ATSB release report into Malaysian A330 Pitot covers left on....

[Mach1Muppet]

Interesting to read the report, but surely someone would have noticed the covers.

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

[SHVC]

Obviously no one did notice the covers.

[Lead Balloon]

Just goes to show, yet again, how often those holes in the Swiss cheese line up in what are supposed to be the 'safest' of aviation operations.

[PoppaJo]

Decision making during the roll was non existent. They picked up the speed issue very early on. But kept going, and going. FO appeared to be waiting for the abort call but nothing. The report goes into a lot of detail across all sorts of things, however only brushes over the two key standouts for me. Decision Making and communication skills.

This one should have never left the ground. CRM just didn’t exist.

[Lead Balloon]

Yet the operator and its operations in Australia are authorised by an AOC issued by CASA.

Cue the press release about safety never having been compromised.

[arf23]

pitot tubes. again.

How about requiring a pitot tube to have a light sensor in it, and pitot covers to have blackout lining. Then if the light sensor isn't seeing light, it'll raise an alert on engine start. It's mad that a $100M aircraft can be incapacitated by not having a bit of orange plastic flapping in the wind. And to counter night-time, I'm sure the aircraft computer can figure out whether it's day or light, adjust accordingly, and also I'd expect the apron to be illuminated. I'm not suggesting existing fleets be retrofitted as the wiring cost would be huge, but for certification going forward..

[Capt Fathom]

If I read correctly, the Captain’s walk-around took 92 seconds? Must have run!

[Oldbrigade]

Yet the operator and its operations in Australia are authorised by an AOC issued by CASA.

Cue the press release about safety never having been compromised.
This is a blatant example of CASA being simply a political entity that pretends it is a safety watchdog. The Operator should have
had its Australian AOC suspended immediately for such basic incompetence. The Australian ATSB and it’s softly softly attitude to the
MH 70 disappearance is yet another example. CASA executives simply hide behind their desks, reap in their mega salaries, and
seriously would not know the flight deck from the tail.

[Uplinker]

Unbelievable.

How can anyone possibly NOT check Pitot probes on an A330?

They are in plain view, very easy to check, as are the Static ports and the AoA vanes. There might not have been streamers attached to the covers, but so what? You simply....Look. At. The. Probes. and you will easily see if they are covered or not.

And as for night time, all engineers and pilots carry a torch don't we, (and I mean a proper, focusable torch, not a phone)........please tell me we all do.

This incident is remeiscent of the BA aircraft that took off with the engine cowls unlatched because nobody did a proper walk-around.

This is really fundamental stuff. Any "pilot" who does not check these most fundamental items before each and every flight is.......well........words fail me. :ugh:

[TURIN]

I've just read the entire report.
From an LAEs point of view.
The certifying LAE says that he knew they were fitted and noticed them on his walk round but then forgot about them? What about the 'mandatory' open log book entry? Reading between the lines he didn't log it.

Also, there is an AD from Airbus requiring pitot covers to be removed before applying electrical power to the aircraft due to the possibility of the pitot probe heating switching on and melting the covers. (I can't find a reference for this so I don't know if it was issued before or after this event).

Placing a placard on the flight deck is also now mandated.

The practice of fitting gags and covers drawn from stores and not booking them out of stores is, sadly, all too common. Time constraints being the main driver. It needs addressing.
In this case it seems the covers were not even the correct type and had minimal streamers attached. For a station like Brisbane where the practice of fitting these covers is an everyday occurrence that is a shocking admission of poor standards from the operator. They should be kept on board and counted in for every Brisbane flight. They're not exactly expensive.

I won't comment on the crew actions as there are far more here qualified to do so.

[compressor stall]

This incident is remeiscent of the BA aircraft that took off with the engine cowls unlatched because nobody did a proper walk-around.

That quite a number of A32F aircraft took off with the cowls unlatched (not just BA) and Airbus published numerous alerts and recommendations (like painting the latches red) suggests something more was at play there.

This incident, however, is in a different category IMHO.

[BuzzBox]

I've just read the entire report.
From an LAEs point of view.
The certifying LAE says that he knew they were fitted and noticed them on his walk round but then forgot about them? What about the 'mandatory' open log book entry? Reading between the lines he didn't log it.

The report states the following (p.3):
At 2045 the AMSA support engineer arrived at the aircraft carrying a set of pitot probe covers, which are commonly used in Brisbane to prevent mud wasp infestation. The support engineer moved an access stand (moveable ladder/platform) to the nose of the aircraft and fitted the pitot probe covers. Ribbons attached to each of the pitot probe covers were visible on the CCTV recording. The support engineer then moved the access stand away and proceeded to the flight deck.

At 2047 the support engineer arrived on the flight deck. According to interviews with the LAE and support engineer, their discussion was brief. The support engineer reported telling the LAE (who was checking aircraft records at the time) that pitot probe covers were fitted to the aircraft. According to the support engineer, the LAE did not acknowledge what had been said, or make an entry in the technical log for the fitment of pitot probe covers (which the support engineer normally expected). The support engineer did not question this.

The LAE had not been aware of the common and recommended practice for the use of pitot probe covers at Brisbane Airport. The LAE stated that it was not normal practice to fit them during transits and later did not recall the support engineer advising of their fitment during the turnaround. The LAE also stated that, had they known pitot probe covers were fitted at that point, they would have either made an entry in the aircraft's technical log that the pitot probe covers were fitted, or told the support engineer to remove them.

It also states (p.4):
The LAE then conducted the external inspection component of the walk-around transit check beginning at 2054 (this component will be referred to as the ‘engineering maintenance walk-around inspection')...The LAE reported noticing the pitot probe covers fitted to the aircraft at the time the nose area was inspected and intended to talk to the support engineer about them. As the support engineer was still absent from the aircraft retrieving supplies, the LAE decided to continue with the engineering maintenance walk-around inspection. The next interaction between the LAE and support engineer was ten minutes later. The LAE, busy with continuing the engineering maintenance walk-around inspection through that period, forgot about the pitot probe covers.

It sounds as the support engineer told the certifying engineer about the pitot covers immediately after they were fitted, but the certifying engineer was busy and didn’t take in what was said. Consequently, no tech log entry was made. The certifying engineer noticed the covers during his subsequent walk-around, but then forgot about them.

[Uplinker]

But the pilots.......

Things having to be written in the Log or someone remembering to tell someone or having to have streamers etc etc. Surely to goodness though, the pilot(s) would want to know that nothing like this has been missed and would therefore would want to physically eyeball such fundamental items as the Pitot probes for themselves before trying to get airborne?

Cock-ups will always happen of course, and many of us have lots of experience of busy turnarounds and busy engineers, but surely that is why us pilots must check such fundamental things properly ??

We seem to be going backwards in safety, instead of learning from past mistakes.

[TURIN]

The report states the following (p.3):


It also states (p.4):


It sounds as the support engineer told the certifying engineer about the pitot covers immediately after they were fitted, but the certifying engineer was busy and didn’t take in what was said. Consequently, no tech log entry was made. The certifying engineer noticed the covers during his subsequent walk-around, but then forgot about them.


This is why one should always make a log entry BEFORE fitting landing gear lock pins or pitot covers etc. It is standard practice.

