Go Back  PPRuNe Forums > PPRuNe Worldwide > Australia, New Zealand & the Pacific
Reload this Page >

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

Wikiposts
Search
Australia, New Zealand & the Pacific Airline and RPT Rumours & News in Australia, enZed and the Pacific

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

Thread Tools
 
Search this Thread
 
Old 17th Mar 2022, 01:36
  #41 (permalink)  
 
Join Date: Oct 2007
Location: Aus
Posts: 2,787
Received 415 Likes on 229 Posts
Care to tell us if it's an OPS SPEC or Foreign AOC that permits you to operate into / out of Malaysia? The fact is that some countries require a FAOC, others not, sometimes it depends on how many times you visit etc.
Malaysia (CAAM) requires a FAOC validation for operators.

https://www.caam.gov.my/wp-content/u...-6005-FAOC.pdf

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

EU (EASA) requires a TCO FAOC validation.

They all amount to the same thing, a document that spells out how you will comply with local regulations, DG requirements and various other things, which in Australia is basically an AOC.
43Inches is offline  
Old 17th Mar 2022, 02:12
  #42 (permalink)  
 
Join Date: Nov 2001
Location: Australia/India
Posts: 5,286
Received 419 Likes on 209 Posts
Originally Posted by BuzzBox
If you want to be pedantic, the Australian legislation refers to the document as a "Foreign Air Transport Air Operator’s Certificate (FATAOC)". Most people I know simply call it a "Foreign AOC".
CASRs do refer to "Foreign Air Transport Air Operator’s Certificate (FATAOC)". But section 27AE of the Act refers to and defines "foreign aircraft AOC". Horse/cart.

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


Lead Balloon is offline  
Old 17th Mar 2022, 03:15
  #43 (permalink)  
 
Join Date: Feb 2000
Location: 500 miles from Chaikhosi, Yogistan
Posts: 4,294
Received 139 Likes on 63 Posts
Originally Posted by 43Inches
Malaysia (CAAM) requires a FAOC validation for operators.
https://www.caam.gov.my/wp-content/u...-6005-FAOC.pdf
USA (FAA) requires a DOT approval certificate with OpsSpec compliance.
EU (EASA) requires a TCO FAOC validation.
They all amount to the same thing, a document that spells out how you will comply with local regulations, DG requirements and various other things, which in Australia is basically an AOC.
My question to the poster saying you only need OPS Specs to fly around was rhetorical, and I was fishing.... I'm well acquainted with those applications. I know of 1 national legacy carrier has about half a dozen FAOCs and some OPS Specs - depending on the country.

In comment about your answer - they may all amount to the same end game, but take different amounts of energy (and time) to acquire....
compressor stall is online now  
Old 17th Mar 2022, 06:34
  #44 (permalink)  
 
Join Date: Jul 2008
Location: Brisbane
Posts: 573
Received 68 Likes on 16 Posts
Well written report. That night I was pushing back and watched them taxi past. They were close enough for me to see the pitot heads but I must admit I didn’t see the red tags. I was held at C8 on B and watched the whole thing. They subsequently closed the runway and we had to use 32. Just made it weight wise using bleeds off.

Sill feel guilty for not noticing anything abnormal. We even joked “there goes disappearing Airlines”. The landing looked exciting and I am impressed with the 330 back up airspeed indicator.
By George is offline  
Old 17th Mar 2022, 08:41
  #45 (permalink)  
 
Join Date: Feb 2018
Location: Brisbane
Posts: 342
Received 19 Likes on 12 Posts
Are the covers/probes viewable when sticking your head out the window on the 330? Imo you’re crazy not to visually confirm at least one is off (with the assumption that if one’s off, it’s likely the ginger beer has done his or her job). It’s a 5 second effort.
TimmyTee is offline  
Old 17th Mar 2022, 10:11
  #46 (permalink)  
 
Join Date: Mar 2010
Location: Hamburg
Posts: 162
Likes: 0
Received 6 Likes on 3 Posts
Originally Posted by TimmyTee
Are the covers/probes viewable when sticking your head out the window on the 330? Imo you’re crazy not to visually confirm at least one is off (with the assumption that if one’s off, it’s likely the ginger beer has done his or her job).
The engineers, walk-around pilot and pushback team should all have properly checked that the pitot covers were removed, but didn't, so where do you realistically draw the line?

