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Z Force
19th Mar 2003, 08:59
Was at Sydney airport yesterday and was told a Virgin aircraft had to return due to a noise outside the cockpit. Upon landing it was discovered one of the pitot covers was still on. I guess it must have burned through as all instrument indications were normal.

sniffer dog
19th Mar 2003, 09:20
Are you sure it wasn't a repeat of the dog escaping again, hooking his lease on the pitot. :D :D :D :Ddog escapes from cargo hold - again!

Clearance Clarance
21st Mar 2003, 10:07
Why are the engineers (the ones who bag pilots on this forum) being so quiet about this one?? New unsafe transit procedures etc. Surely this incident would cement their claims.

Maybe its because the engineering Pre-Flight HAD been signed by a LAME.

Without pointing the finger at any one individual, its obviously been missed by several people - Capt included, but didn't the engineers jump on the alledged pilot who missed feathers in an engine on a walk-around - and then leaked a report to the press in their public scare campain?

It just goes to show anyone can make a mistake, or miss things, but it also proves we still need to watch out for each other, as we always have, no matter what your role is.

mustafagander
22nd Mar 2003, 02:16
Before we all start "grinding our personal axes", can anyone confirm that said event did, in fact, happen??
I mean date, time, reason.

Slab
22nd Mar 2003, 03:52
I can confirm that the event did occur...... VH-VOC out of Sydney on Monday the 17th March at about 0705. The Captain reported a severe rattle below his windshield. The aircraft returned and a pitot cover was found to be installed. It was removed at about 0717, the aircraft refuelled and again departed.

Pitot covers are not normally installed on overnight stops. The daily check which is carried out on the NGs by engineers includes 'removal of the pitot covers, gear pins and fan straps'. If any of these are installed after the daily is carried out and signed, normal practice would be to put an entry in the log so they won't be missed prior to departure. Obviously this wasn't the case in this instance. There was also a small article in The Australian on Tuesday, which mentioned something about the Captain being suspended....... I cannot confirm that this is the case.

It's a shame that such a simple thing could be overlooked by both engineer and flight crew, especially given the recent turbulence over preflights at VB.

Rubber Chicken
23rd Mar 2003, 20:19
Captain was suspended!! Was the engineer suspended too????

EPIRB
24th Mar 2003, 02:10
Part of the Boeing walk around procedures is to check the pitot tubes. Good airmanship would also dictate that you do anyway. Maybe they thought it was an engineer still attached to his headset??

sprucegoose
24th Mar 2003, 08:10
It's been an interesting month or so. What with all the commotion over procedures regarding preflight inspections, whether an engineer should or should not perform a preflight check on every turn, audits catching pilots being less than exemplary on a few instances, all the bagging that has gone on and then this incident here. It is rather unfortunate that given all the hype an item such as a pitot cover would be missed on a preflight check by ALL concerned. Yet I find it rather sickly that there is an ongoing pontification among the pilot brotherhood which continues to bag our fellow pilots. I am sure the individual concerned is MORE than aware and MORE than humiliated by the oversight in light of recent events. The thing is sh!t happens no matter how diligent one is and the only difference between this pilot and the rest is quite likely that he/she got caught. We all make mistakes and upon reflection I am quite sure many of us over the length of our careers have made mistakes that could be construed as worse than missing something on a preflight. The punishment fits the crime under the circumstances but I don't think it calls for additional ridicule by the pilot community unless you are prepared to stand up and claim to be perfect. Let it go. Lesson learned I am sure.

HotDog
24th Mar 2003, 08:43
Sprucegoose......there by the grace of God! How right you are; LAMEs also please note.

Mr. Hat
24th Mar 2003, 10:39
Its just human error really. We are all human we ALL make mistakes. But when idiots sitting in their offices decide they need to cut costs, these errors find their way through the trap. Its all about running it by the skin of your teeth really. Oh look its the pilots fault.. its the engineers fault... Wrong again. The error originated in an airconditioned office and found its way onto the tarmac.

Keep tightening the buckle on the front line people.

Rant over.

bitter balance
24th Mar 2003, 13:29
Mr Hat, come on - someone on the tarmac (LAME, pilot or both) misses a pitot cover and its management's fault?