[Two's in]

Considering the recent UK F-35 that went into the ocean from a carrier launch after ingesting an engine intake blank, those of you who say this should never happen appear to missing the human factors element in all of this. That airplane was surrounded by aviation professionals whose job it was to ensure the aircraft is ready for flight, and it still got missed. There have been a spate of pitot static failures on airliners that were placed in COVID storage and returned to service, only to find the blanks were not fitted properly, or the insects got in anyway. That should be all the evidence needed to demonstrate that the discipline and governance around fitting blanks and covers needs a rigorous review by the industry. If you needed steps or a ladder to fit the blanks, why not leave it there for the person to remove the blanks is one obvious question. Adding paperwork to what should be a standardized safety process is not going to help if it's not a maintenance action.

[Asturias56]

I think the last edition of "Flight" mentioned three cases of some wasps in pitot tubes in BA aircraft at Heathrow last year - I think one was found when they tried to takeoff................

[pax britanica]

An obviously amateur view but when i read the very very clear and well produced report mention of him needing the steps to place the covers and then moved them made me think why not leave them there anyway . If thyew er eneeded elsewhere on the aircraft perhaps do that first and leave the probe covers till last, they aren't going to taxy away or push back with those still there. Another point I picked up was the precise wording under the picture of the aircraft on push back. From the photo it would appear the tug driver could see the streamers whereas in fact he cannot from his cab once the towbar is connected. I thought it was important they pointed that out on the picture not buried in the text.

if I might be indulged with a bit more amateurism, how do Chief Pilots/Operations managers even colleagues etc view the actions of this crew . Basically making a simple but dangerous mistake on walk around, not really handling the go / no go take off issue very well and yet seemingly doing a good job on the hardest part of the whole incident ie getting it back on the ground safely . Again just curiosity on my part . Thanks

[Chris2303]

Yet the operator and its operations in Australia are authorised by an AOC issued by CASA.

Cue the press release about safety never having been compromised.

I'm not sure if this is sarcasm or not so I will ask. Why would MH have an Australian AOC?

[Saintsman]

Obviously no one did notice the covers.

They probably did see the covers, but the brain never registered them. I've seen that happen more than once, particularly when people don't expect them to be there.

[TURIN]

There have been a spate of pitot static failures on airliners that were placed in COVID storage and returned to service, only to find the blanks were not fitted properly, or the insects got in anyway. That should be all the evidence needed to demonstrate that the discipline and governance around fitting blanks and covers needs a rigorous review by the industry. If you needed steps or a ladder to fit the blanks, why not leave it there for the person to remove the blanks is one obvious question. Adding paperwork to what should be a standardized safety process is not going to help if it's not a maintenance action.

Aircraft do not have a set of dedicated steps at hand. One engineer may be covering several aircraft and need the steps on all of them.

Fitting pitot covers IS a maintenance action, hence the requirement for a log book entry.

[TURIN]

I think the last edition of "Flight" mentioned three cases of some wasps in pitot tubes in BA aircraft at Heathrow last year - I think one was found when they tried to takeoff................

It is now a requirement during wasp season for ALL BA A320 series aircraft to have their pitot heads inspected 2 hrs before first flight of the day after a nightstop. Log book entry and cerification required.

[Lead Balloon]

I'm not sure if this is sarcasm or not so I will ask. Why would MH have an Australian AOC?Because section 27 of the Australian Civil Aviation Act says one is required.

The Act makes special provision for applications to CASA for AOCs authorising the operation of foreign registered commercial aircraft in to and out of Australian territory, but at the end of the day it's an AOC issued by CASA under the section that every other AOC is issued by CASA. (I won't complicate things by talking about NZ-registered aircraft or 27A permissions.)

[Consol]

Because section 27 of the Australian Civil Aviation Act says one is required.

The Act makes special provision for applications to CASA for AOCs authorising the operation of foreign registered commercial aircraft in to and out of Australian territory, but at the end of the day it's an AOC issued by CASA under the section that every other AOC is issued by CASA. (I won't complicate things by talking about NZ-registered aircraft or 27A permissions.)

Seriously? Don't you mean an operations spec? The logic of this is that an airline would need an new AOC to fly into every other foreign country. That could be 100 + for some airlines. I know you folks have a high opinion of your system down there but that's not how the world works.

[43Inches]

Seriously? Don't you mean an operations spec? The logic of this is that an airline would need an new AOC to fly into every other foreign country. That could be 100 + for some airlines. I know you folks have a high opinion of your system down there but that's not how the world works.

Australia is not the world, it's a country that has to make every dam thing harder for everyone when it comes to governance. Not for some tyrannical maniac, just because the civil service wants to keep itself relevant and employed shuffling vast amounts of paper (now emails) between irrelevant parties.

WRT to the Pitot covers, this is a very easy fix if aircraft maintenance was anywhere near 21st century standards. Simple NFT data buttons on the pitot covers or any other vital storage covers, a data logger linked to the CMMS program, then the engineer who signs off the item has to physically log it into the system, rather than make a mark saying they did it, when they could easily have not. Red tags/flags and memory system from the 1950s only work if the tags are obvious and the memory 100% reliable. Eventually a tag/flag falls off or the memory forgets and errs with 'done' rather than 'not done'. If the engineers are as lax as the report suggests its most likely that the extra walk to put a placard in the flight deck would get omitted anyway.

The other 'fail safe' is that the crew should have noticed the airspeed failure well before they got airborne or anywhere near the point they had to continue.

One extra point I can see here, is why is there no Sound alert for airspeed failure? On something as smart as the airbus it really should tell you if the primary airspeed indicator has failed on take-off...

[Lead Balloon]

I'm just telling you what Australian law requires, Consol.

If you go to Appendix A CASA's Annual Report for e.g. 2019 - 2020 (https://www.transparency.gov.au/annual-reports/civil-aviation-safety-authority/reporting-year/2019-20-51), you will see the table of AOCs issued by CASA, which table "includes operators involved in one or more of ... foreign aircraft (passengers and cargo), foreign aircraft (cargo) ...".

CASA has an extraordinarily high opinion of its system. It's apparently the cause of Australia's enviable air safety record.

One might pause to wonder what the point of the process is, though, if the kind of incident the subject of the ATSB report the subject of this thread is 'ops normal' for an operator. And that's my point.

[OldLurker]

I think the last edition of "Flight" mentioned three cases of some wasps in pitot tubes in BA aircraft at Heathrow last year - I think one was found when they tried to takeoff................AAIB investigation to various Airbus and Boeing aircraft between 9 June and 19 July 2021 (https://www.gov.uk/aaib-reports/aaib-investigation-to-various-airbus-and-boeing-aircraft-between-9-june-and-19-july-2021)

[43Inches]

One might pause to wonder what the point of the process is, though, if the kind of incident the subject of the ATSB report the subject of this thread is 'ops normal' for an operator. And that's my point.

Australian process revolves around mountains of now electronic paperwork, as you know. The applicant just has to say they will do everything right and they get a tick, then practice very different standards and wait for something to go wrong to get the poker. Meanwhile the operational surveillance focuses on whether the FO wore a high vis while visiting the toilet block or the FA spoke verbatim from the 1000 word long boarding spiel that no one listens to (because it's too long).

[chimbu warrior]

Seriously? Don't you mean an operations spec? The logic of this is that an airline would need an new AOC to fly into every other foreign country. That could be 100 + for some airlines. I know you folks have a high opinion of your system down there but that's not how the world works.

Actually it IS how the world works, and that is what Part 129 is all about. I would imagine that most large carriers have at least 100 Part 129 AOC's, plus a compliance department that monitors requirements and expiry dates.

