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

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

Old 16th Mar 2022, 20:54
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Originally Posted by Asturias56
I think the last edition of "Flight" mentioned three cases of some wasps in pitot tubes in BA aircraft at Heathrow last year - I think one was found when they tried to takeoff................
It is now a requirement during wasp season for ALL BA A320 series aircraft to have their pitot heads inspected 2 hrs before first flight of the day after a nightstop. Log book entry and cerification required.
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Old 16th Mar 2022, 20:58
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Originally Posted by Chris2303
I'm not sure if this is sarcasm or not so I will ask. Why would MH have an Australian AOC?
Because section 27 of the Australian Civil Aviation Act says one is required.

The Act makes special provision for applications to CASA for AOCs authorising the operation of foreign registered commercial aircraft in to and out of Australian territory, but at the end of the day it's an AOC issued by CASA under the section that every other AOC is issued by CASA. (I won't complicate things by talking about NZ-registered aircraft or 27A permissions.)
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Old 16th Mar 2022, 21:24
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Originally Posted by Lead Balloon
Because section 27 of the Australian Civil Aviation Act says one is required.

The Act makes special provision for applications to CASA for AOCs authorising the operation of foreign registered commercial aircraft in to and out of Australian territory, but at the end of the day it's an AOC issued by CASA under the section that every other AOC is issued by CASA. (I won't complicate things by talking about NZ-registered aircraft or 27A permissions.)
Seriously? Don't you mean an operations spec? The logic of this is that an airline would need an new AOC to fly into every other foreign country. That could be 100 + for some airlines. I know you folks have a high opinion of your system down there but that's not how the world works.
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Old 16th Mar 2022, 21:36
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Seriously? Don't you mean an operations spec? The logic of this is that an airline would need an new AOC to fly into every other foreign country. That could be 100 + for some airlines. I know you folks have a high opinion of your system down there but that's not how the world works.
Australia is not the world, it's a country that has to make every dam thing harder for everyone when it comes to governance. Not for some tyrannical maniac, just because the civil service wants to keep itself relevant and employed shuffling vast amounts of paper (now emails) between irrelevant parties.

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

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

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

Last edited by 43Inches; 16th Mar 2022 at 21:57.
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Old 16th Mar 2022, 21:39
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I'm just telling you what Australian law requires, Consol.

If you go to Appendix A CASA's Annual Report for e.g. 2019 - 2020, you will see the table of AOCs issued by CASA, which table "includes operators involved in one or more of ... foreign aircraft (passengers and cargo), foreign aircraft (cargo) ...".

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

One might pause to wonder what the point of the process is, though, if the kind of incident the subject of the ATSB report the subject of this thread is 'ops normal' for an operator. And that's my point.
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Old 16th Mar 2022, 21:41
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Originally Posted by Asturias56
I think the last edition of "Flight" mentioned three cases of some wasps in pitot tubes in BA aircraft at Heathrow last year - I think one was found when they tried to takeoff................
AAIB investigation to various Airbus and Boeing aircraft between 9 June and 19 July 2021
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Old 16th Mar 2022, 21:51
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One might pause to wonder what the point of the process is, though, if the kind of incident the subject of the ATSB report the subject of this thread is 'ops normal' for an operator. And that's my point.
Australian process revolves around mountains of now electronic paperwork, as you know. The applicant just has to say they will do everything right and they get a tick, then practice very different standards and wait for something to go wrong to get the poker. Meanwhile the operational surveillance focuses on whether the FO wore a high vis while visiting the toilet block or the FA spoke verbatim from the 1000 word long boarding spiel that no one listens to (because it's too long).
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Old 16th Mar 2022, 21:59
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Seriously? Don't you mean an operations spec? The logic of this is that an airline would need an new AOC to fly into every other foreign country. That could be 100 + for some airlines. I know you folks have a high opinion of your system down there but that's not how the world works.
Actually it IS how the world works, and that is what Part 129 is all about. I would imagine that most large carriers have at least 100 Part 129 AOC's, plus a compliance department that monitors requirements and expiry dates.
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Old 16th Mar 2022, 22:03
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chimbu knows of what s/he speaks.
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Old 16th Mar 2022, 22:06
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Originally Posted by chimbu warrior
Actually it IS how the world works, and that is what Part 129 is all about. I would imagine that most large carriers have at least 100 Part 129 AOC's, plus a compliance department that monitors requirements and expiry dates.
Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?
By the way, good idea to check pitot covers, if you can't see the hole you haven't checked it
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Old 16th Mar 2022, 22:39
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So for anyone who is actually a pilot the message from the report is that the walkround should be conducted with your eyes open and actually look at the important items on the outside of the aircraft as per the FCOM. As for the issue of continuing the takeoff with no airspeed indication well all the bells and whistles are not going to stop that happening if the crew are merely passengers. Hardly an Airbus problem if an equivalent Boeing product can be taken into the air and flown at 75' over downtown Dubai!

Also WTF CARES if its an AOC or an Ops Spec that a foreign carrier operates under into Australia!
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Old 16th Mar 2022, 23:43
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Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?
And does the “legacy carrier” for whom you work operate non-Australian registered aircraft in to and out of Australia, Consol? If yes, it holds an AOC issued by CASA.

