Dreamliner preflight error, ground and tech crew?

[c100driver]

On the evening of 21 September 2021, a Boeing Company 787-9, registered VH-ZNJ and operated by Qantas Airways was prepared for a freight flight from Melbourne, Victoria, to Los Angeles, United States. This involved removing covers from the pitot probes and static ports, among other tasks, associated with restoring the aircraft to flight status following an aircraft ‘park’ procedure.

At about 0825 on 22 September 2021, a pre-flight exterior inspection was conducted by one of the flight crew, with no anomalies detected. The aircraft was also subject to a pre-departure exterior inspection by ground service dispatch personnel, before departing Melbourne at about 0900. The aircraft landed at Los Angeles about 14.5 hours later, following an uneventful flight. During the post-flight inspection, engineering identified that all 4 engine fan cowl static ports were covered with tape.

[PPRuNeUser0184]

On the evening of 21 September 2021, a Boeing Company 787-9, registered VH-ZNJ and operated by Qantas Airways was prepared for a freight flight from Melbourne, Victoria, to Los Angeles, United States. This involved removing covers from the pitot probes and static ports, among other tasks, associated with restoring the aircraft to flight status following an aircraft ‘park’ procedure.

At about 0825 on 22 September 2021, a pre-flight exterior inspection was conducted by one of the flight crew, with no anomalies detected. The aircraft was also subject to a pre-departure exterior inspection by ground service dispatch personnel, before departing Melbourne at about 0900. The aircraft landed at Los Angeles about 14.5 hours later, following an uneventful flight. During the post-flight inspection, engineering identified that all 4 engine fan cowl static ports were covered with tape.

Fascinating.

[PoppaJo]

Bit like the Malaysian A330, engineer fails to remove items, however post that we do have multiple layers of responsibility from others to try and pickup on these issues post that. Do not rely on ground operators to pickup on these things, it's a bonus if they do, however I have seen a Captain fall into this situation before, who got into serious trouble from the training department when the ground crew reminded them about something that they failed to pickup during a preflight.

I don't believe the Roo has engineers dispatching flights from the stand anymore, however whoever conducted the preflight here, I assume SO, failed miserably.

I am sure our Boeing rated friends could advise us on why no engine warnings at all appeared? Strange.

[Cilba]

Is it standard procedure to use that sort of tape?

[BuzzBox]

I am sure our Boeing rated friends could advise us on why no engine warnings at all appeared? Strange.

According to the ATSB report (p.4):
The engine electronic control (EEC) uses the ambient air pressure data from the ADRS for engine control algorithms, engine thrust calculations and to optimise engine performance. The fan cowl static port air pressure data is only used when an EEC determines that the ADRS data is unreliable. Where no ambient pressure data is available, the EEC assigns a failsafe mode for continued engine operation.

https://www.atsb.gov.au/media/5781226/ao-2021-040-final.pdf

[SASKATOON9999]

And what exactly do we do a pre flight walkround for?
Having seen the pictures - no matter what the rush, time of day, or outside Wx, someone was negligent in their walkround!

Aeroperú Flight 603 didn't find it fascinating either

[ScepticalOptomist]

Yep, someone screwed up. Lucky it didn’t cause any hassles. Lucky no one was injured as a result.

Hopefully lessons learned.

[TimmyTee]

Seems somewhat risky sending a second officer (not saying this one was, but I believe that’s pretty standard for QF WB)
I’m surprised so many captains accept this

[Brakerider]

Seems somewhat risky sending a second officer (not saying this one was, but I believe that’s pretty standard for QF WB)
I’m surprised so many captains accept this

you do realise most of these second officers are ex Captains themselves…

[RickNRoll]

A 787-9 is flying freight?

[morno]

Seems somewhat risky sending a second officer (not saying this one was, but I believe that’s pretty standard for QF WB)
I’m surprised so many captains accept this

Why? They’re type rated aren’t they?

[Two's in]

Yep, someone screwed up. Lucky it didn’t cause any hassles. Lucky no one was injured as a result.

Hopefully lessons learned.

There were a number of failures here, but the most obvious safety breach was whoever applied the tape in the first place without an accompanying maintenance snag requiring it to be removed before flight.

[havick]

I have seen a Captain fall into this situation before, who got into serious trouble from the training department when the ground crew reminded them about something that they failed to pickup during a preflight.

Sounds like a really fun place to work 🙄

[uxb99]

We have checklists for most things, why not a check list for the walk around?

[Uplinker]

I think there is accumulating evidence for a slightly more detailed checklist than simply "Gear pins and covers?.........." Certainly probes and engine cowl locks could be added, based on recent incidents.

One would hope that any pilot member of a crew i.e. who is type-rated, would know how to do a walk around and what to check, no matter what their rank is.

