[Peetwo]

Popinjay to the rescue: Clearing Fudging the books?

Via PJ's BOLLOCKS concocted Media Pages:

A350 pitot probe covers left on prior to pushback demonstrates how assumptions, procedural omissions can lead to unsafe conditions


A Singapore Airlines Airbus A350 was about to be pushed back from the gate at Brisbane’s international terminal on 27 May 2022 when a refueller in an adjacent bay noticed covers were still on the aircraft’s pitot probes, an ATSB investigation final report describes. 

Upon being alerted to this, the licenced aircraft maintenance engineer (LAME) responsible for the aircraft’s turnaround returned to the aircraft and removed the pitot covers. The aircraft then proceeded for its planned passenger service to Changi, Singapore, without further incident. 
 
Pitot probes, which provide airspeed data to aircraft systems and flight crew, are routinely covered during turnarounds at Brisbane due to the nesting behaviour of a species of invasive mud wasp, which has been known to block the tubes in as little as 20 minutes. The covers must be removed prior to take-off. 

In a serious incident in 2018, a Malaysia Airlines A330 took off from Brisbane with its pitot covers still in place, and its crew had to conduct an emergency return landing without airspeed data. 

In this more recent occurrence, the ATSB found Singapore Airlines’ contracted engineering provider at Brisbane, Heston MRO, had not yet implemented an acceptable method for accounting for tooling and equipment prior to aircraft pushback, although that was identified in the ATSB’s investigation into the 2018 occurrence. 

“Additionally, the procedural risk controls which were in place for the removal of the pitot probe covers were circumvented when the LAME certified for their removal in the technical log and removed a relevant warning placard from the flight deck, without visually or verbally confirming that they had been removed,” ATSB Chief Commissioner Angus Mitchell said. 

“The final walk around inspection of the aircraft was also not conducted by the LAME or the headset operator. That inspection is intended to ensure that the aircraft is correctly configured for flight with all panels and doors closed and all covers removed. 

“This incident demonstrates how assumptions and procedural omissions can lead to unsafe conditions; in this case, the potential for an aircraft to take-off with erroneous or absent airspeed indications.” 

While the ATSB was not able to formally establish that fatigue contributed to the occurrence, the investigation did note the LAME had reported the workload associated with their dual role of LAME/regional manager had become considerably more demanding following the COVID-19 pandemic. 

“The engineering provider did not track the work-related hours of personnel with dual roles like the LAME involved in this incident (who was also the regional manager) for fatigue calculation purposes,” Mr Mitchell said. 

“This meant there was an increased risk of a fatigue-related incident with these personnel.” 

The report notes that, since the occurrence, Heston MRO no longer requires the Brisbane regional manager position to undertake dual responsibilities, and tracks work hours of all employees for fatigue management purposes. 

Also, during the ATSB’s investigation, a review of CCTV footage of pre-flight inspections by Singapore Airlines flight crew for the occurrence flight and others around the same time showed they were truncated, and not undertaken in accordance with company procedures. 

“The pre-flight walk-around occurs before the pitot probe covers are to be removed, so this did not contribute to this incident,” Mr Mitchell noted. 

“Nonetheless, it was identified in our investigation as a safety issue, which Singapore Airlines has subsequently addressed.” 

The airline, the report notes, has communicated with flight crews about the importance of pre-flight walk-around checks to be completed in their entirety and in accordance with the procedures. 

The airline has also provided Heston MRO with pitot probe covers with longer streamers, to improve conspicuity. 
Read the final report: Flight preparation event involving Airbus A350-941, 9V-SHH, Brisbane Airport, Queensland, on 27 May 2022[/size]

Publication Date 15/03/2024

This 'defined' investigation took 659 days complete, had a prelim report that took 55 days longer than the 30 day maximum (after the incident/accident) for an ICAO Annex 13 preliminary report copy to be dispatched to ICAO (if in fact it was dispatched at all? Ref: Dear Betsy RE: Bring back Lachie; & where's the ICAO report please?) 

I also note that this FR has 4 associated 'safety issues' published that have apparently been 'adequately addressed' and subsequently 'closed' by PJ's crew: 

1. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-01

Action description

In January 2024, Heston MRO advised that they would be completing a review of their transit toolbox procedures, with any changes to be implemented when a new revision of their manual was released in January 2024. The changes will incorporate a more specific requirement to review and document a check of the transit toolbox prior to certified release to service, which will include the use of a checklist.

2. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-02

Action description

In January 2024, Heston MRO advised they had taken the following safety action:

• They have employed an independent regional manager who will not hold a maintenance authority within the organisation. The intention of the business is to reduce reliance on dual function managers and LAMEs.
  
• There was a policy change that required salaried staff (such as the regional manager/LAME) to supply a timesheet with start and finish times so that accurate fatigue management calculations could be conducted in accordance with the Heston MRO fatigue management framework.
  

3. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-03

Action description

In January 2024, Singapore Airlines advised the ATSB that it was initially emphasised to their A350 pilots via the publication of a memo and later to all pilots through an Internal Notice to Airmen (INTAM) on 12 December 2023, the importance of adhering to standard operating procedures in relation to the completion of exterior checks.

4. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-04

Action description

In January 2024, Singapore Airlines advised the ATSB that they had engaged Heston MRO at Brisbane to use pitot probe covers with better conspicuity by increasing the length of the streamers. Usage of such covers has been implemented by Heston MRO on Singapore Airlines aircraft at Brisbane (see images below).

Annex 13 Para 7.4 also says:

"When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available"

No idea if this actually occurred, in regards to these safety issues, as again there is no listed 'issue' date in the (publicly available) ATSB website safety issue database: https://www.atsb.gov.au/safety-issues-an...r_value=AO 

Finally for a contradiction in ATSB investigative processes, priorities and 'related occurrences' for flight preparation incidents, I note the following 22/09/2021 'short investigation' FR: Aircraft flight preparation occurrence involving Boeing 787-9, VH-ZNJ Melbourne Airport, Victoria on 22 September 2021

Although obviously no where near as serious as departing with pitot/static covers attached, the AO-2021-040 didn't have any associated 'safety issues' identified and therefore a much lower probability of the subsequent MLOSA lessons learnt being disseminated across industry. There is a possibility (remote I know -  ) that if the lessons learnt from the QF incident, had been more effectively disseminated by the ATSB, then maybe the Singapore A350 incident may not have occurred...

MTF...P2