Pitot Covers Brisbane Take 2

[PoppaJo]

There are no words…

Perhaps we need big fluro flashing signs at the stand or something?

If it was night, they would have departed clearly. Then the fun really starts.


An Australian Transport Safety Bureau investigation preliminary report has detailed that an Airbus A350 passenger aircraft was about to be pushed back for departure from Brisbane Airport before it was observed that covers were still in place on its pitot probes.

https://www.atsb.gov.au/media/news-items/2022/pitot-probe-covers/

[Icarus2001]

As part of its investigation, to date the ATSB has interviewed the LAME, AME and the refueller, and reviewed airport security video, which did not show that the required final walk-around of the aircraft was conducted by either the LAME or the AME prior to dispatch.

Well done to the observant refueller on an adjacent bay.

[Eclan]

Looking at the history, it's obviously a Brisbane thing. They should NOTAM it.

[PPRuNeUser0198]

How did the crew pre-flight walk around fail to see this... I assume without any data inputs this would have likely resulted in a rejected take-off due to lack of airspeed data? Or could they have still departed with loss of control risk?

[AviatoR21]

The External Inspection is basically an excuse to take some selfies for Instagram or TikTok accounts :rolleyes:

[brokenagain]

How did the crew pre-flight walk around fail to see this

”Between 0852:18 and 0854:03, the first officer conducted a preflight walk-around”.

Because the FO did a walk around of an A350 in less than 2 minutes.

[ThunderstormFactory]

Have mud wasps ever actually built a nest quickly in any pitot tubes at Brisbane airport? Because if not, I feel this policy about putting on pitot covers during turns is an example of overregulation that actually reduces safety outcomes.

[markis10]

Have mud wasps ever actually built a nest quickly in any pitot tubes at Brisbane airport? Because if not, I feel this policy about putting on pitot covers during turns is an example of overregulation that actually reduces safety outcomes.

Sure have, Etihad was the unlucky airline and they were only on ground for two hours, overall there have been 26 incidents at Brisbane involving wasp activity.
https://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-212/final-report/

In 2006 it was only 55 minutes turnaround https://www.atsb.gov.au/publications/investigation_reports/2006/AAIR/pdf/aair200601453_001.pdf

[KAPAC]

Was suggested on previous post that covers self destruct at a certain speed but idea shot down . Maybe a big orange sign across windshield ? Maybe red streamer across thrust levers that’s kept with covers . Only thing that’s certain it will happen again .

[Capn Bloggs]

How did the crew pre-flight walk around fail to see this...
Read the report!

The captain looked up at and likely observed the fitted pitot covers, however they were required to be fitted at that time as per the operator’s policy

At 0904 the LAME re-entered the flight deck, certified for the transit check in the technical log, cleared the technical log entry for the fitment of the pitot covers, and removed the pitot cover warning placard from the flight deck pedestal.

”Between 0852:18 and 0854:03, the first officer conducted a preflight walk-around”.

Because the FO did a walk around of an A350 in less than 2 minutes.
A speedy walkaround indeed but obviously totally irrelevant to the pitot covers issue.

[PoppaJo]

How did the crew pre-flight walk around fail to see this... I assume without any data inputs this would have likely resulted in a rejected take-off due to lack of airspeed data? Or could they have still departed with loss of control risk?

Should result in a RTO but doesn’t always. Both seats chewing up time during the roll second guessing themselves and asking questions. Waiting for V1 which never arrives. Now stuck in the sad and dangerous situation, either High Speed abort (V1 no idea which side) or take it into the air. Many have done this, Malaysian did the same, although even more problematic is they had Captain who had just moved over from a career from the Boeing, who relied on the FO to get it back in.

Airspeed alive goes back the Cessna 172. Airbus no different.

[Ken Borough]

Between 0852:18 and 0854:03, the first officer conducted a preflight walk-around. The walk- around was truncated from the nose, to the right engine, across to the left engine and back to the airbridge. The aircraft operator’s procedures also required the extremities of the wings, airframe, and tail section to be inspected, however this was not carried out.

Does this failure amount to negligence? And does the FO still have a job at SQ?

[itsnotthatbloodyhard]

Have mud wasps ever actually built a nest quickly in any pitot tubes at Brisbane airport?

How did the crew pre-flight walk around fail to see this..

Mud wasps have caused a number of RTOs at Brisbane. They turn up out of nowhere and work really fast - we’re talking about problems occurring during 30 minute turnarounds. As a result, my outfit leaves the covers fitted until 10-15 minutes before pushback, which isn’t compatible with the timing of our exterior inspection. What happens instead is that there’ll be an open item in the Tech Log which can’t be cleared until the engineer’s removed the covers and physically shown them to the flight crew. Only then will we have a valid Release to Service. If we haven’t seen the removed covers and ensured the Tech Log’s valid, then obviously we shouldn’t be going anywhere.

In a perfect world, we’d be doing the exterior inspection with the jet completely ready to go flying, but that’s rarely how it works, The cargo doors are still open, they’re still refuelling, the NWS lockout pin’s in, the engineer’s headset’s plugged in, etc etc etc. We have to rely on having robust mitigators instead. Having the probe covers still on is much the same. Not ideal, but better than the alternative.

[dr dre]

Does this failure amount to negligence? And does the FO still have a job at SQ?

Wasn’t the FO or other flight crew’s fault at all.
Pitot covers are meant to stay on until several minutes before pushback, whereas the flight crew walk around usually happens 20-30 minutes before ETD. The SOPs dictated pitot covers would have been on during the flight crew’s walk around.

The mitigation the flight crew had in this case was a warning placard placed on the centre pedestal by the engineer which was only to be removed once they had removed the covers, except in this case they removed the placard without taking the covers off or conducting a final walk around before pushback.

The pilots were following SOP and trusted the engineering to comply with their SOPs.

I know some pilots have a habit of opening the windows, leaning out and physically checking to see the pitot tubes are uncovered in a situation like this, however probably impossible to see from the flight deck of an A350.

