MAS A330 BNE leaves pitot covers on
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Ref post 116 from ".....gandar". It is all very well calling for the checks but I wonder if 'he who did it, read it'. That used to be a golden rule - if you are reading a checklist for something which you did, then the other pilot must check that it was done. If, on the other hand, you did it and he reads it, the response can be fairly automatic. Some airlines for whom I did some training did want it done the other way round but any suggestion to the contrary fell on stony ground. Prober
CASA didn't do the investigation , the ATSB did, as it is required to do under ICAO annexes and Australian legislation. The question is regarding the report, did you learn from the mistakes of others? If the answer is yes, job done. If the answer is no then you will probably find yourself the subject of such a report in the future.
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Having read over 100 responses on this thread, I don't think I saw a single response saying anything along the lines of "wow, that could have happened to me".
Pilot training obviously has a long way to go.
Pilot training obviously has a long way to go.
.........Dang it.
I find that very disturbing - this is one of the most fundamental things a pilot should check, but if you are saying that you, and they, could easily have forgotten to check the pitot probes, then, yes I fully agree with you; training does need to be improved ! But surely no pilot should need to have the importance of a pitot probe explained ??
Accidents and incidents do happen, but certain things, such as IAS probes, flight controls full and free and operating in the correct sense, etc. are so fundamental they should never be missed.
And there is huge responsibility on individual pilots here, because the walk-around is one of the few things that is not double-checked by both pilots, so it should be taken very seriously.
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That comment somewhat misses the point. The problem here is that 'keyhole' wasps build nests VERY quickly. There was an incident where an aircraft suffered an airspeed discrepancy due to a wasp nest after being on the ground for less than an hour. Consequently, it had become routine practice for the pitot covers to be left on as long as possible and removed by the engineers shortly before departure, well AFTER the pilot’s walk-around had been completed. It essentially comes down to a non-standard procedure that was not properly communicated between all the relevant parties, along with the failure of some of those concerned to follow up and ensure the necessary checks were completed before departure.
Last edited by BuzzBox; 8th May 2022 at 12:49.
OK.
An unusual and uncommon procedure generally, but even so; a shame they didn't 'confirm (in some way) that all the pitot covers had been removed', and a shame that they continued the take-off with no IAS instead of rejecting. That is two holes in the cheese the crew fell through.
Asked "Gear pins and covers?", the pilot response surely should have been, "I don't know, we must check with the headset person" - especially if this was a 'routine' procedure at this airport. Another hole in the cheese fallen through, making three in total.
I suggested earlier in the thread that if the covers needed to be left on until pushing back, then the ramp person who shows the steering pin to the pilots before they taxi, should also hold up the pitot covers; allowing the pilots to visually confirm that the covers had been removed from the aircraft.
An unusual and uncommon procedure generally, but even so; a shame they didn't 'confirm (in some way) that all the pitot covers had been removed', and a shame that they continued the take-off with no IAS instead of rejecting. That is two holes in the cheese the crew fell through.
Asked "Gear pins and covers?", the pilot response surely should have been, "I don't know, we must check with the headset person" - especially if this was a 'routine' procedure at this airport. Another hole in the cheese fallen through, making three in total.
I suggested earlier in the thread that if the covers needed to be left on until pushing back, then the ramp person who shows the steering pin to the pilots before they taxi, should also hold up the pitot covers; allowing the pilots to visually confirm that the covers had been removed from the aircraft.
"By saying 'wow that could have happened to me', you are effectively saying you think it is conceivable that no pilots visually checked and confirmed that all the pitot probe covers had been removed and the probes were clear before their flight.
I find that very disturbing - this is one of the most fundamental things a pilot should check, but if you are saying that you, and they, could easily have forgotten to check the pitot probes, then, yes I fully agree with you; training does need to be improved ! But surely no pilot should need to have the importance of a pitot probe explained ??
Accidents and incidents do happen, but certain things, such as IAS probes, flight controls full and free and operating in the correct sense, etc. are so fundamental they should never be missed."
I have long given up the thought that "inconceivable" accidents & serious incidents can not occur & this particular event I would once thought inconceivable too. When taking into account factors such as fatigue, lack of familiarity with certain airfields, inadequate training, systemic issues etc (the list goes on), I've stopped saying to myself "how the hell did that happen" because supposedly inconceivable accidents & serious incidents (AF 447 is another one) do occur with somewhat regular monotony. If it can happen, it will unless adequate defences are in place to minimise the likelihood as much as possible...
Just my 2 lire's worth...
I find that very disturbing - this is one of the most fundamental things a pilot should check, but if you are saying that you, and they, could easily have forgotten to check the pitot probes, then, yes I fully agree with you; training does need to be improved ! But surely no pilot should need to have the importance of a pitot probe explained ??
Accidents and incidents do happen, but certain things, such as IAS probes, flight controls full and free and operating in the correct sense, etc. are so fundamental they should never be missed."
