How Qantas Became the Safest Airline

The pilot, his head bent back and shoulders pressed against the cockpit, stood motionless, watching the stars. He felt a vast power stirring in him and a potent joy.
                     Antoine de Saint-Exupéry, Night Flight 

On Saturday morning, February 21, 1942, as a little boy madly excited about aeroplanes, I followed my father through a thicket of gum tree saplings on a hillside in the outer Brisbane suburb of Belmont to look over a tangled mess of wires, splintered plywood, shreds of silver fabric and strange bits of twisted metal. Twenty-four hours earlier, those meaningless pieces of junk had been the Qantas Royal Mail Airliner Sydney, VH-USE. The bodies of the two pilots and seven passengers killed as it speared into the bush of Mt Petrie had been removed, but there were unmistakeable bits of human remains in the dry grass. Some official-looking men prodding and poking rather aimlessly among the wreckage told me sharply: “Don’t touch anything!”—a needless invitation to pocket an oil pressure gauge which had stuck at 80 psi, to be added to my museum of wartime relics. 

Later that day, officials from the Civil Aviation Branch of the Department of the Interior set fire to the crash site. The subsequent inquiry was perfunctory, so my oil pressure gauge would not have been missed—nor was it of any significance. The plane had crashed due to bad design, not pilot error—the tail fin had broken off in a storm and the airliner had fluttered on for another mile like a wounded bird, out of control. The accident is barely remembered today, nor did it linger in the news then. The day before the crash, Australia had been bombed for the first time in its history; with hundreds dead in Darwin there was neither interest nor grief to spare for the nine victims of VH-USE.

The Belmont crash was however one of those pivotal events in the life of Qantas, events from which the airline learned important lessons and on which it built, progressively, its reputation for safety. VH-USE was a de Havilland 86, the last Qantas aeroplane from the “string-bag” era of biplanes, and (apart from the great Short S23 “Empire” flying boats) the last airliner it would order from Britain. The DH-86 had been rushed into production in 1933—from design concept to test flight in four months—to meet the order for a plane if it should win the contract to fly the Australia–Singapore leg of the Empire Air Mail Service. It would link there with Imperial Airways planes to take the letters on to London. The plane was essentially a “stretched” version of the successful DH-84 Dragon biplane, but with tapered wings, four engines, twin pilot controls and ten passenger seats. 

Qantas ordered six of them, four to be shipped as deck cargo, and two to be flown out. The fleet had got off to a bad start when the first plane, VH-USG, crashed on its delivery flight at Ilfracombe, not far from the Qantas base at Longreach. All four crew were killed. There was the first indication that weakness in the tailplane had led to loss of control, but it was discounted by assumptions that a spare engine carried in the cabin had shifted in flight. That was in November 1934. A month earlier, an identical plane, VH-URN Miss Hobart, operated by Holyman Airways, had disappeared over Bass Strait with the loss of twelve lives; a second, VH-URT Loina crashed into the sea off Flinders Island a year later, killing five people.1 

Nobody connected the dots to suspect a common cause. But when a third Holyman plane made a forced landing because of vibrations, the Australian government grounded all DH-86 aircraft in the country, enraging the British aviation industry. There had been five accidents with the loss of twenty lives, but the British Air Ministry refused to believe the crashes were due to anything but pilot error or local conditions. Then a British Airways plane crashed in Austria, a second crashed in Germany killing two people, and a month later a third from the same airline, G-ADYF, crashed at Gatwick. British Airways pilots had been criticising the handling qualities of the plane; at last there was accessible wreckage and the Air Ministry was forced to act in response to growing alarm. It ordered an urgent re-investigation by the Aeroplane and Armament Experimental Establishment of the RAF, the organisation then responsible for testing a new aircraft and issuing its Certificate of Airworthiness.

I am now able to reveal publicly for the first time in Australia the A&AEE’s findings. They amount to a devastating indictment of the DH-86, its designers, the haste of production, and the Establishment’s own incompetence in certifying the aircraft. Over fifteen months, the A&AEE produced five reports on the defects and the modifications required. Rudder control was heavy, with slow response and a tendency to over-balance. With coarse use of the ailerons (wing control surfaces) in bumpy weather, “there was a marked twisting of the wing”. With one engine shut off, the aircraft rapidly developed a swing which was difficult to check. (Qantas had specifically required tests to determine the effects of flight with two engines cut on the one side. No “unusual” behaviour had been reported.) The most conspicuous feature of the controls was their lack of harmony, delay in response and consequent difficulty in co-ordination.

