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.

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.

I am amazed this incident got 124 posts.
Incident.
Investigation.
Corrective Interview with those concerned.
Checklist, Memo issued as required.
Done and dusted.

Albatross 108 were from 2018 so only 16 from 2022

A good deal of discussion here how each hole in the cheese got missed:

Anyone thinking that just 'viewed' the post. :) .........Dang it.

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.

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.
.

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.

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.

"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...

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?

No kidding.

Similar event being discussed here-

https://www.pprune.org/australia-new...tech-crew.html

Abort
 

A long time ago I was the A/C on a C141overnight to the Canal Zone off-loading 150 troops with all their gear. The next morning when we arrived at ops, we were told it was a full cargo load back to Tacoma, WA. Routine, let us know when the port folks have finished switching out all of the pax gear- seats, O2 masks and associated lines, life vests, etc., so the cargo can be loaded. Apparently the port crew were civilians, it was Saturday, and we were on our own. No drama except that in the late 1970’s, the over-riding metric to evaluate one’s performance was blocking out on-time. Normally not a big deal, except we had the new Wing Commander sitting on our jump seat and he was fired up to look good. After a stupid pep talk, we sprung into action. The enlisted guys, to their credit, played along and with a lot of grunting and sweating actually got the bird ready to go with a not so bad showing of the officers as well. The heat index at Howard AFB reminded us how much we were missing the free air conditioning and ice water from the Great NW. Super rushed before taxi checklist, INS’s to NAV, taxi clearance from ground and away we go - on time! The Wing Commander’s time card was punched and we lined up for the copilot ‘takeoff.
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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