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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 18th Mar 2022, 06:57
  #61 (permalink)  
 
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Originally Posted by LKinnon
Pitot covers should be designed to fall apart beyong 60kt.
You would then likely lose the covers every time a big storm blew through?
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Old 18th Mar 2022, 07:18
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Or....

When student pilots are being trained, one of the items they should be trained to check while rolling down the runway is that the airspeed indicator is indicating an increase in airspeed.

1986 in a Cessna 152: "And if we're rolling down the runway for take off, and the airspeed indicator is indicating not much and not increasing, you've probably left the pitot cover on, Lead Balloon, or the pitot probe is blocked (which you should have seen when you did your daily inspection)."

I say again: The stuff up during the truncated ground inspection is one thing. What happened after that is more concerning from a systemic safety perspective.
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Old 18th Mar 2022, 07:19
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Originally Posted by Lookleft
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?
In this case, red 'SPD' flags were annunciated on both PFDs as the aircraft accelerated through 50 knots groundspeed. The Captain noticed the flags and muttered 'speed, speed', but did not communicate the problem to the FO. The Captain was clearly confused by what was happening, but instead of making a decision to reject the take-off, he just let it continue and then called '100 knots' based on the groundspeed readout. The flight crew actions during the take-off, especially those of the Captain, make for 'interesting' reading.
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Old 18th Mar 2022, 10:23
  #64 (permalink)  
 
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PITOT FAULTS



A few observations:



Murphy’ Law applies - if something can happen it will happen !

( I seem to recall over the years more than one incident when PITOT covers had NOT been removed prior to T/O !! )



In my experience as a flight simulator instructor ( albeit RAF ) crew reaction to pitot /static faults were handled worse than any other emergency - especially when sneakily inserted when the crew were distracted by something else.



With an increasing airspeed it is very tempting to take off power and raise the nose leading to dangerously low actual airspeed.

Conversely with a reducing airspeed the natural reaction is to put on power and lower the nose leading to a dangerously high airspeed.



The TOP TIP was always to set a sensible power setting and attitude , sit on hands and resolve the fault in slow time.



A good airspeed check was always SOP on T/O and if a serious discrepancy was picked up the T/O should be ABORTED at about 100kts - well below V1.
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Old 18th Mar 2022, 11:30
  #65 (permalink)  
 
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Originally Posted by Uplinker
Unbelievable.

How can anyone possibly NOT check Pitot probes on an A330?

They are in plain view, very easy to check, as are the Static ports and the AoA vanes. There might not have been streamers attached to the covers, but so what? You simply....Look. At. The. Probes. and you will easily see if they are covered or not.

And as for night time, all engineers and pilots carry a torch don't we, (and I mean a proper, focusable torch, not a phone)........please tell me we all do.

This incident is remeiscent of the BA aircraft that took off with the engine cowls unlatched because nobody did a proper walk-around.

This is really fundamental stuff. Any "pilot" who does not check these most fundamental items before each and every flight is.......well........words fail me.
God help you if you ever become fallible. Just love these twerps.
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Old 18th Mar 2022, 12:51
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Originally Posted by Chris2303
Wasn't it removed during engine start? If it's the JQ incident that I remember.
Yes, that was the one, but the clipboard should never have been put there in the first place.
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Old 18th Mar 2022, 12:52
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Looks like he was shining the flashlight on the pitot tube during the walk around.

Either did not notice(make sure to look and actually observe) or perhaps noticed and then forgot.

Seeing as I am always looking for solutions based on the reality of events occurring(instead of discussing penny pinching), I suggest, as a general rule, having a policy of stopping the walk around when an issue like this is discovered, advise maintenance, and then resume the walk around. It makes it less likely that the issue will get forgotten.
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Old 18th Mar 2022, 16:44
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Are the gear pins still stowed in the cockpit just behind the captain? They were the last time I flew the 330. Why can't they stow the pitot covers there too? If you missed them on the walk-around check, the cockpit safety and equipment check would give an additional opportunity to catch the error. No need for fancy, expensive, and heavy cameras etc.
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Old 18th Mar 2022, 17:38
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Never mind the pitot covers being left on, HTF did the crew manage to complete the take-off roll past V1 and beyond with almost no airspeed indicating? 😬
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Old 18th Mar 2022, 18:38
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Originally Posted by H Peacock
Never mind the pitot covers being left on, HTF did the crew manage to complete the take-off roll past V1 and beyond with almost no airspeed indicating? 😬
If you read pages 9 to 11 of the report, handily linked in the opening post, you will be able to find that out!
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Old 19th Mar 2022, 00:41
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I'm tipping the last question was rhetorical.
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Old 19th Mar 2022, 01:04
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I suggest, as a general rule, having a policy of stopping the walk around when an issue like this is discovered, advise maintenance, and then resume the walk around. It makes it less likely that the issue will get forgotten
Interrupting a pre flight can, and has, been the undoing of flight safety, can point to the loss of a DC-4 and all on board when the aircraft was the main stay of airline operations, our own outfit had an engine cowling come loose in flight and cause damage that took six months to repair, exhaust gases impinging on the airframe changing metal temper was what took time to fix. On both occasions it was interruption to take a phone call that initiated events.
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Old 19th Mar 2022, 01:35
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Never mind the pitot covers being left on, HTF did the crew manage to complete the take-off roll past V1 and beyond with almost no airspeed indicating?
Meanwhile for Australian crew the ATSB are postulating about potential glide ranges in a jet aircraft and are highly critical of the decision making but foreign crew can call an airspeed that doesn't even exist, get airborne and that's OK???
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Old 19th Mar 2022, 02:05
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As a non pilot, was wondering who 'owns' the pitot covers and gear pins and where are they normally kept, common sense says they would live in the cockpit when not in use... but.
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Old 19th Mar 2022, 02:51
  #75 (permalink)  

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Originally Posted by Matt48
As a non pilot, was wondering who 'owns' the pitot covers and gear pins and where are they normally kept, common sense says they would live in the cockpit when not in use... but.
Matt, the pitot covers and as well gear locking pins are stored on the flightdeck. If you play by the rules only the aircraft-paired, one specific set is used to dress the sensors. Exclusively.