The first report concluded: 

In view of the unsatisfactory flying qualities revealed by the handling trials, airworthiness trials were not completed. No tests were made at the stall nor in the dive … the aeroplane was already nose-heavy … night landing trials were not considered advisable. The aeroplane was only satisfactory to fly in calm air and for the gentlest manoeuvres. In bumpy weather and when executing normal manoeuvres for the class of aeroplane, it becomes nearly unmanageable.

This was an aircraft that had to carry passengers safely through the rough summer air of outback Australia and through the storms of the inter-tropic front across the Java and Timor Seas!

Two more reports of trials revealed that seven British aircraft operated by British Airways and British Continental Airways should not be permitted to fly again; another nine were banned from night flights and could carry passengers in daylight only if the pilot had fifty hours experience on the DH-86. By the time the last report had been issued, de Havilland had substantially modified the aeroplane, in particular replacing wood with steel tube to strengthen the fin and adding two vertical stabilisers in the shape of zulu shields. Twenty of the British planes were converted to this model 86B, but not one of the Australian aircraft was modified. In those days aircraft operators were not automatically notified of modifications or required to fit them. In a situation remarkably similar to the recent case of upgraded Rolls Royce Trent 900 engines for the Airbus 380, Qantas and Holyman weren’t told of the tail modifications; the A&AEE reports 2 were kept secret for forty years. 

In 1984 a distinguished aviation journalist, Alec Lumsden, discovered the reports and described the scandal in an article for Aeroplane Monthly. 3 He wrote: 

How the DH-86 obtained a Certificate of Airworthiness in the first place is hard to imagine. What is so interesting to recall is the lack of any hint of concern regarding the comfort of the passengers’ ride, down in the cabin. It must have been hell in there—imagine monsoon weather, perhaps in darkness!

The DH-86 proved to have been one of the most dangerous aircraft ever put into airline service; at least one third of all planes built crashed, killing more than forty-eight passengers and crew, thirty-one of them in Australia.

But those lives lost in the early crashes changed Australian civil aviation. Ivan Holyman used his political connections to pressure the government to end the policy of Imperial Preference which required the purchase of British aeroplanes. He immediately ordered the new all-metal Douglas DC-2 airliners from America and merged his company with Airlines of Australia to form Australian National Airways. By the time war broke out, ANA had a fleet of four DC-2 and four DC-3 airliners. 4 Qantas had been left behind with its biplanes, believing their four engines gave greater safety over water than the twin engines of the American planes. But in 1938 the Empire flying boats were introduced with Imperial Airways for the London to Sydney service, and Qantas was stuck with the DH-86 planes. They were relegated to domestic routes, suffering five more accidents, with ten deaths.

The Belmont crash in 1942 propelled Qantas to buy its first American plane, a second-hand Lockheed L-10A Electra in New York for US$41,250. As VH-AEC, it took over the Darwin route from the DH-86 until impressed into war service with the US Army in New Guinea where it carried troops and ammunition to the front line at Buna. Returned to Qantas after the war, VH-AEC ended its career dramatically destroyed in a crash at Condamine, Queensland, in 1948. Nine passengers and two pilots walked away. 5

Between its first passenger flight, Longreach to Winton in 1922, and 1960, Qantas suffered sixty-five crashes, in almost every type of plane it operated, with seventy-two passengers and crew killed. The list of fatal accidents is a chronicle of the development of aviation. It does not include losses of its aircraft due to enemy action in the Second World War.