Everybody makes mistakes, but forgetting to look to see if probes are uncovered and clear is surely not open to a pilot forgetting. How can one forget ? - it is the reason you are outside, walking around the aircraft.
Looking into the front of a fan engine, you look at the intake probes, right? As well as the condition of the intake housing, the spinner, the fan blades etc. Don't you ?

[tdracer]

I am sure our Boeing rated friends could advise us on why no engine warnings at all appeared? Strange.

It would have set numerous FADEC maintenance faults and the "L/R ENG CONTROL" EICAS messages. However the ENG CONTROL messages are inhibited above 80 knots, so the crew would not have seen them until they landed, and we don't expect the flight crew to check CMC faults (I don't think there is anything that would prevent it, but unlikely there would be any reason for them to look).
Engine operation may have been a bit 'abnormal' - not up to speed on the Trent 1000 Air Data Logic, but the general rule is if both engine sensors agree but disagree with aircraft, the system defaults to the engine sensors to protect engine-to-engine isolation. Of course when engine sensed Pamb became greater than the P total, it likely would have faulted everything and gone to some default failsafe value.

[HOVIS]

There were a number of failures here, but the most obvious safety breach was whoever applied the tape in the first place without an accompanying maintenance snag requiring it to be removed before flight.
We don't know that.
There may well have been a log entry to remove the tape, however, as happened in the other incident discussed recently, a communication breakdown between the certifying engineer and the delegated indivual who was tasked to remove the tape can easily happen.

[Cat Techie]

We don't know that.
There may well have been a log entry to remove the tape, however, as happened in the other incident discussed recently, a communication breakdown between the certifying engineer and the delegated indivual who was tasked to remove the tape can easily happen.

A mechanic would not likely be near a storage aircraft. Never in my lifetime and storage aircraft have been fairly common. Oh, certifying means checking before signing. That simple. I did to another LAEs work yesterday as he didn't have company approvals. Guy was way more capable and experienced than myself but I still checked the work. Argue your way out of that statement of fact. We as engineers know that storage checklists are comprehensive in the scope and responsibilities.

[HOVIS]

A mechanic would not likely be near a storage aircraft. Never in my lifetime and storage aircraft have been fairly common. Oh, certifying means checking before signing. That simple. I did to another LAEs work yesterday as he didn't have company approvals. Guy was way more capable and experienced than myself but I still checked the work. Argue your way out of that statement of fact. We as engineers know that storage checklists are comprehensive in the scope and responsibilities.
Not sure why you want to start a fight over this, I was merely making the observation, as previously stated, that communication errors between individuals can occur. I am not condoning it, or making excuses. It doesn't matter how capable or experienced you are. Everyone, and I mean everyone is capable of erring.

[Uplinker]

Whatever the reason(s) for a mistake; the final arbiter is that one of the pilots - who is actually going to be in the aircraft, taking off - needs to check that important things such as probes have been individually looked at and checked.

The pilot walk-around should be the one that catches any mistakes such as probe covers being left on.

[Icarus2001]

to be in the aircraft, taking off - needs to check that important things such as probes have been individually looked at and checked.

The pilot walk-around should be the one that catches any mistakes such as probe covers being left on.

Did you read the report? There were no probe covers left on.

[neville_nobody]

Everyone's life could have been made easier by having the 'Remove Before Flight' sticker a little more obvious rather than being covered up by yellow tape. Defeats the purpose of the tape if you can't read it.

[PoppaJo]

Sounds like a really fun place to work 🙄
Was one of those airlines with astronaut sort of training standards, you know that place in which everyone fails a command course, the bar is set in a far away galaxy. I’m sure many know which one I’m talking about. Thank god I got another offer and left pronto.

[Uplinker]

Did you read the report? There were no probe covers left on.

Er..... . During the post-flight inspection, engineering identified that all 4 engine fan cowl static ports were covered with tape...........What the ATSB found
The ATSB found that tape covering the 4 fan cowl static ports was not removed by engineering,

OK then ports/probes, my bad, but they should all be checked, no?

[Tom Sawyer]

Bit like the Malaysian A330, engineer fails to remove items, however post that we do have multiple layers of responsibility from others to try and pickup on these issues post that. Do not rely on ground operators to pickup on these things, it's a bonus if they do,
I don't believe the Roo has engineers dispatching flights from the stand anymore, however whoever conducted the preflight here, I assume SO, failed miserably

As an Engineer - it is not "a bonus" if we pick these things up, it is our job! As the aircraft had possibly been in parking mode for a few days, all the aircraft's ports and probes had been covered as per the AMM aircraft parking requirements. These ports on the engine do not have specific blanks manufactured for them, so using tape and plastic sheeting or preferably plastic gauze cut to size is the normal approved method, as it is for a number of other positions on the 787, including some about half way up the fin. When I have covered these ports I usually leave a tail of tape hanging down to make it a bit more obvious, or an extended line of tape up the cowling if the weather outlook is not good. The ports on the fan cowl are easy to miss as they are a long way down in the same way that fan cowl latches have been missed in previous well known incidents, it just takes a bit of effort and awareness that they are there. The workpack job card to re-activate the aircraft from parking would probably just had a generic "Remove all blanks and covers as per AMM 09-xx-xx" statement whereas a list of positions with a signature required for each one would probably have been more of a failsafe.

