November 4, 2010
Quattice flight QF32 was preparing to depart Singapore's Changi Airport.
An Airbus A380, the largest passenger aircraft in the world, onboard 440 passengers, 28
crew, and me, the piloting command.
A 10-01 AM we took off, the four Rolls-Royce engines perred, burning 15 litres of jet fuel
every second.
It was calm, normal, just another takeoff, the kind I'd done thousands of times before.
Then, four minutes into the flight, at just over 7,000 feet, this is flying.
I'm Richard DeCrebney, former Royal Australian Air Force pilot and Quattice captain.
Over 45 years in aviation, thousands of flights and one that nearly didn't make it.
In this podcast, I'm going to talk to you about resilience.
What is it?
How do you build it?
What do you do when the pressure is really on?
I'll share the mindset, the tools, and the frameworks that help me stay calm when everything
was going wrong.
That day on QF32 challenged my resilience, and we passed.
And the journey to that resilience started when I was a young boy.
My father thought that we had to toughen up, so he bought a farm just to the north of Melbourne
where we had motorbikes and we would ride them into the forest.
Now the motorcycles gave us the physical skills to actually manipulate the machines and the
confidence to work with machinery.
It also gave me the technical skills to learn how to maintain and service those bicycles.
These weren't skills given to us by our father. We had to work these things out ourselves.
And necessity is a great mother of an invention, so that worked very well.
But in my final year of school, my mother died, which was certainly the biggest catastrophe
that happened in my life and put me into great traumatic stress.
And when people are faced with traumatic stress, they can allow it to define them
or they can use it to motivate themselves to come out of it and to end up stronger.
So I used my mother's death as a motivation to excel at school and prove to her
that I could gain the skills necessary to join the Air Force.
And that worked. So I joined the Air Force where I flew jet, transport, and helicopter aircraft
for 11 years. And then I joined Quantus, where I flew jumbo, A330, and of course the wonderful A380 aircraft.
And that brings us back to here.
Too bad explosions. I don't know what caused them, but there wasn't time to work out why.
Here's QF-32 passenger on Mok.
I heard a crack. It was so loud that I was wondering why, was that a bomb? So when the explosion came,
my body and my stubble was, I was winging, I was terrified. I was having difficulty breathing.
And there was, you're not in my body, you know, like, look, is this good to be my last
damn on Earth?
Alarm started sounding in the cockpit. We pressed the cancel button to try and stop the alarms,
but they continued. They were noisy. They were distracting us. And we couldn't cancel it.
The top panel is a sea of red lights. The bottom console is a panel of red lights.
E-cam checklists are flooding up on the screens in front of us. No one is saying a word,
but this noise continues and it's distracting. And Matt's pressing the cancel button,
but they just won't stop. I pressed the hitting hold button to stop the aircraft following
a curved departure. Then I pressed the altitude hold button that would cause the nose to lower
and the aircraft follow a constant altitude. I know we're about the mountains.
No one's saying anything, but these noise still continue and it's hard to keep focus.
Then I watched the speed. The speed is increasing. We're about to overspeed. I don't know why,
but I grabbed the thrust levers and pulled them back. And then after 30 seconds, I say the first words
said in the cockpit, which is, we're at a constant altitude, we're at a constant heading,
as speed is stable, we are safe. E-cam actions. Now, E-cam is the electronic centralized
aircraft monitoring system. It's the computer program on the A380 that monitors the 250,000
sensors and parameters to see if anything's wrong. Now, if anything is wrong, this E-cam program
looks up a database of problems and solutions and presents checklist to the pilots in the cockpit.
When I said E-cam actions, that now gives Matt the direction to go down and start actioning
the checklist. You see, in the first 30 seconds of a crisis, when the fear response hits you,
which is the feeling of fight, flight or freeze. These reactions might help you thousands of years ago
with animals challenging you, but in high-tech equipment, these can be the wrong responses.
