MAS A330 BNE leaves pitot covers on

[Buzzing]

The flight returned to Brisbane airport an hour after being airborne due to a technical fault.

It had an emergency landing ... loss of air speed ... only to find out covers still on over the pitot tubes.

One has to question what sort of walk around did the first officer do? It's a basic step from the days of flying school.

(I have a pic of the covered pitot tubes but can't post as I'm new.)

[Maisk Rotum]

An MAS A330 took off from BNE with the pitot covers on. Circled for a while then landed fast damaging nose gear. How does this happen- too many questions.

[TurningFinalRWY36]

Question remains how did they get airborne in the first place? If all pitot covers were left on then there would not be an IAS increase on takeoff roll, therefore you reject. Or was 1 or 2 pitot covers left on and 1 side had airspeed information and the other pilot did an improper crosscheck at the 100/80kt call

[maggot]

Covers are fitted each turn in BNE due to a mud wasp issue.

[Buzzing]

Covers are fitted each turn in BNE due to a mud wasp issue.

supposed to be removed an hour before departure ... but clearly someone forgot ... and wasn't checked either ...

[By George]

Blocked the Runway for over an hour. Interesting to see the main gear doors dangling down. ( manual extension?). Also both main gear doors appeared damaged. Couple of Pilots standing to attention in an office somewhere, poor devils. How did everybody miss those red tapes?

[Station Zero]

Blocked the Runway for over an hour. Interesting to see the main gear doors dangling down. ( manual extension?). Also both main gear doors appeared damaged. Couple of Pilots standing to attention in an office somewhere, poor devils. How did everybody miss those red tapes?

The alternate extension is used in the advent of all three ADRs being switched off for unreliable airspeed hence the doors open and unable to taxi off runway.

Lots of human factors at play here by the looks of it...

[clark y]

Ignoring the flight crew issues, what about the ground crew who left them installed or the pushback crew who didn't notice them?

[chuboy]

Apparently yellow hydraulics were lost as well resulting in no steering after landing. Hence the tug.

The pitot covers have been used at least since Etihad declared a mayday after departure a few years back with no airspeed. Nice little mud wasp nest found on inspection. Amazing how quickly they can build a nest.

[Old King Coal]

https://cimg5.ibsrv.net/gimg/www.gmforum.com-vbulletin/1200x1600/whatsapp_image_2018_07_20_at_08_58_20_778618c31627bc075e4bb0 b5e33d9f36c50b6da8.jpeg

[EDLB]

You can see even a third cover. Makes me wonder why they did not abort. How did they check the rotation speed? Beside looking out of the window the airspeed indicator is the most watched instrument on the TO-run. At least for me.

[Perrin]

During my time in Guam during the Vietnam war we had big problems with them, hence covers on at landing with streamers so long you couldn't miss them. Did not help with EPR probes so high EPR was panels off air pressure blow out with 8 engines it was a pain in the A##.
Long streamers don't cost much.
Keep them up boys.
😁🗽😁

[scotneil]

To By George: please don't offer sympathy for the "poor devils" - I'm all for forgiveness of mistakes (and learning lessons from them) but this is simply incredible - very basic error. I don't understand why the problem wasn't spotted on the ground, at least during T/O roll. Consequences could be disastrous - remember Birgenair in 1996.

[302szd55]

Appalling deviation from normal procedures all round and yet another nail in the coffin of MAS's already tattered reputation. Think it may be time to add them to AF as an airline I will avoid permantly.

[Discorde]

Consequences could be disastrous - remember Birgenair in 1996.

The confusion amongst the Birgenair pilots was exacerbated by contradictory warnings (overspeed plus stick-shaker). Even if they had successfully recovered (using sensible pitch/thrust settings) they would have had to contend with the distraction of continued overspeed warnings. It's worth knowing which CBs to pull in the event of false overspeed or stick-shaker warnings so this distraction can be removed.

For the B757/767 the CBs are:
AURAL WARNING: B16 & H35
STICK SHAKER: C11 & J21

[student88]

I bet you're all such perfect pilots who never make a mistake.

Why are you assuming it was the FOs walk around? The most 'basic' of errors are the easiest ones to make..

[601]

supposed to be removed an hour before departure

With Brisbane wasps, 5 minutes max

[Fifthleg]

What about the turkey that did the pushback-unforgivable really. Last line of defence.......hopeless!

[2efiss]

Who signed off tech log entry?

[krismiler]

Echos of the AeroPeru accident in 1996 where the static vents were covered with tape whilst the aircraft was being cleaned.
https://aviation-safety.net/database/record.php?id=19961002-0

At least this time everyone walked away so lessons have been learnt, with training in unreliable airspeed indication now being given. It still shouldn't have happened though.

[clear to land]

Engineer who signed Pre-Flight complete-Fail, CM who did (did not) do walk around-Fail-or possibly procedures leading to them to expect to see Pitot Covers-then it should be like a steering bypass pin check-visual sighting required!, Pushback crew-Fail, CM1 and CM2 speed check during Take-off roll-Fail. We are all familiar with Swiss Cheese but this is beyond comprehension. :ugh:

[Flava Saver]

Not passing judgment but there seems to be plenty of cheese holes here.

Walk around.

Push back confirming all ground checks complete.

Taking off with not much air data in front of them.

An airspeed crosscheck during the roll?

Verry happy a safe outcome achieved (thank god), but there’s some serious **** to sort out.

[lomapaseo]

A scary list of mistakes in a multiple protection environment.

I suspect that some of these are not human error but rather continuous fails over multiple flights.

I've seen three layers of protection not work in preventing an accident because

one layer was hidden from any in-service checks and only worked in the eyes of the board designer

one layer could not be relied on because the crew were not adequately trained in its use

and the last layer was just a common flaw with a known failure rate of one in a 1000 flights

[Eric Janson]

The correct procedure should be to make an entry in the Technical Log that Pitot covers have been installed. Same procedure for Gear Pins.

Some Airlines do not have such simple common sense procedures in place.

I've had 2 cases where the Gear Pins were present in the cockpit and during the walkaround I discovered another set of Gear Pins had been installed! Asian Airline.

[misd-agin]

You can see even a third cover. Makes me wonder why they did not abort. How did they check the rotation speed? Beside looking out of the window the airspeed indicator is the most watched instrument on the TO-run. At least for me.

Third most - airspeed and engines are #1 and #2. Peripheral vision takes care of most of the 'outside'.

[misd-agin]

I bet you're all such perfect pilots who never make a mistake.

Why are you assuming it was the FOs walk around? The most 'basic' of errors are the easiest ones to make..

Most guys pay special attention to the items that have killed people.

The covers were missed on the walk around, the lack of airspeed indication was missed on initial acceleration, the airspeed check either didn't occur or the lack of airspeed was ignored(both are hard to believe).

It also means that the pilots either didn't look at their airspeed indicators for the entire takeoff roll or for some unbelievable reason ignored the lack of airspeed indications.

Missing, or ignoring the actions I described, is unacceptable behavior among professionals. Please stay a student pilot as the rest of us are are trying to even after decades in the business.

[Officer Kite]

Incident: Malaysia A333 at Brisbane on Jul 18th 2018, unreliable airspeed, hydraulic leak (http://avherald.com/h?article=4bb4f5b3&opt=0)

I presume this is the incident, if it is, then leaving the pitot covers on would hardly have caused a hydraulic leak and nose wheel steering issues. It seems there is more to it.

The picture is simply an aircraft that appears to be on a ramp with the covers on, how do we know it flew with them on? All it takes is one numpty to invent something.

[Jetjock330]

A while back, another middle eastern airline (nameless) had a wasp build up during the turn around time, and returned for landing with no pitot, found blocked by wasps and sand particles.

I can only imagine that it is procedure to protect the pitot's by putting their covers on whilst on turn around, which were forgotten by a few links in the chain of departure.

[EEngr]

then leaving the pitot covers on would hardly have caused a hydraulic leak and nose wheel steering issues. It seems there is more to it.