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

As an aside, in the 16+ years I have been flying airliners I cannot recall there ever being pitot covers fitted on the aircraft I have arrived at, in preparation for flight! Merely an observation. That doesn't mean I don't check carefully on the walk-around, I do. The 92 seconds this incident Captain spent on his external inspection, including 9 seconds at the nose gear, is a pretty poor effort.
Stuart Sutcliffe is offline  
Old 17th Mar 2022, 10:26
  #47 (permalink)  
 
Join Date: Mar 2002
Location: Moved beyond
Posts: 1,174
Received 88 Likes on 50 Posts
Originally Posted by TimmyTee
Are the covers/probes viewable when sticking your head out the window on the 330? Imo you’re crazy not to visually confirm at least one is off (with the assumption that if one’s off, it’s likely the ginger beer has done his or her job). It’s a 5 second effort.
On the A330, the pitot probes are directly below the sliding windows on either side, but they're low down on the fuselage. They're not visible by sticking your head out the window. You might just see them if you got out of the seat and leaned out of the window, but you'd risk falling out. Why not just do the job properly in the first place and check during the walk around? If the covers must still be fitted at that stage due to wasp nests, then make sure it's written up in the tech log. A verbal confirmation with the engineer on headset wouldn't hurt either.



BuzzBox is offline  
Old 17th Mar 2022, 11:01
  #48 (permalink)  
Thread Starter
 
Join Date: Jun 2020
Location: Cold, wet and windy
Posts: 100
Received 5 Likes on 3 Posts


Both the LAE and Captain seemed to take a look, whether it didn't register, who knows?
Mach1Muppet is offline  
Old 17th Mar 2022, 12:00
  #49 (permalink)  
 
Join Date: Nov 1999
Location: UK
Posts: 2,491
Received 101 Likes on 61 Posts
I can see how an overworked engineer, with another two aircraft to turn around might notice the covers and think "I must get some steps to take those off". But then, the fueler comes over to have the chit signed and someone else comes up to him and says a cargo roller has jammed in the forward hold. On his way to the cockpit to write up the fuel in the tech log, someone says the rear sink is blocked or the IFE is not working etc, etc.

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

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


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

Training, training, training.
Uplinker is offline  
Old 17th Mar 2022, 21:37
  #50 (permalink)  
 
Join Date: Feb 2018
Location: East of Westralia
Posts: 682
Received 109 Likes on 32 Posts
Originally Posted by Uplinker
I can see how an overworked engineer, with another two aircraft to turn around might notice the covers and think "I must get some steps to take those off". But then, the fueler comes over to have the chit signed and someone else comes up to him and says a cargo roller has jammed in the forward hold. On his way to the cockpit to write up the fuel in the tech log, someone says the rear sink is blocked or the IFE is not working etc, etc.

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

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


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

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

Unfortunately too many have succumbed to the “cheaper is better” mantra.
ScepticalOptomist is offline  
Old 18th Mar 2022, 01:21
  #51 (permalink)  
 
Join Date: Feb 2002
Location: UK
Age: 58
Posts: 3,494
Received 152 Likes on 83 Posts
Originally Posted by Uplinker
I can see how an overworked engineer, with another two aircraft to turn around might notice the covers and think "I must get some steps to take those off". But then, the fueler comes over to have the chit signed and someone else comes up to him and says a cargo roller has jammed in the forward hold. On his way to the cockpit to write up the fuel in the tech log, someone says the rear sink is blocked or the IFE is not working etc, etc.

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

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


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

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

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

Ropes on pitot covers is no good i'm afraid, they are clipped in place to stop them blowing off.
TURIN is offline  
Old 18th Mar 2022, 02:29
  #52 (permalink)  
 
Join Date: Oct 2007
Location: Aus
Posts: 2,787
Received 415 Likes on 229 Posts
As I said earlier the aviation industry might fly cutting edge technology, but the work practices behind the scenes are 1950s era. External Covers that can result in catastrophic loss if left in place should be NFT buttoned, and a data-logger involved which records when they are put in place and when they are removed. Then the human peanut is not relied on to remember. The reader needs to be close enough to read the tag, so it will be when they are removed, not when they are looked at. The record of removal should be straight into a computerised maintenance management system (CMMS) and it will not release the aircraft for flight until that item is logged in the system as done. That is a big red flag saying 'don't fly me stupid' comes up in front of the meat bag sitting in the flight deck looking at their tablet or whatever.
43Inches is offline  
Old 18th Mar 2022, 02:37
  #53 (permalink)  
 
Join Date: Jan 2008
Location: Where I hang my hat.
Posts: 186
Received 1 Like on 1 Post
Everyone going about their duties, (not my job to look for the thingies).
Matt48 is offline  
Old 18th Mar 2022, 02:40
  #54 (permalink)  
 