[Lead Balloon]

chimbu knows of what s/he speaks.

[Consol]

Actually it IS how the world works, and that is what Part 129 is all about. I would imagine that most large carriers have at least 100 Part 129 AOC's, plus a compliance department that monitors requirements and expiry dates.
Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?
By the way, good idea to check pitot covers, if you can't see the hole you haven't checked it

[Lookleft]

So for anyone who is actually a pilot the message from the report is that the walkround should be conducted with your eyes open and actually look at the important items on the outside of the aircraft as per the FCOM. As for the issue of continuing the takeoff with no airspeed indication well all the bells and whistles are not going to stop that happening if the crew are merely passengers. Hardly an Airbus problem if an equivalent Boeing product can be taken into the air and flown at 75' over downtown Dubai!

Also WTF CARES if its an AOC or an Ops Spec that a foreign carrier operates under into Australia!

[Lead Balloon]

Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?And does the “legacy carrier” for whom you work operate non-Australian registered aircraft in to and out of Australia, Consol? If yes, it holds an AOC issued by CASA.

Lookleft: If you could just try to set aside your blind prejudice for a moment, you might see that there may be systemic issues at play here: Systemic issues for which the operator is supposed to be responsible and CASA is supposed to be concerned. What else is the air operator certification process for? The apparent failure to do a proper pre-flight inspection is one thing. The crew’s decision making and communications after the consequences of the failure manifested themselves are another. The latter worry me much more than the former. But no doubt you can’t help yourself but disagree, because you don't like the messenger. You need to try to move on.

[BuzzBox]

Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?

Foreign operators require approval by the State concerned to conduct transport operations within that State's territory. The approval process is essentially a validation of the operator's AOC and in some countries (eg Australia, Canada, Malaysia) the approval document is known as a 'Foreign AOC'.

[Lead Balloon]

In Australia it is an AOC authorising the operation of a foreign aircraft in to and out of Australian territory. The short description is 'Foreign aircraft AOC'. It's the aircraft that's foreign, not the AOC.

[Lookleft]

But no doubt you can’t help yourself but disagree, because you don't like the messenger. You need to try to move on.

As do you LB. We all get it that you haver a visceral dislike of CASA and the ATSB and that you use every opportunity to highlight how much you know and how little everyone else knows in legal matters. If only the Mods set up a sub-forum that was called Regulator Failures then the rest of us could discuss things like doing a proper walkaround and speaking up when your flight instruments are not working the way they should. The systemic failures in this instance really have very little to do with CASA but more to do with flight crew of any nationality just going through the motions and not doing the very basic aviating which is the first part of the ANC mnemonic.

Its not that I dislike the messenger its just that the messenger wants to always steer the message away from anything that could be relevant to pilots who fly for a living. Honestly most of us don't give a crap about whether CASA issues AOC's to foreign carriers.

[Lead Balloon]

As usual, you presume to speak for "most of us".

I think the ATSB has a done a very good job on this occasion.

If this kind of incident had occurred in a small Australian charter operator, I very much doubt CASA would just shrug and move on. If CASA's certification and surveillance of foreign carriers operating in to and out of Australia is just a rubber stamp exercise, that's a safety issue.

[43Inches]

It does have a lot to do with CASA oversight of who is authorised to operate within Australia on a commercial basis. Who they authorise and how they operate directly affects the jobs of us who are local pilots and engineers who do the right thing and demand the correct remuneration for the responsibility. If someone is allowed to fly commercially into Australia and compete with us using substandard training being paid peanuts then that affects our jobs and quality of life. Or you could try to get a job in our thriving shipping industry, where anyone can register their ship in Panama or wherever and employ anyone that can stand up to sail it to ports in Australia, what's all those options now, hmm ANL.... We own 35 ships (only about 5 of those do international shipping, the rest are local shipping around Australia ) out of 3000 that visit Australia yearly, and carry only 2% of our own goods internationally from our shores in our own ships. If Qantas fails due to it's current debt, that will be Australia's international air travel gone foreign as well.

[compressor stall]

Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?
By the way, good idea to check pitot covers, if you can't see the hole you haven't checked it

Care to tell us if it's an OPS SPEC or Foreign AOC that permits you to operate into / out of Malaysia? The fact is that some countries require a FAOC, others not, sometimes it depends on how many times you visit etc.

[BuzzBox]

This is why one should always make a log entry BEFORE fitting landing gear lock pins or pitot covers etc. It is standard practice.

I don't disagree. In this case Malaysia Airlines didn't require a tech log entry for the fitment of pitot covers at all. Page 51 of the report states:

The Malaysia Airlines technical handling manual did not require a technical log entry to record the fitment of pitot probe covers, but engineers were able to do so. When interviewed, AMSA managers stated that they expected a maintenance log entry would be made by an appropriately approved person for the fitment of pitot probe covers.

According to the report, interim measures were in place for the provision of engineering services, because Malaysia Airlines had only recently recommenced operations into Brisbane. AMSA engineers did not have Malaysian CAA approval and could not make tech log entries:

Furthermore, the support engineer was not permitted to enter the details of the fitment of pitot probe covers into the aircraft’s technical log and did not press the issue after seeing that the LAE did not do so. The support engineer may not have seen it as a sign that the LAE did not hear the support engineer’s statement.

One of the safety actions undertaken by Malaysia Airlines following the incident was to update its technical handling manual to require a tech log entry to record the fitment of pitot probe covers (see p.126).

There were many 'holes in the Swiss cheese' that led to this incident; it seems to me that lack of coordination/communication between the two engineers was one of them.

[BuzzBox]

In Australia it is an AOC authorising the operation of a foreign aircraft in to and out of Australian territory. The short description is 'Foreign aircraft AOC'. It's the aircraft that's foreign, not the AOC.

If you want to be pedantic, the Australian legislation refers to the document as a "Foreign Air Transport Air Operator’s Certificate (FATAOC)". Most people I know simply call it a "Foreign AOC".

[43Inches]

Care to tell us if it's an OPS SPEC or Foreign AOC that permits you to operate into / out of Malaysia? The fact is that some countries require a FAOC, others not, sometimes it depends on how many times you visit etc.

Malaysia (CAAM) requires a FAOC validation for operators.

https://www.caam.gov.my/wp-content/uploads/2021/03/CAGM-6005-FAOC.pdf

USA (FAA) requires a DOT approval certificate with OpsSpec compliance.

EU (EASA) requires a TCO FAOC validation.

They all amount to the same thing, a document that spells out how you will comply with local regulations, DG requirements and various other things, which in Australia is basically an AOC.

[Lead Balloon]

If you want to be pedantic, the Australian legislation refers to the document as a "Foreign Air Transport Air Operator’s Certificate (FATAOC)". Most people I know simply call it a "Foreign AOC". CASRs do refer to "Foreign Air Transport Air Operator’s Certificate (FATAOC)". But section 27AE of the Act refers to and defines "foreign aircraft AOC". Horse/cart.

Yes, most people do call it a "Foreign AOC", which isn't what it is. What possible confusion could arise...

[compressor stall]

Malaysia (CAAM) requires a FAOC validation for operators.
https://www.caam.gov.my/wp-content/uploads/2021/03/CAGM-6005-FAOC.pdf
USA (FAA) requires a DOT approval certificate with OpsSpec compliance.
EU (EASA) requires a TCO FAOC validation.
They all amount to the same thing, a document that spells out how you will comply with local regulations, DG requirements and various other things, which in Australia is basically an AOC.