A single root cause could be that the person(s) who were supposed to catch the pitot covers on a walk-around also missed some gear locking pins.

[flightleader]

How about years of beancounters management that cut cost that lead to outsourcing of operational maintenance to ground handling companies that have no pride or interests in the airline brand name? Plus the lack of continuous audit on operational standard of these contracted GHA?

Blaiming that two guys at the last line of defence is myopic!

[etudiant]

During operations, would it perhaps be simpler and safer to just keep the pitot heat on even when the aircraft is on the ground?
As is, they seem to be pretty susceptible to fouling, from water or wasps, resulting in serious damage and loss of life

[maggot]

Walk around is completed with the covers on.

[Judd]

It also means that the pilots either didn't look at their airspeed indicators for the entire takeoff roll or for some unbelievable reason ignored the lack of airspeed indications

Boeing have the 80 knot call check during the take off roll. I always check the ground speed at the same time for a "reasonableness" check. I have not flown an Airbus but understand they have a 100 knot check during the take off roll. The problem with 100 knots is that it is getting into the high speed regime. If something is picked up, such as significant difference between the ASI readings at that speed check, it doesn't leave much time to decide what action to take, as V1 for example, is much closer. I would have thought the 80 knot call recommended by Boeing means the problem is caught earlier and action taken earlier re keep going or rejecting. It is common to see in the simulator the PM calling 80 knots as an afterthought even though the actual IAS was rapidly passing 90 knots at the time he called 80. Poor airmanship indeed.
Boeing recommend that that if an SOP call (such as 80 knots on take off) is not forthcoming by the PM for whatever reason, the PF should make it and give the actual reading he sees. e.g. "Passing 94 knots my side." . Good airmanship.

[ACMS]

Chuboy:—Nose Wheel steering on the 330 is Green HYD, not yellow.
With alternate gear extension you lose Nose wheel steering.
Expected with All 3 ADR’s off.

What I’d like to know is how did they ever manage to takeoff without any IAS at all?
What speed did they rotate at??????

There must be more to this story surely?

[junior.VH-LFA]

Not familiar with the Airbus, but I have to ask the question.. how did they call a V1 or Rotate call if they weren't getting any speed indications.

[krismiler]

Probably confused when there were no readings at the stage they would expect to see 100 knots, by the time they realised what was going on they decided to take it into the air rather than risk a high speed stop with no idea where they were in relation to V1.

Agree with the statement about an 80 kt call out in post #33, on medium jets at light weight 100 kts isn't that far off V1, particularly at some airports which were designed with turbo props in mind rather than jets.

I will admit that when I first heard of the incident I assumed it must have been the static vent covers which were left in place as normal airspeed readings would be given until the aircraft was climbing. I didn't think the crew of a heavy jet would get airborne without any speed checks.

[Centaurus]

I will admit that when I first heard of the incident I assumed it must have been the static vent covers which were left in place as normal airspeed readings would be given until the aircraft was climbing

In the 737 Classic simulator, the indications of a captain's blocked static vent are quite dramatic after lift off; but not before.

When the co-pilot calls "Positive Rate" (his static vent is OK), the first thing noticed is no movement of the captain's main altimeter and his IVSI. Yet we have often seen the captain calling for gear up without confirming his altimeter reading, simply because he is reacting to a call from the PM. A few seconds, later a windshear warning sounds even though there is no windshear. That warning is because the captains airspeed indicator stops moving and starts to go backwards fooling the system into thinking a loss of airspeed is a likely windshear.

With the aircraft climbing normally, but with captain's airspeed indicator needle steadily reducing due to the blocked static vent, (and no movement on his main altimeter and IVSI), eventually his stick shaker actuates and the ASI gradually falls to zero. Unless the pilot has seen this phenomena during his simulator training (and many have not), there is guaranteed confusion as to what is happening. In other words a grand WTF moment. A quick check of the ground speed reading can ascertain the problem and decisions made.

[LeadSled]

Folks,
How to fool the system:

Quite a while ago now, in one day at YSSY, three aeroplanes got airborne, the gear would not retract ---- two from one airline, the third, as I recall, anther airline handled by the former.

Same reason in all cases, gear pins not removed by the same departure "engineer".

Another example, one of mine, nose gear pins left in at EGLL, a very tidy minded "engineer" rolled up the red flags and held them with a rubber band "so the greasy flags don't leave greasy streaks on the U/C legs"?? Rather defeats the purpose of having bleeding great long red flags, doesn't it??

Another personal experience, doing the walk-around on a B744 ---- no flag at all on the nose gear pin, at least I was following what I always taught trainees ---- look for the "hole in the hole", not just the absence of the flag --- which is why you need a real torch, not a toy. (Ain't modern LED globes great)

Also on the B744, I have had pitot covers, with no flags, left on, to be discovered by me on the walk around,the post facto claim was that strong winds must have torn them off.

In short, if it can be done, one day, somebody will it.

But, in this case, it is certainly a trail of holes all lining up ---- proving anything is possible. The tec. crew is the last line of defense, on the face of it, looks like they screwed up.

Tootle pip!!

[golfyankeesierra]

A Tech Log info entry that covers were installed would have been useful. I see that sometimes for the gear pins when they are used at unusual moments.
And pitot covers are much more critical then the pins..

[arketip]

Not familiar with the Airbus, but I have to ask the question.. how did they call a V1 or Rotate call if they weren't getting any speed indications.

Not familiar with the type pitot covers, but could it be that the heaters burned through the covers enough to give some speed indication?

I've seen some pretty burned pitot covers.

[ACMS]

Airbus use a 100 kt call ( its not just for IAS crosscheck either ) BUT most of us check quite a few times the IAS is alive, especially looking for expected acceleration with a nice long trend vector...most of us if not all of us should notice no IAS way before 100 kts. Even at 100 kts there is still ample time to notice the discrepancy and STOP before V1

I would venture to suggest that they must have had some IAS indications that changed after airborne, perhaps as posted above the covers melted and then blocked after airborne?

I would be very surprised if a current professional crew got airborne without any airspeed indications at all.....

[krismiler]

Aircraft get airborne with the gear pins installed - Tech log entry required verifying removal.
A320 engine cowlings open in flight - Tech log entry required verifying closure after maintenance.
Aircraft departs with pitot covers on - Can you see where this is leading ?

A pitot tube with a cover on is obstructed and could give different indications to one which is sealed air tight as changes in static pressure could get through.

[PJ2]

Pitot heat is always OFF on the ground to avoid overheating.

I wonder what level of applied heating would create a sufficiently hostile nesting environment for insects building nests within the tubes, and still not lead to damage of the pitot tube itself ?

Obviously research is required, and it is always simpler to ensure removal before flight. But that didn't work here for reasons that require investigation. The problem has been around since pitot tubes were introduced, and the BUSS is a good backup.

Would a small amount of heating prevent nesting?

PJ2

[krismiler]

If the pitot tube was completely blocked air tight then it would carry that pressure for the entire flight as it would not leak out ie surface pressure would be retained where as if it was simply obstructed it would be unable to measure dynamic pressure and the higher surface pressure in the system would release as the aircraft climbed. Largely academic as indications would be grossly in error either way.

GPS ground speed readout with an allowance for wind is a good back up.

Does anyone know if fuel was dumped as an immediate return to BNE would result in an overweight landing unless dumping took place. No accurate airspeed indications would greatly complicate the overweight landing checklist when configuring.

[pilotmike]

Incident: Malaysia A333 at Brisbane on Jul 18th 2018, unreliable airspeed, hydraulic leak (http://avherald.com/h?article=4bb4f5b3&opt=0)

The picture is simply an aircraft that appears to be on a ramp with the covers on, how do we know it flew with them on? All it takes is one numpty to invent something.
The circular arcs on the fuselage behind and centred on the pitots themselves with radii matching the lengths of the flags is quite a giveaway. A very big clue that they've spent a fair bit of time at high airspeed slapping against the paintwork!.

When else did you ever see those marks before?

