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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, 07:08
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ATSB release report into Malaysian A330 Pitot covers left on....

Interesting to read the report, but surely someone would have noticed the covers.

https://www.atsb.gov.au/publications...r/ao-2018-053/
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Old 16th Mar 2022, 07:50
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Obviously no one did notice the covers.
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Old 16th Mar 2022, 08:09
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Just goes to show, yet again, how often those holes in the Swiss cheese line up in what are supposed to be the 'safest' of aviation operations.
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Old 16th Mar 2022, 08:39
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Decision making during the roll was non existent. They picked up the speed issue very early on. But kept going, and going. FO appeared to be waiting for the abort call but nothing. The report goes into a lot of detail across all sorts of things, however only brushes over the two key standouts for me. Decision Making and communication skills.

This one should have never left the ground. CRM just didnít exist.

Last edited by PoppaJo; 16th Mar 2022 at 11:21.
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Old 16th Mar 2022, 08:51
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Yet the operator and its operations in Australia are authorised by an AOC issued by CASA.

Cue the press release about safety never having been compromised.
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Old 16th Mar 2022, 09:15
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pitot tubes. again.

How about requiring a pitot tube to have a light sensor in it, and pitot covers to have blackout lining. Then if the light sensor isn't seeing light, it'll raise an alert on engine start. It's mad that a $100M aircraft can be incapacitated by not having a bit of orange plastic flapping in the wind. And to counter night-time, I'm sure the aircraft computer can figure out whether it's day or light, adjust accordingly, and also I'd expect the apron to be illuminated. I'm not suggesting existing fleets be retrofitted as the wiring cost would be huge, but for certification going forward..
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Old 16th Mar 2022, 09:19
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If I read correctly, the Captain’s walk-around took 92 seconds? Must have run!
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Old 16th Mar 2022, 10:03
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Originally Posted by Lead Balloon View Post
Yet the operator and its operations in Australia are authorised by an AOC issued by CASA.

Cue the press release about safety never having been compromised.
This is a blatant example of CASA being simply a political entity that pretends it is a safety watchdog. The Operator should have
had its Australian AOC suspended immediately for such basic incompetence. The Australian ATSB and itís softly softly attitude to the
MH 70 disappearance is yet another example. CASA executives simply hide behind their desks, reap in their mega salaries, and
seriously would not know the flight deck from the tail.



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Old 16th Mar 2022, 10:36
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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.
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Old 16th Mar 2022, 11:00
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I've just read the entire report.
From an LAEs point of view.
The certifying LAE says that he knew they were fitted and noticed them on his walk round but then forgot about them? What about the 'mandatory' open log book entry? Reading between the lines he didn't log it.

Also, there is an AD from Airbus requiring pitot covers to be removed before applying electrical power to the aircraft due to the possibility of the pitot probe heating switching on and melting the covers. (I can't find a reference for this so I don't know if it was issued before or after this event).

Placing a placard on the flight deck is also now mandated.

The practice of fitting gags and covers drawn from stores and not booking them out of stores is, sadly, all too common. Time constraints being the main driver. It needs addressing.
In this case it seems the covers were not even the correct type and had minimal streamers attached. For a station like Brisbane where the practice of fitting these covers is an everyday occurrence that is a shocking admission of poor standards from the operator. They should be kept on board and counted in for every Brisbane flight. They're not exactly expensive.

I won't comment on the crew actions as there are far more here qualified to do so.
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Old 16th Mar 2022, 11:17
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This incident is remeiscent of the BA aircraft that took off with the engine cowls unlatched because nobody did a proper walk-around.
That quite a number of A32F aircraft took off with the cowls unlatched (not just BA) and Airbus published numerous alerts and recommendations (like painting the latches red) suggests something more was at play there.

This incident, however, is in a different category IMHO.
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Old 16th Mar 2022, 14:00
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Originally Posted by TURIN View Post
I've just read the entire report.
From an LAEs point of view.
The certifying LAE says that he knew they were fitted and noticed them on his walk round but then forgot about them? What about the 'mandatory' open log book entry? Reading between the lines he didn't log it.
The report states the following (p.3):
At 2045 the AMSA support engineer arrived at the aircraft carrying a set of pitot probe covers, which are commonly used in Brisbane to prevent mud wasp infestation. The support engineer moved an access stand (moveable ladder/platform) to the nose of the aircraft and fitted the pitot probe covers. Ribbons attached to each of the pitot probe covers were visible on the CCTV recording. The support engineer then moved the access stand away and proceeded to the flight deck.

At 2047 the support engineer arrived on the flight deck. According to interviews with the LAE and support engineer, their discussion was brief. The support engineer reported telling the LAE (who was checking aircraft records at the time) that pitot probe covers were fitted to the aircraft. According to the support engineer, the LAE did not acknowledge what had been said, or make an entry in the technical log for the fitment of pitot probe covers (which the support engineer normally expected). The support engineer did not question this.

