Fear of landing – Pitot blankets left on planes in Brisbane. Still.

On May 27, 2022, an Airbus A350-941, registered in Singapore as 9V-SHH, was being prepared for scheduled passenger flight SQ256 from Brisbane, Australia to Changi Airport, Singapore.

A technical maintenance contractor in Brisbane providing maintenance, repair and overhaul (MRO) services has been tasked with the maintenance, certification and dispatch required for the A350 during the two-hour rotation.

Two personnel were responsible for the service: a certified aircraft maintenance engineer (LAME) and an aircraft maintenance engineer (AME).

In Australia, an aircraft maintenance engineer can maintain aircraft and rotorcraft, while a licensed aircraft maintenance engineer deals with structures, powertrains, mechanical and electrical systems, and avionics systems . Inspections and repairs require a certified aircraft maintenance engineer. He or she oversees the work of other aircraft engineers, ranging from AMEs to apprentices and aircraft maintainers.

An AME must work under the direction of a licensed engineer. The licensed engineer signs the work and then certifies that the aircraft is fit to fly.

In Brisbane, the chartered engineer responsible for line maintenance duties was also the contractor’s regional manager for Brisbane, Wellcamp and Coolangatta airports.

That day, he was overseeing the AME handling the Singapore Airlines A350, but he was also assisting with rotations for another plane that was parked in the nearby bay.

The AME had started working for the contractor three weeks earlier and had not yet completed his induction training. To begin, the licensed engineer guided AME through the initial exterior inspection of the A350.

The AME used an elevating work platform and installed pitot covers on the four pitot probes. It was standard procedure: all planes parked at Brisbane Airport have pitot probe covers fitted because of the mud wasps in the area, which like to build nests in pitot probes.

Pitot probes do not work when sealed or blocked. The high population of mud wasps in the Brisbane area, particularly the ‘exotic keyhole wasp’, has repeatedly caused problems by building nests in probes, blocking sensors. Pitot blankets prevent wasps from entering the probe. They are attached with streamers to draw attention to their placement.

While the AME was installing the pitot covers, the licensed mechanic went to the cockpit of the aircraft to check the technical log for defects. He noted in the log that the pitot covers had been installed and placed a warning sign on the engine control pedestal to show that the pitot covers had been installed. He then went to the adjacent bay to attend to the other aircraft.

The morning continued.

About half an hour before the scheduled flight departure time, the co-pilot performed the pre-flight overview. The first officer walked from the nose to the right engine, then cut to the left engine and returned to the bridge. The walk should also include walking around the wings and the complete airframe and tail, but this did not happen. Security footage shows the first officer looking up at the pitot blankets. However, as they were to be installed while the aircraft was parked, no action was required or expected. As for the first officer, everything was fine.

The licensed engineer came back to the bay and talked to the AME about the fuel numbers. At the headset, the fired engineer spoke to the flight crew to confirm fuel loading.

He returned to the cockpit for the technical log, noting that the plane was certified for the transit check. He erased the technical log entry indicating that the pitot covers had been installed and removed the pitot cover warning sign from the cockpit pedestal.

None of the engineers had visited the A350.

Back on the tarmac, the dismissed engineer affixes the warning sign to the dashboard of his work vehicle. The problem was that he had never checked that the pitot covers had been removed. He hadn’t even asked the TEA to remove them, he just assumed that since the TEA had signaled that he had completed the work, the pitot covers would have been removed.

Meanwhile, the AME assumed that the Chartered Engineer would make a final visit, so he didn’t have to.

The licensed mechanic returned to the tarmac and met the AME at the nose of the plane, where they chatted for a few minutes. The pushback tug was already in place. The licensed mechanic ended the conversation saying he needed to return to the adjacent bay to finish refueling the other aircraft.

The AME was left to perform headset duties for the pushback, where a tug pushes the aircraft backwards from the terminal until the aircraft is clear and can taxi under its own power.

Bay 81 security footage showing SQ256 4 minutes before pushback

In the adjacent bay, an aircraft refueler looked the other way to see the Singapore Airlines A350 appear ready to push back with the pitot blankets still in place.

Security footage shows that when the chartered engineer arrived at the adjacent bay, the aircraft’s refueler pointed to the A350, informing him that the pitot covers had not been removed.

Security footage of the tanker pointing to the A350

At the same time, the flight crew requested approval for the pushback from air traffic control and turned on the aircraft’s beacons.

The fired engineer had to back away at full speed, as he arrived at the bay just as the aerobridge began to retract from the aircraft.

The flight crew told the AME they were ready for pushback. The AME asked the flight crew to stand by.

The chartered engineer quickly positioned a raised work platform on either side of the nose to remove the pitot covers. There were only two minutes left before the scheduled departure time.

LAME removing pitot blankets 1 minute before departure time

As soon as the cowlings were removed, the tug began to push the A350 back.

Obviously, we have to wait for the final report; however, it looks like there are no surprises here. The maintenance, repair and overhaul contractor should definitely be criticized. The LAME did not follow procedures, they just assumed the job had been done correctly. He may have gotten away with it already, except the AME was new to the job and still learning the ropes.

The ATSB’s preliminary report was released in August. The Director of Transportation Safety makes a statement regarding the ongoing investigation.

From there, the investigation will include reviewing flight crew pre-flight inspection procedures, final technical inspection procedures, and induction training procedures. It will also review engineer training records, fatigue and change management policies and procedures, and other safety video recordings.

In other words, they look for systemic issues and whether the training and procedures are adequate or whether this was an incident just waiting to happen. The investigation level is listed as “short”.

As for the flight crew’s pre-flight inspection procedures, the co-pilot’s visit did not actually affect the incident, as the pitot covers were still expected to be in place at the time. However, the video of his truncated walk was already highlighted in the preliminary report.

A the previous ATSB investigation in Brisbane involved a Malaysia Airlines Airbus A330 which took off with three pitot blankets still in place. The ATSB described it as one of its largest and most complex investigations in recent years. This report also showed that pre-departure checks and inspection rounds were omitted or incomplete. In response to this incident, Maylasia Airlines added the requirement to place a warning placard on the cockpit to alert the flight crew to the installation of pitot covers.

As we saw in this case, it didn’t actually fix the underlying problem.

This incident was dealt with just in time, but I hope the supply man got a raise or at least a few beers on the company!

About admin

Check Also

What are Scandinavian Airlines’ oldest active aircraft?

Scandinavian Airlines (SAS) is known for being the flag carrier of Denmark, Norway and Swedenand …