Mud Skipper
24th Mar 2003, 19:53
And they still want to remove more Swiss cheese.

Most of us like the taste, but if you eat too much it's really bad for your health.

When the holes line up who takes responsibility?

AN LAME
24th Mar 2003, 21:32
Spruce goose

Couldn't agree with you more. Everbody makes mistakes and sh!t does happen

And to all... I would hope that the LAME is disciplined in the appropriate manner by VB. And if the appropriate manner is suspension, then so be it.

Kaptin M
24th Mar 2003, 22:05
Does VB's AOM specifically state that pitots must be checked, as part of the pilot's Exterior Inspection?

Tankengine
24th Mar 2003, 22:28
Qantas's does, so you would expect the same from VB as they both should be basically the Boeing manual.

lethalweapon
25th Mar 2003, 01:49
Bloody engineers - can't trust them to do anything right (joke).


We bend them - you mend them. :rolleyes:

Kaptin M
25th Mar 2003, 13:07
Are you VB boys and gals shy??...or just not sure of what your AOM states??

Does VB's AOM specifically state that pitots must be checked, as part of the pilot's Exterior Inspection?

Sperm Bank
28th Mar 2003, 09:16
M. YES!

Vol1 N.P. 20.6 "Probes,sensors,ports,vents and drains....Unobstructed"

Think I would be inclined to check them even if we didn't have to.

longjohn
31st Mar 2003, 17:43
Sprucegoose,

Yes shit does happen.

Hopefully though it is not through failure to adhere to SOP's.

I find your attitude to safety rather suprising. Do you think the travelling public would appreciate this level of professionalism?

Whilst I am not advocating a public hanging, cetainly some investigation is warranted.

I would suggest you apply a more concerned and mature approach to your airlines safety, for your own sake!

permFO
2nd Apr 2003, 08:13
Yes mistakes can happen but if they do there should be a way of cross checking to pick them up. That is why we check the controls prior to take-off to make sure control locks haven't been mistakenly left on. Thats why both pilots check the take-off speeds to make sure there is not a mistake made by one person. That is why we should be checking our airspeed indicators on take-off to make sure the pitot tubes are not blocked! Who was calling the speeds during the take-off and what were they referencing. Leaving the pitot cover on was not the reason for the suspension I would imagine . As has been mentioned we all make mistakes.

Dan Kelly
2nd Apr 2003, 09:31
and how often when you're either calling or responding to the checklist do you actually look at the item being challenged?

I know that I regularly watch folk do one or all of of the following:

A. Read the checklist, which usually is leaning on the control column, and not look away from it. As long as the correct response is given, every one is happy.

B. Respond to the checklist whilst scanning the horizon for a threat aircraft intent on knocking one from the sky.

C. Call the checklist from memory, because we all know thet we don't have to read it as we know it!

Any or all three completely negate the whole philosophy of modern day checklists, which are used to check that actions have been accomplished, not to order that accomplishment.

If both pilots don't, where possible, both eyeball the checklist switch/knob/setting etc., then the check of the checker is totally missed, and the whole concept compromised.

I've had folk argue black and blue that they read all checklist items, but I know from watching their eyes that they haven't even looked in the correct place. Additionally there is no way a human could possibly read a checklist item from the checklist and then observe the appropriate item and then give the appropriate response, in the rapid fire way many checklists, particularly after landing one's, are read!

Willie Nelson
3rd Apr 2003, 08:08
Because I have made the aforementioned error myself,

I do not start up until I have counted off a specific number of items (eg; chocks, socks and harnesses) On my current aircraft this is presently a thirteen point checklist from memory, if I don't get to thirteen I don't get in.

I look at each item as I call the number, to avoid what Dan talks about (which I have also done.)

Keep in mind, I do not fly a 737, and I am sure there would be more items to remember but it works for me.

Willie

Kaptin M
3rd Apr 2003, 08:45
Were the ground staff involved also suspended from duty?

I am NOT trying to play pilots off against engineers/artisans - I ask this only out of interest of even handedness.
As has already been pointed out earlier by someone, the aircraft would have been "handed over" to the pilots by (presumably) a LAME who would have briefed the Captain on the aircraft's condition, and any work carried out or defects carried over.

