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Irish Steve
12th May 2005, 18:37
Will this raise any queries, or is there a different agenda here.

Over 18 months ago, when I was still a lowly ramp lead agent, during a walkround inspection, I found both alternate static ports on a 737 covered with speed tape. The aircraft had night stopped. I called the line maintenance engineer back, in case he'd dropped a b:mad:k and forgotten to take it off.

Turned out he hadn't forgotten to take it off, as he'd not put it on, but he had missed the fact that it was there.

After a lot of head scratching, and phone calls, as there was no way I was letting that aircraft go without an answer, it transpired that the aircraft had received a "deep wash" at it's home base, and someone had forgotten to remove the tape after it had been completed.

As if that wasn't bad enough, not only had they missed it, the aircraft had flown for over 2 days in that condition!!!

Was anything said? Was anything done? Well, the only thing I know is that the ramp manager, when I got asked why it had gone 30 or 40 minutes late, made it VERY clear that if I put ANYTHING in writing, (which I had told him I was about to do) life would become difficult!!!

It should have been an AAIB investigation. I suspect that nothing at all happened.

The carrier involved was not a small cheapskate operator, they are one of the Eastern European operators that I had thought were a better level than some.

To me, this was a far more insidiously dangerous situation than flying an aircraft certified to fly on 3 engines. It was kept quiet, too quiet. This thread and the related threads have attracted more heat and emotive language than almost anything I've seen outside of Jet Blast in close on 3 years. I find that strange and slightly worrying. There was the potential for an accident. Most days, someone has an incident that has the potential to become an accident, but they're not disected to the level that this one has been. In a minute, we're going to be asked what colour underwear the flight crew were wearing, it's got to that level.

Edited to correct a confusion in the title after it was split from another thread

akerosid
12th May 2005, 19:07
That was what brought down the Aeroperu 757 a while back.

Amazing to think, even after being reminded of it, they let it go. But surely they would have experienced some problems on the flight from wherever? Speed indications etc, which would have told them something was amiss?

Vin Diesel
12th May 2005, 19:13
Would it not have been possible for you to contact the national authorities anomynously at the time? Circumventing the relevant duty manager?

Why after 18months since the incident do you choose to bring it up now? Better late than never, but the time it should have been investigated was then, although, you could still blow the whistle and alert the IAA???

Though PPrune may bring some differing opinions from engineers and pilots on the issue, nothing meaningful will come of it. The IAA are the authority who should be alerted to this, even at this late stage, if you deem it worthy.

IMO

Flightmech
12th May 2005, 19:31
Wasn't the Birgenair 757 that crashed out of Puerto Plata also atrributed to blocked/covered pitot tubes and/or static ports? The AeroPeru accident is covered on the Air Crash Investigation series on satellite and indeed was caused by taped ports.

White Knight
12th May 2005, 21:05
If the static ports are covered up I don't think that that this aeroplane would have managed TWO days worth of flying without someone noticing!!! Methinks you're talking bollocks;) ;)

Earthmover
12th May 2005, 21:28
Flightmech, for info - Birgenair ALW301 06 Feb 96. From the Flight Safety Foundation:

The official report correlates the airspeed discrepancy with a total blockage of the Capt’s pitot tube. ‘The most likely source of obstruction was mud and/or debris from a small insect ...... The aircraft was not flown for 20 days before the crash and was returned to service without a verification of the pitot-static system as recommended by the manufacture’s maintenance procedures.’

Irish Steve
12th May 2005, 21:34
OK, let's correct a mistake that's not of my making.

The original post was made into the ongoing discussion about the BA 747 that went into Manchester on 3, and if you look at my wording, it's very clear that I said ALTERNATE STATIC PORTS I DO know the difference between pitot, static and alternate static, along with quite a few other things, as a result of the aviation training I've done that had nothing to do with ramp operations, and everything to do with ATPL exams back in the days when they were hard work written papers.

Hopefully, the error on the title can be corrected, I will see if I can do it, but as one of the mods did the split, they may have to correct it. (.OK, I was able to correct it, and it's now reading what I would have typed if I'd done it, sorry for any confusion )

It happened. The reason I can now speak out about it is that I no longer work on the ramp, so there's no way I can be threatened, intimidated or anything else about this scenario, one of several that I witnessed.

The IAA have been informed, in writing, and will hopefully be looking in to this, so my conscience is now clear.

At the time, it was made very clear to me that if I reported it, or even lodged a written report within the internal system of the company, I would regret it.