[Icarus2001]

Does this failure amount to negligence? And does the FO still have a job at SQ?

It appears that like the last incident, the covers were on during the walk around AS EXPECTED. The crew would wait for the AME to remove them, that is why the engineer signs the ML as such.

Personally I would like to view them before doing any start procedures.

[Lead Balloon]

Ken will hopefully apologise for the inferences which could reasonably be drawn from his questions.

In any event, it’s an odd order of pre-flight inspections (though I understand the justification for it). If there’s stuff left to do which the crew cannot practicably confirm, by first-hand observation before taxiing, it’s little wonder this kind of problem arises.

[MickG0105]

Probably handy to keep Ken's questions in context. He prefaced his questions with a direct quote from the investigation report, specifically,

Between 0852:18 and 0854:03, the first officer conducted a preflight walk-around. The walk-around was truncated from the nose, to the right engine, across to the left engine and back to the airbridge. The aircraft operator’s procedures also required the extremities of the wings, airframe, and tail section to be inspected, however this was not carried out.

Regardless of whether the pitot covers should have still been in place when the FO conducted the preflight walk-around, it is fairly clear that said walk around was manifestly deficient and failed to comply with SQ procedures. Technically it doesn't meet the legal standard for negligence but it was clearly a breach of duty.

I wouldn't expect someone to be sacked for that but neither would I expect there to be no action at all.

[Lead Balloon]

As usual (with rare exceptions) a valid point, Mick.

My apologies to Ken if his implied call for the FO’s head was based on the pitot covers remaining on rather than the ‘truncated’ walk-around.

[blackburn]

From personal expereince, the wasps also do their work in fuel drain tubes on aircraft parked at the Brisbane GA area. (Dec 2020)

[Capn Bloggs]

At the airline I worked for it was required that the captain and the first officer viewed the gear pins and covers- three of each- before they were stowed in their dedicated stowage.
That can't be done because of the wasps. Read the report: it describes an alternative procedure (which on this occasion failed).

[fireflybob]

I always understood that certain engineering procedures required a dual inspection, such as after work on critical items like flying controls.

If this final check of pitot covers removed rests with engineering, should there not be a dual inspection given the critical nature of this item?

[Australopithecus]

There is. The engineer has to physically display the covers to the pilots demonstrating that they have been removed. We are lucky to get one engineer at a gate, let alone two.

[Bosi72]

Thinking outside of box, maybe it is time to redesign pitot tubes to eliminate need for covers?

[Lead Balloon]

Or design the aircraft such that the probes and ports are always located such that flight crew can visually confirm there are no covers on them.

[megan]

Thinking outside of box, maybe it is time to redesign pitot tubes to eliminate need for coversTiger Moth I flew had such an arrangement that blocked off the tube when there was no airflow, available from Spruce aircraft supplies.


https://cimg9.ibsrv.net/gimg/pprune.org-vbulletin/800x400/1661045895_f059bf267264569aa99ef0b89dd0c13e151534f8.jpeg

[Traffic_Is_Er_Was]

Do they rattle much at Mach 0.85 in the Moth?

[unobtanium]

for something that stick's out like fluro dogs ball's you'll think the problem lie's with the incompetent ground handler's AMSA and now rebranded heston. you can have all the procedues in the world but if the dispatch guy has no clue doesn't bother looking up and seeing REMOVE BEFORE FLIGHT FLAGS 1meter from his incompetent head this wiill just continue

[Australopithecus]

There is no reason that gates couldn’t have a private webcam showing the aircraft. The crew could then monitor in real time the baggage loading, fueling and yes, pitot covers. “How hard can it be?”he asked rhetorically.

[morno]

Do they rattle much at Mach 0.85 in the Moth?

:D hahaha, ahhh I got a good laugh at that

[Traffic_Is_Er_Was]

Quite hard when airlines share multiple gates at multiple airports that none of them own. I guess that's why they employ their own ground handlers and engineering. If aircraft manufacturers thought it was so dire, you'd think there'd be an electronic monitoring system. If Airbus et al can build in cameras so the pilots can see where the wheels are, and the punters can see a nice view ahead from the tail, perhaps they can put ones so the pilots can see if the various pins and covers have been removed. Or carry them all on the flight deck. If they aren't in the rack, don't push back.

[Traffic_Is_Er_Was]

REMOVE BEFORE FLIGHT FLAGS
There's the problem right there....it doesn't say "Remove Before Taxi". The engineers are obviously of the belief that the pilot will take them off at line up.

[Motorola]

A BNE engineer showed me the correct number of pitot tube covers just before push back. I asked him if the covers were from my aircraft and he said no. He was scamming the system by carrying around a spare set of covers to fool flight crews with.

[Lead Balloon]

A BNE engineer showed me the correct number of pitot tube covers just before push back. I asked him if the covers were from my aircraft and he said no. He was scamming the system by carrying around a spare set of covers to fool flight crews with.And…

What did you do next?

[Lead Balloon]

Do they rattle much at Mach 0.85 in the Moth?That’s funny, right there.

(Re your subsequent post drawing a distinction between “Flight” on a “Remove Before” cover on the one hand and taxi then take off on the other: Don’t forget where the rules say a ‘flight’ starts and when flight crews commence logging - and rightly claiming - numero uno responsibility ‘flight time’…)

[vne165]

Tie the covers to the gate or something fwd and in line.... not rocket science ffs. Use some string and ingenuity.

[Traffic_Is_Er_Was]

Don’t forget where the rules say a ‘flight’ starts
Certainly my comment was tongue in cheek, and there's a reason why pre-flight checks come before pre-take-off checks. It doesn't matter what is written on them if they are forgotten about.

[noclue]

Would leaving them heated during turnarounds deter a wasp from moving in? Or would they “burn out” or fail due extended use?