During an external inspection a day or so ago, I noticed how much the "honey cart" obscured my ability to view the RHS pitot - it took a deliberate effort to move to a vantage point where I could, in fact, see the pitot and AoA vane.

So we have now reached the point where the aircraft is closed up and ready for engine start.
Would it be fair to suppose that at least ONE of the ground crew involved with the pushback/start procedures might have seen the pitot cover at THAT time?

As a further point of interest, what COLOUR are VB's pitot covers?
If they are RED - similar to that Company's paint scheme, might that also have helped "camouflage the offending item, and not have been such a good idea?
In HINDSIGHT, of course. :(

I feel there are lessons for MANY people (besides the pilots), in this seemingly simple incident.

Edit - Willie, what happens if you find 14............or 15?? :eek: :{

permFO
3rd Apr 2003, 12:55
Kaptin I like your point about the colour of the aeroplane possibly masking the red warning flag of the pitot cover in which case it would not be surprising that the engineer and one/both of the pilots missed that it was still on. My argument is still that leaving the cover on should have been picked up during the take-off roll when one of the airspeed indicators and speed tape would not have been indicating anything. At that point it is the pilots responsibility.

gaunty
3rd Apr 2003, 16:21
Kaptin M

I can personally vouch for this.

As a further point of interest, what COLOUR are VB's pitot covers?
If they are RED - similar to that Company's paint scheme, might that also have helped "camouflage the offending item, and not have been such a good idea?
In HINDSIGHT, of course.


Moons ago a helo client whose machine was painted in the orangey SAR type colours almost indistinguishable from that of the slightly faded, once flouro "orangey", you know the colour, intake and exhaust covers and flags, who, whilst leaving the site of our meeting, was observed trying to work out why he was having difficulty during the start.

It took me a moment to work out that the intake covers were actuallty still on, but given the colour of the cover and the similarity of the aircraft colour scheme it was very hard to pick. The appropriate signal produced a very embarrased pilot from the cockpit. No damage done, except to the pride of a much respected and highly experienced and professional pilot.

The new set of covers and flags ordered that day were much more distinguishable.


Notwithstanding that as permFO and some others pointed out, the "during TO airspeed calls" should have made it fairly obvious that something was up, or not in this case.

Surely "Airpeeds alive", "80 knots" crosscheck or similar is part of the drill.

Regardless of the engineering and preflight input.
At that point it is the pilots responsibility.

Oh, and yes I have commenced a TO with a cover on.:rolleyes:

sprucegoose
4th Apr 2003, 12:32
longjohn, thank you for your critical analysis however I wasn't expressing a viewpoint on safety, I was expressing my dismay at the willingness of pilots to jump on and judge others so harshly when in fact everyone makes mistakes. With respect to safety and one company culture vs another it doesn't matter a whole hill of beans when the "human factor" rears its ugly head. That is an entirely different point to the one I was making however.

An investigation was warrented, it did occur and there was a rather unfortunate chain of events that led to the error in question. As I said the punishment was warranted but the lynching is not. Not sure what my approach to safety has to do with this thread.

Bankstown
4th Apr 2003, 12:36
Surely the pitot heat would have burned through the pitot cover on taxi out leaving accurate airspeed indications on takeoff?

sprucegoose
4th Apr 2003, 15:06
Well........Murphy's Law.

permFO
4th Apr 2003, 15:48
Bankstown, with the pitot heat on the covers would probably have melted on to the pitot tube and blocked the intake.
Sprucegoose-You are obviously in the know, were there airspeed indications?

sprucegoose
4th Apr 2003, 17:26
I do know a bit. I would hate to fuel the negative speculation here by speaking out of place. Lets just say that the airspeed indications are not the only system that is affected by a blocked pitot on the 737 and there were other seemingly minor discrepancies which divereted attention from the airspeed check at 80kts and knowing what they were I would say any crew would have been momentarily distracted as well. The NG gets to 80kts quite briskly too I might add. By the time the pieces fell into place it was beyond that magic 80kts and the decision to continue, which was the correct decsicion given the situation, was made. By the time they were airborne or shortly thereafter the pitot cover did burn through completely and the return was made with all systems working normally. Thats all I will say on the matter but the whole chain or errors that led to its occurence was really quite unusual and probably wouldn't happen again like that in a million years. Never a good time for something like that to happen but given all the BS surrounding the issue of preflights at the moment it probably couldn't have happened at a worse time.