I needed the income, the dole in Ireland is even lower than in the UK, and as I'd been self employed for quite a few years, getting the dole was not going to be easy, so I had to make some hard choices. I'm no longer in that situation, and I've decided that it's time some of the more worrying aspects about some of these incidents came out. I'm not scandal making, but I do care seriously about what happens in the industry, and these sorts of incidents, and others, do no one any favours at all.

The local station had no responsibility for this incident other than the line maintenance engineer and the operating crew missing seeing the tape. What's slightly worrying is that the crew that flew it in were also the crew that were taking it out after the night stop, so they'd missed it the previous evening when they took the aircraft over.

As such, the main issue here was at the aircraft's home base, but the implications are significant. If a pitot heater had failed, and the crew had switched to alternate static, any instruments connected to the taped port would have mis read. If they had then switched the other side to alternate to see if there was any difference, all the instruments that use static would have been mis reading. That's brought aircraft down, several times, and I have to admit that I was both worried and relieved that I'd found it and made sure that it went on its' way later with the ports
open

If bringing it out in to the open now means that the relevant flight safety management pilots go back to their home bases and ask "How do we cover ports when an aircraft is washed, and how do we check the covers are removed afterwards? ", then I've achieved what I want, people are aware of something very simple, insidious and potentially a killer in the wrong circumstances. That's worth doing.

HotDog
13th May 2005, 00:33
"How do we cover ports when an aircraft is washed, and how do we check the covers are removed afterwards? "

Use the manufacturers covers and plugs with streamers on them.

This is not an isolated incident and happens quite frequently. To make it worse, some maintenance people use silver coloured speed tape that is very easily missed on aluminium.

The best thing to do is to make an entry in the maintenance log when the ports are covered which has to be signed off before the next flight.

fernytickles
13th May 2005, 00:54
Did you write a CHIRP at the time of the incident?

Irish Steve
13th May 2005, 01:22
Did you write a CHIRP at the time of the incident?

No, several reasons. Wasn't sure if non flight crew can raise CHIRP reports, and second, pure simple fear.

If you'd been sat where I was when it was "discussed", even confidential reporting doesn't look very inviting if it's going to mean it gets back to management, and there was a real risk that it might, and they'd have known exactly where to come, the number of people working on the ramp at that time that would know enough to report an incident like this was way too small for comfort, they'd have come to me in about 5 seconds. At the time, I had a mortgage and some very large bills to pay, and losing the job wasn't going to do anything to improve flight safety at the time.

To make it worse, some maintenance people use silver coloured speed tape that is very easily missed on aluminium.

Exactly what they\'d done, and to be fair, it was only that I was quite close that I spotted it, and realised something strange was going on. I would have thought that a pair of suitably moulded plugs, with red streamers, would be standard aircraft kit, along with the gear locking pins, pitot cover etc, and that way, there\'s not the same level of doubt. Still requires that the cleaner uses them, rather than taking the quick route of a bit of speed tape.

barit1
13th May 2005, 02:00
Here's a vaguely related accident:

Iced pitot during climb (http://www.ntsb.gov/ntsb/brief.asp?ev_id=41233&key=0#)

The trapped air in the pitot system caused a steadily increasing IAS indication in climb. Crew thought they were overspeed and attempted to reduce speed, resulting in a deep stall.

Kaptin M
13th May 2005, 02:59
Good to see a man who'll stand up for his principles, Irish Steve.
How would you and your mortgage have felt if there HAD been an accident as a result of something similar being the cause?:mad:

mutt
13th May 2005, 06:29
IrishSteve,

This is at least the 2nd time that you have started a topic regarding this incident. Considering that it happened close to 2 years ago, it looks as if you are just trying to vent your feelings about servisair!

Mutt.

emeritus
13th May 2005, 08:27
Irish Steve

Several points....

1...You did your job and safety was enhanced. You are not responsible for the others that allowed/missed this problem.

2..At the end of the day it was only the alternate system. (fortunately)

3..After 30 years of airline flying I never had to use the alt sys for real and I suspect just about everyone else would not have either.

4..Any pilot worth his salt should have a fair idea of what to expect if the need arose to switch to alternate.

5..If the official reporting system is denied/discouraged there is still the word of mouth.


