SINGAPORE– The ATSB has issued a fresh warning regarding removing pitot probe covers following an incident involving a Singapore Airlines (SQ) A350-900, which nearly commenced pushback with the attached covers.
According to the final report on the occurrence at Brisbane Airport (BNE) on May 27, 2022, it was revealed that Heston MRO, the contracted engineering provider for Singapore in Brisbane, had not yet established a satisfactory procedure for accounting for tooling and equipment before aircraft pushback.
Singapore Airlines A350 Pilot Probe Incident
ATSB chief commissioner Angus Mitchell stated, “The procedural risk controls established for the removal of the pitot probe covers were bypassed when the licensed aircraft maintenance engineer (LAME) certified their removal in the technical log and eliminated a pertinent warning placard from the flight deck, without visually or verbally confirming their removal.”
The presence of the covers on the aircraft, bearing registration 9V-SHH, was brought to the attention of a refueller in an adjacent bay. Upon being alerted, the LAME returned to the aircraft and removed the covers before pushback, allowing the flight to proceed to Singapore without further incident.
Mitchell mentioned, “The last walk-around inspection of the aircraft was not performed by either the LAME or the headset operator. This inspection aims to verify that the aircraft is properly configured for flight, with all panels and doors closed and all covers removed.”
Ensuring Aircraft Safety
“This incident highlights how assumptions and procedural lapses can result in unsafe conditions, such as the potential for an aircraft to take off with inaccurate or missing airspeed indications.”
Pitot probe covers are necessary in Brisbane to prevent mud wasps from obstructing the tubes, which can occur in as little as 20 minutes, as stated by the ATSB. These probes provide crucial airspeed data to aircraft systems and flight crews.
In a significant incident in 2018, a Malaysia Airlines (MH) A330 departed from Brisbane with its pitot covers still attached, leading the crew to perform an emergency return landing due to the absence of airspeed data.
While the ATSB couldn’t formally determine if fatigue played a role in this event, the investigation highlighted that the workload for individuals with dual roles, such as the LAME/regional manager involved in this incident, had significantly increased following the COVID-19 pandemic.
The engineering provider didn’t monitor the work-related hours of personnel with dual roles like the LAME involved in this incident (who also served as the regional manager) for fatigue assessment purposes,” Mitchell explained. “This heightened the risk of fatigue-related incidents involving these individuals.
Updates and Improvements
The report highlights that Heston MRO has revised its policies following the incident, eliminating the requirement for the Brisbane regional manager to hold dual responsibilities and implementing a system to monitor employees’ work hours for fatigue management.
Additionally, during the ATSB’s investigation, analysis of CCTV footage depicting pre-flight inspections conducted by Singapore Airlines flight crew for the occurrence flight and others during the same period revealed that these inspections were abbreviated and not conducted as per company protocols.
“The pre-flight walk-around takes place before the removal of pitot probe covers, so it did not contribute to this particular incident,” Mitchell remarked. “Nevertheless, it was identified as a safety concern during our investigation, which Singapore Airlines has subsequently addressed.”
The report mentions that the airline has communicated with flight crews about the importance of thoroughly completing pre-flight walk-around checks and in compliance with established procedures. Furthermore, the airline has supplied Heston MRO with pitot probe covers featuring longer streamers to enhance visibility.
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