Essentially, the engineer who carried out and/or supervised the jobcard failed. Whoever carried out the Daily check failed. Whoever carried out the the EDTO pre-flight/transit check failed. The operating crew member who did the walk round failed. Whoever carried out the final ground walk round failed. The only defence for all this is that around the time of the incident the industry was at reduced manpower and workload levels so there was a lot of "de-skilling" and knowledge fade in the system, and in general, parking and re-activating aircraft in a normal line maintenance environment is not a common procedure. Luckily it was not a primary air data system.

[FlareHighLandLong]

How much retraining did the crew member (perhaps SO) get after their 18 months driving Uber? Were preflights discussed at all?

Maybe they were a bit distracted and stressed by the loss of income and time spent in quarantine.

[PoppaJo]

As an Engineer - it is not "a bonus" if we pick these things up, it is our job!
I was referring to the likes of Swissport.

[C441]

We have checklists for most things, why not a check list for the walk around?
There is. It's in the FCOM and anyone who's completed the type rating should be conversant with the FCOM and its contents, especially the walk around procedure if that's going to be a significant part of your job.

One of the best Captains I ever flew with once quipped "You're not just lookin' for the **** that's not there, you're lookin' for the **** that shouldn't be and that includes lookin' for the stuff that's on the ground when it should be on the jet!"

[unobtanium]

you mean the REMOVE BEFORE FLIGHT text that is printed on the bright red tape, secured with bright yellow tape, stuck on an all white engine cowl?

or does boeing require too many thing's to be taped up leading to potential errors like this?

https://cimg4.ibsrv.net/gimg/pprune.org-vbulletin/1389x635/787_844377a6155ed4e8779b8cacc26ba8daaa01f0c8.jpg

[LostWanderer]

There have been a few fatal jet accidents due to tape left on ports of passenger jets and missed in the walk around. This is piloting 101...no excuse. Overseas aviation authorities would be out for blood looking to see if the pilot was distracted/on phone etc...and if so, farewell career. Wonder if this one will survive the axe and how CASA/QF will handle it.

[t_cas]

There have been a few fatal jet accidents due to tape left on ports of passenger jets and missed in the walk around. This is piloting 101...no excuse. Overseas aviation authorities would be out for blood looking to see if the pilot was distracted/on phone etc...and if so, farewell career. Wonder if this one will survive the axe and how CASA/QF will handle it.

In a “just culture” mature and supportive organization, this incident would and should lead to better outcomes. Not sackings. The mere mention of such punitive action only supports a failing safety culture. No matter how good you are, when the “reason model” dictates; you had better be ready to mitigate. This can only be achieved effectively and consistently in a true just culture.

Just culture does not excuse negligence.

[morno]

There have been a few fatal jet accidents due to tape left on ports of passenger jets and missed in the walk around. This is piloting 101...no excuse. Overseas aviation authorities would be out for blood looking to see if the pilot was distracted/on phone etc...and if so, farewell career. Wonder if this one will survive the axe and how CASA/QF will handle it.

You've never made a mistake?

And by the way, that’s why places that adopt that approach are much more likely to have accidents, because they don’t accept that every mistake is a possible learning experience, not a sacking experience.

I've worked in countries that are punitive in their approach, not ‘Just’, and I have seen what it does to the safety culture. Not good.

[Bootstrap1]

For all the armchair experts let me explain some things for you.
Pitot probes have proper Boeing covers with flags that have "Remove before flight"
All the static probes, engines, fuselages and vertical stabiliser do not have Boeing covers.
In this instance they are covered with clear plastic film that is open at the bottom to allow condensation to drain, This plastic film is held in place with the yellow tape.
The yellow tape in question is a 3M product which is the correct spec as per Boeing for covering static ports. There is also some red/white barber pole tape that is applied as well as the "flag"

If the aircraft is covered like this it is because the aircraft is being parked for more than 24 hours. There are specific job cards for carrying out the parking tasks. They are some of the most poorly written and amended cards I have ever used.

There is also a card to remove the covers/tape etc. None of this is in the log book as it is covered by the job cards which are controlled in the electronic maintenance system.