[pilotmike]

Walk around is completed with the covers on.

Seriously???? Why not do it immediately on parking then, before anyone has any chance to open a door, a bay, a hatch? It would be so much easier, 'cos you'd already know the plane was perfectly servicable and safe as it had just flown safely with all the hatches shut and no covers on.

I hope you're joking, but something inside me tells me that you're actually serious about that.

[Dan_Brown]

During my time in Guam during the Vietnam war we had big problems with them, hence covers on at landing with streamers so long you couldn't miss them. Did not help with EPR probes so high EPR was panels off air pressure blow out with 8 engines it was a pain in the A##.
Long streamers don't cost much.
Keep them up boys.
😁🗽😁

Right on the money. Those streamers or warning flags, would be ok for a Cessna 150. They should be long. Long enough to trip over.

[arketip]

Pitot heat is always OFF on the ground to avoid overheating.

Not always

[sycamore]

Pitot covers and static covers should all be joined together on a long flagged cord...

[maggot]

Seriously???? Why not do it immediately on parking then, before anyone has any chance to open a door, a bay, a hatch? It would be so much easier, 'cos you'd already know the plane was perfectly servicable and safe as it had just flown safely with all the hatches shut and no covers on.

I hope you're joking, but something inside me tells me that you're actually serious about that.
At my airline, in that port, yes.
And yes it's a threat but it is deemed to be a lesser that than the wasp issue. Thus the tech log remains open until the covers are presented to the crew just before pushback.

[misd-agin]

You can write anything you want in a tech log but that doesn't mean anything to the airplane.

At every job I've had it's the pilot's responsibility to check for gear pins and pitot covers. The only pins I havn't been responsible for is the NWS bypass pin and the arming pins on bombs, missiles, and rockets. The push crew, or arming crew, showed us those pins.

Technique - power is set, and then it's 'speed, speed, speed(HUD- speed if required)' verifying that all airspeed indicators are working.

[4 Holer]

Rather than throw the crew totally under the bus who was the mechanic that checked the doors were closed, pins and covers out/removed then did the pushback very basic work practice stuff does not need to be written anywhere... mechanic needs to be taken out the back of the hangar.

[Capn Bloggs]

You can write anything you want in a tech log but that doesn't mean anything to the airplane.

At every job I've had it's the pilot's responsibility to check for gear pins and pitot covers.
I suggest you and pilotmike do some research on the wasp problem at Brisbane before ripping into Maggot's company policy. Why don't you ask him/her how many times his company has taken off with the covers still on?

[CurtainTwitcher]

I suggest you and pilotmike do some research on the wasp problem at Brisbane before ripping into Maggot's company policy. Why don't you ask him/her how many times his company has taken off with the covers still on?
Even more significant, how many unreliable airspeed events would occur with the covers OFF and a blocked pitot in BNE? At least 3 in a one or two week period that I am aware of prior to the policy being implemented. The FMC picked at least one up on the taxi (clever Boeing), and the other two were air returns.

If the covers are not fitted immediately after shutdown and removed just prior to push (where the engineer physically shows you in the flight deck prior to signing off the tech log) you have a high probability of an unreliable airspeed event, even with a < 45 minute turn. There seems to be some anecdotal evidence that the warmth attracts theses wasps. There are test rigs of unheated pitot probes placed around the bays. From what I can see not much activity in the test units, but i've seen wasps go straight towards the aircraft pitot within a few minutes of shutdown.

[Tom Sawyer]

Rather than throw the crew totally under the bus who was the mechanic that checked the doors were closed, pins and covers out/removed then did the pushback very basic work practice stuff does not need to be written anywhere... mechanic needs to be taken out the back of the hangar.

I think you need to be a bit more aware of the policy at BNE due to mud wasps, and how much pressure Engineers and their companies are being put under before throwing around ideas of abuse to resolve the situation.

1. It is BNE policy which airlines comply with that pitot covers are fitted and remain on as long as possible during the transit. 5 mins before departure has been quoted here, and I believe that be correct from I have heard, but not sure if that is 5 mins before ETD or 5 mins before expected ATC push clearance. By that time the Crew walk-round has been done (and hopefully covers noted as fitted). The Engineer has fitted the covers as required on arrival, done the transit check, and hopefully made a Tech Log entry covering the fitment. The Engineer is then potentially in a position of having to sign off that entry as covers removed whilst they are still fitted and signing the flight clearance, getting the Capts acceptance and getting off the aircraft so that doors can be closed and the covers remaining on as long as possible prior to pushback which he then has to remove and try and meet an OTP target and comply with the requirement. To remove the covers, get back onboard, stow the covers, sign the log, get the captains signature, pull the pages, get off again so the bridge can be pulled could take longer than the 5 mins, and maybe anything longer could be enough time for ingress of mud wasps to start their nest building. So one Engineer put in a situation of having to be compliant, whilst being told to maintain OTP. One Engineer = cheaper transit.

2. As airlines want to pay less and less for maintenance, Engineers and the MRO's are having to handle more aircraft with less staff. The engineer may have 2-3 aircraft on the ground with faults or all departing within minutes of each other - all requiring pitot covers removing. I'm currently with an Line Maint MRO and I pay more to get my car serviced than what some airlines pay for a transit and rectification. If airlines paid a more realistic price, maybe there would be more than one engineer at the aircraft as the companies could employ more staff. The licensed engineer could then remain onboard as long as possible, waiting for a last minute call from the Tech/Mech/AME confirming covers removed so that the log can be signed to get off the aircraft as close to a cleared push back time as possible. But one Engineer transit = cost saving.

3. It is not always an Engineer on the headset these days. Again due to cost cutting more and more Ground Handling Companies are performing the push back function. No offence to these guys, but again prices being paid by the airlines are not realistic, so the people employed are not really "aviation professionals" and more than likely do not even know what the function of pitot tube is. I would hope they would notice the covers fitted, but would they know what to do about it if they noticed them fitted? Was it a one man pushback conducted from a towbarless tug so that the only time he got anywhere near the aircraft was to unplug the headset from the external comms panel, which probably would not lead to him being stood far enough back from the nose to notice the covers still fitted? One man, non-engineer pushback = cost saving.

Now, nothing of the above excuses what has happened, but the above does have potential to add into the factors that have created the event. The holes in the cheese all came together. Wanting to take the Engineer "behind the hangar" is not going to get rid of the holes in this cheese. In fact, there is a reasonable chance an Engineer could lose his job over this if found his actions were not compliant with the airlines policy and procedures and contributed to the event, but at the same time someone somewhere "did well" to get a reduced maintenance price and save the airline some $$$$$.

[Terry McCassey]

Pitot covers and static covers should all be joined together on a long flagged cord...


The most sensible I have ever seen in my time were the Belgium Air Force who tied all the ejector seat pins together with red cord on their Mirage 5B's - totally foolproof. Not really practical though on any external covers.

[India Four Two]

I used to live in Brisbane and I remember these Mud Dauber Wasps:

Vase-cell Mud-Dauber wasp - Sceliphron formosum (http://www.brisbaneinsects.com/brisbane_apoidwasps/VaseCellMudDauber.htm)

This article states that the wasps take one or two days to complete a mud nest. I wonder what is happening that can create a pitot blockage in five minutes.

[Goddamnslacker]

https://cimg8.ibsrv.net/gimg/www.gmforum.com-vbulletin/1080x810/img_20180722_wa0001_092c3d956356b87ec6e9d477afd34fbec63f4be7 .jpg
https://cimg9.ibsrv.net/gimg/www.gmforum.com-vbulletin/1080x810/img_20180722_wa0000_b533d7676250c0aeb7412988dc60d9a70f783276 .jpg

[ancientaviator62]

On the RAF C130K the pitot covers and the nosewheel pin were tied together with a long bungee and had large streamers. As the loadmaster supervised the start externally on i/c it was very easy to check on their removal. First check on applying external power to the a/c was to check that the pitot heaters were off !