It's important that during the first 30 seconds of a crisis that you avoid becoming subject
to the fear response. And pilots have a mantra that we use to protect ourselves during this first
30 seconds when there is chaos around you. It's called aviate navigate communicate. aviate means
fly the aircraft. Stay alive. Navigate means find a safe place. Then communicate. When you finally
guarantee that you're alive and you're staying alive and you're found a safe place,
then you can talk to people about your predicament. aviate navigate communicate. This is what we did
in the cockpit. It took 30 seconds. And after the 30 seconds, our cortex or the complex part of the
brain has come online and we can now rationalize through what we're going to do. If Matt had started to
action a checklist too early, we might have finished the first checklist, but the aircraft might have
hit the ground inverted. So this aviate navigate communicate mantra is not just important for pilots
in an aircraft. It's important for anyone in a crisis where they are suddenly surprised
by an event. They have to keep their focus. They have to stay alive. They have to find a safe place.
And then you can talk to people about the problem. This is supervising check captain David Evans
addressing the passengers five minutes after the engine exploded.
I do apologize. I'm sure where we have a technical issue with number two engine.
We have dealt with the situation. The aircraft is secure at this stage. We're going to have to hold
for some time whilst we do light now load by dumping some fuel and a number of checklists we have
to perform. As you can, I'm sure you are aware. We're not proceeding to send you at this stage.
We're making our left turn now to track back towards Singapore. And as we progress with this,
we'll keep you informed of this stage. Everything is secure. Aircraft is flying safely and we'll get
back to you very shortly with further information. Thank you for your patience. I was really fortunate to
have an experienced crew on the aircraft that day. Normally we would have a crew of three to fly
from Singapore to Sydney. Matt Hicks had been flying for 23 years. He was my first officer and he
will be sitting on my right. Mark Johnson, an X-Air Force F-111 and Hercules pilot, had 8,000 hours
of flying experience. And that would be the normal crew, but today we had an augmented crew because we had
Harry Wuben, a senior check captain. Harry Wuben had 32 years of flying experience and he will be there
to check me on that flight to see if I could operate the flight and follow instructions. Look after
the aircraft, look after the passengers, follow air traffic control instructions when everything's going
well. But Harry was actually learning to be a check captain that day. So we had David Evans of
very experienced captain of 17,000 flying hours. He was teaching Harry to become a check captain. So in
fact we had five pilots in the cockpit that day, 140 years of experience, 71,000 hours, and we needed
every bit of that experience. We combined the knowledge and all our brains that day into a
superbrain to solve the problems that we'd never expected to see and in fact that the industry had
not seen before. We had a superbrain and we created novel solutions to problems that we'd never seen
before and it worked. This was a black swan event. Black swan events are unthinkable events
that are very low probability but have significant outcomes. 9/11 was a black swan event. The GFC was a
black swan event and so was QF32. But the benefit we had on board that day was we had five super
efficient experienced knowledgeable pilots. We took all of those brains and merged them into one
superbrain with the most enhanced shared mental model of the aircraft, the environment and what we
had to do because we took up a holding pattern about 20 miles to the east of Singapore where we
flew for one hour completing the checklist and working out what was going on. We actioned what we
call threatened error management which is to identify all the threats and to stop them, fix them
or to mitigate the fact that we can't fix them. We had about a hundred checklists that we did in the
air over an hour and 20 minutes in that holding pattern and we did another 20 ECM checklists on
the ground. Matt was actioning the checklists reading them out and moved into controls and I was
monitoring him. I was flying the airplane talking to a traffic control. The other pilots were
monitoring us talking to the cabin behind. This was a very highly efficient team all looking after
each other, backing each other up but pulling all the knowledge into this superbrain to solve the
unthinkable black swan event. I needed to prepare the aircraft for a loss of all engines because I
couldn't guarantee the supply of fuel to the engines. So I told air traffic control I want to climb
to 10,000 feet and keep us inside 30 miles from the airport. So in case the worst thing happened,
we could glide that heavy A380 from the holding pattern down to land at Singapore with no engines
remaining. And I did something else which was we inverted the logic. Now inverting the logic
is not my idea. It's gene cranses. Gene crans was a leader at NASA at Houston during the Apollo
space program. And during the Apollo 13 flight in 1970 when the Apollo 13 spacecraft exploded on
its way to the moon. The mission controllers at Houston were melting down under the onslaught of
all the error messages on the screens and the checks they had to do. They really couldn't work out
what state the spacecraft was in or what to do. So gene crans stood up and said forcefully,
gentlemen, stop wondering about what's broken and focus on what's working. That's called
reversing the logic. The mission control is at Houston did reverse the logic and they reduced the
millions of components on that NASA spacecraft just down to the few that mattered. They regained their
composure, they regained their mindfulness and calm and Apollo 13 made it back to her safely.
