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Dreamliner preflight error, ground and tech crew?

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Dreamliner preflight error, ground and tech crew?

Old 30th May 2022, 06:44
  #21 (permalink)  
 
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to be in the aircraft, taking off - needs to check that important things such as probes have been individually looked at and checked.

The pilot walk-around should be the one that catches any mistakes such as probe covers being left on.
Did you read the report? There were no probe covers left on.
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Old 30th May 2022, 07:53
  #22 (permalink)  
 
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Everyone's life could have been made easier by having the 'Remove Before Flight' sticker a little more obvious rather than being covered up by yellow tape. Defeats the purpose of the tape if you can't read it.

Last edited by neville_nobody; 30th May 2022 at 10:25.
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Old 30th May 2022, 12:37
  #23 (permalink)  
 
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Originally Posted by havick View Post
Sounds like a really fun place to work 🙄
Was one of those airlines with astronaut sort of training standards, you know that place in which everyone fails a command course, the bar is set in a far away galaxy. I’m sure many know which one I’m talking about. Thank god I got another offer and left pronto.
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Old 30th May 2022, 14:34
  #24 (permalink)  
 
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Originally Posted by Icarus2001 View Post
Did you read the report? There were no probe covers left on.
Er.....
. During the post-flight inspection, engineering identified that all 4 engine fan cowl static ports were covered with tape...........What the ATSB found
The ATSB found that tape covering the 4 fan cowl static ports was not removed by engineering,
OK then ports/probes, my bad, but they should all be checked, no?
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Old 30th May 2022, 22:23
  #25 (permalink)  
 
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Originally Posted by PoppaJo View Post
Bit like the Malaysian A330, engineer fails to remove items, however post that we do have multiple layers of responsibility from others to try and pickup on these issues post that. Do not rely on ground operators to pickup on these things, it's a bonus if they do,
I don't believe the Roo has engineers dispatching flights from the stand anymore, however whoever conducted the preflight here, I assume SO, failed miserably
As an Engineer - it is not "a bonus" if we pick these things up, it is our job! As the aircraft had possibly been in parking mode for a few days, all the aircraft's ports and probes had been covered as per the AMM aircraft parking requirements. These ports on the engine do not have specific blanks manufactured for them, so using tape and plastic sheeting or preferably plastic gauze cut to size is the normal approved method, as it is for a number of other positions on the 787, including some about half way up the fin. When I have covered these ports I usually leave a tail of tape hanging down to make it a bit more obvious, or an extended line of tape up the cowling if the weather outlook is not good. The ports on the fan cowl are easy to miss as they are a long way down in the same way that fan cowl latches have been missed in previous well known incidents, it just takes a bit of effort and awareness that they are there. The workpack job card to re-activate the aircraft from parking would probably just had a generic "Remove all blanks and covers as per AMM 09-xx-xx" statement whereas a list of positions with a signature required for each one would probably have been more of a failsafe.

Essentially, the engineer who carried out and/or supervised the jobcard failed. Whoever carried out the Daily check failed. Whoever carried out the the EDTO pre-flight/transit check failed. The operating crew member who did the walk round failed. Whoever carried out the final ground walk round failed. The only defence for all this is that around the time of the incident the industry was at reduced manpower and workload levels so there was a lot of "de-skilling" and knowledge fade in the system, and in general, parking and re-activating aircraft in a normal line maintenance environment is not a common procedure. Luckily it was not a primary air data system.
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Old 30th May 2022, 22:33
  #26 (permalink)  
 
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How much retraining did the crew member (perhaps SO) get after their 18 months driving Uber? Were preflights discussed at all?

Maybe they were a bit distracted and stressed by the loss of income and time spent in quarantine.
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Old 31st May 2022, 01:41
  #27 (permalink)  
 
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As an Engineer - it is not "a bonus" if we pick these things up, it is our job!
I was referring to the likes of Swissport.
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Old 31st May 2022, 04:14
  #28 (permalink)  
 
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Originally Posted by uxb99 View Post
We have checklists for most things, why not a check list for the walk around?
There is. It's in the FCOM and anyone who's completed the type rating should be conversant with the FCOM and its contents, especially the walk around procedure if that's going to be a significant part of your job.

One of the best Captains I ever flew with once quipped "You're not just lookin' for the shit that's not there, you're lookin' for the shit that shouldn't be and that includes lookin' for the stuff that's on the ground when it should be on the jet!"
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Old 31st May 2022, 04:23
  #29 (permalink)  
 
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you mean the REMOVE BEFORE FLIGHT text that is printed on the bright red tape, secured with bright yellow tape, stuck on an all white engine cowl?

or does boeing require too many thing's to be taped up leading to potential errors like this?



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Old 31st May 2022, 06:44
  #30 (permalink)  
 
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There have been a few fatal jet accidents due to tape left on ports of passenger jets and missed in the walk around. This is piloting 101...no excuse. Overseas aviation authorities would be out for blood looking to see if the pilot was distracted/on phone etc...and if so, farewell career. Wonder if this one will survive the axe and how CASA/QF will handle it.
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Old 31st May 2022, 08:16
  #31 (permalink)  
 
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Originally Posted by LostWanderer View Post
There have been a few fatal jet accidents due to tape left on ports of passenger jets and missed in the walk around. This is piloting 101...no excuse. Overseas aviation authorities would be out for blood looking to see if the pilot was distracted/on phone etc...and if so, farewell career. Wonder if this one will survive the axe and how CASA/QF will handle it.
In a “just culture” mature and supportive organization, this incident would and should lead to better outcomes. Not sackings. The mere mention of such punitive action only supports a failing safety culture. No matter how good you are, when the “reason model” dictates; you had better be ready to mitigate. This can only be achieved effectively and consistently in a true just culture.