1923 DH-9C Tambo 3

1928 DH-50J Adelaide Hills 1

1934 DH-50A Winton 3

1934 DH-86A Ilfracombe 4

1942 DH-86A Belmont, Qld 9

1942 Short S23 Empire Darwin 2

1943 Short S23 Empire Port Moresby 13

1943 Lockheed C-56B Port Moresby 15

1944 Short S23 Empire Sydney 1

1946 Avro Lancastrian Indian Ocean 10

1951 DHA-3 Drover Lae, PNG 7

1951 DH-84 Dragon Koranka, PNG 1

1951 DH-84 Dragon Yarramunda, PNG 3   6,7

As this record indicates, New Guinea flying was the most risky Qantas undertook, anywhere. There were at least another fourteen crashes there that resulted in, at most, minor injuries. One of them gave me a personal bird’s eye view of the dangers. In August 1958, I hitched a ride on one of the new DHC-3 Otters flying freight into the mountain airstrip of Tapini, north of Port Moresby. It’s a nervy approach—up a gorge, banking hard to land over a hillock on a short strip sloping uphill at fifteen degrees. The Otter landed heavily and bounced, the undercarriage collapsed, smashing the propeller and starting a small fire. As we careered off the strip, we were saved from plunging into a gully by a big fence post, handily put in the day before. The Otter had to be dismantled and carried out to the coast in pieces. That was to be almost the last recorded crash of a Qantas plane, but it was eclipsed by the destruction of Super Constellation VH-EAC Southern Wave in a misjudged takeoff from Mauritius in 1960. The aircraft was completely destroyed by fire, but all thirty-eight passengers and twelve crew escaped, with only minor injuries. 8

So where did the myth that Qantas had never lost a passenger come from? Most agree on the 1988 movie Rain Man featuring Tom Cruise as Charlie and Dustin Hoffman as Raymond, brothers travelling across America. By then, Qantas hadn’t had a crash for nearly thirty years nor a fatality for nearly forty. 

Charlie: Ray, all airlines have crashed at one time or another, that doesn’t mean that they are not safe. 
Raymond: Qantas. Qantas never crashed.
Charlie: Qantas? 
Raymond: Never crashed. 
Charlie: Oh that’s gonna do me a lot of good because Qantas doesn’t fly to Los Angeles out of Cincinnati, you have to get to Melbourne! Melbourne, Australia in order to get the plane that flies to Los Angeles!

Charlie was right about all airlines having crashes; unknowingly though he had put his finger on one important reason for the remarkable record—Qantas was by then a long-distance airline. Long international routes require fewer take-offs and landings, which are statistically the most hazardous phases of flight. Qantas is also a relatively small airline with a fleet of 130 aircraft, one-fifth the size of the biggest carriers. While it doesn’t rate in terms of fleet size, its reach is proved by its place in the hierarchy of world airlines—fourteenth in the number of destinations and tenth in passenger miles travelled. 9

By 1988 too, all its aircraft were powered by jet engines. Just as monocoque fuselage construction and the strength of metal monoplane wings ended the flimsy “string bag” era, jet propulsion enabled airlines to escape the unreliability of propellers and piston engines. Indeed, the reliability of the jet engine is recognised as having been the single most important contributor to air travel safety since the Wright Brothers’ first flight. The year before Southern Wave crashed and burned, Qantas had taken delivery of its first Boeing 707 jetliner, which would bring its propeller-driven international flying to a close after twenty-five years. 10

Understandably, airlines don’t like to talk about their accidents; in time all but the most horrific pass from national memory. Everyone in the aviation industry knows that previous crash history is an unreliable guide to future safety. Nervous passengers can check any number of websites that analyse crash data by country, airline, aircraft type and other factors, but they should know they can buckle up on any major carrier, confident that the chance of an accident is one in 9.2 million. Their safety depends on the integrity of the aeroplane design, the quality of its maintenance and ultimately, the skill of its pilots when confronted with an emergency. Pilot error, due to inexperience, lack of training, or just poor judgment, is still the major cause of all world aircraft accidents. In the last sixty years, the proportion attributed to pilot error has declined, but only from 48 to 46 per cent. 11

The importance of pilot training and the difference pilot decisions can make was dramatically demonstrated in the major Qantas accident at Bangkok in 1999. VH-OJH, a Boeing 747-438 with 391 passengers and a crew of nineteen, over-ran the runway when landing in a rainstorm. Nobody was hurt, but it cost $100 million to repair the aircraft. The investigation revealed there had been confusion on the flight deck about whether to abort the landing, resulting in the failure to select reverse thrust to slow the landing roll. Just as important, the training and the procedure manuals provided inadequate or incorrect preparation for pilots landing at Bangkok in heavy rain when the tyres would aquaplane. 12 The accident led to a complete review of pilot training and regular simulator practice of all possible emergencies.