I have long given up the thought that "inconceivable" accidents & serious incidents can not occur & this particular event I would once thought inconceivable too. When taking into account factors such as fatigue, lack of familiarity with certain airfields, inadequate training, systemic issues etc (the list goes on), I've stopped saying to myself "how the hell did that happen" because supposedly inconceivable accidents & serious incidents (AF 447 is another one) do occur with somewhat regular monotony. If it can happen, it will unless adequate defences are in place to minimise the likelihood as much as possible...
Just my 2 lire's worth...
Everything old is new again...From the ATSB
I wonder if the same...uuhhhh..."communication" would have been achieved if it was night, rather than mid-morning - would we have had another instance of unreliable airspeed on departure?
The ATSB is investigating the flight preparation event involving an Airbus A350-941, registered 9V-SHH, at Brisbane Airport, Queensland on 27 May 2022.
At about 0915 Eastern Standard Time, the aircraft was in the final stages of being prepared for departure from bay 81. All turnaround service functions had been completed, all passengers had boarded, all doors were closed, and the aerobridge was in the process of being retracted from the aircraft.
An aviation refueller on an adjacent bay observed that the aircraft appeared to be ready to push back, but the pitot covers were still fitted. The refueller communicated with one of the engineers responsible for the aircraft that the pitot covers were still fitted. With three minutes remaining until the normal departure time, the engineer positioned an elevated work platform towards the nose of the aircraft and removed the covers, before the pushback commenced.
As part of the investigation, the ATSB will examine the circumstances leading to this flight preparation event, including interviewing the relevant parties involved, analysing the CCTV footage and assessing the risk controls relevant to the fitment and removal of the pitot covers.
Should a critical safety issue be identified at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.
A final report will be published at the conclusion of the investigation.
At about 0915 Eastern Standard Time, the aircraft was in the final stages of being prepared for departure from bay 81. All turnaround service functions had been completed, all passengers had boarded, all doors were closed, and the aerobridge was in the process of being retracted from the aircraft.
An aviation refueller on an adjacent bay observed that the aircraft appeared to be ready to push back, but the pitot covers were still fitted. The refueller communicated with one of the engineers responsible for the aircraft that the pitot covers were still fitted. With three minutes remaining until the normal departure time, the engineer positioned an elevated work platform towards the nose of the aircraft and removed the covers, before the pushback commenced.
As part of the investigation, the ATSB will examine the circumstances leading to this flight preparation event, including interviewing the relevant parties involved, analysing the CCTV footage and assessing the risk controls relevant to the fitment and removal of the pitot covers.
Should a critical safety issue be identified at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.
A final report will be published at the conclusion of the investigation.
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Abort
Airbus use a 100 kt call ( its not just for IAS crosscheck either ) BUT most of us check quite a few times the IAS is alive, especially looking for expected acceleration with a nice long trend vector...most of us if not all of us should notice no IAS way before 100 kts. Even at 100 kts there is still ample time to notice the discrepancy and STOP before V1
I would venture to suggest that they must have had some IAS indications that changed after airborne, perhaps as posted above the covers melted and then blocked after airborne?
I would be very surprised if a current professional crew got airborne without any airspeed indications at all.....
I would venture to suggest that they must have had some IAS indications that changed after airborne, perhaps as posted above the covers melted and then blocked after airborne?
I would be very surprised if a current professional crew got airborne without any airspeed indications at all.....
It was hot, we were heavy, performance was nothing to write home about. As the PNF, waiting for the airspeed to get off the peg, acceleration felt normal. Cross- checking the co-pilot’s airspeed showed the same indication; he was still on the peg - 60 kts My eyes were darting from my airspeed indicator to the end of the runway, back to co-pilot’s airspeed. I was having a crisis. Don’t believe my instruments which are both in agreement, or trust my gut and abort. Abort. First question the FE asks and needs to know is at what speed the brakes were applied. As we taxied off the runway, the light bulb in my head went off, and I had the loadmaster open up the hatch and verify what I hoped he would not see - installed pitot covers. He did. We decided on 100 kts.which resulted in a 44 min ground cooling time. To be on the safe side, we decided to air cool the brakes as well after takeoff. This plan was shelved at 1000’AGL as we had #4 overheat. With the throttle at idle and the gear down, we weren’t climbing well enough to clear the terrain, so, gear up, away we go. 4-5 hours later we land and the C141makes a B-line for the left edge of the runway. We block-in. The scanner outside informs the #5 tire fuse plug has melted.
Where to start….
1. General Officer on the flight deck changes the crew dynamic. I had lost some amount of authority. Btw, general was current on the aircraft.
2. Checklist discipline was obviously terrible. We all sang the correct tune. There was Red X log entry that the FE and I glossed over.
3. FE does the walk around, A/C should back up. I was loading the INS, co-pilot was pushing pallets. The routine was f**
4. We are trained to notice things that are different, not the same.
5. High speed aborts are dangerous. We actually stopped only 500’ from the end. Abort probably initiated at 130 kts which was 10-15 kts above V-1.
6. If one fuse plug melted, how close were the others?
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