My question to the poster saying you only need OPS Specs to fly around was rhetorical, and I was fishing.... I'm well acquainted with those applications. I know of 1 national legacy carrier has about half a dozen FAOCs and some OPS Specs - depending on the country.

In comment about your answer - they may all amount to the same end game, but take different amounts of energy (and time) to acquire....

[By George]

Well written report. That night I was pushing back and watched them taxi past. They were close enough for me to see the pitot heads but I must admit I didn’t see the red tags. I was held at C8 on B and watched the whole thing. They subsequently closed the runway and we had to use 32. Just made it weight wise using bleeds off.

Sill feel guilty for not noticing anything abnormal. We even joked “there goes disappearing Airlines”. The landing looked exciting and I am impressed with the 330 back up airspeed indicator.

[TimmyTee]

Are the covers/probes viewable when sticking your head out the window on the 330? Imo you’re crazy not to visually confirm at least one is off (with the assumption that if one’s off, it’s likely the ginger beer has done his or her job). It’s a 5 second effort.

[Stuart Sutcliffe]

Are the covers/probes viewable when sticking your head out the window on the 330? Imo you’re crazy not to visually confirm at least one is off (with the assumption that if one’s off, it’s likely the ginger beer has done his or her job).

The engineers, walk-around pilot and pushback team should all have properly checked that the pitot covers were removed, but didn't, so where do you realistically draw the line?

It’s a 5 second effort.
A bit longer I think. 😉 It will take you 5 seconds just to open the DV window on a Boeing 777. Then you will need to lean out and look down at the probes, and you'll have to be partially up and off of your seat, with your head and upper torso outside the window aperture to do that. Some ground-pounder with a Health & Safety qualification certificate, hung on the back of his door, will probably have a fit if pilots did that regularly. 😄

As an aside, in the 16+ years I have been flying airliners I cannot recall there ever being pitot covers fitted on the aircraft I have arrived at, in preparation for flight! Merely an observation. That doesn't mean I don't check carefully on the walk-around, I do. The 92 seconds this incident Captain spent on his external inspection, including 9 seconds at the nose gear, is a pretty poor effort.

[BuzzBox]

Are the covers/probes viewable when sticking your head out the window on the 330? Imo you’re crazy not to visually confirm at least one is off (with the assumption that if one’s off, it’s likely the ginger beer has done his or her job). It’s a 5 second effort.

On the A330, the pitot probes are directly below the sliding windows on either side, but they're low down on the fuselage. They're not visible by sticking your head out the window. You might just see them if you got out of the seat and leaned out of the window, but you'd risk falling out. Why not just do the job properly in the first place and check during the walk around? If the covers must still be fitted at that stage due to wasp nests, then make sure it's written up in the tech log. A verbal confirmation with the engineer on headset wouldn't hurt either.


https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/1280x891/a330_800neo_front_view_scaled_dc3690d465b071a07b056b6ff1397e 0824ba5a6b.jpg

[Mach1Muppet]

https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/735x644/capture1_58b3c914c9c07ae003bb528e4a32dfb8e4e6f1ee.jpg
https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/752x634/capture2_11fb7a1b0344e61938202cf89220391567fe9e50.jpg
Both the LAE and Captain seemed to take a look, whether it didn't register, who knows?

[Uplinker]

I can see how an overworked engineer, with another two aircraft to turn around might notice the covers and think "I must get some steps to take those off". But then, the fueler comes over to have the chit signed and someone else comes up to him and says a cargo roller has jammed in the forward hold. On his way to the cockpit to write up the fuel in the tech log, someone says the rear sink is blocked or the IFE is not working etc, etc.

I can see that the first item - the covers - could get forgotten. But why did the pilots not notice during their walk around? Do they really need a streamer to see if a cover is on a pitot probe? Why not simply just look at each probe - I always do, (as well as each landing gear pin hole or strut to check no lock pins have been left in).

I would hope that engineers have a checklist to make sure everything gets done and not missed on the turnaround, and also it seems that pilots need a more comprehensive checklist than the present "Gear pins and covers?",
e.g:
Engine cowls? Closed and locked
Gear pins? Removed
Engine blanks? Removed
Pitot covers? Removed
Static covers? Removed
AoA vanes? Clear
Fuel panel? Closed


Our industry used to pride itself on learning from mistakes. Let's learn from this one. Ropes attached to the pitot covers so they can be removed from ground level without having to go and find steps. Checklists for engineers. Instruction for pilots on how to check the aircraft on a walk-around, and I don't mean a series of written words in an FCOM; I mean someone actually physically showing the pilots where the ground lock pin holes are on the undercarriage struts. Where the pitot probes are. What to look for and where everything is.

Training, training, training.

[ScepticalOptomist]

I can see how an overworked engineer, with another two aircraft to turn around might notice the covers and think "I must get some steps to take those off". But then, the fueler comes over to have the chit signed and someone else comes up to him and says a cargo roller has jammed in the forward hold. On his way to the cockpit to write up the fuel in the tech log, someone says the rear sink is blocked or the IFE is not working etc, etc.

I can see that the first item - the covers - could get forgotten. But why did the pilots not notice during their walk around? Do they really need a streamer to see if a cover is on a pitot probe? Why not simply just look at each probe - I always do, (as well as each landing gear pin hole or strut to check no lock pins have been left in).

I would hope that engineers have a checklist to make sure everything gets done and not missed on the turnaround, and also it seems that pilots need a more comprehensive checklist than the present "Gear pins and covers?",
e.g:
Engine cowls? Closed and locked
Gear pins? Removed
Engine blanks? Removed
Pitot covers? Removed
Static covers? Removed
AoA vanes? Clear
Fuel panel? Closed


Our industry used to pride itself on learning from mistakes. Let's learn from this one. Ropes attached to the pitot covers so they can be removed from ground level without having to go and find steps. Checklists for engineers. Instruction for pilots on how to check the aircraft on a walk-around, and I don't mean a series of written words in an FCOM; I mean someone actually physically showing the pilots where the ground lock pin holes are on the undercarriage struts. Where the pitot probes are. What to look for and where everything is.

Training, training, training.

If the company you work for is happy to spend some money on training, these errors can be reduced.

Unfortunately too many have succumbed to the “cheaper is better” mantra.

[TURIN]

I can see how an overworked engineer, with another two aircraft to turn around might notice the covers and think "I must get some steps to take those off". But then, the fueler comes over to have the chit signed and someone else comes up to him and says a cargo roller has jammed in the forward hold. On his way to the cockpit to write up the fuel in the tech log, someone says the rear sink is blocked or the IFE is not working etc, etc.

I can see that the first item - the covers - could get forgotten. But why did the pilots not notice during their walk around? Do they really need a streamer to see if a cover is on a pitot probe? Why not simply just look at each probe - I always do, (as well as each landing gear pin hole or strut to check no lock pins have been left in).

I would hope that engineers have a checklist to make sure everything gets done and not missed on the turnaround, and also it seems that pilots need a more comprehensive checklist than the present "Gear pins and covers?",
e.g:
Engine cowls? Closed and locked
Gear pins? Removed
Engine blanks? Removed
Pitot covers? Removed
Static covers? Removed
AoA vanes? Clear
Fuel panel? Closed


Our industry used to pride itself on learning from mistakes. Let's learn from this one. Ropes attached to the pitot covers so they can be removed from ground level without having to go and find steps. Checklists for engineers. Instruction for pilots on how to check the aircraft on a walk-around, and I don't mean a series of written words in an FCOM; I mean someone actually physically showing the pilots where the ground lock pin holes are on the undercarriage struts. Where the pitot probes are. What to look for and where everything is.