A more recent cluster of incidents suggests that after fifty years of increasing reliability, aviation may now be entering a new risky phase. Today’s new generations of airliners depend hugely on computers for both information and control. In October 2008, QF72, Airbus 330-303 VH-QPA flying at 37,000 feet off the West Australian coast suddenly disconnected its auto-pilot and took two dives. A flight attendant and eleven passengers were seriously injured, and 107 others suffered minor injuries. Preliminary investigations showed malfunctions in two of the on-board computers; Airbus has subsequently modified the software in the flight control primary computer, but the actual cause of the aircraft’s behaviour has still not been proved. 13

Eight months later, Air France flight AF447, an Airbus 330-203, F-GZCP disappeared over the Atlantic on a flight from Rio de Janeiro to Paris with 228 people on board. Bodies and wreckage were recovered but not the flight recorders. The reason for the crash has not been determined, but French investigators established that a batch of error reports had been automatically transmitted before the plane vanished, indicating faulty computer processing of flight data readings or faulty sensing instruments, or both. 14

An explosion of the vastly more powerful engines can bring down the plane. The engines of the early Boeing 707 developed 13,500 foot pounds of thrust (60 kN); the Trent 900 engine in the Airbus 380 is now six times as powerful (355 kN). Composite materials are increasingly used for their lightness in wing surfaces and fuselage panels. Strong as steel in some directions, the weakness of carbon fibre is in withstanding high shock loads. When the number two engine of flight QF32 Airbus 380 out of Singapore exploded on November 4, that was the reason the engine pod could not contain the shattered engine parts. The shrapnel tore through electrical cables and hydraulic and fuel lines in the wing, and some pieces pierced the aircraft’s fuselage. As the investigation proceeded, it became clear how close the 440 passengers and twenty-nine crew had come to disaster—and how important training had been in producing calm, efficient and correct actions by the pilots. 15 When Boeing developed its first jet airliner, the 707, it slung the engines under the wing to keep them as far as possible from the passenger cabin in case of fire or disintegration of the high-speed turbines. That now seems not far enough away.

Just how vulnerable a modern airliner is to damage to the hundreds of kilometres of wiring feeding its complex systems is obvious from any reading of an Australian Transport Safety Bureau report. Take Final Report AO-2008-053 of November 22. When an oxygen cylinder burst in the cargo compartment of Boeing 747-438 VH-OJK on flight QF30 over the South China Sea in July 2008, it blew out the side of the fuselage, sliced through eighty-five wires controlling flaps, navigation, oxygen and landing and braking systems, then burst like a missile through the floor of the passenger cabin and the overhead panels. Flying at 29,000 feet, the plane de-pressurised, giving those on board only two minutes of TUC (Time of Useful Consciousness) without oxygen. Within those two minutes however, the captain had made an emergency descent through 23,000 feet where the TUC was eight to nine minutes, and most passengers were able to use their masks. The oxygen bottle was never found, and an exhaustive investigation concluded it was, fortunately, a rare if inexplicable event. The plane landed safely, if crippled. The report concluded that the crew’s response to the emergency had been exemplary. 16

Aircraft today are bigger, faster, carry more passengers over longer distances, crammed with electronic equipment to make flying safer and more comfortable. It is so far from the days of a single radial engine, an open cockpit and someone to swing the propeller—where Qantas began—as to be inconceivable to anyone who has not lived through that period. But is the complexity reaching a point where understanding, maintaining and controlling the systems are beyond the capacity of less than perfect human beings? In the last sixty years, the percentage of passengers surviving a fatal crash has remained almost constant, around 24 per cent, but the numbers of passenger seats in airliners have increased twenty times over. The significance for a major accident is obvious.17 We should remember the lesson from the accidents that befell QF30 and QF32—that however clever the designer of the aircraft, however good the ground crews and thorough the security, it is always the pilot, and only the pilot, who can save us.

Geoffrey Luck is a one-time private pilot who flew in outback Queensland and Papua New Guinea, and survived three aircraft incidents.


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3 Aeroplane Monthly, April 1984 pp180-185 









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