[CurtainTwitcher]

Here is regulator's (CASA) documentation on the wasp problem. AIRWORTHINESS BULLETIN AWB 02-052 Issue 4 – 3 May 2018 Wasp Nest Infestation - Alert (https://www.casa.gov.au/file/78246/download?token=jiWYF9rF). From the document it is a the Key Hole Wasp, not the mud dauber as per post #62 (https://www.pprune.org/rumours-news/611306-mas-a330-bne-leaves-pitot-covers-2.html#post10202883). Figure 13 even has a image of the pitot test rig.

[Euclideanplane]

This article states that the wasps take one or two days to complete a mud nest. I wonder what is happening that can create a pitot blockage in five minutes.
Depending on the METAR, the time of day, and the exact species, the wasp may decide to quit for the day. It will close the entry to the cell fairly quickly, then continue work next day or after weather clears.

[josephfeatherweight]

As alluded in many of the posts above, there are numerous questions to be asked about how this aircraft managed to get airborne with these pitot covers on - leaving that aside for a second, this crew subsequently did a good job getting it back on the ground - not an easy exercise in most aircraft - many before them have not succeeded.

[framer]

It’s really interesting to me to watch threads when things like this occur and see the same thing again and again, year after year. It is such an integral part of our wiring to seek to lay blame on an individual or individuals.
One has to question what sort of walk around did the first officer do?
Or was 1 or 2 pitot covers left on and 1 side had airspeed information and the other pilot did an improper crosscheck at the 100/80kt call
supposed to be removed an hour before departure ... but clearly someone forgot ..
what about the ground crew who left them installed or the pushback crew who didn't notice them?
please don't offer sympathy for the "poor devils" - I'm all for forgiveness of mistakes (and learning lessons from them) but this is simply incredible - very basic error.
What about the turkey that did the pushback-unforgivable really.
Who signed off tech log entry?
Missing, or ignoring the actions I described, is unacceptable behavior among professionals. Please stay a student pilot as the rest of us are are trying to even after decades in th
....I got up to post 26 of 68 before I stopped cutting and pasting.
I’m not knocking any of the posters above because I have the same incredulous feelings straight off the bat when I hear of incidents like this, but it is worth noting that our fall back position as humans does nothing/zip/zero to prevent a recurrence or determine a ‘why’, and also bolsters our own sense of well being by highlighting ( to ourselves) why it would never happen to us. It’s a natural response.
Last Monday I was taxiing along and asked for the Before Start Checklist instead of the Before Takeoff Checklist........ how on earth could I make such an obvious and simple mistake? I’m supposed to be a professional and I don’t even know what checklist comes next? People make mistakes that seem rediculous from the outside and every system should take that into account as much as is possible. Tom Sawyer and a few others have already headed off down that road and identified conflicting SOP’s, unbalanced tension between commercial and safety outcomes, inadequate resources, OTP pressure etc
These are the things that leave the reliably fallible humans exposed when errors are made and should be addressed during the Inestigation. They won’t be. No investigation is going to ask the question “if this Engineer was only dispatching one aircraft would the incident have occurred?” Instead they’ll just highlight any short comings by pilots/ dispatchers/ Engineers and make a sweeping comment about how fatigue wasn’t a factor. ( I’m not saying it was).
As for us out on the line there is one thing that keeps us as safe as possible, the ability to go nice and slow when the pressure is on. To take 20 seconds and recap where you’re at. In short,’Don’t Rush’.
Thats my two bob anyway.

[Old Fella]

The correct procedure should be to make an entry in the Technical Log that Pitot covers have been installed. Same procedure for Gear Pins.

Some Airlines do not have such simple common sense procedures in place.

I've had 2 cases where the Gear Pins were present in the cockpit and during the walkaround I discovered another set of Gear Pins had been installed! Asian Airline.

Not only Asian Airlines personnel make mistakes Eric.

[601]

I wonder what is happening that can create a pitot blockage in five minutes.

Nothing has happened. On Hamilton Is during the 80s, we reckoned that there was a mud wasp that would sit near the terminal building waiting for us to land and shut down. Within a few munites, if we did no put the pitot covers on, it would have started building a nest in the head.

It is not only pitot heads that are a target for mud daubers. I have had Citation pressurise on the ground after engine start as a wasp had built a nest in an overboard vent. Our solution was to put a piece of paper in the tube that would be blown out by the venting airflow.

[misd-agin]

I suggest you and pilotmike do some research on the wasp problem at Brisbane before ripping into Maggot's company policy. Why don't you ask him/her how many times his company has taken off with the covers still on?

I'm not ripping into their company policy. I am commenting on that I don't care if the tech log says "pitot tubes removed" because I don't believe it until a pilot has verified that they are in fact removed. We have several items that ONLY a pilot on the flight can tell the Captain "job is done." That includes pitot tube covers, gear pins, and engine cowl latches. If anything occurs with those items after a pilot's preflight an operating crew member will go out and verify that it has been accomplished. The tech log entry doesn't count.

[maggot]

I'm not ripping into their company policy. I am commenting on that I don't care if the tech log says "pitot tubes removed" because I don't believe it until a pilot has verified that they are in fact removed. We have several items that ONLY a pilot on the flight can tell the Captain "job is done." That includes pitot tube covers, gear pins, and engine cowl latches. If anything occurs with those items after a pilot's preflight an operating crew member will go out and verify that it has been accomplished. The tech log entry doesn't count.
Does having three covers handed to you count? Stick your head out the window. Only takes a second or two
The tech log coupon is just part of the system to remind all of the obvious and not miss it amongst other distraction.

[stilton]

Not always


Pitot heat comes on automatically with engine start 757 / 767

[Lascaille]

So one Engineer put in a situation of having to be compliant, whilst being told to maintain OTP.

With all respect and sympathy for the hypothetical Engineer, this is intrinsic to the role. As an Engineer you sign and it means something, individual professional liability. The importance of pushing back against commercial pressures (and how to go about it) is literally taught as part of an Engineering education.

If some engineers there are working around delays induced by policy (by signing the log then removing the covers) then some other engineers should at least write a damn email to their manager saying 'someone suggested doing this, on enquiry others report having been told it is allowable here, so please clarify if there is a dispensation that allows it given that the airport policy adds (5, 10, 15 minutes) per departure?' Then the company has to say 'no, absolutely not' and engineers who were doing it can stop doing it and take the time they need, and everyone can address performance queries by saying 'well this was happening before. Not me, but it went on...'

[Anilv]

Its not only engineers who are around. There's usually a load-chief standing-by, tug-driver, wing-walkers, security staff. Any one off them could have caught it but in this day and age I'm sure they were probably with their heads over their handphones.

Anilv

[73qanda]

then some other engineers should at least write a damn email to their manager saying 'someone suggested doing this, on enquiry others report having been told it is allowable here, so please clarify if there is a dispensation that allows it given that the airport policy adds (5, 10, 15 minutes) per departure?
I am pretty sure there is a reporting system required as part of the SMS set up specifically for things like this. I imagine that all the companies involved comply with the requirements.

[Sqwak7700]

I can’t speak for MAS, but at the airline I work for (major in SE Asia), our tech log procedures are incredibly sloppy.

Our carrier has no defined handover from pilots to engineers and viceversa. I’ve seen pilot external walkarounds being performed in aircraft not released for flight, with engine cowlings open and two engineers inside the engine doing work. These are flawed procedures, not pilots normalising deviance.

When I worked in the US the procedures where very tight. If engineering was still working in a plane when you arrived at the plane, you made a 180 and waited in the terminal. We even had placards that rested on the throttle quad to warn pilots not to touch anything.

I wonder what MAS procedures are like.

[ACMS]

So if the Engineers are changing a Wheel we should go back into the crew bus and wait? Really?
HAECO has and uses DO NOT TOUCH placards as well mate, I’ve come across them a few times.

If they require us not to touch something they let us know.