Just culture does not excuse negligence.
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Old 31st May 2022, 09:04
  #32 (permalink)  
 
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Originally Posted by LostWanderer View Post
There have been a few fatal jet accidents due to tape left on ports of passenger jets and missed in the walk around. This is piloting 101...no excuse. Overseas aviation authorities would be out for blood looking to see if the pilot was distracted/on phone etc...and if so, farewell career. Wonder if this one will survive the axe and how CASA/QF will handle it.
You've never made a mistake?

And by the way, that’s why places that adopt that approach are much more likely to have accidents, because they don’t accept that every mistake is a possible learning experience, not a sacking experience.

I've worked in countries that are punitive in their approach, not ‘Just’, and I have seen what it does to the safety culture. Not good.
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Old 2nd Jun 2022, 07:53
  #33 (permalink)  
 
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For all the armchair experts let me explain some things for you.
Pitot probes have proper Boeing covers with flags that have "Remove before flight"
All the static probes, engines, fuselages and vertical stabiliser do not have Boeing covers.
In this instance they are covered with clear plastic film that is open at the bottom to allow condensation to drain, This plastic film is held in place with the yellow tape.
The yellow tape in question is a 3M product which is the correct spec as per Boeing for covering static ports. There is also some red/white barber pole tape that is applied as well as the "flag"

If the aircraft is covered like this it is because the aircraft is being parked for more than 24 hours. There are specific job cards for carrying out the parking tasks. They are some of the most poorly written and amended cards I have ever used.

There is also a card to remove the covers/tape etc. None of this is in the log book as it is covered by the job cards which are controlled in the electronic maintenance system.

So at the end of the day someone didn't remove them and signed for it. The task was certified without being checked and the flight crew missed it on the walk around.

With QF being in a state of flux for the past 2 years and managers doing anything but managing these events are happening. It isn't good for anyone. The 787 gear pins being left in 12 months ago also was put down to organisational change amongst other factors. It may seem to be a simple error, but nothing is ever simple. Those who work in this industry would understand it.
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Old 2nd Jun 2022, 23:29
  #34 (permalink)  
 
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Originally Posted by Bootstrap1 View Post

There is also a card to remove the covers/tape etc. None of this is in the log book as it is covered by the job cards which are controlled in the electronic maintenance system.

So at the end of the day someone didn't remove them and signed for it. The task was certified without being checked and the flight crew missed it on the walk around.
I don't know anything about this particular airframe, but are these covers easily seen from ground level? Or would you need some kind of platform?
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Old 3rd Jun 2022, 06:56
  #35 (permalink)  
 
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If the aircraft is covered like this it is because the aircraft is being parked for more than 24 hours. There are specific job cards for carrying out the parking tasks. They are some of the most poorly written and amended cards I have ever used.

There is also a card to remove the covers/tape etc. None of this is in the log book as it is covered by the job cards which are controlled in the electronic maintenance system.

So at the end of the day someone didn't remove them and signed for it. The task was certified without being checked and the flight crew missed it on the walk around.

With QF being in a state of flux for the past 2 years and managers doing anything but managing these events are happening. It isn't good for anyone. The 787 gear pins being left in 12 months ago also was put down to organisational change amongst other factors. It may seem to be a simple error, but nothing is ever simple.
Not good at all.

Pretty ordinary outcomes for an airline that is supposed to be better than ordinary.
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Old 3rd Jun 2022, 17:57
  #36 (permalink)  
 
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Originally Posted by 717tech View Post
I don't know anything about this particular airframe, but are these covers easily seen from ground level? Or would you need some kind of platform?
No platform needed - the engine statics are on the lower quadrant of the engine fan cowl (both sides), roughly 45 deg. from horizontal.
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Old 7th Jun 2022, 14:13
  #37 (permalink)  
 
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Agree, “To Err is Human”.

Last edited by QF-leo; 7th Jun 2022 at 21:12.
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Old 21st Jun 2022, 03:41
  #38 (permalink)  

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Originally Posted by Uplinker View Post
The pilot walk-around should be the one that catches any mistakes such as probe covers being left on.
Always has been. Yet, again, real people make mistakes and one of those is also not doing their job at all.

Punching the X button over this repeatedly only can only achieve so much. What's next, punching the people?

​​​​
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Old 21st Jun 2022, 11:12
  #39 (permalink)  
 
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Originally Posted by Tom Sawyer View Post
The only defence for all this is that around the time of the incident the industry was at reduced manpower and workload levels so there was a lot of "de-skilling" and knowledge fade in the system, and in general, parking and re-activating aircraft in a normal line maintenance environment is not a common procedure. Luckily it was not a primary air data system.
When you say "defence" I suspect you mean "contributing factor". Minor quibble, but the truth of the matter is that the risks associated with this period were easily identifiable and the extra planning, manpower and supervision required to prevent this regrettable incident should have been allocated by management, if they weren't so busy attacking their workforce's pay and conditions. And for that, there is no defence. Luckily, indeed, it was not a primary air data system. If it's like the 350, it's a very important part of the backup air data systems, tho'.
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Old 21st Jun 2022, 21:30
  #40 (permalink)  
 
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Originally Posted by Busbuoy View Post
When you say "defence" I suspect you mean "contributing factor". Minor quibble, but the truth of the matter is that the risks associated with this period were easily identifiable and the extra planning, manpower and supervision required to prevent this regrettable incident should have been allocated by management, if they weren't so busy attacking their workforce's pay and conditions. And for that, there is no defence. Luckily, indeed, it was not a primary air data system. If it's like the 350, it's a very important part of the backup air data systems, tho'.
Well summarised & the only thing i can add is whilst they were so busy attacking the pay & conditions they were still raking in millions of jobkeeper $$ every week.
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