Investigation Summary
The approach was conducted at night in deteriorating weather conditions. While a preceding Thai Airways A330 landed successfully, a Qantas flight (QF15) just three minutes ahead of QF1 had conducted a go-around due to poor visibility, a fact unknown to the QF1 crew. The first officer was the pilot flying, using a flaps 25 setting and planning for idle reverse thrust per company policy. The aircraft was high and fast on final approach, and visibility dropped sharply as they crossed the threshold. Fearing a long touchdown, the captain ordered a go-around. The first officer advanced the throttles but did not engage the TO/GA switches. As the aircraft touched down, the captain perceived an improvement in visibility and decided to land, retarding the throttles without announcing his actions. Crucially, he failed to retard the No. 4 engine throttle fully, leaving it at go-around power. This mismatch prevented the autobrakes from engaging and the spoilers from deploying automatically. The crew did not commence manual braking until 1,600 meters down the runway, by which point the aircraft was aquaplaning on standing water. The 747 exited the runway at 88 knots, losing its nose and right wing landing gear in the soft terrain.
Final Conclusions
The ATSB investigation concluded that the primary cause was the breakdown in cockpit resource management during the transition from a go-around back to a landing. The captain's unannounced override of the first officer's controls led to the No. 4 engine remaining at high thrust, which disabled critical deceleration systems (autobrakes and speed brakes). Contributing factors included Qantas's then-standard procedure of using flaps 25 and idle reverse thrust on wet runways, which provided less safety margin than flaps 30 and full reverse. The investigation also cited deficiencies in Qantas's training regarding contaminated runways and the lack of clear procedures for cancelling a go-around once initiated.
Photographic Evidence (1)
Video Analysis
WHY did This Airplane MISS the RUNWAY? | Qantas flight 001 — A detailed breakdown of the human factors and procedural errors that led to the Qantas Flight 1 runway excursion in Bangkok, including the botched go-around and the technical reasons the autobrakes failed to engage.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Senior Check Captain
First Officer
Second Officer
Systems & Failure Modes
Autobrake System
The system was automatically disarmed because the No. 4 thrust lever was not in the idle position, leading the aircraft to believe a go-around was still in progress.
Speed Brakes / Spoilers
Automatic spoiler deployment was inhibited by the advanced position of the No. 4 thrust lever, significantly reducing aerodynamic braking and weight on the wheels.
Thrust Reversers
Company policy at the time mandated the use of idle reverse thrust rather than full reverse thrust, even on wet runways.
Interesting Facts
- 01The aircraft was repaired at a cost of approximately AU$100 million to maintain Qantas's record of no jet-age hull losses.
- 02The captain was a Senior Check Captain but had significantly less experience on the Boeing 747-400 than the first officer.
- 03The No. 4 engine remained at high thrust during the landing roll because the captain did not fully retard its lever.
- 04The aircraft came to rest 220 meters past the end of the runway with its nose on a perimeter road.
- 05Thirty-eight passengers sustained minor injuries, mostly during the evacuation.
Safety Actions & Advisories
Qantas Procedural Changes
Qantas changed its standard operating procedures to mandate the use of Flaps 30 and full reverse thrust for landings on contaminated or wet runways.
CASA Regulatory Review
The Civil Aviation Safety Authority (CASA) updated regulations regarding contaminated runways and improved its surveillance of airline flight operations.