[Dan_Brown]

Framer

Good post indeed. We all suffer from the same problem, because we're human. Human fallibility will never be eliminated. Outfits and certain areas of the world who recognise this are on the right track. Punitive action will not cure this. One outfit in the ME, got rid of a Captain because he allowed the A/C to get a "little slow" shall we say.. Instead of trying to find out WHY it happened, they concentrated on stall recognition and recovery.

I find I'm more likely to make a mistake, if I am distracted or have allowed myself to be rushed. Experience should reduce the chances of this but not always. What about fatigue? Just because they are within the FDTL limits I.E, legal, doesn't' mean to say the person is fit to operate. With fatigue/stress, the victim is often the not really aware of the deterioration of their performance. People don't seem to have the time to prepare as we used to,because of "commercial pressure".. A loco Captain told me years ago the pilots didn't have the time to perform a decent a walk around, on many occasions. Profits and schedule keeping, before safety, seems to be the norm now.

[Global Aviator]

https://cimg8.ibsrv.net/gimg/www.gmforum.com-vbulletin/1080x810/img_20180722_wa0001_092c3d956356b87ec6e9d477afd34fbec63f4be7 .jpg
https://cimg9.ibsrv.net/gimg/www.gmforum.com-vbulletin/1080x810/img_20180722_wa0000_b533d7676250c0aeb7412988dc60d9a70f783276 .jpg

BNE - KUL - 3 crew? If not who be taking that pic? Fair amount of concentration required under the circumstances.

Also who the chook would let the pics out?

Or is it a sim pic of the scenario?

[Babbalito]

From TS:

By that time the Crew walk-round has been done (and hopefully covers noted as fitted)

When I started out, the pilot's walk round was done as the very last job before strapping in to trap these types of error. In the BNE scenario, a specific threat countermeasure needed to be in place, actioned and checked. The way it's done today negates the mitigation and voila!

[cooperplace]

As alluded in many of the posts above, there are numerous questions to be asked about how this aircraft managed to get airborne with these pitot covers on - leaving that aside for a second, this crew subsequently did a good job getting it back on the ground - not an easy exercise in most aircraft - many before them have not succeeded.

does the stall warning require input from the pitot tubes in this aircraft?

[cee cee]

Malaysia Airlines flight emergency caused by plastic covers left on gauges (http://www.abc.net.au/news/2018-07-25/malaysia-airlines-flight-emergency-plastic-covers-left-on-probes/10035646)
pointing to
Malaysia Airlines flight emergency: Plastic covers left on fuselage - PM - ABC Radio (http://www.abc.net.au/radio/programs/pm/malaysia-airlines-flight-emergency-plastic-covers-left/10035736)

Of course it is possible that the information from the news article came from pprune...

[TURIN]

Tom Sawyer, spot on.

The commercial pressure to get an on time departure these days is shocking. The station managers of some airlines do not give a stuff about 'safety' as they perceive it. They interrupt the crew during their briefing, shout on their phones in the cockpit while engineer and crew are having a technical discussion, they hover over you, yes I have had three ground staff from one airline in the cockpit all watching me fill the log book in while comments such as , "we are going to lose our slot" are bandied about. CRM/SOPS/Human factors seem alien to them. "Get the brakes off" they say, not realising the air bridge is still attached, tow bar not connected or that the crew are part way through a check list which if interrupted could cause a vital step to be missed. It does not surprise me that things get missed, I have done it myself, fortunately the holes in the cheese didn't line up, the next level in the procedure caught my error, but it can happen oh so easily when corners get cut due to 'norms'.

However,

When I worked in the US the procedures where very tight. If engineering was still working in a plane when you arrived at the plane, you made a 180 and waited in the terminal. We even had placards that rested on the throttle quad to warn pilots not to touch anything.

Must have been a while ago, its hard enough these days to keep the crew out of the flight deck even with the big 'DO NOT TOUCH' placard on the throttles. I actually had one US Captain, walk into the flight deck throw the placard out the door and start the APU! No regard to anyone's safety.

Be safe everyone, and slow down.

[TURIN]

BNE - KUL - 3 crew? If not who be taking that pic? Fair amount of concentration required under the circumstances.

Also who the chook would let the pics out?

Or is it a sim pic of the scenario?

Really, you think thats a pic from this event?

I wondered too at what point the computers on an Airbus decide that tha data is invalid and drop out of Normal Law. Is it only when airborne?

[gordonfvckingramsay]

The importance of pushing back against commercial pressures (and how to go about it) is literally taught as part of an Engineering education.


Ha! Tell that to one of our wonderful Aussie ($afety first) airlines.....Engineering On Demand usually means "nil time to rectify" then a deferral. Commercial pressures are going to kill us one day.

Important to remember, the crew didn't follow a bunch of fvckups with one very big fvckup, pilots are still the last line of defence.

[Fris B. Fairing]

Forgive me if I haven't read the thread thoroughly enough but is the picture in post #10 of the incident aircraft? Furthermore, do we know for a fact that the pitot covers were left on? The preliminary report doesn't say that. Perhaps they were just being charitable?
Rgds

[DutchRoll]

Forgive me if I haven't read the thread thoroughly enough but is the picture in post #10 of the incident aircraft? Furthermore, do we know for a fact that the pitot covers were left on? The preliminary report doesn't say that. Perhaps they were just being charitable?
Rgds
Yes it is a fact that the pitot covers were left on. ATSB preliminary reports are just a brief statement of facts about the flight (eg..... airspeed indications failed, they came back). They do not attribute any causes or suspected causes.

For the others here (speaking as a current aussie A330 pilot):

1) BNE has an ongoing mud wasp problem and it is standard procedure to leave pitot covers on until just before departure.
2) An open (ie, not signed off) tech log entry is required showing that covers are installed.
3) It is permissible to do the walkaround with the covers still on and this does happen when you arrive early at the aircraft. On the Airbus, the pilot not flying the sector does the walkaround.
4) In our company, the tech log is checked by the Captain in front of the F/O, for being signed off with no open entries before authorising the final door to be closed. I imagine most other airlines would apply similar CRM procedures.
5) Our engineers will come to the cockpit with the covers and show them to us before signing off the covers as "removed" in the tech log.
6) The A330 has the item "Gear Pins and Covers - Removed" as a challenge-response in the Before Start Checklist.
7) Yes on the Airbus there is a "100 knots" call during the takeoff roll as an airspeed crosscheck. The response from the flying pilot is "Checked".
8) The ADR 1+2+3 Fault is inhibited between 80 knots and liftoff.

I have absolutely no idea why they actually got airborne. I would've thought it would have registered this fault before the 80 knots inhibition phase. In any case, they can't possibly have got to 100 knots without an airspeed discrepancy (ie, not increasing from what it was at the start of the takeoff roll)!

[CurtainTwitcher]

In the event the pitot covers were left on there was no airspeed discrepancy between all three indicators at all, they were all equally inaccurate!

Similar to the A330 stall warning logic being inhibited below 60kts, as it isn't possible to be airborne with <60kts IAS is it? AF447 proved that was faulty logic.

Recently we had a partial loss of airspeed event at ~120kts on the FO side (PF) from a very large insect impact totally blocking the pitot tube. The crew flew the OPT attitude and TO thrust until they could get the performance data and then flew loss of airspeed attitude & thrust settings for a happy ending. Perhaps the crew in this event did a similar thing?

Which leads to the future of fully automated aircraft, how would an fully automated aircraft deal with these sorts of scenario's?

[DutchRoll]

Yeah but “airspeed discrepancy” also includes barreling down the runway with speed indications still the same as when you were parked at the gate! They can’t possibly have had an airspeed increase with the covers on.

[CurtainTwitcher]

Yeah but “airspeed discrepancy” also includes barreling down the runway with speed indications still the same as when you were parked at the gate! They can’t possibly have had an airspeed increase with the covers on.
Agreed, I probably should have included a /sarc tag (https://en.wikipedia.org/wiki/Poe%27s_law) in there...

[A320skoda]

Pitot covers installed are made of fabric so they don’t melt if pitot heat comes on with them installed. This fabric let’s a small amount of air through like a very dense filter. It’s possible airspeed did register up to a certain point as there would still have been some pressure getting to the probe.