There is a stowage box, you will find a photo in the report. Checking for the covers removed is task of fatal importance.

That is why the engineers need to make a written entry to the logbook when installing them.

That is why each of the pilots should check, independently, as per procedure
- the one on the flight deck will verify all pins and covers are inside
- the one on the outside will inspect there are no pins or covers left installed outside.

This is pretty standard setup for critical items, but wait for the good part....
​​​​​​.
​​​​​​.
additionally there is a written check list, challenge-response, which pilots need to read and answer aloud before pushback. Our concern here is the item:

GEAR PINS AND COVERS? ..... REMOVED (both).

Where each declares doing his part.
​​​


​​​​​​
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Old 19th Mar 2022, 03:37
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Originally Posted by megan
Interrupting a pre flight can, and has, been the undoing of flight safety, can point to the loss of a DC-4 and all on board when the aircraft was the main stay of airline operations, our own outfit had an engine cowling come loose in flight and cause damage that took six months to repair, exhaust gases impinging on the airframe changing metal temper was what took time to fix. On both occasions it was interruption to take a phone call that initiated events.
Of course, you have a good point and I did consider that. But think about it for a while on a modern jet or turboprop. How often do we find something that is reportable to maintenance on a walkaround. I mean something that will cause an incident for sure. Almost never. However, finding pitot covers on will cause an incident for sure(at least an RTO).

One has to weigh the chances of forgetting to complete the rest of the walkaround(which will almost never result in an incident) versus forgetting to mention the pitot covers(guaranteed to cause an incident). Standard weighing of potential outcomes of each option available, both of which can lead to the undoing of flight safety.

Therefore, I still suggest interrupting the walk-around to advise maintenance if one finds a significant issue. It can also prevent a delay by getting maintenance onto the problem earlier.

Last edited by punkalouver; 19th Mar 2022 at 12:43.
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Old 19th Mar 2022, 08:06
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Originally Posted by Two's in
... If you needed steps or a ladder to fit the blanks, why not leave it there for the person to remove the blanks is one obvious question.
1) Because it's not good practice to leave stands in close proximity to an airplane

2) Because you probably don't have every size stand on every parking bay.

TTS
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Old 19th Mar 2022, 10:37
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Matt, the pitot covers and as well gear locking pins are stored on the flightdeck. If you play by the rules only the aircraft-paired, one specific set is used to dress the sensors. Exclusively.

There is a stowage box, you will find a photo in the report. Checking for the covers removed is task of fatal importance.
If you read the report Malaysian Airlines does not regularly carry Pitot Covers in the aircraft, and the Covers were supplied by the support engineer on this occasion from ground stock. This is why I made the comments earlier about having a computerised system recording ground fitting of protective/storage equipment, such as covers, locks and such. The aircraft did not have its own set of Pitot Covers, the crew checking the box, would have no effect. The primary cause of this is the split duties between two engineers, who were not exactly cluey on what exactly each was responsible for, this has caused MANY accidents, change of shifts, sudden change of duty, busy work cycles, etc. The old remember everything in my head and remember to do paper checklists just flies out the window. WRT to the crew this is a case of a non standard local procedure for fitment of these items catching the normal crew out. Still there is no excuse for how they got past 50 knots with red flags on the speed indicators.
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Old 19th Mar 2022, 10:55
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Originally Posted by 43Inches
If you read the report Malaysian Airlines does not regularly carry Pitot Covers in the aircraft, and the Covers were supplied by the support engineer on this occasion from ground stock.
Just for illustration, with regard to a different major international airline and fleet type, if British Airways carries pitot covers on it's 777 aircraft, they are not stored in the flight deck.

If carried, where mght they be stored? No idea. Only the gear pins are stored in the flight deck.
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Old 19th Mar 2022, 10:55
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Originally Posted by FlightDetent
Matt, the pitot covers and as well gear locking pins are stored on the flightdeck. If you play by the rules only the aircraft-paired, one specific set is used to dress the sensors. Exclusively

There is a stowage box, you will find a photo in the report. Checking for the covers removed is task of fatal importance.

.
This sort of thing is airline specific. In my experience pitot covers are not kept on board unless it is a standard procedure to fit them every day. Which for most airlines in temperate climates, it isn't.


That is why the engineers need to make a written entry to the logbook when installing them.
On the vast majority of airlines, yes. The report states that it was not at the time a requirement for MAH.

​​​​.
​​​​​​.
additionally there is a written check list, challenge-response, which pilots need to read and answer aloud before pushback. Our concern here is the item:

GEAR PINS AND COVERS? ..... REMOVED (both).

Where each declares doing his part.

​​​​​​
When I first started doing headset procedures on the pushback, it was standard procedure for the flight crew to ask "your checks please?"
The response was to confirm all pins and pitot covers removed, doors and hatches checked closed and secure. (steering lock out pin fitted-added specific to type, I'm old enough to remember aircraft that didn't use them).
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