Aviation safety issues and actions

Flight crew operating manual procedure for Vref40 check

Issue number: AO-2014-162-SI-01
Who it affects: All Qantas Boeing 737 pilots
Issue owner: Qantas Airways Ltd
Operation affected: Aviation: Air transport
Background: Investigation Report AO-2014-162
Date: 16 November 2015

Safety issue description

The Flight Crew Operating Manual procedure for crew comparison of the calculated Vref40 speed, while designed to assist in identifying a data entry error, could be misinterpreted, thereby negating the effectiveness of the check.

Proactive Action

Action organisation: Qantas Airways Ltd
Action number: AO-2014-162-NSA-004
Date: 16 November 2015
Action status: Closed

Qantas Airways Ltd. (Qantas) has advised that the Central Display Unit pre-flight procedure has been modified as follows. After the take-off data has been verified and compared by both flight crew, they are to check the ‘APPROACH REF’ page and verify the Vref40 speed.

Current issue status: Adequately addressed
Status justification:

The action by Qantas provides an additional defence to address the risk associated with this safety issue. 

Last update 10 March 2016