[DutchRoll]

Hmmm..... modern pitot covers are heat resistant. But they’re not designed to let anything through. :)

[A320skoda]

Hmmm..... modern pitot covers are heat resistant. But they’re not designed to let anything through. :)

go and blow through one, I think you will be disappointed

[tdracer]

Which leads to the future of fully automated aircraft, how would an fully automated aircraft deal with these sorts of scenario's?
Any full automation worth it's salt would have done a 'reasonableness' check on airspeed (e.g. cross compared with ground speed changes) and aborted the takeoff by 80 knots.
It may surprise you, but the engineers who design this stuff are not idiots...
Bad air data is actually one of the easier design cases for full automation - there are multiple sources, cross compared with each other and GPS - determining which sensor(s) are wrong is usually fairly easy. Plugged Pitot ports are especially easily detected during takeoff since it messes so dramatically with airspeed. Plugged static ports are a much tougher problem since that won't change appreciably during a TO roll and would only become apparent once airborne.

[Lord Farringdon]

In the event the pitot covers were left on there was no airspeed discrepancy between all three indicators at all, they were all equally inaccurate!

Similar to the A330 stall warning logic being inhibited below 60kts, as it isn't possible to be airborne with <60kts IAS is it? AF447 proved that was faulty logic.

Recently we had a partial loss of airspeed event at ~120kts on the FO side (PF) from a very large insect impact totally blocking the pitot tube. The crew flew the OPT attitude and TO thrust until they could get the performance data and then flew loss of airspeed attitude & thrust settings for a happy ending. Perhaps the crew in this event did a similar thing?

Which leads to the future of fully automated aircraft, how would an fully automated aircraft deal with these sorts of scenario's?

I'm guessing it wouldn't have you to get airborne to start with.

[Tom Sawyer]

Pitot covers installed are made of fabric so they don’t melt if pitot heat comes on with them installed. This fabric let’s a small amount of air through like a very dense filter. It’s possible airspeed did register up to a certain point as there would still have been some pressure getting to the probe.




The Airbus pitot probe one's I had in my hand today weren't of a fabric variety. They were a made of of vinyl outer layer which was fully air/water resistant. I have seen fabric ones but they are of a fabric weave density that is similar to denim which would not let any significant airflow through to register any speed of a usable reference. There is picture at post 10 of the thread showing the covered probes from the actual incident.....they look pretty melted to me despite their supposed heat resistance.

[horizon flyer]

The railway engineers even 100 years ago had a statement " That if something can happen even a million to one it will happen"

So if the covers are so important to remove, as I know they are why not design them to ripe off at a certain air speed or design auto covers
which is not new as I have seen them on 1930s aircraft. Relying on humans to do such a critical operation is bound to fail, its a given.

So I think it is poor design knowing humans can fail.

[DaveReidUK]

The railway engineers even 100 years ago had a statement " That if something can happen even a million to one it will happen"

Murphy's Law (http://Cambridge89.9km London117.7km Bury St. Edmunds129.0km Southampton163.1km Norwich170.0km Canterbury195.5km Sidmouth234.5km Exmouth247.5km Newquay346.9km Truro356.1km) predates the railways by several thousand years ... :O

[flynerd]

So if the covers are so important to remove, as I know they are why not design them to ripe off at a certain air speed or design auto covers
which is not new as I have seen them on 1930s aircraft. Relying on humans to do such a critical operation is bound to fail, its a given..

How about a pitot design change that enables them to be momentarily rotated 180 degrees and thus enable them to be self clearing? It could get rid of covers, mud-dobber nests, ice, insects.

Flyn.

[JumpJumpJump]

How about a pitot design change that enables them to be momentarily rotated 180 degrees and thus enable them to be self clearing? It could get rid of covers, mud-dobber nests, ice, insects.

Flyn.

Because that type of design would allow the pitot to rotate in flight at some point, probably with a greater frequency that pitots become clogged, or covers are left on...

...............................

I am trying to find a way that our guys in the front got to rotate without noticing the discrepancy, is there a chance, at all, that the covers were already defective and allowed air in due to a break in the fabric, either before the flight or due to being pushed hard against the inlet and after rotating the relative airflow changed the position of the cover over the inlet and subsequently blocked the impact air..... I am very obviously clutching at straws, but it just seems so much more plausible than the idea of them not aborting the takeoff due to an airspeed discrepancy.

[Goddamnslacker]

Welcome to the real world where Management do not want Engineers to carry out Arrivals & Pushbacks - utilising unskilled Ramp staff to do these tasks so the LAME can be used on other aircraft with defects - less LAME Engineers - unskilled cheaper Ramp staff - more bonus for Management!
All the Major Airlines are pushing more and more for this...Opens up the Swiss Cheese for more Human Error. Ask how many Pilots have had engineers on pushback & have rectified a defect that has occurred or advised the Tech Crew that it would be better to return to the gate & apply a deactivation procedure and MEL.
Most Majors all now use Maintenance Control remove advice which normally is under pressure (from management) to get the aircraft out....as a pilot, I prefer an engineer that I can talk too and is current/experienced on the type or who can see visually if I have a defect prior to getting airbourne...
Less Engineers on the Ramp is nothing but a Management Driven Bonus KPI...

[DogDay2000]

A pool of hydraulic fluid was found at the holding point they departed from by the AOO

[flightleader]

Wellsaid, GDSlacker!

[Traffic_Is_Er_Was]

A pool of hydraulic fluid was found at the holding point they departed from by the AOO
Did the engineer forget to put the plug in too?

[lucille]

I just perused the ATSB web site to see if they have released any information. I only gleaned one thing : their report is not due out until Third Quarter 2019 - i.e about 15 months time. SIgh. This will take such a long time that any educational and operational value for the rest of us will be lost.

How long can it possibly take to analyze the CVR and FDR? How many people were involved in the dispatch of that aircraft, and how long to take written statements form each of them? I guess they're well used to being overtaken by melting glaciers at the ATSB.

[DutchRoll]

How long can it possibly take to analyze the CVR and FDR? How many people were involved in the dispatch of that aircraft, and how long to take written statements form each of them? I guess they're well used to being overtaken by melting glaciers at the ATSB.
The problem is more likely the reviews, reviews of reviews, submission of draft for comments, reviews of comments, reviews of reviews of comments, resubmission for comments, reviews of resubmission for comments, and so on ad nauseum. Everyone and his dog demands that they have their two bob's worth prior to formal release.

[Diavel]

To By George: please don't offer sympathy for the "poor devils" - I'm all for forgiveness of mistakes (and learning lessons from them) but this is simply incredible - very basic error. I don't understand why the problem wasn't spotted on the ground, at least during T/O roll. Consequences could be disastrous - remember Birgenair in 1996.

Is it possible that the pitot covers actually were removed before pushback, and then the flight developed a serious hydraulic issue after takeoff, and the pitot covers refitted later. I know it sounds incredible, but to me as an A330 pilot, it seems even more incredible that they were able to take off with the pitotcovers on.

[fdr]

Coming off Boeings onto the A320/330/340, I have to say that the standby speed indication on the Airbus was a nice change. The B777 didn't often have AoA displayed on the PFD, so in the same case, the only rational option was to use a differential between attitude and FPV to ascertain AoA. In around 2010 or so, that was pushed out of the available options, with Boeing recommending not to use the FPV in the case of a loss of all airspeed due to input into the display being degraded. Thereafter, you have GS and not much else other than reverting to the NNCL and the gross unreliable airspeed tables, which at least end up pointing you at planet earth but are hardly a precision system. At least with the 787 that became less of an issue, but, Airbus, your standby speed was a nice solution.

[Wing Root]

Airspeed indication failure on take-off involving Airbus A330, 9M-MTK (http://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-053/)

Preliminary report is out...

