[Peetwo]

MAL AO-2018-053 serious incident - Preliminary report released.

Use of pitot probe covers

The pitot probe covers were fitted on the aircraft’s three pitot probes by one of the engineering support personnel, as it was his understanding this was normal practice. He later reported that he advised the operator’s maintenance engineer that pitot probe covers were fitted during a brief exchange discussing turnaround tasks, but that the maintenance engineer did not directly respond.

The maintenance engineer later reported that he did not recall hearing the advice, and he did not make an entry in the aircraft’s technical log to record that the covers had been fitted.

The presence of the pitot covers was not detected by the operator’s maintenance engineer or captain during separate external aircraft inspections.

The operator’s maintenance engineer boarded the aircraft during turnaround, and the engineering support personnel left the bay to attend to other aircraft. The pitot covers were not detected by ground handlers during pushback.

The flight crew and operator’s maintenance engineer later reported that they would not routinely use pitot probe covers on a turnaround. They advised that the operator did not normally fly to airports where the use of pitot probe covers was standard. Security video recordings of the operator’s three previous turnarounds at Brisbane Airport showed that pitot probe covers were not used.

The pitot covers fitted to the aircraft were provided by the engineering support provider and were manufactured to fit Airbus aircraft types including the A330.

They consisted of a tightly woven Kevlar sheath about 12 cm long, with a 30 cm streamer.

Examination of the three covers fitted to the aircraft following the occurrence found that they were partially burned by the heated pitot probes. They each had a hole burned through where the cover folded around the probe in the airstream. The streamers were damaged by contact with the aircraft skin during the flight (Figure 4 and Figure 5).

Figure 4: Pitot probe covers removed from 9M-MTK after the incident flight
[img=463x0]https://www.atsb.gov.au/media/5774867/ao2018053_figure-4.jpg?width=463&height=463&mode=max&sharpen=2[/img]
Source: ATSB

Figure 5: Reconstruction of pitot probe covers on 9M-MTK, showing pitot cover damage and rub marks on aircraft skin from the streamer
[img=463x0]https://www.atsb.gov.au/media/5774875/ao2018053_picture-7.png?width=463&height=463&mode=max&sharpen=2[/img]
Source: ATSB

Ongoing investigation

The ATSB has interviewed the flight and ground crews, and examined data from the aircraft’s FDR, CVR and DAR, as well as airport security video footage from before and after the flight.

The investigation will examine the:

• procedures, arrangements and interactions between the operator’s maintenance engineers, flight crews, engineering support provider and ground handling service provider
  
  
• procedures relating to ground and flight crew pre-flight checks, including walk-around procedures
  
  
• training records for flight crew, engineers and ground handling personnel
  
  
• warnings, cautions and other information displayed to the flight crew during the occurrence flight
  
  
• ATC recordings
  
  
• closed-circuit video recordings
  
  
• FDR, CVR and DAR recordings.
  

The investigation will also interview the air traffic controllers who communicated with the flight crew during the flight.

Safety actions

Proactive safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

• The aircraft operator provided a notice to all of its engineers and flight crew, which highlighted the need for pitot covers to be fitted to aircraft at Brisbane Airport during turnarounds or when parked, as well as the required procedures for their fitment and removal.
  
  
• The aircraft operator and engineering support provider clarified and formalised more detailed service level arrangements.
  
  
• The engineering support provider improved its procedures for conducting turnarounds, including improved inspection, documentation, and tool control.
  
  
• The ground handling service provider provided all employees with a ‘read and sign’ bulletin emphasising its arrival and departure inspection procedures.
  

Safety advisory notice to all international operators using Brisbane Airport
Action number: AO-2018-053-SAN-003

The Australian Transport Safety Bureau advises all operators that conduct flights to Brisbane Airport to consider the use of pitot probe covers and, if covers are used, ensure there are rigorous procedures for confirming that covers are removed before flight.

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Finally from Ironsider, via the Oz on twitter:

 Robyn Ironside@ironsider
ATSB investigation confirms serious safety oversight..

 The Australian @australian



Forgotten probe covers designed to keep out wasps and marked ‘remove before flight’ forced Malaysia Airlines’ Brisbane landing emergency
https://t.co/ofrE14oXcc


1:44 PM - 30 Aug 2018

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Malaysia Airlines safety breach ‘endangered all’

A serious safety oversight that has stunned many in the aviation industry has been blamed for an incident involving Malaysia Airlines at Brisbane Airport last month.

Flight MH134 was forced to return to Brisbane soon after takeoff on July 18 when the Airbus A330-300’s airspeed indication failed.

The aircraft made an “overweight” landing and had to be towed from the main runway to the gate due to the loss of nose wheel steering and minor damage to the main landing gear doors.

A preliminary report by the Australian Transport Safety Bureau found the reason for the loss of airspeed indication was that the pitot probes were not uncovered before takeoff.

Pitot probes provide air data computers and flight instruments with airspeed information and are ineffective if covered or blocked.

The report noted that external checks of the aircraft by the captain and maintenance engineer failed to detect the probe covers, which are red and have a long tag carrying the words “remove before flight”. Ground handlers also failed to notice the covers, which were fitted by one of the engineering support personnel as advised by Brisbane Airport.

An airport wasp problem has led to pitot probes being covered while aircraft are on the ground, even during routine turnarounds, to prevent nests being built.