And that's what we did on QF32. We reversed the logic. Because with all the failures in the systems,
we had 650 wires broken, we'd lost half our networks. We had damaged 65% of our roll control. The fuel
system was a mess. And these were all things that overloaded me. I lost the ability to keep a mental
model of all these failures and they're not going to fix. I lost the ability to keep my mental image
of what the aircraft was and what we would do to get it back on the ground. But when I reversed
the logic, when I looked at the things that were working, it simplified the A380 from its four
million parts down to just a basic aircraft like a sessner or a piper. We just need a few wheels
to land on when there are enough wings and enough flight controls and just enough fuel to get down.
Reversing the logic took a super complex problem and made it really simple and understandable.
And when I reversed the logic, my calm came back to me and my mental model, the machine returned
and I regained control. And that was one of the most important things that I did on the aircraft.
We were circling in the holding patterns the Easter Singapore for an hour and 20 minutes.
Dave was trying to work out the landing performance. How would we make our approach to land in
Singapore? What would be the configuration of our flaps and slats and what speed will become in?
I asked Dave what a landing performance was and he said he couldn't calculate it. I said,
well, what do you mean? And I said, well, Dave, just keep working on it because we have an hour and a
quarter of fuel left in one of the engines before it will run out of fuel and fail. We have one
and a quarter hours before the next degradation in our systems occurs. So we've got time. I said,
Dave, just keep working on it because now I had to talk to the passengers. I had to bring on a sense
of calmness before I talk to the passengers. I did what we call the box breathing technique. It
means breathe in over four seconds, hold it for four seconds and then breathe out slowly through
your nose for four seconds. You're breathing in and out through your nose that creates the
physiological sense of calmness. And when I did that two or three times, I returned to a sense of calm
and then I spoke to the passengers for about ten minutes explaining what had happened, why,
what was about to happen and what we required them to do and how long it would take.
At the end of that public address to the passengers, Dave came back saying, Richard, I have landing
performance. We have a hundred meters. Now what does that mean that we have a hundred meters?
Well, the runway at Singapore is 4,000 meters long. And if we were landing at maximum landing
weight on a wet runway, we would need about 1800 meters of that four kilometer runway to stop.
But we've lost about 60% of our brakes. We've lost a lot of flight controls and we have four fuel
imbalances that are out of limits. All these failures would cause the landing distance
of Singapore to increase from 1800 meters to 3,900 meters. We would have 100 meters remaining
at Singapore airport when we came to a stop. And people say that's terrible. And it really does
sound terrible that out of 4,000 meters, you're only left with 100 meters. What happens if you just
have a slight error that takes you over that? But reverse the logic. We have a hundred meters.
All we have to do now is land the aircraft as well as the test pilots did that certify the aircraft
into lose. We have to understand how they certified it, how they flew it, and we have to replicate
that. So that's one of the elements of resilience, which is knowledge. So I thought a hundred meters
good. We just have to land the way the test pilots did. So I wasn't worried, even though I'm sure
every other pilot in the cockpit was. I think if I told the passengers that we would have 100 meters
left at the end of the runway, that would have caused a panic in the aircraft. We made our approach
and Harry told me to be careful of the speed because we can't afford to slow down. And I discovered
that when we slowed down one knot or two kilometers per hour in speed, we would get speed warnings.