The pitot probe covers were fitted on the aircraft’s three pitot probes by one of the engineering support personnel, as it was his understanding this was normal practice. He later reported that he advised the operator’s maintenance engineer that pitot probe covers were fitted during a brief exchange discussing turnaround tasks, but that the maintenance engineer did not directly respond. The maintenance engineer later reported that he did not recall hearing the advice, and he did not make an entry in the aircraft’s technical log to record that the covers had been fitted.

The presence of the pitot covers was not detected by the operator’s maintenance engineer or captain during separate external aircraft inspections.https://cimg0.ibsrv.net/gimg/www.gmforum.com-vbulletin/422x282/ao2018053_picture_4_9b1649d678f79de124364a518ed52dfa81d4fbfe .png

Covers on during push

[lucille]

The quality of ground staff at Brisbane must truly be substandard. Not one person made any comment about the covers still being on during push back. There is not a single excuse which can be made to defend any of them.

As for the two pilots, one can only weep at their level of negligence and incompetence and wonder how on earth they managed to escape scrutiny for so long as to be able to retain positions on a flag carrier. Truly incomprehensible.

[roybert]

Is it possible that the pitot covers actually were removed before pushback, and then the flight developed a serious hydraulic issue after takeoff, and the pitot covers refitted later. I know it sounds incredible, but to me as an A330 pilot, it seems even more incredible that they were able to take off with the pitotcovers on.

Diavel Let me see if I understand what your say. The covers were removed before they pushed back from the gate. Took off for their destination with the covers off. Developed a Hydraulic issue in flight. Then the pilot not flying climbs out the cockpit window in flight and puts the covers back on, then they land to find the covers on. Huh???

[RHSandLovingIt]

I think you'll find he meant that they departed, developed tech issue and landed without the covers on. Then a "diligent" member of ground crew replaced the covers.

Obviously, the pic posted above of the alleged pushback would indicate that this theory is incorrect... As one can clearly see the pitot covers in place and it is clearly stated in the initial report that the covers were found on the aircraft.

More concerning is this:

2331:38: The cockpit voice recorder (CVR) recorded that the captain called ‘100 knots’. The the aircraft’s recorded groundspeed at this time was 100 kt.
Data from the FDR showed that ADR1 first sensed airspeed above 30 kt at 2331:39. At rotation, the FDR recorded 38 kt airspeed from ADR1 and the airspeed from ADR3 had not yet reached 30 kt. ADR3 first sensed airspeed above 30 kt at 2331:54.

What was the captain reading? The g/s figure? :confused:

[maggot]

Some informed detail in todays article, may quash the theorists thinking the covers were installed on landing

Brissie times (https://www.brisbanetimes.com.au/national/queensland/wasp-headache-continues-for-airlines-at-brisbane-airport-20180830-p500pw.html?crpt=homepage)

[markfelt]

Final report has finally been released.

Looks like a long read.

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-053/

[widgeon]

Final report has finally been released.

Looks like a long read.

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-053/
Wow , so many missed opportunities to avoid the incident.

[Lookleft]

There has been a lot of focus on the deterioration of basic flying skills but what this highlights, an incident that occurred 4 years ago, is a deterioration in the basic understanding of the fundamentals of what keeps an aircraft flying! Are there too many pilots who have accepted the mantra that flying is always safe and nothing can go wrong? Is there a lack of understanding that as pilots we are the last line of defense? Are there too many pilots that are merely passengers in a uniform? I don't know what the solution is but reversing the denigration of the job category of pilot by airlines would be a good start.

[averow]

Dumb question on my part: why is this not practical on the outside of the airplane ? If one knows the specific model of the airplane why not connect the external covers together with very bright orange colored cords? I would be happy to be corrected.

[Bksmithca]

There has been a lot of focus on the deterioration of basic flying skills but what this highlights, an incident that occurred 4 years ago, is a deterioration in the basic understanding of the fundamentals of what keeps an aircraft flying! Are there too many pilots who have accepted the mantra that flying is always safe and nothing can go wrong? Is there a lack of understanding that as pilots we are the last line of defense? Are there too many pilots that are merely passengers in a uniform? I don't know what the solution is but reversing the denigration of the job category of pilot by airlines would be a good start.
Lookleft I agree that there's a problem but not sure it's a deterioration of the basics. The captain had over 14000 hours total time and the first office was over 6500 hours total time. Never worked in the airline world but in the military the pilot or first office did the walk around and removed all the tie downs and covers not the flight engineer or a ground agent. As to why they didn't see the flags or understand why they were not getting any airspeed indication is a question that they need to answer

[Bksmithca]

Dumb question on my part: why is this not practical on the outside of the airplane ? If one knows the specific model of the airplane why not connect the external covers together with very bright orange colored cords? I would be happy to be corrected.
Average. On the aircraft that I worked on the remove before flight tags were red 3 ft streamers that flapped in the breeze

[mustafagander]

Pretty shabby operation as I see it.
I know nothing about Airbus but the Boeings with which I am familiar have a Before Start checklist item "Gear Pins and Pitot Covers....Removed". That ought to jog your memory about whether you're SURE that you saw them removed.

[Maninthebar]

Pretty shabby operation as I see it.
I know nothing about Airbus but the Boeings with which I am familiar have a Before Start checklist item "Gear Pins and Pitot Covers....Removed". That ought to jog your memory about whether you're SURE that you saw them removed.

Page 7 of the report notes:
"At 2312 the FO called for the Before start procedure. The captain (as PM) commenced the check by stating a phrase captured on the cockpit voice recorder (CVR) that sounded like ‘gear pitot covers’ but could also have been ‘gear pins and covers’. The FO immediately responded with ‘removed’."

See also p.36 which quotes QRH and FCOM procedures

[pineteam]

Pretty shabby operation as I see it.
I know nothing about Airbus but the Boeings with which I am familiar have a Before Start checklist item "Gear Pins and Pitot Covers....Removed". That ought to jog your memory about whether you're SURE that you saw them removed.

Airbus has the same. The PM is responsible for that and it’s part of the Before Start checklist.

[India Four Two]

Lots of things went wrong and an analysis was required, but did it justify 165 pages?

[mustafagander]

I42,

Of course it did. A wonderful make work project for the "people" in CASA.

[Prober]

Ref post 116 from ".....gandar". It is all very well calling for the checks but I wonder if 'he who did it, read it'. That used to be a golden rule - if you are reading a checklist for something which you did, then the other pilot must check that it was done. If, on the other hand, you did it and he reads it, the response can be fairly automatic. Some airlines for whom I did some training did want it done the other way round but any suggestion to the contrary fell on stony ground. Prober

[Lookleft]

CASA didn't do the investigation , the ATSB did, as it is required to do under ICAO annexes and Australian legislation. The question is regarding the report, did you learn from the mistakes of others? If the answer is yes, job done. If the answer is no then you will probably find yourself the subject of such a report in the future.

[Derfred]

Having read over 100 responses on this thread, I don't think I saw a single response saying anything along the lines of "wow, that could have happened to me".

Pilot training obviously has a long way to go.

[albatross]

I am amazed this incident got 124 posts.
Incident.
Investigation.
Corrective Interview with those concerned.
Checklist, Memo issued as required.
Done and dusted.

[Bksmithca]

I am amazed this incident got 124 posts.
Incident.
Investigation.
Corrective Interview with those concerned.
Checklist, Memo issued as required.
Done and dusted.
Albatross 108 were from 2018 so only 16 from 2022

[nonsense]

A good deal of discussion here how each hole in the cheese got missed:

https://www.youtube.com/watch?v=f80WwpNuaxg

[Chronic Snoozer]

Having read over 100 responses on this thread, I don't think I saw a single response saying anything along the lines of "wow, that could have happened to me".

Anyone thinking that just 'viewed' the post. :) .........Dang it.

[Uplinker]

Having read over 100 responses on this thread, I don't think I saw a single response saying anything along the lines of "wow, that could have happened to me".

Pilot training obviously has a long way to go.

By saying 'wow that could have happened to me', you are effectively saying you think it is conceivable that no pilots visually checked and confirmed that all the pitot probe covers had been removed and the probes were clear before their flight.