[Cilba]

After push back on many aircraft the nose gear pin is held up so both pilots can see it. Is there any reason why the pitot covers can't be held up one by one so the pilots can see them?

[Lead Balloon]

What about old mate whom Motorola says is in the habit of: "scamming the system by carrying around a spare set of covers to fool flight crews with"?

[megan]

Only too happy to provide some light relief. The point is, someone in the 1930's recognised a problem and came up with a solution that was simple using the technology available at the time. Is it beyond the wit of man (or woman), who can build your .85M vehicle, to come up with a modern day equivalent. Kelly Johnson or Joe Sutter could have solved the problem during their coffee break if they saw the need.

[nonsense]

What about old mate whom Motorola says is in the habit of: "scamming the system by carrying around a spare set of covers to fool flight crews with"?
Deliberate circumvention of safety protocols in other industries is typically grounds for immediate dismissal; it's hard to imagine why this would not be the case where hundreds of lives and hundreds of millions of dollars worth of equipment are put at risk.
But the example illustrates nicely why an engineering solution (pitots which are somehow inherently wasp-proof) or elimination (some other way of determining air speed) would be inherently safer than an administrative process requiring fitting and removal of covers, which is open to accidental or deliberate errors.

[Traffic_Is_Er_Was]

if they saw the need
There is obviously little need beyond the controls already in place, as basically a sock placed over the pitot as required seems to have sufficed for the entirety of aviation history so far.

[Scooter Rassmussin]

What if you just leave the pitot heat on during Brisbane turnarounds .

[framer]

In my opinion these continuing pitot cover issues in Brisbane are a symptom of a greater underlying problem that effects aviation everywhere. The tension between safety and commercial success is real, and a finely balanced thing.
The Airlines operating in and out of Brisbane will be informing their crews of the process through notams and intams etc, but how much time pressure are the crews under when reading them? Would they be more likely to remember to check if they signed on 15 minutes earlier? Would the Airline go broke if they signed on 15 minutes earlier?
The Engineer and tug driver who failed to remove them or notice that they were still fitted, did they get a briefing ( in person) about how the system works and a reminder about the Human Factors likely to derail the system? If so is it annual or once, three years ago? Would the Airline/ third party contractor become uncompetitive if they took the time to conduct this training?
Did the Engineer have other aircraft to dispatch at the same time? Had his shift extended out past 12 hours in the recent past with no inbuilt rostering practice to ensure they caught up on sleep/ rest? Would the company be competitive if they ran such a rostering system?
Did the Airport company fail to maintain guidance lights to a gate so that an aircraft was waiting off a bay with engines running for the Engineer to get there and assist? Does the Airport company consider guidance unserviceability as a safety risk or are their staff not aware of downstream operational effects? Would the Airport company go broke if it considered guidance reliability as a safety concern and maintained accordingly?
Is the tug driver considered a professional and in receipt of regular operational briefs and HF training? If they were would the company remain competitive?
In my opinion we could reduce overall incident rates by tinkering with the legal minimum requirements for rostered ‘in person’ briefs and training, minimum staff on the ground per dispatch etc. The operational staff are busy and being Human, a certain percentage of them won’t manage the workload in a safe way.

[Icarus2001]

In my opinion we could reduce overall incident rates by tinkering with the legal minimum requirements

Everything you say above is true. However the “incident rate” is already vanishingly small. Thanks mostly to alert crews and ground staff.

This pitot incident beggars belief given previous occurrences. A simple matter to check the covers are on board.

[BuzzBox]

A simple matter to check the covers are on board.

l haven't operated out of BNE for years, but I suspect the covers being used to mitigate the wasp problem are supplied by the engineers, not from the aircraft. It probably takes too long for an engineer to retrieve the covers from the flight deck on arrival, because of the mob of passengers trying to disembark. The 'simple' solution for that problem would be for the engineers to supply them for the duration of the turn-around, which obviously creates another problem...

[kellykelpie]

Two minute walk around because they were too busy reading all the tree notams…

[framer]

Yip. Two minute walk around because there is not enough time to read all the notams and do a seven minute walk around and depart on time.

However the “incident rate” is already vanishingly small. Thanks mostly to alert crews and ground staff. I agree but I think it’s pretty obvious that the pilot group and probably the flying public would like to see the small incident rate get smaller. To achieve that I think we should start with your observation about alert crews and ground staff, how could we build on that? I think by ensuring their workload is manageable and that topical hazards are regularly discussed in a formal setting. It would definitely work, but how much would it cost?
This pitot incident beggars belief given previous occurrences. A simple matter to check the covers are on board.
What seems so clearly to be a simple task, is in fact the opposite, impossible. The covers are in a tarmac room or a van or a push back tug.

[compressor stall]

As ground engineering are putting them on and off and they're not the set in the cockpit, what about a long bright pink 4mm cord connecting each cover to each other on same side and tied to the tow bar or eng headset or similar? This would probably need to be authorised by the OEM and in the AMM or some other approval.

[Two_dogs]

https://www.degroffaviation.com/pitotshield-v2/#1632524086068-71f7c826-2fdc

[Traffic_Is_Er_Was]

Did the Airport company fail to maintain guidance lights to a gate so that an aircraft was waiting off a bay with engines running for the Engineer to get there and assist? Does the Airport company consider guidance unserviceability as a safety risk or are their staff not aware of downstream operational effects? Would the Airport company go broke if it considered guidance reliability as a safety concern and maintained accordingly?
The engineer still has to be at the bay whether the NIGS is working or not. Off schedule arrivals probably put more pressure on engineering. Perhaps the practice of airlines outsourcing to the lowest bidder/paying peanuts for engineering services or engineering companies delivering contracted services to multiple airlines with the bare minimum resources possible, thereby expecting or forcing one engineer to be in multiple places at once is more the issue.