:ok:

TwoDeadDogs
13th May 2005, 09:11
Steve
You did okay,all things considered. That manager should have his arse kicked for threatening you for highlighting a safety deficiency.
Mutt, He didn't say if it was Circusair, did he??
As for a confidential CHIRP-style system, well, It does not work all that well for non-pilots. It's less well known about and less easily accessed. I'd wager that the average chock-flinger in EIDW hasn't ever heard of the AAIU, much less know how to find them. The wash crew should have picked that one up before the aircraft ever left the wash bay. As for the last comment that it was "only" the alternate system, that beggars belief. The whole point of an alternate is that it is available when the primary becomes unavailable.
The comment about speed tape being hard to see is a good and pertinent one. How many people know where the full complement of streamers, blanks and covers are stored? Are they aboard or are they shoved in a locker somewhere?
regards
TDD

Irish Steve
13th May 2005, 09:14
Considering that it happened close to 2 years ago, it looks as if you are just trying to vent your feelings about servisair!

OK, I didn't actually name servisair, but as you have, the reality is that I've come to the painful conclusion that there needs to be some changes in the way that airlines are handled on the ground.

SA are unique in that they advertise they will handle pretty much anything, but it became very clear after a while that there are massive holes in their training for such situations. They are good at training people how to operate SA equipment. They do NOTHING to train the ramp people on certain aircaft families, let alone types, with the result that there are huge health and safety issues that are an accident waiting to happen.

I could go into more details, but that's distraction from the point. It came up originally as part of a message related to the BA 747 into Manchester, triggered by the LHR incident where both runways were closed at the same time for a few minutes, and related to that. The section of the messaage that started this thread was stripped our and reposted under a new (slightly wrong) title by the mods.

I Know from experience that the quality of handling by SA varies from station to station, I've been on the receiving end of it as a passenger and as an aircraft operator.

Locally, they've had one fataility where someone got too close to a live prop. I'd prefer not to see someone else hurt by a total lack of awareness at management levels.

Kaptin M
13th May 2005, 10:43
It is becoming more obvious - thanks to mutt's highlighting of it - that you have a problem with your previous employer, Irish Steve, and are hoping to gain some further "exposure" by writing about it here on PPRuNe.

So please allow me to ask you to now provide some cold, hard FACTS, to back up some of your earlier assertations.
You seemingly imply that if you had reported the problem, you would have been made redundant At the time, it was made very clear to me that if I reported it, or even lodged a written report within the internal system of the company, I would regret it.

I needed the income, the dole in Ireland is even lower than in the UK, and as I'd been self employed for quite a few years, getting the dole was not going to be easy, so I had to make some hard choices. Can you cite one (or more) previous examples of employees of the company concerned, who suffered this fate?
Or was it your own imagination that led you to this conclusion?

Please explain to your wider audience (that you've invited, by way of your posting), why you - an airline employee - consider the cost of your house(s) more important than the lives of individuals who were onboard aircraft operated by that company for whom you worked? At the time, I had a mortgage and some very large bills to pay, and losing the job wasn't going to do anything to improve flight safety at the time.What would be the outcome if EVERYONE....lame, pilot, policeman, ambulance driver, etc adopted YOUR attitude?

Quite frankly, you didn't have the balls to make an issue of it at the time when it WAS critically important.
I doubt that you will have the FACTS to back up your gutless, platonic reasons for not making an issue of it (had you really wanted to) at the time.

In REALITY, you were only doing your job, when you "discovered" something that had slipped past the other humans - and you SHOULD have been commended for it.
End of story (imo)!

Irish Steve
13th May 2005, 11:30
I can't reply fully at the moment, too much else on the plate, but before you eat my head for lunch, a couple of clarifications.

I didn't work for the airline, I was working for the handling agent.

I didn't ignore the issue, I pushed it as far as I could at the time, having first made sure that there was no risk to the aircraft. No different to many other people and situations that I've seen discussed here and in other places. If the tape hadn't been removed, then someone else would have had to take over from me to get the aircraft moving.

Subsequent events have confirmed that my concerns about my situation were justified.

I can't "prove" what you're looking for, but when you're the only one on the ramp with any form of formal flying qualification, there's a lot that happens that most ramp people don't even notice.

I didn't let the aircraft leave in a dangerous condition, and I did as much as I could at the time to try and make sure that it didn't happen again.

If you care to search, in another (ATC related) thread I've also mentioned an incident that happened to me while flying that occurred over 10 years ago, it was relevant to the thread at the time, and has flight safety implications.

Yes, if an ineffective unskilled manager now gets some heat, that's not going to worry me at all, he deserves it.

When I made the comments it was part of a larger message related to safety in general, and in the context of an incident that didn't cause any problems getting massive attention, while other incidents that could have been equally or more serious were getting no attention or being ignored.

mutt
13th May 2005, 12:07
TwoDeadDogs.