I find that very disturbing - this is one of the most fundamental things a pilot should check, but if you are saying that you, and they, could easily have forgotten to check the pitot probes, then, yes I fully agree with you; training does need to be improved ! But surely no pilot should need to have the importance of a pitot probe explained ??

Accidents and incidents do happen, but certain things, such as IAS probes, flight controls full and free and operating in the correct sense, etc. are so fundamental they should never be missed.

And there is huge responsibility on individual pilots here, because the walk-around is one of the few things that is not double-checked by both pilots, so it should be taken very seriously.
.

[BuzzBox]

By saying 'wow that could have happened to me', you are effectively saying you think it is conceivable that no pilots visually checked and confirmed that all the pitot probe covers had been removed and the probes were clear before their flight.

That comment somewhat misses the point. The problem here is that 'keyhole' wasps build nests VERY quickly. There was an incident where an aircraft suffered an airspeed discrepancy due to a wasp nest after being on the ground for less than an hour. Consequently, it had become routine practice for the pitot covers to be left on as long as possible and removed by the engineers shortly before departure, well AFTER the pilot’s walk-around had been completed. It essentially comes down to a non-standard procedure that was not properly communicated between all the relevant parties, along with the failure of some of those concerned to follow up and ensure the necessary checks were completed before departure.

[Uplinker]

OK.

An unusual and uncommon procedure generally, but even so; a shame they didn't 'confirm (in some way) that all the pitot covers had been removed', and a shame that they continued the take-off with no IAS instead of rejecting. That is two holes in the cheese the crew fell through.

Asked "Gear pins and covers?", the pilot response surely should have been, "I don't know, we must check with the headset person" - especially if this was a 'routine' procedure at this airport. Another hole in the cheese fallen through, making three in total.

I suggested earlier in the thread that if the covers needed to be left on until pushing back, then the ramp person who shows the steering pin to the pilots before they taxi, should also hold up the pitot covers; allowing the pilots to visually confirm that the covers had been removed from the aircraft.

[VH-MLE]

"By saying 'wow that could have happened to me', you are effectively saying you think it is conceivable that no pilots visually checked and confirmed that all the pitot probe covers had been removed and the probes were clear before their flight.

I find that very disturbing - this is one of the most fundamental things a pilot should check, but if you are saying that you, and they, could easily have forgotten to check the pitot probes, then, yes I fully agree with you; training does need to be improved ! But surely no pilot should need to have the importance of a pitot probe explained ??

Accidents and incidents do happen, but certain things, such as IAS probes, flight controls full and free and operating in the correct sense, etc. are so fundamental they should never be missed."

I have long given up the thought that "inconceivable" accidents & serious incidents can not occur & this particular event I would once thought inconceivable too. When taking into account factors such as fatigue, lack of familiarity with certain airfields, inadequate training, systemic issues etc (the list goes on), I've stopped saying to myself "how the hell did that happen" because supposedly inconceivable accidents & serious incidents (AF 447 is another one) do occur with somewhat regular monotony. If it can happen, it will unless adequate defences are in place to minimise the likelihood as much as possible...

Just my 2 lire's worth...

[KRviator]

Everything old is new again...From the ATSB (https://www.atsb.gov.au/publications/investigation_reports/2022/aair/ao-2022-032/)
The ATSB is investigating the flight preparation event involving an Airbus A350-941, registered 9V-SHH, at Brisbane Airport, Queensland on 27 May 2022.

At about 0915 Eastern Standard Time, the aircraft was in the final stages of being prepared for departure from bay 81. All turnaround service functions had been completed, all passengers had boarded, all doors were closed, and the aerobridge was in the process of being retracted from the aircraft.

An aviation refueller on an adjacent bay observed that the aircraft appeared to be ready to push back, but the pitot covers were still fitted. The refueller communicated with one of the engineers responsible for the aircraft that the pitot covers were still fitted. With three minutes remaining until the normal departure time, the engineer positioned an elevated work platform towards the nose of the aircraft and removed the covers, before the pushback commenced.

As part of the investigation, the ATSB will examine the circumstances leading to this flight preparation event, including interviewing the relevant parties involved, analysing the CCTV footage and assessing the risk controls relevant to the fitment and removal of the pitot covers.

Should a critical safety issue be identified at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

A final report will be published at the conclusion of the investigation.I wonder if the same...uuhhhh..."communication" would have been achieved if it was night, rather than mid-morning - would we have had another instance of unreliable airspeed on departure?

[DaveReidUK]

"Should a critical safety issue be identified at any time during the investigation ..."

No kidding.

[clark y]

Similar event being discussed here-

https://www.pprune.org/australia-new-zealand-pacific/646942-dreamliner-preflight-error-ground-tech-crew.html

[Obama57]

Airbus use a 100 kt call ( its not just for IAS crosscheck either ) BUT most of us check quite a few times the IAS is alive, especially looking for expected acceleration with a nice long trend vector...most of us if not all of us should notice no IAS way before 100 kts. Even at 100 kts there is still ample time to notice the discrepancy and STOP before V1

I would venture to suggest that they must have had some IAS indications that changed after airborne, perhaps as posted above the covers melted and then blocked after airborne?

I would be very surprised if a current professional crew got airborne without any airspeed indications at all.....




A long time ago I was the A/C on a C141overnight to the Canal Zone off-loading 150 troops with all their gear. The next morning when we arrived at ops, we were told it was a full cargo load back to Tacoma, WA. Routine, let us know when the port folks have finished switching out all of the pax gear- seats, O2 masks and associated lines, life vests, etc., so the cargo can be loaded. Apparently the port crew were civilians, it was Saturday, and we were on our own. No drama except that in the late 1970’s, the over-riding metric to evaluate one’s performance was blocking out on-time. Normally not a big deal, except we had the new Wing Commander sitting on our jump seat and he was fired up to look good. After a stupid pep talk, we sprung into action. The enlisted guys, to their credit, played along and with a lot of grunting and sweating actually got the bird ready to go with a not so bad showing of the officers as well. The heat index at Howard AFB reminded us how much we were missing the free air conditioning and ice water from the Great NW. Super rushed before taxi checklist, INS’s to NAV, taxi clearance from ground and away we go - on time! The Wing Commander’s time card was punched and we lined up for the copilot ‘takeoff.
It was hot, we were heavy, performance was nothing to write home about. As the PNF, waiting for the airspeed to get off the peg, acceleration felt normal. Cross- checking the co-pilot’s airspeed showed the same indication; he was still on the peg - 60 kts My eyes were darting from my airspeed indicator to the end of the runway, back to co-pilot’s airspeed. I was having a crisis. Don’t believe my instruments which are both in agreement, or trust my gut and abort. Abort. First question the FE asks and needs to know is at what speed the brakes were applied. As we taxied off the runway, the light bulb in my head went off, and I had the loadmaster open up the hatch and verify what I hoped he would not see - installed pitot covers. He did. We decided on 100 kts.which resulted in a 44 min ground cooling time. To be on the safe side, we decided to air cool the brakes as well after takeoff. This plan was shelved at 1000’AGL as we had #4 overheat. With the throttle at idle and the gear down, we weren’t climbing well enough to clear the terrain, so, gear up, away we go. 4-5 hours later we land and the C141makes a B-line for the left edge of the runway. We block-in. The scanner outside informs the #5 tire fuse plug has melted.

Where to start….
1. General Officer on the flight deck changes the crew dynamic. I had lost some amount of authority. Btw, general was current on the aircraft.
2. Checklist discipline was obviously terrible. We all sang the correct tune. There was Red X log entry that the FE and I glossed over.
3. FE does the walk around, A/C should back up. I was loading the INS, co-pilot was pushing pallets. The routine was f**
4. We are trained to notice things that are different, not the same.
5. High speed aborts are dangerous. We actually stopped only 500’ from the end. Abort probably initiated at 130 kts which was 10-15 kts above V-1.
6. If one fuse plug melted, how close were the others?

[/QUOTE]