[Lead Balloon]

The engineer still has to be at the bay whether the NIGS is working or not. Off schedule arrivals probably put more pressure on engineering. Perhaps the practice of airlines outsourcing to the lowest bidder/paying peanuts for engineering services or engineering companies delivering contracted services to multiple airlines with the bare minimum resources possible, thereby expecting or forcing one engineer to be in multiple places at once is more the issue.Sounds just like the aged ‘care’ sector…

[BuzzBox]

Sounds just like the aged ‘care’ sector…

That's exactly what it's like. Resources are stretched thin, with a single engineer often responsible for the dispatch of multiple aircraft. It's little wonder that people sometimes cut corners to get things done (and avoid a bollocking from above) and occasionally something gets missed.

[Lead Balloon]

And where is the so-called ‘safety’ regulator in all this?

[Capt Quentin McHale]

I was reliably informed (pre Covid) that two operators that use BNE quite regularly use their own engineers (not contractors) to install/remove said pitot covers. Once the covers are installed, a maintenance entry is made in the aircraft logbook and when the covers are removed the log entry is cleared and Captain informed. If the log entry is not cleared the aircraft DOES NOT MOVE.

Rgds McHale.

[Servo]

I was reliably informed (pre Covid) that two operators that use BNE quite regularly use their own engineers (not contractors) to install/remove said pitot covers. Once the covers are installed, a maintenance entry is made in the aircraft logbook and when the covers are removed the log entry is cleared and Captain informed. If the log entry is not cleared the aircraft DOES NOT MOVE.

Rgds McHale.

That is certainly the case at Virgin mate.

[BuzzBox]

And where is the so-called ‘safety’ regulator in all this?

Good question.

[Capn Bloggs]

I was reliably informed (pre Covid) that two operators that use BNE quite regularly use their own engineers (not contractors) to install/remove said pitot covers. Once the covers are installed, a maintenance entry is made in the aircraft logbook and when the covers are removed the log entry is cleared and Captain informed. If the log entry is not cleared the aircraft DOES NOT MOVE.
Precisely the procedure used in this case. Read the report.

[BuzzBox]

Precisely the procedure used in this case. Read the report.

Yep, the relevant paragraph of the Preliminary Report states (my emphasis):

At 0904 the LAME re-entered the flight deck, certified for the transit check in the technical log, cleared the technical log entry for the fitment of the pitot covers, and removed the pitot cover warning placard from the flight deck pedestal. The LAME then returned to the tarmac and placed the placard on the dash in their work vehicle. The LAME stated that they had not verified that the pitot covers were removed, or requested that the AME remove the pitot covers, but assumed that they would have been removed by that time.

It seems fairly clear that engineers, presumably under pressure to dispatch aircraft on time, are cutting corners when it comes to certifying the pitot covers have been removed.

[Lead Balloon]

And in the interests of crystal clarity, the engineers involved were not employees of the airline concerned. Capt McHale's post covered two issues: The who and the what.

[BuzzBox]

To be perfectly clear, the engineers employed by airlines are not immune from the same pressures and, like others, are doing the job with less resources than they had previously.

[Lead Balloon]

Roger, Buzzbox.

[lucille]

It beggars belief that this could happen a second time after the much publicised MH near disaster.

Too much OH&S energy being spent on enforcing fluoro jackets instead of doing something which really matters.

[Lead Balloon]

My particular interest in the relationship between the people trusted to remove the covers and the operator of the aircraft to which the covers are fitted arises from the requirements imposed by CASA on APTA, which requirements were justified by CASA on the basis that individuals responsible for safety-related activities were not APTA employees. CASA required APTA to provide very detailed evidence to show how APTA would ensure those individuals would do their job properly. At no point did CASA identify any instance of those individuals not doing their job properly.

But here we have two instances of individuals not doing their job properly - for whatever reason - in relation to a safety-critical pre-flight action on an aircraft full of passengers, and the individuals apparently have no legal relationship with the aircraft operator. (The individuals will owe a common law duty of care, but that wasn’t good enough for CASA in APTA’s case.) They’ll be employees of contractors to … somebody, but does the aircraft operator have any contractual power to direct the individuals involved?

And don’t forget: The failure to conduct a check to confirm these covers have been removed is a strict liability offence on the part of the PIC and the aircraft operator (at least in the case of Australian aircraft). For those who think that checking that some clearing endorsement on a piece of paper provides a defence of honest and reasonable mistake of fact, remember: If you have to raise a defence you are, by definition, being prosecuted.

[Cilba]

Well said, Lead Balloon. Whatever "procedures" are in place, the buck stops with the PIC. And as I've said previously, it's not rocket science for someone to hold up the covers one by one, with their hi-vis streamers, for both pilots to see after pushback.

[framer]

The engineer still has to be at the bay whether the NIGS is working or not. Off schedule arrivals probably put more pressure on engineering. Perhaps the practice of airlines outsourcing to the lowest bidder/paying peanuts for engineering services or engineering companies delivering contracted services to multiple airlines with the bare minimum resources possible, thereby expecting or forcing one engineer to be in multiple places at once is more the issue.
Traffic is er was, I agree 100%
Your point is basically the point I was trying to make. The tension between commercial success and safety is always there and in my opinion is stretched too far away from safety. Whether it’s greater between Airlines and third party engineering contractors or Airport companies and Airlines I don’t know but the position that the Engineer finds themselves in has the same origin as the position the pilots, baggage handlers, cabin crew, refuellers, tug drivers, etc find themselves in. The origin is executive level decisions to increase productivity by maximising the output/ efficiency of operational staff and resources. Whether it’s a single honey-cart driver for all of Melbourne, or a clapped out 35 year old baggage belt loader blocking a gate in Sydney because it won’t start, or a Brisbane Engineer running between gates to attend to two simultaneous departures, the reason for it is executive level decision making with a lack of big picture safety knowledge. The only way to influence that decision making is to put a floor under it with legislation ( in my opinion of course).

[Lead Balloon]

The 'safety' regulator is supposed to intervene when the commercial pressures result in more safety incidents.