Training, training, training.

That description is all too common which is why a written entry in the log is mandated. Just trying to get from fuel truck to flight deck is like the running of the bulls some times, getting chased by dispatchers, loaders, cabin crew, then the phone goes off and you are now wondering why you wanted to get to the flight deck in the first place! Distractions from critical tasks will always be there.

Yes, engineers have check lists, there is usually a copy in the back of the tech log or in a supplementary folder with all the insurance certificates and aircraft legal docs somewhere on the flight deck. Legally it should be referred to every time a Transit or pre flight check is signed but frankly no one hardly ever does unless there has been a recent change.

Ropes on pitot covers is no good i'm afraid, they are clipped in place to stop them blowing off.

[43Inches]

As I said earlier the aviation industry might fly cutting edge technology, but the work practices behind the scenes are 1950s era. External Covers that can result in catastrophic loss if left in place should be NFT buttoned, and a data-logger involved which records when they are put in place and when they are removed. Then the human peanut is not relied on to remember. The reader needs to be close enough to read the tag, so it will be when they are removed, not when they are looked at. The record of removal should be straight into a computerised maintenance management system (CMMS) and it will not release the aircraft for flight until that item is logged in the system as done. That is a big red flag saying 'don't fly me stupid' comes up in front of the meat bag sitting in the flight deck looking at their tablet or whatever.

[Matt48]

Everyone going about their duties, (not my job to look for the thingies).

[Matt48]

Clipboard lying in intake duct.. removed.

[neville_nobody]

Our industry used to pride itself on learning from mistakes. Let's learn from this one. Ropes attached to the pitot covers so they can be removed from ground level without having to go and find steps.

Yes until airlines decided that bonuses as opposed to straight salaries for management were a good idea. Good luck justifying your "safety" case for a longer piece of rope and a big flag attached in someone's budget prior to this incident.

Aviation in the future will be dominated by penny pinching safety reports as that is the only way anything will be justified by the accountants. They will just shoot it down on cost until we bend an aeroplane and have a starring role in a ATSB report then they can justify the cost.

[Chris2303]

Clipboard lying in intake duct.. removed.

Wasn't it removed during engine start? If it's the JQ incident that I remember.

[Roj approved]

Yes until airlines decided that bonuses as opposed to straight salaries for management were a good idea. Good luck justifying your "safety" case for a longer piece of rope and a big flag attached in someone's budget prior to this incident.

Aviation in the future will be dominated by penny pinching safety reports as that is the only way anything will be justified by the accountants. They will just shoot it down on cost until we bend an aeroplane and have a starring role in a ATSB report then they can justify the cost.

As Stelios Haji-Ioannou of EasyJet famously said “If you think health and safety is expensive, try an accident”.

[Uplinker]

...............Yes, engineers have check lists, there is usually a copy in the back of the tech log or in a supplementary folder with all the insurance certificates and aircraft legal docs somewhere on the flight deck. Legally it should be referred to every time a Transit or pre flight check is signed but frankly no one hardly ever does unless there has been a recent change.

"Well there's your problem, lady !"

Many years ago when I was a fairly new flying sprog; I innocently asked an engineer if they used checklists, as we pilots did. "No", came the reply; "we use common sense". Well that's all well and good, until someone forgets something or gets distracted, which is what checklists are supposed to mitigate. I personally would not trust my own memory, especially in an environment full of distractions. If I was an engineer, I would write and use my own checklists in a pocket sized format, if non were available. (But I am not blaming the engineers in this instance).

Ropes on pitot covers is no good i'm afraid, they are clipped in place to stop them blowing off.
Yes, I know; so they need to be redesigned to be secure but removable without steps. The covers I have seen have a velcro strap that goes around the back of the pitot probe cover to stop it falling off. A thin rope, attached to the end of that strap would enable a person on the ground pulling on the rope to unpeal the velcro strap and then pull the cover free. The rope would be very visible and obvious, so no separate streamer would be required.

Getting hold of steps can be a pain in the hoo hoo. When it is icy, pilots need steps to check the top wing surface, but the only steps usually available are the fueler's, which don't quite reach. There should be a set of steps on every main stand.

Yes, I know. This would all cost money - It might add as much as a whole pound Sterling per passenger ticket. But Safety is our primary concern, isn't it ?.................................isn't it?

[Lookleft]

Both the LAE and Captain seemed to take a look, whether it didn't register, who knows?

Quite possibly that is the case. We (airline pilots) have seen the video of the basketball passing competition between two teams. We were all surprised the first time we saw it that there was a person in a gorilla suit walk through the middle of the competition. Its called functional blindness. Basically if you are not looking for a specific object then it won't register that it is in fact in your field of view. Its why bike riders have cars do a u-turn in front of them. What is harder to fathom is the lack of airspeed not being noticed on the PFD's. The pilots should be expecting to see that during the take-off. Tracking technology on the pitot covers is not a bad idea but should there be some sort of alarm similar to the take-off warning config if the IAS is not increasing? Ideally, trained pilots should pick up such a basic fault but I use the analogy of the professional soldier and the conscript. The conscript has basic training but is not interested in improving their skills beyond what is necessary. The professional soldier wants to keep improving so they can be the best they can possibly be. I think worldwide that there are too many pilots who are in the conscript category. The recent incident in Dubai is another example. Four pilots who did not know how to comprehend a situation that was different to the hundreds of departures they had sat through and watched previously.

[LKinnon]

Pitot covers should be designed to fall apart beyong 60kt.

[Stuart Sutcliffe]

Pitot covers should be designed to fall apart beyong 60kt.
You would then likely lose the covers every time a big storm blew through?

[Lead Balloon]

Or....

When student pilots are being trained, one of the items they should be trained to check while rolling down the runway is that the airspeed indicator is indicating an increase in airspeed.

1986 in a Cessna 152: "And if we're rolling down the runway for take off, and the airspeed indicator is indicating not much and not increasing, you've probably left the pitot cover on, Lead Balloon, or the pitot probe is blocked (which you should have seen when you did your daily inspection)."

I say again: The stuff up during the truncated ground inspection is one thing. What happened after that is more concerning from a systemic safety perspective.

[BuzzBox]

What is harder to fathom is the lack of airspeed not being noticed on the PFD's. The pilots should be expecting to see that during the take-off. Tracking technology on the pitot covers is not a bad idea but should there be some sort of alarm similar to the take-off warning config if the IAS is not increasing?

In this case, red 'SPD' flags were annunciated on both PFDs as the aircraft accelerated through 50 knots groundspeed. The Captain noticed the flags and muttered 'speed, speed', but did not communicate the problem to the FO. The Captain was clearly confused by what was happening, but instead of making a decision to reject the take-off, he just let it continue and then called '100 knots' based on the groundspeed readout. The flight crew actions during the take-off, especially those of the Captain, make for 'interesting' reading.

[mahogany bob]

PITOT FAULTS



A few observations:



Murphy’ Law applies - if something can happen it will happen !