So at the end of the day someone didn't remove them and signed for it. The task was certified without being checked and the flight crew missed it on the walk around.

With QF being in a state of flux for the past 2 years and managers doing anything but managing these events are happening. It isn't good for anyone. The 787 gear pins being left in 12 months ago also was put down to organisational change amongst other factors. It may seem to be a simple error, but nothing is ever simple. Those who work in this industry would understand it.

[717tech]

There is also a card to remove the covers/tape etc. None of this is in the log book as it is covered by the job cards which are controlled in the electronic maintenance system.

So at the end of the day someone didn't remove them and signed for it. The task was certified without being checked and the flight crew missed it on the walk around.

I don't know anything about this particular airframe, but are these covers easily seen from ground level? Or would you need some kind of platform?

[Lead Balloon]

If the aircraft is covered like this it is because the aircraft is being parked for more than 24 hours. There are specific job cards for carrying out the parking tasks. They are some of the most poorly written and amended cards I have ever used.

There is also a card to remove the covers/tape etc. None of this is in the log book as it is covered by the job cards which are controlled in the electronic maintenance system.

So at the end of the day someone didn't remove them and signed for it. The task was certified without being checked and the flight crew missed it on the walk around.

With QF being in a state of flux for the past 2 years and managers doing anything but managing these events are happening. It isn't good for anyone. The 787 gear pins being left in 12 months ago also was put down to organisational change amongst other factors. It may seem to be a simple error, but nothing is ever simple.Not good at all.

Pretty ordinary outcomes for an airline that is supposed to be better than ordinary.

[tdracer]

I don't know anything about this particular airframe, but are these covers easily seen from ground level? Or would you need some kind of platform?
No platform needed - the engine statics are on the lower quadrant of the engine fan cowl (both sides), roughly 45 deg. from horizontal.

[QF-leo]

Agree, “To Err is Human”.

[FlightDetent]

The pilot walk-around should be the one that catches any mistakes such as probe covers being left on.Always has been. Yet, again, real people make mistakes and one of those is also not doing their job at all.

Punching the X button over this repeatedly only can only achieve so much. What's next, punching the people?

​​​​

[Busbuoy]

The only defence for all this is that around the time of the incident the industry was at reduced manpower and workload levels so there was a lot of "de-skilling" and knowledge fade in the system, and in general, parking and re-activating aircraft in a normal line maintenance environment is not a common procedure. Luckily it was not a primary air data system.
When you say "defence" I suspect you mean "contributing factor". Minor quibble, but the truth of the matter is that the risks associated with this period were easily identifiable and the extra planning, manpower and supervision required to prevent this regrettable incident should have been allocated by management, if they weren't so busy attacking their workforce's pay and conditions. And for that, there is no defence. Luckily, indeed, it was not a primary air data system. If it's like the 350, it's a very important part of the backup air data systems, tho'.

[blubak]

When you say "defence" I suspect you mean "contributing factor". Minor quibble, but the truth of the matter is that the risks associated with this period were easily identifiable and the extra planning, manpower and supervision required to prevent this regrettable incident should have been allocated by management, if they weren't so busy attacking their workforce's pay and conditions. And for that, there is no defence. Luckily, indeed, it was not a primary air data system. If it's like the 350, it's a very important part of the backup air data systems, tho'.
Well summarised & the only thing i can add is whilst they were so busy attacking the pay & conditions they were still raking in millions of jobkeeper $$ every week.

[srjumbo747]

I love all the ‘experts’ here with their ‘informed’ views.
Maybe they just forgot to do the walkround.
simples

[Icarus2001]

and the extra planning, manpower and supervision required to prevent this regrettable incident should have been allocated by management

Available manpower was not the issue. Engineer and pilot missed the tape.
How many more people should walk around?

[das Uber Soldat]

Engine operation may have been a bit 'abnormal' - not up to speed on the Trent 1000 Air Data Logic,
What does the Trent 1000 have to do with anything?

[Icarus2001]

AS POSTED ABOVE...

The engine electronic control (EEC) uses the ambient air pressure data from the ADRS for engine control algorithms, engine thrust calculations and to optimise engine performance. The fan cowl static port air pressure data is only used when an EEC determines that the ADRS data is unreliable.

[roundsounds]

Available manpower was not the issue. Engineer and pilot missed the tape.
How many more people should walk around?

“missed the tape” look for the pins not the tape.
“walkaround” it’s an external inspection, not a walkaround.

[Icarus2001]

Roundsounds you seem a little confused. There was TAPE across the cowl static ports. There were NO PINS.
Walk around the aircraft to perform a visual inspection.

[No Idea Either]

Me thinks you know what roundsounds meant Icarus, don’t be disingenuous……..