[PiperCameron]

The 'safety' regulator is supposed to intervene when the commercial pressures result in more safety incidents.

Only after said safety incidents occur, and are reported, and then it takes, what, a couple of years of paper shuffling for them to say something constructive or otherwise? Hopefully it won't come to that.

[BuzzBox]

And don’t forget: The failure to conduct a check to confirm these covers have been removed is a strict liability offence on the part of the PIC and the aircraft operator (at least in the case of Australian aircraft). For those who think that checking that some clearing endorsement on a piece of paper provides a defence of honest and reasonable mistake of fact, remember: If you have to raise a defence you are, by definition, being prosecuted.

Which just goes to show the stupidity of a 'safety' system that makes the PIC strictly liable for any number of 'offences' they might commit. In the real world, an airline captain cannot physically check every single thing for which they might be held liable if not done properly. Airline captains must rely on others to do their jobs in accordance with the regulations.

[Lead Balloon]

Except that it is possible for the PIC him or herself to confirm removal, first hand. It’s only impractical as a consequence of procedures arising from commercial pressures.

[BuzzBox]

I was referring to the plethora of 'things' for which a PIC might be held liable, not pitot covers in particular.

[Lead Balloon]

I don't think you have an understanding of the particular procedure in this particular set of circumstances.

The procedure requires the covers to be left fitted while the pilots are busy in the cockpit doing their pilot thang prior to pushback and start, due to the risk of mudwasps doing their wasp thang in a very short period of time. The procedure requires the pilots to rely on someone else to remove the covers just before pushback.

[Australopithecus]

I am in the habit of taking a photo of the engineer displaying the covers, sharing it with the F/O and keeping it for as long as needed.

[Capn Bloggs]

Open the window and look over the side at the probes. Attach escape rope to ankle in case you lean out too far. Do not trust FO to hold you as he wants your seniority number! :}
Or, use selfie stick to view probes.

[Lead Balloon]

Levity aside, that has to be the better solution. Back to the PIC confirming removal by first-hand observation.

If that doesn’t happen due to the costs of delay/inconvenience or whatever, that will show - once again - that affordable safety is very much alive and thriving.

[Lead Balloon]

Ermmmm, Captain, FO or SO does walk around and removes pitot covers or gets mechanic to remove them while they are observing said removal. …Ermmmm, not in the case of turnarounds at Brisbane.

You really do need to read the reports on the incidents before posting on this thread again.

[BuzzBox]

Ermmmm, Captain, FO or SO does walk around and removes pitot covers or gets mechanic to remove them while they are observing said removal.

Curious to know if you've ever been a crew member on a large airliner? If you had, you would know that what you have suggested is not practical for most airline operations. There is too much other sh!t going on in the cockpit shortly before pushback for one of the pilots to leap out and remove the pitot covers, or watch someone else do it.

[morno]

I’m going to go with no. He probably only learnt that ‘first hour’ thing yesterday.

Manufacturers also stipulate when external inspections are to be carried out in accordance with the FCOM, and those are generally no where near pushback time. Plenty of time for a wasp to build a wasp nest.

[BuzzBox]

No, no I haven't. So I guess that excludes any comment from the great unwashed?

Not at all, but if you come here as a "know all" without any relevant experience, then you can expect your views to be challenged.

[Traffic_Is_Er_Was]

I guess the obvious solution is you have to make it practically impossible to miss, and obvious to all, that they are still fitted. Does this mean extra, extra long tails? Tying them back to the nose gear pin so they have to come off/out as a set? Tying them back to the towbar? Something like that? Unfortunately this probably means that the covers in use are airport specific, as the aircraft carried ones would not usually need the extra fittings (if any). During pushback/engine start when the pilot is talking to the guy on the headset, surely it would not be too hard for a challenge and response to be implemented somewhere in that exchange.

[BuzzBox]

If the Captain, FO or SO hasn't got time to check those pitot covers are off prior to pushback in a more practical manner, then aviation has a problem. And it would appear Brisbane airport has an even bigger problem.

The following is a non-exhaustive list of the typical activities that occur in the cockpit of an airliner during the last 15 minutes or so before pushback:

The take-off briefing is completed.
The final load sheet figures are received and the data entered into the Flight Management Computer (FMC).
The final performance figures are calculated and the data entered into the FMC.
The refuelling is completed, along with the associated paperwork.
The ATC clearance is obtained. At many airports around the world, that clearance is not received until about five minutes before pushback. A change to the expected clearance might well require another calculation of the performance data, data re-entry, updating the FMC with a revised SID and an amended briefing.
Last minute maintenance activities, including certification of the Aircraft Maintenance Log by the releasing engineer and acceptance by the PIC. That sometimes involves the write-up of a deferred defect by the engineer, requiring the PIC to consult the aircraft's Minimum Equipment List (MEL). The MEL might impose performance restrictions or additional procedures that require amended performance calculations and/or re-briefing.

Most of that activity requires the presence of BOTH pilots for cross-checking and briefing purposes, and it is not unusual for that process to be interrupted on multiple occasions by well-meaning engineers, traffic staff and cabin crew as they provide updates on maintenance, passenger boarding, cargo loading, etc. It is a massive time management exercise that doesn't leave room for a pilot to leave the cockpit. In the majority of cases there are only two pilots on board; a third pilot is normally only required for long-haul flights.

You might like to note that "perving on passengers" isn't featured on that list.

[BuzzBox]

I really don't have problems with my views being challenged. Happens multiple times per day.

That's no surprise. :rolleyes:

[BuzzBox]

Your words, not mine.

[Uplinker]

Problem 1: At this airport mud wasps can apparently put mud into a PITOT tube within 30 mins of an aircraft arrival. So PITOT covers need to be fitted and left ON during and after the pilot's walk-around.

Problem 2: To fit and remove the covers, (on many airliners) mobile steps are required, making it therefore an operation undertaken by engineers, who need to go and find and bring a set of steps to the stand.