( I seem to recall over the years more than one incident when PITOT covers had NOT been removed prior to T/O !! )



In my experience as a flight simulator instructor ( albeit RAF ) crew reaction to pitot /static faults were handled worse than any other emergency - especially when sneakily inserted when the crew were distracted by something else.



With an increasing airspeed it is very tempting to take off power and raise the nose leading to dangerously low actual airspeed.

Conversely with a reducing airspeed the natural reaction is to put on power and lower the nose leading to a dangerously high airspeed.



The TOP TIP was always to set a sensible power setting and attitude , sit on hands and resolve the fault in slow time.



A good airspeed check was always SOP on T/O and if a serious discrepancy was picked up the T/O should be ABORTED at about 100kts - well below V1.

[deja vu]

Unbelievable.

How can anyone possibly NOT check Pitot probes on an A330?

They are in plain view, very easy to check, as are the Static ports and the AoA vanes. There might not have been streamers attached to the covers, but so what? You simply....Look. At. The. Probes. and you will easily see if they are covered or not.

And as for night time, all engineers and pilots carry a torch don't we, (and I mean a proper, focusable torch, not a phone)........please tell me we all do.

This incident is remeiscent of the BA aircraft that took off with the engine cowls unlatched because nobody did a proper walk-around.

This is really fundamental stuff. Any "pilot" who does not check these most fundamental items before each and every flight is.......well........words fail me. :ugh:
God help you if you ever become fallible. Just love these twerps.

[Matt48]

Wasn't it removed during engine start? If it's the JQ incident that I remember.
Yes, that was the one, but the clipboard should never have been put there in the first place.

[punkalouver]

Looks like he was shining the flashlight on the pitot tube during the walk around.

Either did not notice(make sure to look and actually observe) or perhaps noticed and then forgot.

Seeing as I am always looking for solutions based on the reality of events occurring(instead of discussing penny pinching), I suggest, as a general rule, having a policy of stopping the walk around when an issue like this is discovered, advise maintenance, and then resume the walk around. It makes it less likely that the issue will get forgotten.

[Near Miss]

Are the gear pins still stowed in the cockpit just behind the captain? They were the last time I flew the 330. Why can't they stow the pitot covers there too? If you missed them on the walk-around check, the cockpit safety and equipment check would give an additional opportunity to catch the error. No need for fancy, expensive, and heavy cameras etc.

[H Peacock]

Never mind the pitot covers being left on, HTF did the crew manage to complete the take-off roll past V1 and beyond with almost no airspeed indicating? 😬

[deeceethree]

Never mind the pitot covers being left on, HTF did the crew manage to complete the take-off roll past V1 and beyond with almost no airspeed indicating? 😬
If you read pages 9 to 11 of the report, handily linked in the opening post, you will be able to find that out! :ok:

[tossbag]

I'm tipping the last question was rhetorical.

[megan]

I suggest, as a general rule, having a policy of stopping the walk around when an issue like this is discovered, advise maintenance, and then resume the walk around. It makes it less likely that the issue will get forgottenInterrupting a pre flight can, and has, been the undoing of flight safety, can point to the loss of a DC-4 and all on board when the aircraft was the main stay of airline operations, our own outfit had an engine cowling come loose in flight and cause damage that took six months to repair, exhaust gases impinging on the airframe changing metal temper was what took time to fix. On both occasions it was interruption to take a phone call that initiated events.

[neville_nobody]

Never mind the pitot covers being left on, HTF did the crew manage to complete the take-off roll past V1 and beyond with almost no airspeed indicating?

Meanwhile for Australian crew the ATSB are postulating about potential glide ranges in a jet aircraft and are highly critical of the decision making but foreign crew can call an airspeed that doesn't even exist, get airborne and that's OK???

[Matt48]

As a non pilot, was wondering who 'owns' the pitot covers and gear pins and where are they normally kept, common sense says they would live in the cockpit when not in use... but.

[FlightDetent]

As a non pilot, was wondering who 'owns' the pitot covers and gear pins and where are they normally kept, common sense says they would live in the cockpit when not in use... but.Matt, the pitot covers and as well gear locking pins are stored on the flightdeck. If you play by the rules only the aircraft-paired, one specific set is used to dress the sensors. Exclusively.

There is a stowage box, you will find a photo in the report. Checking for the covers removed is task of fatal importance.

That is why the engineers need to make a written entry to the logbook when installing them.

That is why each of the pilots should check, independently, as per procedure
- the one on the flight deck will verify all pins and covers are inside
- the one on the outside will inspect there are no pins or covers left installed outside.

This is pretty standard setup for critical items, but wait for the good part....
​​​​​​.
​​​​​​.
additionally there is a written check list, challenge-response, which pilots need to read and answer aloud before pushback. Our concern here is the item:

GEAR PINS AND COVERS? ..... REMOVED (both).

Where each declares doing his part.
​​​


​​​​​​

[punkalouver]

Interrupting a pre flight can, and has, been the undoing of flight safety, can point to the loss of a DC-4 and all on board when the aircraft was the main stay of airline operations, our own outfit had an engine cowling come loose in flight and cause damage that took six months to repair, exhaust gases impinging on the airframe changing metal temper was what took time to fix. On both occasions it was interruption to take a phone call that initiated events.

Of course, you have a good point and I did consider that. But think about it for a while on a modern jet or turboprop. How often do we find something that is reportable to maintenance on a walkaround. I mean something that will cause an incident for sure. Almost never. However, finding pitot covers on will cause an incident for sure(at least an RTO).

One has to weigh the chances of forgetting to complete the rest of the walkaround(which will almost never result in an incident) versus forgetting to mention the pitot covers(guaranteed to cause an incident). Standard weighing of potential outcomes of each option available, both of which can lead to the undoing of flight safety.

Therefore, I still suggest interrupting the walk-around to advise maintenance if one finds a significant issue. It can also prevent a delay by getting maintenance onto the problem earlier.

[TurningTheSpanners]

... If you needed steps or a ladder to fit the blanks, why not leave it there for the person to remove the blanks is one obvious question.

1) Because it's not good practice to leave stands in close proximity to an airplane

2) Because you probably don't have every size stand on every parking bay.

TTS

[43Inches]

Matt, the pitot covers and as well gear locking pins are stored on the flightdeck. If you play by the rules only the aircraft-paired, one specific set is used to dress the sensors. Exclusively.

There is a stowage box, you will find a photo in the report. Checking for the covers removed is task of fatal importance.

If you read the report Malaysian Airlines does not regularly carry Pitot Covers in the aircraft, and the Covers were supplied by the support engineer on this occasion from ground stock. This is why I made the comments earlier about having a computerised system recording ground fitting of protective/storage equipment, such as covers, locks and such. The aircraft did not have its own set of Pitot Covers, the crew checking the box, would have no effect. The primary cause of this is the split duties between two engineers, who were not exactly cluey on what exactly each was responsible for, this has caused MANY accidents, change of shifts, sudden change of duty, busy work cycles, etc. The old remember everything in my head and remember to do paper checklists just flies out the window. WRT to the crew this is a case of a non standard local procedure for fitment of these items catching the normal crew out. Still there is no excuse for how they got past 50 knots with red flags on the speed indicators.

[Abbey Road]

If you read the report Malaysian Airlines does not regularly carry Pitot Covers in the aircraft, and the Covers were supplied by the support engineer on this occasion from ground stock.
Just for illustration, with regard to a different major international airline and fleet type, if British Airways carries pitot covers on it's 777 aircraft, they are not stored in the flight deck.