amos2
4th Apr 2003, 18:03
Hmmm...still does'nt answer the question as to how anyone can miss a pitot cover during the walk around! Especially as we are told that both a crew member and an engineer did a walk around! Very strange, very unusual! :confused:

sprucegoose
4th Apr 2003, 18:12
Well it was strange and unusual. But it happened and thats my point. Stuff happens. The "human factor". I am sure you would appreciate that there are obviously quite a few circumstances unique to this particular situation which in combination led to a "human error" by a couple of people. I can't say any more than I have but it was quite definitely one of those one in a million combinations of events. Good thing, in my opionion, is that it probably will never happen again simply because it happened at all.

amos2
4th Apr 2003, 20:01
You mean Virgin are amending their SOPs to ensure it never happens again?...or are you saying it will never happen again? :confused:

airsupport
5th Apr 2003, 05:58
Yet another example of why it is "safer" to have at least 2 independent preflights. :rolleyes:

It would appear from this, that sadly possibly a Pilot and an Engineer MAY have missed the cover this time. :(

However, how much less safe would it be with only 1 person (Pilot OR Engineer) doing the preflight? :(

Dehavillanddriver
5th Apr 2003, 07:55
Airsupport,

HOW can you sit there and relate the two issues?

This was a first flight of a day when the engineer was supposed to have done a daily inspection and signed the log that the aircraft was ready for service.

The industrial issue would have not been an issue in this case because the engineer would still have been required under the proposed changes.

Don't confuse a stuff up with an industrial point - the two are in no way related.

And if I was making an industrial point I would not raise the point that the engineer despite doing an inspection missed the cover as well!

sprucegoose
5th Apr 2003, 08:04
Amos2, the engineering SOP's ARE being changed as I understand it. The pilot SOP's don't need changing. My point is two fold in that the likelyhood of those set of circumstances happening again which led to the oversight are highly unlikely and given the focus on the issue of preflight inspections in general and this event in particular even less so. Still sh!t happens and no amount of grammatically correct, technically perfect SOP's will prevent that. Human factor...................I think we do a good job at VB and where the faults are identified we act quickly to rectify them. What more can be done?

airsupport
5th Apr 2003, 09:11
It never ceases to amaze me , how supposedly highly intelligent people cannot understand simple English, and twist everything to suit their own theories. :(

I was saying that here is an example of a case where, (it does appear) there were 2 independent inspections and something still was missed. :(

Obviously, it would be an even LESS SAFE operation IF there were only 1 inspection, be it by an Engineer OR a Pilot.

5 independent inspections would be safer still, but obviously the cost would be excessive. :rolleyes:

10 would be SAFER still. ;)

Sperm Bank
5th Apr 2003, 12:20
Airsupport.... you are flogging a dead horse mate. We have heard it all before. Having 2 people check this item made NO difference to safety what so ever. It has nothing to do with "supposedly highly intelligent people understanding english", or at least your version of english! More to the point it has NOTHING to do with this thread.

It was a very unfortunate event and as Spruce said it was just one of those things that pop up and catch us out from time to time. Nothing more, nothing less.

airsupport
5th Apr 2003, 12:53
Yes, I now realise that it is a waste of time trying to have an important discussion here, it always ends up with a Pilot bashing Engineers thread, or vice versa. :(

It has nothing to do with Engineers versus Pilots, and it is NOT an industrial thing as I am not even in the ALAEA, and have no personal interest in this, except for my worry about safety.