And I got a stall warning, which means the aircraft was losing lift and my crash. We got these speed
and stall warnings during the approach. And I've never, ever heard those warnings before on a flight
outside a simulator. Something was terribly wrong that we didn't understand because we should not
have received those speed and stall warnings, but we continued with the approach because I've proven
the airplane safe to make an approach and land 10 minutes before we landed. I'd actually conducted
a dress rehearsal of the landing at 4,000 feet in the air at the right speed and the right configuration
for landing. We proved the aircraft safe. So when these speed and stall warnings occurred on the
approach and they were terrible sounds that I didn't expect that could put again a fear response
into the pilots, I thought, we have this covered. I've proven the aircraft safe. We can continue.
We had a hundred meters, but I knew it was really going to be close. We asked Mark to go down and see
Michael Von Wreath, who was the flight service director in the cabin. Mark said, Michael, this will be a
very limiting landing and there might be a passenger evacuation. Michael said, Mark,
the aircraft, the passengers and the crew are ready. Moments later, we made our landing.
It was a smooth landing and we used all but about a hundred meters of the runway to stop
just as the performance had said. And as we approached 80 knots slowing down on the runway,
Michael Von Wreath, the cabin service manager said, on the public address,
welcome to Singapore, local time is served, so please keep seated with us. It will fasten
until we've reached our final parking position. Michael had kept his calm the whole time despite
having the aircraft and the crew ready for an evacuation if the aircraft ran off the runway.
He was calm. He was resilient. But we stopped a hundred meters from the end of the runway.
The fire trucks surrounded us and this is when the second part of QF32 started. We're now entering
a phase where Dave, the check captain thought we were more at risk on the ground for the next two
hours than we were for the previous two hours in the flight after the explosion.
Because when we stopped, air traffic control told us QF32 shut down your engines and contact the
fire controller who was now in one of the fire engines that is surrounding you. And when we did that
situation got worse. Because when we shut down all four engines, we thought the power generator
in the tail would continue to give us electricity and air conditioning air. But that failed because
so many other things in the aircraft had. Remember only one out of the 22 systems have
unaffected during this black swan event. So when we shut down the four engines, the 400 kilowatts
of power generation sources on the aircraft returned not just down to the generator in the tail
because that didn't work. We returned it down to two car batteries. So we lost six out of our seven
radios. We lost nine out of our ten computer screens in the flight deck. And we lost the radio that
we would talk to the fire crew. So we couldn't get contact with the fire crew. And we had fuel now
gushing out of the wings faster than it was gushing out in the flight. We had white hot brakes
with now four tons of fuel pooling around the aircraft. He has kept in service manager Michael
von Rith talking about his fears of fuel spilling onto the tarmac. That was just horrific to see
how the fuel was coming out and how it was swimming on the runway and we were sitting in it.
So I made a very stern announcement. No toilet visits because of the flush. No mobile phones,
no laptops, nothing because one wrong move and this whole thing blows up.
Dave said this was a much more dangerous situation on the ground than it had ever been during
the two hours in flight. And when we made contact with the fire controller, Matt said, please put
what over the hot brakes immediately and put phone over the fuel that's gushing under the aircraft.
The fire controller said, well, I will, but shut down the engines. Matt said, we have the controller
said, no, you haven't. In frustration, I opened the window and looked out along the long wing.
And I saw that engine number one, the rotor was still turning. It was still running.
We had used three systems in the cockpit to try and shut down that engine, but all had failed.
We had a runaway engine that we couldn't control and our situation was getting worse.
Because we had all this fuel now pulling around the aircraft, we had an engine that wouldn't
shut off and the situation was getting dire. And one of the passengers made a comment later
about the flight saying she could see the fuel on the ground and she realized that one spark
and we would be senders. And this ended a really difficult phase on the ground where we had to do
the most complex decision analysis. How do we get people out of the aircraft? Do we do a passenger
evacuation or do we open the doors and let them go downstairs carefully? The decision whether to
evacuate or not is one of the hardest decisions a pilot will ever make because there are so many
factors that will affect that decision. In our case, I knew that when passengers evacuate down
slides, about 15 percent of them will be injured because they might damage an ankle at the bottom
of the slide. They might have a fractured hip when people concertina into them down the slides.