If carried, where mght they be stored? No idea. Only the gear pins are stored in the flight deck.

[TURIN]

Matt, the pitot covers and as well gear locking pins are stored on the flightdeck. If you play by the rules only the aircraft-paired, one specific set is used to dress the sensors. Exclusively

There is a stowage box, you will find a photo in the report. Checking for the covers removed is task of fatal importance.

.

This sort of thing is airline specific. In my experience pitot covers are not kept on board unless it is a standard procedure to fit them every day. Which for most airlines in temperate climates, it isn't.


That is why the engineers need to make a written entry to the logbook when installing them.

On the vast majority of airlines, yes. The report states that it was not at the time a requirement for MAH.

​​​​.
​​​​​​.
additionally there is a written check list, challenge-response, which pilots need to read and answer aloud before pushback. Our concern here is the item:

GEAR PINS AND COVERS? ..... REMOVED (both).

Where each declares doing his part.

​​​​​​

When I first started doing headset procedures on the pushback, it was standard procedure for the flight crew to ask "your checks please?"
The response was to confirm all pins and pitot covers removed, doors and hatches checked closed and secure. (steering lock out pin fitted-added specific to type, I'm old enough to remember aircraft that didn't use them).

[TURIN]

If British Airways carries pitot covers on it's 777 aircraft, they are not stored in the flight deck.

Where mght they be stored? No idea.

Engineering line stores at main base.

[Matt48]

Magic, thanks Turin.

[Abbey Road]

Engineering line stores at main base.
TURIN, do you know if any consideration is given to the idea that a BA aircraft diverting into somewhere, somewhere other than a scheduled destination, could then end up declared as AOG at said destination? Does BA engineering management assume that there will be pitot covers suitable for the particular BA aircraft type wherever it is AOG, given that it could be some time before a suitable qualified and licensed rectification team can get to the aircraft.fixit, and get it away again?

Or are all/most pitot heads on airliners these days of similar enough shape and size that a set of 'universal' pitot covers will do the trick? The idea does, of course, assume that the diversion airfield has any spare pitot covers to protect an itinerant aircraft from marauding insects before it can fly again. Do these sort of things figure in BA's decision not to carry pitot covers on the aircraft? Just curious ......

[TURIN]

As far as I'm aware, line stations in general don't hold pitot covers in stores unless their station is one designated as at risk from insects. If the a/c are scheduled to nightstop for any length of time at an 'at risk' station then provision will be made either to place pitot covers on board (noted as a tech log entry ADD/HIL/DDR etc) or to have the pitot covers shipped to the line station for the duration of the schedule.
If the a/c diverts to a non normal destination then a suitable local engineering MRO would be tasked with the job, and one would assume that if that station is on the 'at risk' list then they would have pitot covers in stock anyway... one would hope.

On the other hand, as happened last summer, every aircraft had to have the pitot heads inspected and signed off in the tech log within two hours of first flight of the day instead of fitting the pitot covers. (i think that was for scheduled ground time of less than 24 hrs and may have only been short haul. IE A320).
I think the pitot covers are type specific with an approved part number.

On the other hand there are some airlines that insist on pitot covers being fitted anytime they are on the ground for more than a few hours regardless of the local insect threat.

[Abbey Road]

... and one would assume that if that station is on the 'at risk' list then they would have pitot covers in stock anyway... one would hope.
A line of thinking that seems to feature depressingly commonly in BA operations - hope. 😒

On the other hand there are some airlines that insist on pitot covers being fitted anytime they are on the ground for more than a few hours regardless of the local insect threat.
A practise which aligns with my experiences prior to working for BA.

Thanks for your thoughts, TURIN.

[Uplinker]

God help you if you ever become fallible. Just love these twerps.

Well thank you, that's kind of you.

As a fairly normal - and therefore completely fallible - human being, I personally think it is most important to check such things as the pitot and static probes before attempting every flight* - for the very reason that we are fallible and covers might have been left on for whatever reason or whatever mistake. Do you disagree with this precaution? Why do we do a walk around and what is it we should be doing during one?

As for the gorilla effect someone else mentioned. Are they saying that pilots might miss seeing a cover or a streamer on a probe because normally they don't see one there? Just look at each actual probe as part of your walk around - your life might literally depend on you checking them. If you don't see normal, unobstructed probes, then there is obviously a problem which needs resolving - we shouldn't need streamers etc, to tell us; we should always look at each probe and port, and vane etc.

(If the traffic lights are red, and the green man is lit up; do you just walk across the road without looking or do you check in each direction that no traffic is coming and it is safe to cross?)

And another crew that continued accelerating along the runway with confusing cockpit displays - previously a FD that did not indicate 'fly up', now, no IAS. I am confused by this. Do pilots no longer do RTO training in the Sim? Where is the command decision making? How are these pilots passing their Sim tests?

What is happening to pilots? We seem to be witnessing accidents caused by allegedly well trained and allegedly correctly checked pilots, but who are making the most fundamental errors - errors that have killed people in the past and that we were all supposed to learn from. There are more and more tests to pass when applying to an airline before even getting to the interview stage, but we are seeing these fundamental errors. What's going on?


*and that the gear pins have been removed and the engine cowls are closed and locked, and the flight controls are full and free and in the correct sense.

[43Inches]

Removal of all covers and locking devices should be done prior to an external inspection for flight. What's the point of inspecting something that has covers on it so you can't see what's inside or underneath. There is also the relevance check, what is an A330 pilot actually checking on a walk around, being 10 meters away from the closest pitot tube on the ground you can only see it's there, not hanging loose or something is covering it, no way you'd be able to see a wasp or insect inside it. It seems this captain may need a vision check as he failed to see the pitot covers as well as misread the speed flags on take-off.

What is happening to pilots? We seem to be witnessing accidents caused by allegedly well trained and allegedly correctly checked pilots, but who are making the most fundamental errors - errors that have killed people in the past and that we were all supposed to learn from.

This goes back to what I said earlier, when CASA rubber stamps these operators to come into Australia they are condoning their down sides as well. Another operator that had pilots fly below minimas due to basic incompetence on numerous occasions at different locations around Australia, told passengers to pray after an engine failure, flew to Melbourne by accident after a navigation error, and nothing much done, they still fly here.

[Lead Balloon]

My point in raising the AOC issue was that an application by an operator of foreign aircraft to operate those aircraft in to and out of Australian territory must, under the Civil Aviation Act, be assessed by CASA against the same criteria as are applied to the assessment of any other application for an AOC. If CASA is just ‘rubber stamping’ these applications, CASA is failing in its duty. If CASA is not conducting surveillance of the holders of these AOCs, CASA is failing in its duty.

And was anybody issued an infringement notice or prosecuted for contravention of CASR 91.245? A strict liability offence applicable to any crew of any aircraft in Australian Territory. We can confidently predict what CASA would do to a powerless nobody Australian pilot who did what this crew did.

[itsnotthatbloodyhard]

It seems this captain may need a vision check as he failed to see the pitot covers

I’ve been trying to understand this, and all I can think is that what he saw wasn’t completely out of place - i.e. if there’d been a possum impaled on a probe, or a pink g-string hanging off it, it would’ve looked obviously wrong. But a probe cover on a probe isn’t something that we never see or that looks completely abnormal, so perhaps it just didn’t set off the right mental alarm bells. Not sure I can quite file it under ‘Mistakes I Could Never Conceivably Make Under Any Circumstances’.