Mutt, He didn't say if it was Circusair, did he??

Actually he did..... it started with the missing headset story

http://www.pprune.org/forums/showthread.php?s=&threadid=136784

Then it appeared in the Safety CRM and QA forum.

http://www.pprune.org/forums/showthread.php?s=&threadid=168226

And now into Rumours and News!

Mutt.

Irish Steve
13th May 2005, 13:14
it started with the missing headset story

Which was not this aircraft, this incident, or in any way related, and this incident wasn't mentioned at all in that discussion. Despite making contact with the operator at Bristol, I never did get $350 worth of headset back, or any offer of payment for it.

Then it appeared in the Safety CRM and QA forum.

Correct. As a result of the comments made in that thread, and some private feedback by E-mail, and discussions with several people who became aware of it, I made formal reports to the regulators. I was also "encouraged" to make people aware of what had happened, to try and raise awareness so that the chances of a repeat would be lessened. I'm doing that.

It's here now because one of the mods cut it out of the thread about the FAA/CAA difference of opinion about the BA747. I didn't post it as a seperate thread. I'm not complaining, it's for sure been seen by a lot more people that are at the sharp end every day, and that's why the comments were made.

I never identified who I was working for at the time, or what airline was involved, that's been done by other people, and I can't be responsible for the actions of those other people.

MOR
13th May 2005, 13:42
Well having seen first-hand some of the "handling" carried out by SA, I can only concur that it occasionally veers into unsafe practice.

Assuming the aircraft departed without the tape on the ports,Irish Steve did all he could, nobody got hurt, case closed.

Maybe he could have pursued it, but the outcome of that is highly doubtful.

Also, any pressure on his job for highlighting safety concerns is clearly illegal under EU law, and would more likely have resulted in problems for his manager - but then who wants to put the family income on the line, unless lives are directly threatened. Quite understandable.

The real problem here is an obviously unsafe maintenance procedure, but then there is little he could do to affect that.

If he is on a mission against SA - which isn't apparent to me - then fine. He certainly isn't the first here to rail against his (ex) employer, and he has just cause.

HotDog
13th May 2005, 14:07
I was watching our aircraft docking at the gate in Seoul one afternoon, waiting to board to operate it home. From the departure lounge window, I saw the tape over the alternate static vent. I pointed it out to the incoming crew and I was in a position to have the flight engineer severely reprimanded for not noticing this serious discrepancy. I had a private talk to him and brought the matter up at a subsequent check and training meeting without mentioning names. An appropriate notice to crew was distributed and the F/E concerned was never caught out again with this oversight. Maintenace, who were originally at fault were also severely criticised but eventually, we suffered another similar incident some years later. So, there you go Irish Steve, get over it, we are all human and make mistakes. Cheers, HD.

ILS 119.5
13th May 2005, 17:07
"get over it, we are all human and make mistakes"

Yes I agree, but these mistakes cost LIVES. Procedures must be in place to ensure that mistakes are rectified. It is not to bo**ock humans but to ensure human error is reduced to nothing. Hard to do in this day and age but safety is paramount in my view and when I fly everything is triplechecked. I do not want to die with 250 pax with it being my fault. Unfortunately companies do not see the safety element as paramount, money is first. The old saying "if you think safety is expensive, then wait till you have an accident" comes into mind.

Finally I agree with the poster of this thread that something had to be done. Unremoved Pitot Head covers do and have caused fatal aircraft crashes and if nobody stands up and says something then flying becomes unsafe.

Irish Steve
13th May 2005, 22:51
Unremoved Pitot Head covers

Quick clarification, as the thread was mis titled for about 12 hours, and I'm not looking to get more read in than was there.

The problem with the aircraft was that the Alternate static ports had been covered with speed tape to prevent ingress of water during a deep wash at the aircraft's home base, and it had not been removed prior to return to service. As it was alternate ports, it would not have been immediately apparent there was a problem, so the aircraft flew for 2 days with the speed tape on the ports. As the port is polished aluminium, with no paint, and speed tape is metallic colour, it wasn't easy to see.

CosmosSchwartz
13th May 2005, 23:28
Well having seen first-hand some of the "handling" carried out by SA, I can only concur that it occasionally veers into unsafe practice

A tad harsh methinks. SA staff do their best but they are working most of the time with one hand tied behind their backs. Besides which, what the hell does any of this have to do with SA?