Problem 3: Apparently engineers are few and far between at this airport or with some operators, so tech log completion can be hectic, by harassed single engineers, and double checks not carried out.

Problem 4: Looking to see if covers are on the flight deck is bad practice. The actual external airframe needs to be checked for covers and pins removed, because ground staff and engineers might use their own covers and pins to save time.

Potential solutions?:

1: Ground crew holds up the three PITOT covers and the steering pin to PIC during the wave-off before taxi.

2: Sew long strings to the PITOT covers to enable the velcro to be unpeeled and the covers pulled off from the ground, without needing to use steps.
Or, fit the covers to fishing rod type arrangements so they can be fitted and removed without steps.

3: Both pilots open their DVs and lean out to check that covers have been removed just before push-back. (A real pain to have to move EFB / plates from window, then unstrap and take headset off etc).(On some aircraft, not all the PITOT probes can be seen that way).

4: Come in 10 mins early to read all the NOTAMS, and/or read them again - more thoroughly - during the cruise to the destination airport.

5: Stop airlines offering ever-lower seat prices, necessitating ever more corners to be cut. Make them compete instead on service, punctuality, baggage allowance, comfort, food, etc etc, but not below a defined minimum seat cost. ( Ha ha ha, good luck with that one !).

6: At least do something to mitigate the mud wasp problem. Whatever procedures are currently in place are not working safely enough.

:ok:

[BuzzBox]

At this airport mud wasps can apparently put mud into a PITOT tube within 30 mins of an aircraft arrival. So PITOT covers need to be fitted and left ON during and after the pilot's walk-around.

According to CASA, mud wasps can build nests and significantly block pitot tubes within 20 minutes. Another study found that wasp activity could be observed around the nose of the aircraft within a few minutes of arrival at the gate (https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0242063&type=printable).

3: Both pilots open their DVs and lean out to check that covers have been removed just before push-back. (A real pain to have to move EFB / plates from window, then unstrap and take headset off etc).(On some aircraft, not all the PITOT probes can be seen that way).

Not all aircraft have sliding DV windows. The A350 that was involved in the latest incident is one such aircraft.

6: At least do something to mitigate the mud wasp problem. Whatever procedures are currently in place are not working safely enough.

The Brisbane Airport Corporation has taken steps to reduce (but not eliminate) the mud wasp population. According to a recent media release, wasp activity has been reduced by 64%.
(https://newsroom.bne.com.au/success-in-bne-wasp-reduction/)

In my view, the most practical 'solution' is a Tech Log entry combined with:
1: Ground crew holds up the three PITOT covers and the steering pin to PIC during the wave-off before taxi.

[Uplinker]

Not all aircraft have sliding DV windows. The A350 that was involved in the latest incident is one such aircraft.
Oh right. Ha ha! I am type rated on the A350, but have never been on board one :8

[BuzzBox]

Oh right. Ha ha! I am type rated on the A350, but have never been on board one :8

Seriously?? When I did A350 differences training (A330/A350), we had to do two sectors in the aircraft with a training captain (1 x PF/1 x PM), followed by four sectors of consolidation before we could go back to flying the original ‘type’.

[uxb99]

Why don't civilian aircraft adopt military ways. A panel in the aircraft where the covers are stored. If a cover is missing plane doesn't fly.

[Icarus2001]

Why don't civilian aircraft adopt military ways. A panel in the aircraft where the covers are stored. If a cover is missing plane doesn't fly. This has been COVERED above. Engineers sometimes use different covers, not those from the aircraft, in this case due the wasps.
It is usually the case that they are from the stowage in the flight deck, like the gear pins.

[Lead Balloon]

This has been COVERED above. …I see what you did there!

[Tom Sawyer]

Ah, no I don't. Removal of pitot tube covers should be a simple job. You learn it from hour one of flight training. If you want to turn it into a legal exercise then maybe you should join CASA's legal department.

It already a legal exercise! An Engineer (should) remove the covers and certify that the work has been carried out by signing the tech log for the work, and then the CRS for the release of the aircraft as fit to fly. A legally required signature in a legally required document.

One thing I have been pondering as an Engineer, the usual process is do and verify the job, and then certify for the work in the tech log. In this scenario, the Engineer removes, or observes and verifies covers being removed, goes up stairs, gains access to aircraft, fights way down the aisle to flight deck, gains entry to tech, makes entry and certifies, deals with last minute cabin issue, gets off aircraft, jet bridge off, possible ATC delay etc etc......how long for this process to be carried out? Enough time for problem wasps to do their thing? So we end up with a hole in the process where you certify the work and then pull the covers immediately before pushback.......as long as they have been remembered by you as you deal with 2 other aircraft and deal with a customer airline who is too focused on OTP than basic standards and safety. So strictly speaking we end up with an incorrect process and hence risk to safe flight.

Just to verify also that pitot covers are not stowed onboard large aircraft. In fact over the past few years when parking aircraft we did not have enough company stock in stores to cover the whole fleet!

Someone mentioned having all 3 covers joined together by cord with a warning penant right in front of tug drivers window and so visible to pushback team. Seems best solution to me, but doesn't solve the process problem.

[Lead Balloon]

So the certification of removal is done before the removal happens?

If yes, that’s commercial pressure perverting safety procedure, pure and simple.

[Uplinker]

@Buzzbox, well it has appeared on my licence as a combined A330/A350 rating, but I have never yet set foot in the latter, nor done a differences course. :)

@uxb99 Because a cover or a pin on the flight deck does not prove that the aircraft is ready to fly - another cover or pin might have been fitted to the aircraft. Those who turn round to look at the cover and pin storage on the flight-deck to confirm covers and pins removed are setting themselves up for a massive fail one day. The actual aircraft needs to be checked externally.