Forget Engineers for a minute, the same would apply if you just talk about Pilots. It would have to be safer IF both Pilots did an independent preflight before each flight, rather than only 1 doing it. It may slow down the turnround, but it would be safer. ;)

Engineers don't have such hangups, for as long as I can remember, when working on primary flight controls, and even nowadays engine controls, 2 Engineers (LAMEs) must carry out independent inspections. It doesn't matter how experienced and qualified the Engineer involved is, the second independent inspection MUST be carried out before flight. Why, for SAFETY.

sprucegoose
5th Apr 2003, 13:41
Airsupport, you are correct. The more inspections, the less likely that an error, should it occur, will go unnoticed. The issue is with Boeings recommended procedures regarding the need for a Boeing prescribed engineering preflight on every turn vs. a pilot carrying out a Boeing prescribed pilot preflight inspection only. Yes yes yes two is better than one and three ia better than two and so on. Boeing drew the line and VB and Qantas as I understand it (and for that matter quite possibly a lot more operators) have quite acceptably chosen to operate IAW the manufacturer's recommended practice. What we don't know and what we must know to have a valid argument for or against the Boeing recommended procedure is how often is an item unique to the engineering preflight inspection found faulty that would not likely be seen by a pilot vs. the number of items common to both inspections that go noticed by one party or the other. In the case of the latter it will be argued that proper training in the conduct of and strict adherence to pilot preflight inspections will most probably show up anything likely to be of immediate danger before further flight. Boeing have obviously decided that is good enough. We do everything else that Boeing recommends as far as operating the 737 and nobody complains. I would say VB at this juncture probably have the best daily inspected, engineering preflighted pilot walked around fleet of 737's on the planet due in no small part to the recent press over the shortfalls observed on a FEW occasions by CASA with that process. Yet VOI still went off as it did and the human factor beat the system hands down. Would a third person have prevented this? Who knows. But it would have appeared safer if they were there just in case I guess..........

Sperm Bank
5th Apr 2003, 14:45
I think it would be nice to look past the pilot v's engineer argument. There isn't one in my opinion! Most of us who have been in the industry long enough won't even engage in such neanderthal discussion. Engineers are an integral part of the cycle of safety to keep us in the air. I consider the engineers to be my collegues and as such have learnt an enormous amount from informal discussions over the years.

Spruce your point re for or against the Boeing procedure is an interesting one. If we use statistical analysis (the basis for nearly all research and developmental protocols, particularly in aviation) we could learn that the difference between 10 (-8) and 10 (-7) really makes no difference. I.E. it is virtually impossible to put a realistic figure on it. The same applies to our simulator sessions. How many times have you done a simulator session which involved multiple system failures? I'd say nearly every one. How many real time incidents/accidents over the past 50 years have involved the same? Virtually none. There may have been a series of mitigating factors which acted as a prelude to the disaster, but the actual disaster was caused primarily by ONE factor standing alone. I think our training these days is not progressing in the right direction but that is another story!

Getting back to statistics, whether it be 1 in 10 million or 1 in 100 million, (read flight hours) it is as I say very hard to justify a percieved added layer of safety when there is no evidence to prove the layer would make any difference what-so-ever. We can all sit back and pontificate until the cows come home about how much more safe one procedure is than another. The reallity and the FACTS are sometimes very different to what we think or say is the case.

Like every other airline pilot, I want the engineers to do a pre flight inspection in addition to mine. A bean counter (particularly with a mathmatical background in satistics) could quite easily argue that my preference is unwarranted.

I hate it when the truth hurts!

airsupport
5th Apr 2003, 15:35
Hey, steady on.

With posts like those, you will restore my faith in the Industry. ;)
:D

amos2
5th Apr 2003, 16:04
Whilst I admire the support that SG & SB are providing for Capt XX and their robust defence for him in that he was apparently distracted during his walk around, never picked up where he left off, and subsequently took off with the captains pitot cover still in place, I can't quite reconcile myself with their statement that "It was one of those unfortunate things that just pops up and catches us out from time to time".
Whilst there is no doubt that engineering were at fault here in that the daily they conducted was sloppy and down right poor, unfortunately at the end of the day the captain carries the can! Some might say that this is why captains are paid big dollars!
I wonder whether SG & SB might think that the SQ tail scrape is also "one of those things that pops up etc."
I also wonder whether Spruce and Sperm have ever flown the F27 and parked it on an overnight without engineering back up? If they have, and then on the daily in the morning, overlooked either the aileron, rudder or elevator lock, whether they would also consider that "one of those things" ? ;)

Sperm Bank
5th Apr 2003, 16:52
Amos there is no doubt there was a mistake made. The pilot, no matter how much deliberation we engage in made a serious error. I can't speak for Spruce, but I am not defending the pilot in this case. However things like this do happen from time to time no matter how hard we try to avoid them. The human factors Spruce referred to are significant and when on the very rare ocassion all the holes line up, viola!