The lack of an RTO is a bit harder to rationalise…

[KAPAC]

Brisbane having issue with nesting wasps , could it be a work around, covers come off last minute ? Captain could have seen them but understanding was they get taken off 45 mins later by someone just before doors closed ? Banning any airline for standards causes loss of face and would involve lots of politics , unlikely in today’s environment.

[neville_nobody]

Banning any airline for standards causes loss of face and would involve lots of politics , unlikely in today’s environment.

So we’ll just smash the local operators instead.

[Lead Balloon]

You're not suggesting that politics would be taken into consideration by CASA, KAPAC? (Rhetorical question...) Banning isn't the only option, and I wouldn't expect it to be the first or even near the top of the list of available regulatory options to deal with the circumstances.

Precisely, neville.

[tossbag]

FAA bans an airline (US. Big, big country, lots of power), airline gets pissed off and works on getting re-certification.

CASA bans an airline (Australia. Piss ant country, postures a lot, little power), airline calls Australia racist, knowing that if they pull the racist card Australia will cave, (and know that CASA are gutless and would probably never ban them in the first place), airline has all Australian airlines banned from their country of origin due trumped up reasons.

[Lead Balloon]

Surely it's only about the safety of air navigation and the travelling public? (Another rhetorical question.)

[compressor stall]

And was anybody issued an infringement notice or prosecuted for contravention of CASR 91.245? A strict liability offence applicable to any crew of any aircraft in Australian Territory. We can confidently predict what CASA would do to a powerless nobody Australian pilot who did what this crew did.
I doubt it. Part 91 wasn’t in force at the time of the incident.

[Lead Balloon]

Reg 244 of CAR then?

[Uplinker]

Removal of all covers and locking devices should be done prior to an external inspection for flight. What's the point of inspecting something that has covers on it so you can't see what's inside or underneath. There is also the relevance check, what is an A330 pilot actually checking on a walk around, being 10 meters away from the closest pitot tube on the ground you can only see it's there, not hanging loose or something is covering it, no way you'd be able to see a wasp or insect inside it. It seems this captain may need a vision check as he failed to see the pitot covers as well as misread the speed flags on take-off.

I suppose it might be possible that at this airport, covers are routinely left on until the very last minute owing to the wasps, so pilots might have been told to disregard the pitot covers during their walk-around? But even if so, the 'Before Engine Start/Pushback checklist' should have a specific line added; "Pitot covers? - Three seen clear", or similar.

I don't think pilots are expected to make a comprehensive engineering inspection of the pitot probes - as you say, we can't always get close enough. Just that each one is uncovered, and seems unblocked, undamaged and serviceable. If insects have blocked one or all of the pitot probes in the time between removing the covers and pushing back; there will be an IAS disagree during the take-off roll, possibly leading to an RTO. Oh, wait........

I am beginning to wonder if some recent crashes and incidents around the World might indicate that we are seeing potential evidence of forged pilot licenses, or "Parker pen" hours in log books? Or perhaps some wayward TRE helping their mates get through Sims?

[morno]

I suppose it might be possible that at this airport, covers are routinely left on until the very last minute owing to the wasps, so pilots might have been told to disregard the pitot covers during their walk-around? But even if so, the 'Before Engine Start/Pushback checklist' should have a specific line added; "Pitot covers? - Three seen clear", or similar.

I don't think pilots are expected to make a comprehensive engineering inspection of the pitot probes - as you say, we can't always get close enough. Just that each one is uncovered, and seems unblocked, undamaged and serviceable. If insects have blocked one or all of the pitot probes in the time between removing the covers and pushing back; there will be an IAS disagree during the take-off roll, possibly leading to an RTO. Oh, wait........

I am beginning to wonder if some recent crashes and incidents around the World might indicate that we are seeing potential evidence of forged pilot licenses, or "Parker pen" hours in log books? Or perhaps some wayward TRE helping their mates get through Sims?

The Airbus already has a line in its before start checklist, “Gear Pins and Covers….. Removed”.

Like any checklist, unless it’s done properly, it merely becomes a response to get you to the next stage of flight. I don’t see how adding anything extra to a checklist is going to improve anything in this instance.

The last line of defence became that erroneous airspeed during the take off roll. Once that was missed and the takeoff continued, all the safeguards in place had failed.

[runway16]

So the incident happened in July 2018. It is now March 2022. That is a long gap to report on this event.

[Ngineer]

Unbelievable.

How can anyone possibly NOT check Pitot probes on an A330?

They are in plain view, very easy to check, as are the Static ports and the AoA vanes. There might not have been streamers attached to the covers, but so what? You simply....Look. At. The. Probes. and you will easily see if they are covered or not.

And as for night time, all engineers and pilots carry a torch don't we, (and I mean a proper, focusable torch, not a phone)........please tell me we all do.

This incident is remeiscent of the BA aircraft that took off with the engine cowls unlatched because nobody did a proper walk-around.

This is really fundamental stuff. Any "pilot" who does not check these most fundamental items before each and every flight is.......well........words fail me. :ugh:

He most likely carried out the walk around and saw them fitted. Standard procedure to fit covers on transits at BNE due to mud wasps. They get removed prior to push (most likely after the crew walk-around). Yeah, an incident waiting to happen, but bloody mud wasps these days.

[43Inches]

If you are going to comment on a report at least read the report;

In interview with the ATSB, the captain did not recall seeing pitot probe covers. Based on the captain’s walk-around path, torch use (particularly dwell time on check items), and total time taken, the ATSB assessed the captain’s walk-around as having omitted many of the required check items and was conducted without due attention (see Flight crew pre-flight walk-around for the occurrence flight).

There is even a picture of him shining a torch on the pitot covers in question during the walk around, taken from security cameras.

Which is why the earlier comments that the captain should maybe undertake some eye tests.

And before the box in the cockpit is mentioned again, or some sort of checklist that the pilots missed, Malaysian doesn't carry pitot covers in the aircraft, the offending items were provided by a third party ground org.

[Uplinker]

The Airbus already has a line in its before start checklist, “Gear Pins and Covers….. Removed”.

Like any checklist, unless it’s done properly, it merely becomes a response to get you to the next stage of flight. I don’t see how adding anything extra to a checklist is going to improve anything in this instance..

Yes, I know, but it is too general - we have had aircraft taking off with the engine cowls unlocked, and this one with all the pitot covers on. Pilots need to be aware of the importance of checks and checklists, not just pay lip service. (I have had the response, "full left" when I have been holding full right, during the control checks, because I deliberately do them in a different order to make sure we both are really checking properly, not just vocalising the expected answer).

If this airport has a particular problem requiring covers to be left on until immediately before pushback, then extra checks obviously need to be introduced. The pitot covers should be shown to the pilots as well as the steering pin before taxi?


(BTW, apologies, I did not realise this was an incident from 2018. Could anyone who flies there report if any new procedures are in place?

[tossbag]

I did not realise this was an incident from 2018

Sorry bro, that's how we roll down here, you know, primacy and recency and all that jazz. Why produce a contemporary report to be learnt from in a reasonable amount of time. Yes, given that you can always learn from a lesson like this one, just leave it 4 years for the fix.

[WHBM]

There are some excellent euphemisms in the report, which I will find opportunity to use when appropriate elsewhere. I particularly like "due to reduced diligence". What a put-down !