Yes, Irish Steve was working for them, but the problem mentioned here would appear to be a MAINTENANCE issue, originating at the aircraft's home base, before being picked up by....... oh, a SA staff member.

What I can't understand is why SA management wouldn't want it highlighted. As I said, it wasn't a SA attributable problem, so what were they worried about?

Irish Steve
13th May 2005, 23:57
slight embarassment was that the LM engineer that had done the checks overnight was SA LM.

I suspect, based on other experience, that the ramp manager was scared sh:mad:tless at the mountain of paperwork that this would have generated, as he was unfortunately less than capable in that area.

The other ( more likely ) possibility, is that he may not have been very happy at the thought of regulators and investigators looking too closely at the operation. Others have commented on the "handling". I concur. Most of the time, it is not the guys on the ramp that are the problem, they do the best they can with inadequate numbers, poorly maintained equipment, and attitudes from management that belong to the stone age. An external inspection of records and operational practise by someone who knows what is supposed to happen would be very uncomfortable in some cases.

MOR
14th May 2005, 02:07
A tad harsh methinks. SA staff do their best but they are working most of the time with one hand tied behind their backs. Besides which, what the hell does any of this have to do with SA?

His point was that he felt unable to take it further for fear that his job might be at risk if he did - therefore it has everything to do with SA.

In my time I have seen them wipe out hatches with GPU's that weren't chocked and got blown into the aircraft by high winds, I have seen one baggage loader lock another in the hold by mistake, I have seen ramp guys very nearly sliced and diced by props, one guy who was doing our pushback with his clipboard in his hand, and as he was disconnecting lost the clipboard, which promptly disappeared into No 2 engine... that one cost a bit... then there was the one that placed some steps against an aircraft which weren't secured, and moved away from the aircraft when the pax started de-planing... shall I go on...

Of course these things aren't confined to SA, but by the same token they aren't immune to error. Saying they do their best with "one hand tied behind their backs" merely highlights the problem - nobody is singling out the ramp guys - we are talking about the whole organisation.

Plastic Bug
14th May 2005, 04:08
Howdy Steve!

Look, you found an oops. A very serious, potentially deadly oops, but you found it. I'll quote you here:

"Over 18 months ago, when I was still a lowly ramp lead agent, during a walkround inspection, I found both alternate static ports on a 737 covered with speed tape. The aircraft had night stopped. I called the line maintenance engineer back, in case he'd dropped a bk and forgotten to take it off."

I would imagine that the Engineer at that point removed the tape. Guess what?

You're done!

As a ramp agent, I have no idea why you are doing walkarounds, but whatever, you discovered something wrong and that's a good thing. You have no need to beat yourself up, nobody died and you did the right thing notifying the appropriate person who is supposed to be doing walkarounds of the defect you found. Did the Engineer raise an issue regarding the defect? Not your problem. Will it happen again? Well, that's what you are worried about, isn't it?

Unfortunately, the way things are going in the industry today, there are people out there who don't think there is anything wrong with covering static ports with speed tape. As has been mentioned previously, silver tape on a silver area of the fuselage is rather hard to spot. That's why you are not supposed to do that, nevermind the sticky stuff left behind that picks up all manner of stuff, making the static ports not so static.

So, if you really believe there is an issue, drop a dime anonymously and let the local yokels know that there may be a serious problem with the organization in question. You will be "anonymous", but they are going to want to know your background, so if you are not a Certifying Engineer or Pilot, you better have your ducks in a row or they will not take you very seriously.

A note to those that leave the ground for a living: the airplane allegedly flew for two days in this condition. How many of you out there really REALLY pay attention to your standby instruments?

Keep the Faith!

PB

mono
14th May 2005, 10:47
For plastic bug,

This a/c type has an alternate system which is switchable. In normal configuration the Stby intsruments are fed from static ports integrated within the pitot heads. The alternate is switched if the normal and aux static systems go down.

Sheilanagig
14th May 2005, 12:04
Is that the sound of a big axe grinding?

And bye the way change the name...... at least the Irish bit, no Irishman with your lack of balls

Plastic Bug
15th May 2005, 03:02
Hey Mono,

Thanks for that. There WAS something rattling around in the back of the vacant space between my ears last night when I posted, that must be what it was.

Ya know, the "only used when the regular sources fail" deal kinda makes the scenario worse, doesn't it? You'll only find out the alt stuff doesn't work when you really, REALLY need it. Wonder how often the alt stuff gets checked? Preflight, weekly, when someone says: "hmm, wonder what this switch does?".

OK, the last was a bit silly...well, maybe not.

PB