[glekichi]

How about tethers suction cupped or similar to the cockpit side windows?
So many solutions available.
Obvious thing is the current system isn't working.
Guess a tech log entry is not so reliable given the numerous cases where work is signed for but not done. (including other topics)

[C441]

First item of the Before Start checklist:
"Pins & Pitot covers". Go no further until you are absolutely certain they've been removed…… If not certain, ask the LAME to visually confirm. May take a minute but so be it.

[Tom Sawyer]

So the certification of removal is done before the removal happens?

If yes, that’s commercial pressure perverting safety procedure, pure and simple.

It has been going for years, right in front of your eyes;
Steering By-Pass pin, shown to crew after engine start/pushback.......part of the certfied Transit Check for some airlines.
Final walk round, cargo doors, pax doors closed and locked......part of the certified Transit Check for some airlines. How do you certify for the door being closed if you need to open it to get off the aircraft post signing the Tech Log?

Pretty basic stuff maybe, but examples where practicalities over ride the process. Same could be said for the pitot covers. Leave them on for as long as possible prior to pushback to prevent wasp ingress with removal already certified in tech log or remove them and sign for the work leaving time for wasps to do what they do in the interluding 10-15 mins? I can exactly see how this happened in a process sense and adding in an Engineer dealing with multiple aircraft, distracted by another fault and some airlines' OTP obsession. Recognising the inbuilt issue and having a inbuilt protection is the issue, such as show covers with the by-pass pin as they are all joined together, and crew to stow warning placard which is placed next to the throttles once they have sighted the covers post pushback.

Blame is better to give than to receive!

[framer]

Tom SawyerSo we end up with a hole in the process where you certify the work and then pull the covers immediately before pushback..
That shouldn’t happen. If Engineers are making a conscious decision to do this then they don’t understand how fallible their minds are. Distraction is probably the greatest threat but their are others. If any Engineers are reading this I hope you’re disturbed by the idea of signing them off as removed prior to removing them. I’m pretty sure most of you would not contemplate it.

[neville_nobody]

"Pins & Pitot covers". Go no further until you are absolutely certain they've been removed…… If not certain, ask the LAME to visually confirm. May take a minute but so be it.

This 100%. Pilots need to stop "helping out" management and their metrics and start creating problems. So often I see pilots to eager to solve problems and take on responsibility that really shouldn't be there. If the flight's delayed until we can complete a checklist properly the flight is delayed. Especially so in something like this where the risk is so high.

Remember that they will blame you for any mistakes if you take on the responsibility and solve problems for them. If BNE flights are always delayed 5 mins to check the pitots are correct then they will soon enough get the message. If you get some push back just quote them chapter and verse of the manual and the problem will become theirs to deal with. Nothing gets solve quicker in aviation than an issue that affects a manager's bonus.

[Lead Balloon]

Deliberate, systemic certification of safety-critical pre-flight actions before they’ve been carried out? The accident investigation report writes itself.

[Car RAMROD]

So just before telling the guy on the headset that your cleared to push, what do y’all say or ask them?

do you ask that all the doors are closed, and the bypass pin is installed?
ask them if the pitot covers are removed too, maybe.

[megan]

Remember that they will blame you for any mistakes if you take on the responsibility and solve problems for them. If BNE flights are always delayed 5 mins to check the pitots are correct then they will soon enough get the message. If you get some push back just quote them chapter and verse of the manual and the problem will become theirs to deal with. Nothing gets solve quicker in aviation than an issue that affects a manager's bonusOur choppers had the choice of using Mobil Jet oil, as used in our engines, or a particular automotive automatic thransmission fluid in the main transmission driving the rotor. Company decided to use the automotive product because it was one third the price, trouble was after a period of time the transmission pressure would drop into the yellow, when it happened I got into the habit of shutting down at an out station and having maintenance come and do an oil change because badgering management to change to Mobil was getting no where. Only had to call out maintenance a couple of times and management saw the wisdom of changing to Mobil, an hours flight time for the rescue ship could buy buckets and buckets of Mobil Jet..

[Tom Sawyer]

Tom Sawyer
That shouldn’t happen. If Engineers are making a conscious decision to do this then they don’t understand how fallible their minds are. Distraction is probably the greatest threat but their are others. If any Engineers are reading this I hope you’re disturbed by the idea of signing them off as removed prior to removing them. I’m pretty sure most of you would not contemplate it.

Framer, I totally agree that this should not happen but these are positions we are put into. I have cited two examples of where we sign for items as part of the Transit Check, but they are not carried out until after close up/pushback and the check has already been certified in the Tech Log for practical reasons, so straight up it is happening and accepted by Crew, Engineers, QA and the CAMO, and the Authority. Taking the by-pass pin a stage further, it is not that unusual these days to have a ground handler doing a push back and pulling the pin for display to crew........yet it is the Engineer who has taken responsibility prior to the event as part of the check. We may not even be there for push back - I worked for one international carrier where this was exactly the case.

Now pitot covers are a different level in flight safety terms and we know what the procedure should be. Flipping this around a bit for sake of argument; Engineer does the procedure correctly and removes covers, verifies and signs for the job after completion at say 15-20 mins before departure, so maybe 30 mins plus before take off, barring any issues. Aircraft departs and gets airborne with a ASI fault as per the first in the series of three, the EY aircraft, and is found to have mud wasp nest blocking pitot tube. Subsequent inquiry finds pitot covers removed too early. Where do we go from there? Is it deemed acceptable risk, and on what basis, after all, we don't really know how many ASI incidents have been averted by the fitting of pitot covers in BNE. At the moment the data from incidents is mud wasps 1, pitot covers 2 so not conclusive. We can't control mud wasp nest building, but we can control pitot covers but they come with an inherent safety risk that needs controls and management, which may include accepting signing for the job before carrying out the task as per steering by-pass pin which is controlled by showing the pin. For that matter covers could be shown to the crew through the DV window as they are removed immediately prior to push when the person is on the steps (if you can find any).