Some airlines such as Qantas require the flight crew to be presented with or shown the covers once they are removed from the pitot probes shortly before takeoff.

Australian and International Pilots Association technical and safety manager Shane Loney said plenty of questions remained about the MH134 incident.

“The key things are, how they came to leave with the pitot covers still on, and what was seen (in the cockpit) at the 100-knot call,” Mr Loney said. “I would not have expected the airspeed indications to be accurate at that point but the report suggests the 100-knot-speed call was made. I wonder what the crew were looking at?”

Former airline captain Byron Bailey said it was unclear from the report whether the co-pilot called “check” in response to the captain’s call of 100 knots. “It is unbelievable that a professional airline crew could sit on the takeoff roll for 42 seconds and not notice they had no airspeed,” Mr Bailey said.

“These calls are mandatory checks. The incompetence of this crew endangered the lives of all on board because flying around with no airspeed indication is haz­ardous in the extreme,” he said.

The report said the flight crew and engineer were not in the habit of using pitot covers on turnarounds and did not normally fly to airports where the use of covers was standard. Security video showed pitot covers were not used on three previous turnarounds by Malaysia Airlines’ flights at Brisbane Airport despite airworthiness bulletins and airfield information about the wasps.

The ATSB issued a safety advisory in response to the incident, urging airlines to ensure “there were rigorous procedures for confirming pitot covers were removed before flight”.

ATSB chief commissioner Greg Hood said it was a serious incident and the investigation was continuing. “We will be focusing specifically on the procedures for flight crew and ground crew in relation to the pre-flight checks for the aircraft, and also the cockpit warning systems received by the flight crew as they accelerated down Runway 01,” Mr Hood said.

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Safety risk mitigation of nesting wasps and pitot tube safety issue goes global -   

Via the Oz today:

Wasp study sparks global buzz

ROBYN IRONSIDE
A study by Brisbane Airport Corporation into mud wasps could ­determine the future design of aircraft pitot probes.

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Brisbane Airport leads way in studies of mud wasp activity

A landmark study by Brisbane Airport Corporation into the ­behaviour of mud wasps could ­determine the future design of aircraft pitot probes.

With the problem of wasps building their nests in pitot probes affecting several subtropical airports, the study is attracting international attention.

As well as a half-dozen airports in the US and the South Pacific, Airbus is seeking to use information gleaned from the Brisbane study to inform the future design of pitot probes, which provide air data computers and other instruments with airspeed information.

Overseen by BAC wildlife co-ordinator Jackson Ring, the study examines the risk mud wasps pose to aircraft and the best way to ­reduce those risks.

Mr Ring said the study made use of 100 3D-printed pitot probes replicating the exact specifications of various aircraft designs ­including the A330, B737-400 and 737-800, Dash 8, B747 and E190.

The probes were mounted on sheets of aircraft life material and set up in 24 locations at parking positions around the ­airfield.

“Each set location is inspected regularly for evidence of mud wasp activity, and if a blocked pitot probe is located the contents are hatched and examined by an ecologist,” Mr Ring said.

“From this study, the BAC is gaining some insight into what species are present at Brisbane Airport, the prey used in provisioning nests, the pitot probe size/type preference, any seasonal trends and possible environmental factors that may affect nesting.”

In addition, BAC encouraged airline staff to report mud wasp ­activity along with relevant information on the time of day, weather conditions and food source.

Mr Ring said all information was passed to aircraft manufacturers and shared with airline operators and the broader industry.

“The research is ongoing, and the data collected will inform our pest mitigation program ­moving forward and provide ­invaluable learnings for the industry,” he said.

Although the study began in 2014, the serious implications of the wasp issue were given far greater impetus recently ­when a Malaysia Airlines’ aircraft took off from Brisbane Airport with its pitot probes covered.

Similar to other airports with a wasp problem, Brisbane requires aircraft to cover their pitot probes after ­landing to avoid them being blocked by mud wasp nests, which can be built in as little as 20 minutes.

The red covers, carrying the words ­“remove before flight”, were somehow missed by ground crew, engineers and the pilot on the night of July 18, leading to the ­Malaysia Airlines’ A330 taking off without airspeed indication.

Fortunately, the pilots were able to use a back-up system to get enough information to land safely, without injury to any passengers or crew.

A preliminary report by the Australian Transport Safety ­Bureau found the Malaysia Airlines’ crew was not aware of the requirement to cover the pitot probes in Brisbane and had not done so on three previous turnarounds.

There have been more than a dozen incidents since 2008 ­involving blocked pitot probes at Brisbane Airport because of wasp activity. In the case of a 2013 ­rejected takeoff incident, it was determined that the captain’s pitot probe was almost com­pletely obstructed by a wasp nest despite the A330 being on the ground for only two hours.

Mr Ring said the airport had achieved a significant reduction in wasp activity through a comprehensive pest control program but it recognised that wasps would never be completely eradicated from the site.

Therefore, he said, pitot tube coverings were the most effective mitigation measure available, as recommended by BAC, the Civil Aviation Safety Authority and the ATSB.

All airlines were expected to follow safety bulletins on pitot covers issued by BAC and CASA but some had instituted their own procedures to leave no doubt the probes were ­uncovered before take off. These included presenting the captain with the covers or waving the covers in front of the cockpit before push back.

MTF...P2