Join Date: Jan 2008
Location: Where I hang my hat.
Posts: 186
Received 1 Like on 1 Post
Clipboard lying in intake duct.. removed.
Matt48 is offline  
Old 18th Mar 2022, 03:37
  #55 (permalink)  
 
Join Date: Jul 2003
Location: Somewhere
Posts: 3,071
Received 138 Likes on 63 Posts
Our industry used to pride itself on learning from mistakes. Let's learn from this one. Ropes attached to the pitot covers so they can be removed from ground level without having to go and find steps.
Yes until airlines decided that bonuses as opposed to straight salaries for management were a good idea. Good luck justifying your "safety" case for a longer piece of rope and a big flag attached in someone's budget prior to this incident.

Aviation in the future will be dominated by penny pinching safety reports as that is the only way anything will be justified by the accountants. They will just shoot it down on cost until we bend an aeroplane and have a starring role in a ATSB report then they can justify the cost.
neville_nobody is offline  
Old 18th Mar 2022, 03:55
  #56 (permalink)  
 
Join Date: Nov 2006
Location: Auckland, New Zealand
Posts: 80
Received 17 Likes on 11 Posts
Originally Posted by Matt48
Clipboard lying in intake duct.. removed.
Wasn't it removed during engine start? If it's the JQ incident that I remember.
Chris2303 is offline  
Old 18th Mar 2022, 04:36
  #57 (permalink)  
 
Join Date: Oct 2009
Location: Australia the Awesome
Posts: 399
Received 0 Likes on 0 Posts
Originally Posted by neville_nobody
Yes until airlines decided that bonuses as opposed to straight salaries for management were a good idea. Good luck justifying your "safety" case for a longer piece of rope and a big flag attached in someone's budget prior to this incident.

Aviation in the future will be dominated by penny pinching safety reports as that is the only way anything will be justified by the accountants. They will just shoot it down on cost until we bend an aeroplane and have a starring role in a ATSB report then they can justify the cost.
As Stelios Haji-Ioannou of EasyJet famously said “If you think health and safety is expensive, try an accident”.
Roj approved is offline  
Old 18th Mar 2022, 04:59
  #58 (permalink)  
 
Join Date: Nov 1999
Location: UK
Posts: 2,491
Received 101 Likes on 61 Posts
Originally Posted by TURIN
...............Yes, engineers have check lists, there is usually a copy in the back of the tech log or in a supplementary folder with all the insurance certificates and aircraft legal docs somewhere on the flight deck. Legally it should be referred to every time a Transit or pre flight check is signed but frankly no one hardly ever does unless there has been a recent change.
"Well there's your problem, lady !"

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

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

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

Yes, I know. This would all cost money - It might add as much as a whole pound Sterling per passenger ticket. But Safety is our primary concern, isn't it ?.................................isn't it?
Uplinker is offline  
Old 18th Mar 2022, 05:12
  #59 (permalink)  
 
Join Date: Jul 2008
Location: Australia
Posts: 1,253
Received 195 Likes on 90 Posts
Both the LAE and Captain seemed to take a look, whether it didn't register, who knows?
Quite possibly that is the case. We (airline pilots) have seen the video of the basketball passing competition between two teams. We were all surprised the first time we saw it that there was a person in a gorilla suit walk through the middle of the competition. Its called functional blindness. Basically if you are not looking for a specific object then it won't register that it is in fact in your field of view. Its why bike riders have cars do a u-turn in front of them. What is harder to fathom is the lack of airspeed not being noticed on the PFD's. The pilots should be expecting to see that during the take-off. Tracking technology on the pitot covers is not a bad idea but should there be some sort of alarm similar to the take-off warning config if the IAS is not increasing? Ideally, trained pilots should pick up such a basic fault but I use the analogy of the professional soldier and the conscript. The conscript has basic training but is not interested in improving their skills beyond what is necessary. The professional soldier wants to keep improving so they can be the best they can possibly be. I think worldwide that there are too many pilots who are in the conscript category. The recent incident in Dubai is another example. Four pilots who did not know how to comprehend a situation that was different to the hundreds of departures they had sat through and watched previously.
Lookleft is offline  
Old 18th Mar 2022, 06:38
  #60 (permalink)  
 
Join Date: Jan 2012
Location: Mascot
Posts: 27
Likes: 0
Received 0 Likes on 0 Posts
Pitot covers should be designed to fall apart beyong 60kt.
LKinnon is offline  


Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service

Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.