I'm not advocating that the Engineer did nothing wrong. I'm not advocating this approach to all Engineering tasks. I'm trying to apply some real world reality to the situation that reduces the risks from both aspects. We can't Eliminate the risk (Mud wasps). We can't Engineer the risk out (pitot tubes). So we are left with Manage, which is down to fallible humans. I don't think the lessons from the MH incident have been learnt. More robust and active "Manage" measures are required from both Engineering and Flight Crew, and recognition that we do not operate in a perfect, controlled world but one that where one "solution" could impact another causing another issue.

[neville_nobody]

Framer, I totally agree that this should not happen but these are positions we are put into.

But why are you in that position? That’s the real crux of the issue.

There is nothing stopping you from waiting right up to end, getting a thumbs up from the pilot, removing the pitot covers, walking up to the flight deck handing over the covers or showing them to the Captain, signing the paperwork and walking off the aircraft.

[BuzzBox]

Tom Sawyer

Well said.

[Capt Quentin McHale]

As C441 points out....First item of the Before Start checklist:
"Pins & Pitot covers".

I am led to believe a former iconic airline had, along with the pitot cover log reference, a "before start and pushback" checklist between cockpit and engineer on headset when doors closed and the aerobridge was retracted and went along the lines of.....
Pilot...Doors
Engineer...Checked closed and locked

Pilot...Pins and pitot covers
Engineer...Removed and stowed

Etc, etc,etc,

Even though the log book entry was cleared and covers shown to crew, for some reason management decided the checklist was a waste of time and got rid of it.
To me it would serve as a backup reminder just in case.

Rgds McHale.

[HOVIS]

Tom Sawyer, spot on. 👍

[Uplinker]

.............There is nothing stopping you from waiting right up to end, getting a thumbs up from the pilot, removing the pitot covers, walking up to the flight deck handing over the covers or showing them to the Captain, signing the paperwork and walking off the aircraft.

True in principle, but as Tom Sawyer is trying to tell you: if you have ever been a part of, say an A330 turnaround, the airbridge will have to be left on until the engineer has removed the PITOT covers, (from both sides of the aircraft), taken the mobile steps away, walked up the airbridge stairs, to doors 2 (usually), waited and got past the passengers stowing their cases and standing around in the aisle, waited and got past the purser who is exiting or entering the flight deck, and into the flight deck. Then he sits down and writes the release in the tech log, removes the tear-out pages and exits the aircraft past all the pax standing in the aisles etc.

Then, doors 2 is closed, and someone needs to be found to drive the airbridge away.

Then, the pilots wait for the headset guy to come on the interphone and give their checks and the pilots can call for push and start. That is a good 10 mins already since the covers were removed.

Push and start can take 5 mins or sometimes more to start both engines and complete the after start checks and call for taxi. Then you have maybe a 10 minute taxi...

Plenty of time for the mud wasps to do their thing after the covers were removed.

The PITOT covers ideally need to be removed after push and start, with the steering bypass pin (by having strings to pull them away by someone at ground level without needing steps), and shown to the pilots during the wave-off.

[framer]

Tom Sayer; Framer, I totally agree that this should not happen but these are positions we are put into.
I think we’re mainly in agreement about this. I think it’s worth noting though that most Brisbane Engineers don’t sign for removing the covers before doing it so if they can get it right, surely the others can get it right?
Anyway, I don’t mean the above to sound antagonistic, have a nice night everyone :)

[Icarus2001]

https://www.atsb.gov.au/media/news-items/2024/a350-pitot-probe-covers-left-prior-pushback-demonstrates-how-assumptions-procedural-omissions-can-lead-unsafe-conditions

Just shows up the holes in the process. So many opportunities to be noticed.

[Bull at a Gate]

Hope Singapore Airlines gave the observant refueller some first class tickets to somewhere nice!

[framer]

I’ve heard of forestry companies using cameras that will measure the trees on the truck and at the same time alert the company to a missing wheel nut. Maybe there is a solution to pitot covers being left on in there somewhere.

[Sailvi767]

Hope Singapore Airlines gave the observant refueller some first class tickets to somewhere nice!

Terminated him for causing a pushback delay!

[RickNRoll]

While the ATSB was not able to formally establish that fatigue contributed to the occurrence, the investigation did note the LAME had reported the workload associated with their dual role of LAME/regional manager had become considerably more demanding following the COVID-19 pandemic.



Hmmmmmmmmm.

[The Golden Rivet]

Just had a thought why couldn’t each aerobridge have a set of pitot covers attached with a bungee, so that the engineer applies the pitot covers and the aerobridge on retraction removes them?

[TURIN]

😂
For one thing on a big wide body the air bridge is tens of feet behind the nose of the aircraft. That's a very long bungee pulling in the wrong direction.

[Icarus2001]

Just had a thought why couldn’t each aerobridge have a set of pitot covers attached with a bungee, so that the engineer applies the pitot covers and the aerobridge on retraction removes them?

That would not work for lots of reasons.

There is a system in place but it was not followed. A ground staff member, or engineer does a final walk around to check panels are closed etc before putting on the headset for pushback. At that point the covers come off. I have been known to stick a piece of paper over my PFD that says PINS when we tow or do something out of the usual sequence and a nose pin has had to go back in after I have walked around.

[Chronic Snoozer]

Just had a thought why couldn’t each aerobridge have a set of pitot covers attached with a bungee, so that the engineer applies the pitot covers and the aerobridge on retraction removes them?

Someone will come up with an AI program that scans for pitot covers on CCTV as the aircraft is pushed back. A light will flash or an alert sound to advise a cover has been detected still fitted.

[framer]

There is a system in place but it was not followed.
It is not followed in a predictable fashion though, that is the problem.
We understand this problem very well and have decades of experience mitigating it all over the planet in many high consequence industries.
I think Brisbane Airport should add another slice of cheese and make it barely recognisable as Swiss.

[flightleader]

It seems to me that the common denominator in both 2018 MH and 2022 SQ pitot covers not removed cases is the ground handling engineering company at BNE airport.