But even if people don't injure them on the slide, when they're moving away from the aircraft,
in our case, there were so many other threats. Perhaps they walk through the fuel,
create a spark and ignite the four tons of jet fuel on the ground.
Perhaps they walk in front of engine number one that's still running, it gets sucked into it.
Perhaps a passenger might be covered in foam by a fire truck. This is very thick foam that can
be four, five, six feet deep. It's used to stop flame spreading in a crisis. The fire engines will
spread foam over the whole situation to try and make it inert. But if a passenger gets covered
by this foam, they become invisible. And in previous cases, passengers have been run over by
fire trucks when they've been invisible under the foam. There are so many threats that
faced us that day with the evacuation. We actually worked out that passengers were safer inside
the aircraft than out. So we made a decision that half the pilots probably around the world would
disagree with to keep the passengers on board where the cabin crew could remain in charge of them.
And when the situation improved and the risks decreased outside, we could let them out. That's what we
did. Once again, here's passenger Hon Mok. It was a very hot day. The plane was very stuffy. It was
incredibly humid. It was like sauna and you can see films outside of the window where I sat. We waited
for an hour and then it was announced that we can get out. But then again, I was sitting in the last
few rows at the back. It took another hour before I could get out of the plane.
So it would be two hours before the final passenger disembarked from QF32 after we'd stopped on
the runway. We walked them downstairs. They took no cabin baggage and we got every passenger
off without a single injury without even a broken toenail. 444 passengers went to the terminal
off the aircraft with no injuries after the blacksmith event. But engine number one was still running
and it would run for a further two hours in our absence. The only way the fireman could stop
engine number one was to inject foam into the engine that did stop it but it also caused 18 million
dollars worth of damage. All the passengers moved to the passenger terminal where I met them in three
different lounges where we gave what I call the full and open disclosure. It's a brief where we told
the passengers what had happened, why, what was about to happen to them and what they needed to do.
I explained to them that the media would be outside and they'd be critical of the crew and the
aircraft and the engine and even the passengers. You see the passengers were now getting worried because
they kept their mobile phones off inside the aircraft for safety reasons. But now they're in the
terminal and they can see the screens in the side of the waiting rooms showing a CNN program showing
QF32 crashing. The passengers were turning on their mobile phones now and the loved ones were calling
them to say they thought that they had died. I could tell that the mood was getting bad very quickly
in the terminal because the passengers perhaps thought the incident was much worse than they thought
it was in the aircraft. And then I gave what I called the personal guarantee because I could see that
the passengers were still in fear after the incident not knowing what was about to happen to them
or who could they call if they needed a point of contact at Qantas. So I told the passengers to get
out of pencil and I said these words. Qantas is a value added airline but we've done a terrible job
today and I'm very sorry but I'll give you this guarantee that if you think the Qantas is not doing
what you want it to do or if you don't think that we care you must call me on this mobile number
and I will solve the problem. So we gave my mobile number to every passenger on board QF32
which is an active I suppose humility and certainly vulnerability because of the passengers
thought that I'd lied to them they could bring up and abuse me they could bring up and say I have a
question but 15 years after QF32 out of those 440 passengers that got my mobile phone number
none of them called to ring up to complain none of them called up to ask for help
but 20 called up saying can we please have a beer sometime. So I'm telling every listener in this
podcast don't be afraid to give your personal guarantee in a crisis that humility and vulnerability
will induce teamwork loyalty and trust many people ask me why did we do all the things that we did
because certainly many pilots disagree with many of our decisions and in having to answer that
question I have to delve into the elements of resilience I have to look into the human condition
which is how we're built what we can do how we respond and how you build equipment to work with
humans and we have to look at the 8 elements of resilience which is knowledge training experience
teamwork leadership decision-making crisis management and risk we have to look at all these inputs
that you must know if you want to survive the unthinkable events in this podcast I'm going to be
interviewing leaders and exploring the elements of resilience and when you harness these elements
of resilience you won't just survive when you get hit by a black swan but in the good times you'll
thrive I'd love to hear from you please send your questions to
[email protected] and don't
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