Lookleft: If you could just try to set aside your blind prejudice for a moment, you might see that there may be systemic issues at play here: Systemic issues for which the operator is supposed to be responsible and CASA is supposed to be concerned. What else is the air operator certification process for? The apparent failure to do a proper pre-flight inspection is one thing. The crew’s decision making and communications after the consequences of the failure manifested themselves are another. The latter worry me much more than the former. But no doubt you can’t help yourself but disagree, because you don't like the messenger. You need to try to move on.
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Old 16th Mar 2022, 23:45
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Originally Posted by Consol
Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?
Foreign operators require approval by the State concerned to conduct transport operations within that State's territory. The approval process is essentially a validation of the operator's AOC and in some countries (eg Australia, Canada, Malaysia) the approval document is known as a 'Foreign AOC'.
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Old 16th Mar 2022, 23:49
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In Australia it is an AOC authorising the operation of a foreign aircraft in to and out of Australian territory. The short description is 'Foreign aircraft AOC'. It's the aircraft that's foreign, not the AOC.
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Old 17th Mar 2022, 00:32
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But no doubt you can’t help yourself but disagree, because you don't like the messenger. You need to try to move on.
As do you LB. We all get it that you haver a visceral dislike of CASA and the ATSB and that you use every opportunity to highlight how much you know and how little everyone else knows in legal matters. If only the Mods set up a sub-forum that was called Regulator Failures then the rest of us could discuss things like doing a proper walkaround and speaking up when your flight instruments are not working the way they should. The systemic failures in this instance really have very little to do with CASA but more to do with flight crew of any nationality just going through the motions and not doing the very basic aviating which is the first part of the ANC mnemonic.

Its not that I dislike the messenger its just that the messenger wants to always steer the message away from anything that could be relevant to pilots who fly for a living. Honestly most of us don't give a crap about whether CASA issues AOC's to foreign carriers.
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Old 17th Mar 2022, 00:54
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As usual, you presume to speak for "most of us".

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

If this kind of incident had occurred in a small Australian charter operator, I very much doubt CASA would just shrug and move on. If CASA's certification and surveillance of foreign carriers operating in to and out of Australia is just a rubber stamp exercise, that's a safety issue.
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Old 17th Mar 2022, 01:01
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It does have a lot to do with CASA oversight of who is authorised to operate within Australia on a commercial basis. Who they authorise and how they operate directly affects the jobs of us who are local pilots and engineers who do the right thing and demand the correct remuneration for the responsibility. If someone is allowed to fly commercially into Australia and compete with us using substandard training being paid peanuts then that affects our jobs and quality of life. Or you could try to get a job in our thriving shipping industry, where anyone can register their ship in Panama or wherever and employ anyone that can stand up to sail it to ports in Australia, what's all those options now, hmm ANL.... We own 35 ships (only about 5 of those do international shipping, the rest are local shipping around Australia ) out of 3000 that visit Australia yearly, and carry only 2% of our own goods internationally from our shores in our own ships. If Qantas fails due to it's current debt, that will be Australia's international air travel gone foreign as well.
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Old 17th Mar 2022, 01:15
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Originally Posted by Consol
Nope. You're mixing up ops specs. I work for a legacy carrier. We have one AOC in state of registry. We comply with relevant ops specs in other countries. We do not have 40+ AOCs. Should we cease operations immediately?
By the way, good idea to check pitot covers, if you can't see the hole you haven't checked it
Care to tell us if it's an OPS SPEC or Foreign AOC that permits you to operate into / out of Malaysia? The fact is that some countries require a FAOC, others not, sometimes it depends on how many times you visit etc.
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Old 17th Mar 2022, 01:16
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Originally Posted by TURIN
This is why one should always make a log entry BEFORE fitting landing gear lock pins or pitot covers etc. It is standard practice.
I don't disagree. In this case Malaysia Airlines didn't require a tech log entry for the fitment of pitot covers at all. Page 51 of the report states:

The Malaysia Airlines technical handling manual did not require a technical log entry to record the fitment of pitot probe covers, but engineers were able to do so. When interviewed, AMSA managers stated that they expected a maintenance log entry would be made by an appropriately approved person for the fitment of pitot probe covers.
According to the report, interim measures were in place for the provision of engineering services, because Malaysia Airlines had only recently recommenced operations into Brisbane. AMSA engineers did not have Malaysian CAA approval and could not make tech log entries:

Furthermore, the support engineer was not permitted to enter the details of the fitment of pitot probe covers into the aircraft’s technical log and did not press the issue after seeing that the LAE did not do so. The support engineer may not have seen it as a sign that the LAE did not hear the support engineer’s statement.
One of the safety actions undertaken by Malaysia Airlines following the incident was to update its technical handling manual to require a tech log entry to record the fitment of pitot probe covers (see p.126).

There were many 'holes in the Swiss cheese' that led to this incident; it seems to me that lack of coordination/communication between the two engineers was one of them.
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Old 17th Mar 2022, 01:31
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Originally Posted by Lead Balloon
In Australia it is an AOC authorising the operation of a foreign aircraft in to and out of Australian territory. The short description is 'Foreign aircraft AOC'. It's the aircraft that's foreign, not the AOC.
If you want to be pedantic, the Australian legislation refers to the document as a "Foreign Air Transport Air Operatorís Certificate (FATAOC)". Most people I know simply call it a "Foreign AOC".
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