while de Crespigny was off the aircraft monitoring the aircraft exterior and the firefighters’ efforts to shut down the no. 1 engine with water and foam — von Reth received permission to disarm and open another door. “Cabin attendants … were in [the alert phase] for two hours, probably the longest a cabin crew have ever been in an alert phase,” de Crespigny said in QF32.
During the hour-long disembarkation, von Reth reminded the cabin crew, “Stay on your doors. Be ready.” At one point, a false electronic command to evacuate was displayed. A more experienced colleague had to counsel one flight attendant to disregard this indication, von Reth said. Throughout this alert phase — including the 45-minute wait for the airstairs and the first bus to arrive — de Crespigny made PA announcements about every 10 minutes, and Johnson walked through the cabin and spoke with passengers.
The ATSB’s analysis concluded, “Given that there was no indication of an immediate threat to the safety of those on board, and that the option of an immediate evacuation remained throughout, the crew’s decision to evacuate via the stairs likely provided the safest option.”
Industry awareness of potentially hazardous distractions while using portable electronic devices (PEDs) — for passengers, flight attendants and pilots — has increased in recent years. The ATSB report thus cited QF32 as a new case study of the importance of complying with crewmember instructions on PED use. This reason is in addition to the long-assumed risk of interference with aircraft systems, many of which were in a degraded state during QF32. Von Reth and de Crespigny also noted the potential generation of sparks by PEDs in the presence of spilled fuel.
The ATSB report said, “Video and still images showed that some of the passengers did not comply with the crew’s instructions, such as moving about the cabin when they had been instructed to remain seated [and] using PEDs during flight, and in particular during the approach, landing and post-landing phases, when instructed to switch them off.
“[Emergency] instructions will be significantly different to the normal announcements made during a flight and contain specific information and instructions not normally provided to passengers. … Actions need to be carried out quickly, and there can be insufficient time for crew to be repeating information to passengers distracted by their PEDs.”
Nevertheless, von Reth said the most typical passenger behavior he saw was compliance. “At one stage, when a passenger tried to use his phone on the ground, all the passengers yelled out ‘Turn off that phone!’ — the passengers became part of the team, and I thank Michael for that,” de Crespigny said.
The ATSB report also noted that although no unsafe situation resulted from this event, “the lack of conspicuity of the cabin emergency call function delayed the transfer of potentially important information to the flight crew.” Another cabin-related finding was that the recording of cockpit voice recorder (CVR) audio was overwritten, so that audio data did not cover the period of the engine failure and initial flight crew response. The missing audio would have enhanced investigators’ understanding of the cabin–flight deck crew resource management aspects of the flight, the report said.
- ATSB. “In-flight uncontained engine failure overhead Batam Island, Indonesia, 4 November 2010, VH-OQA, Airbus A380-842.” ATSB Transport Safety Report. Aviation Occurrence Investigation AO-2010-089. June 27, 2013.
- A 28-year Qantas employee at the time, assigned to the Airbus A380 fleet, von Reth has since shared the cabin safety aspects of the QF32 event in several industry forums. Excerpts from the ASW interview have been available for viewing on the FSF website, which has a companion interview with de Crespigny.
- The flight crew’s response has been summarized in two ASW articles, one based on the account of events in a 2011 video interview with the QF32 captain (ASW, 12/11–1/12) and the other based on the ATSB’s final report (ASW, 9/13).
- “Rescue and firefighting personnel should stay at least 7.5 m [25 ft] from the intake of an operating turbine engine to avoid being sucked in, and 45 m [148 ft] from the rear to avoid being burned from the blast,” the ATSB report noted.