Have never flown the F27 but I suspect the lads would have picked up the transgression on a control check prior to take-off.
I am not aware of any airline accidents where the flight control locks were left in.

As I say, the statistics don't auger much in our favour when we try and put an emotional/paranoid slant on things. The good things about statistics is that we can also prove that without a certain percentage of redundancy/safety layers etc, things can possibly go wrong.

sprucegoose
5th Apr 2003, 16:53
Amos2, I think you missing my intended point which was not to defend the people involved by accepting that sh!t happens but to realise that no matter how hard we try there will be those occasions when the chain of events occur just the right way, the wind blows from one direction or the other and the stars all line up in a once in a millenium fashion so that sh!t will happen. My original post on this thread was nothing to do with what I have tangently become involved in and that was I feel it poor form for pilots to be as quick as they are to jump on fellow pilots when something such as this particular incident occurs. It could happen to anyone because sh!t does happen. That opinion has nothing to do with how many people I think should do a walk around, whether I have ever flown an F27 or what I think about 747's scapping their arse on the ground.

amos2
5th Apr 2003, 17:34
Well, I don't disagree that S..t happens Spruce, and I also agree that the statement "there but for the grace of God go I" is valid for me and for all of us!
However, if you or I get caught out I really do believe that we should carry the can, take our medicine, and carry on...and not bitch on for the rest of our days about how hard done by we have been!
As I said before, I give you and Sperm full marks for your defence and support of captain XX, but really, he and engineering have got to wear this one! Let's face it,neither he or the engineer are going to lose their job over it...the SQ crew may well do so! ;)

sprucegoose
5th Apr 2003, 19:34
I agree with you Amos2. I never said that Captain XX didn't have to wear the heat for the incident nor any other captain involved in an incident. In fact I did say as much in my original post. I by no means meant to imply that when ones sh!t happens your responsibility for that is in any way diminished.

fruitloop
5th Apr 2003, 20:15
Amos2 Quote

I also wonder whether Spruce and Sperm have ever flown the F27 and parked it on an overnight without engineering back up? If they have, and then on the daily in the morning, overlooked either the aileron, rudder or elevator lock, whether they would also consider that "one of those things" ?

I,ve yet to see flight crew ever install manual locks (gust lock lever behind Capt's seat ) and would be surprised if they didn't
"notice it"when doing their pre-departure.

Red streamer,red cover.red aircraft ,I guess Murphy is still here !!

airsupport
6th Apr 2003, 04:56
Just as a point of interest on an F27, missing that the gust lock is engaged, shouldn't be a problem, unless you are also going to takeoff on only one engine :rolleyes: , as with the gust lock engaged you cannot advance both throttles to takeoff. ;)

Also just out of interest, I think it is a terrible shame that this "attitude" exists between SOME Pilots and SOME Engineers, and has done that I know of for some 40 years. :(

I have flown all over the World as extra crew with some fantastic Pilots, however I will never forget the first time I ever flew in the jump seat.

It was ironically on an F27, out of Essendon back in about 1968.

After takeoff the gear would not retract, the FIRST thing the Captain said was "the fu***** Engineers have left the pins in" (no mention of him missing them), then he called ATC and said we were returning with mechanical problems.

They were both quite busy flying the F27, and making it plain what they thought of Engineers, so I had a good look around the cockpit. Just under where I was sitting, I noticed that the emergency gear selector was still selected to "down", so I asked them was that right? Of course they selected it up to "normal" and we were able to continue the flight.

They had missed this on their preflight, but never once did either of them apologise for what they had said about Engineers. I can only imagine though how embarassed they would have been IF we had of returned to essendon like that.

It is very sad that SOME Pilots and SOME Engineers are still very quick to blame each other. :(