The LAE had not been aware of the common and recommended practice for the use of pitot probe covers at Brisbane Airport. The LAE stated that it was not normal practice to fit them during transits and later did not recall the support engineer advising of their fitment during the turnaround. The LAE also stated that, had they known pitot probe covers were fitted at that point, they would have either made an entry in the aircraft's technical log that the pitot probe covers were fitted, or told the support engineer to remove them.
It also states (p.4):
The LAE then conducted the external inspection component of the walk-around transit check beginning at 2054 (this component will be referred to as the Ďengineering maintenance walk-around inspection')...The LAE reported noticing the pitot probe covers fitted to the aircraft at the time the nose area was inspected and intended to talk to the support engineer about them. As the support engineer was still absent from the aircraft retrieving supplies, the LAE decided to continue with the engineering maintenance walk-around inspection. The next interaction between the LAE and support engineer was ten minutes later. The LAE, busy with continuing the engineering maintenance walk-around inspection through that period, forgot about the pitot probe covers.
It sounds as the support engineer told the certifying engineer about the pitot covers immediately after they were fitted, but the certifying engineer was busy and didnít take in what was said. Consequently, no tech log entry was made. The certifying engineer noticed the covers during his subsequent walk-around, but then forgot about them.
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Old 16th Mar 2022, 14:38
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But the pilots.......

Things having to be written in the Log or someone remembering to tell someone or having to have streamers etc etc. Surely to goodness though, the pilot(s) would want to know that nothing like this has been missed and would therefore would want to physically eyeball such fundamental items as the Pitot probes for themselves before trying to get airborne?

Cock-ups will always happen of course, and many of us have lots of experience of busy turnarounds and busy engineers, but surely that is why us pilots must check such fundamental things properly ??

We seem to be going backwards in safety, instead of learning from past mistakes.
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Old 16th Mar 2022, 15:08
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Originally Posted by BuzzBox View Post
The report states the following (p.3):


It also states (p.4):


It sounds as the support engineer told the certifying engineer about the pitot covers immediately after they were fitted, but the certifying engineer was busy and didnít take in what was said. Consequently, no tech log entry was made. The certifying engineer noticed the covers during his subsequent walk-around, but then forgot about them.

This is why one should always make a log entry BEFORE fitting landing gear lock pins or pitot covers etc. It is standard practice.
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Old 16th Mar 2022, 17:04
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Considering the recent UK F-35 that went into the ocean from a carrier launch after ingesting an engine intake blank, those of you who say this should never happen appear to missing the human factors element in all of this. That airplane was surrounded by aviation professionals whose job it was to ensure the aircraft is ready for flight, and it still got missed. There have been a spate of pitot static failures on airliners that were placed in COVID storage and returned to service, only to find the blanks were not fitted properly, or the insects got in anyway. That should be all the evidence needed to demonstrate that the discipline and governance around fitting blanks and covers needs a rigorous review by the industry. 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. Adding paperwork to what should be a standardized safety process is not going to help if it's not a maintenance action.

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Old 16th Mar 2022, 18:28
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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................
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Old 16th Mar 2022, 18:33
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An obviously amateur view but when i read the very very clear and well produced report mention of him needing the steps to place the covers and then moved them made me think why not leave them there anyway . If thyew er eneeded elsewhere on the aircraft perhaps do that first and leave the probe covers till last, they aren't going to taxy away or push back with those still there. Another point I picked up was the precise wording under the picture of the aircraft on push back. From the photo it would appear the tug driver could see the streamers whereas in fact he cannot from his cab once the towbar is connected. I thought it was important they pointed that out on the picture not buried in the text.

if I might be indulged with a bit more amateurism, how do Chief Pilots/Operations managers even colleagues etc view the actions of this crew . Basically making a simple but dangerous mistake on walk around, not really handling the go / no go take off issue very well and yet seemingly doing a good job on the hardest part of the whole incident ie getting it back on the ground safely . Again just curiosity on my part . Thanks
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Old 16th Mar 2022, 19:19
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Originally Posted by Lead Balloon View Post
Yet the operator and its operations in Australia are authorised by an AOC issued by CASA.

Cue the press release about safety never having been compromised.
I'm not sure if this is sarcasm or not so I will ask. Why would MH have an Australian AOC?
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Old 16th Mar 2022, 19:50
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Originally Posted by SHVC View Post
Obviously no one did notice the covers.
They probably did see the covers, but the brain never registered them. I've seen that happen more than once, particularly when people don't expect them to be there.

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Old 16th Mar 2022, 20:51
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Originally Posted by Two's in View Post
There have been a spate of pitot static failures on airliners that were placed in COVID storage and returned to service, only to find the blanks were not fitted properly, or the insects got in anyway. That should be all the evidence needed to demonstrate that the discipline and governance around fitting blanks and covers needs a rigorous review by the industry. 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. Adding paperwork to what should be a standardized safety process is not going to help if it's not a maintenance action.
Aircraft do not have a set of dedicated steps at hand. One engineer may be covering several aircraft and need the steps on all of them.

Fitting pitot covers IS a maintenance action, hence the requirement for a log book entry.
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