Back in 2021, a Qantas Boeing 787-9 Dreamliner flew transpacific from Melbourne to Los Angeles
with tape covering four fan cowl static ports. This was despite a Qantas engineer
placing quote-unquote "remove before flight" barricade streamer tape on the covered static
ports the day before the flight. While the 14-plus-hour flight was uneventful,
the incident triggered an investigation by the Australian Transport Safety Bureau (ATSB).
On Tuesday, the ATSB released its findings concerning the September 22, 2021, incident.
Let’s take a look at this full incident in today’s video!
The aviation safety agency found the aircraft departed with reduced redundancy to the engine
electronic control system because the coverings were left in place. The ATSB
also found that Qantas' own procedures did not identify all of the aircraft's static ports,
and the procedure for restoring the plane back to service did not reference Boeing procedures. This
allowed different interpretations of which ports would be covered.
The incident involved VH-ZNJ, which was due to fly a freight flight from Melbourne (MEL) to Los
Angeles (LAX) on September 22. The night before, an engineer prepared the aircraft for the flight.
This preparation included removing covers from the pitot probes and static ports. The following
morning, before departure, one of the flight crew conducted a pre-flight exterior inspection,
with no anomalies detected. The aircraft was also subject to a pre-departure exterior
inspection by ground service dispatch personnel.
Around 09:00 the Dreamliner took off and set course for LAX. Flying time
across the Pacific was 14 and a half hours. The flight was described as "uneventful." Indeed,
it was only during the post-flight inspection that the covered static ports were discovered.
Static ports provide important air pressure data to aircraft systems,
but the fuselage static ports and vertical fin static ports
play the primary role. The fan cowl static port air pressure data is only used when an aircraft's
engine electronic control determines that the data coming from the other static ports is unreliable.
Let’s take a look at the series of events that transpired before the flight
and how this led to the mistake.
Before flying out of Melbourne, the Boeing 787-9 had sat idle for 39 hours. When an aircraft sits
on the ground between 24 and 72 hours, Qantas requires it to be subject to 'normal' parking
procedures. These parking procedures include fitting pitot covers and covering the static
ports, in accordance with Boeing recommendations. The Boeing 787-9 has six fuselage, four engine fan
cowl, and four vertical fin static ports. On the evening of September 21, a licensed
aircraft maintenance engineer (LAME) was tasked to return the Dreamliner to flight status.
This included uncovering the pitot and fuselage static ports and completing the other maintenance
tasks. The LAME was unaware that the fan cowl ports had been covered earlier, but also didn’t
check to see if they were covered or uncovered during their job to prepare the 787 for flight.
Another LAME was tasked to complete the return to service procedure the next morning.
But the LAME did not inspect the aircraft, nor were they required to as part of this procedure.
The certificate of release to service was signed off ahead of the flight crew arriving. Taking the
plane to Los Angeles was a captain, two first officers, and two second officers. The captain
tasked one of the second officers to conduct the pre-flight exterior inspection.
The second officer commenced the exterior inspection at the aircraft's nose,
in line with standard procedures. The pilot found a pitot cover on the apron but could
not establish whether that cover came from VH-ZNJ or another plane. The pilot gave the cover to an
engineer who was also out on the apron. Back in the cockpit, the second officer mentioned
the cover found on the ground but reported no other problems, and the inspection completed.
Just before pushback, a contracted Dnata dispatcher conducted their
walk-around inspection and also did not notice the four covered static ports.
The dispatcher gave the all-clear and the jet departed within minutes.
Melbourne Airport CCTV footage revealed the fan cowl static port covers could be seen in
certain views. Additionally, one of the LAMEs and an aircraft maintenance engineer (AME)
walked past the engines several times while completing other maintenance tasks.
However, there was no indication that either mechanic specifically looked at the engine
fan cowl. The CCTV footage also showed the second officer and the dispatcher did not conduct their
exterior inspections in line with the documented procedures and exterior inspection route.
"The tape on the engine fan cowls was not removed by that engineer,
as per the manufacturer's procedures, and this wasn't identified by flight crew or dispatch
during pre-departure checks," said ATSB Director Transport Safety Stuart Macleod
earlier this month when reporting on the investigation’s findings.
"While the flight was uneventful, the covered ports meant redundancy for
the engine electronic control system was reduced."
Worryingly, a similar incident occurred in Australia four years ago.
In July 2018, a Malaysia Airlines A330-300 left Brisbane (BNE) with its three pitot
probes covered and almost immediately began getting unreliable airspeed indications.
The Airbus was able to turn around and land safely with assistance from Brisbane ATC.
Unrelated to aircraft coverings but definitely connected in terms of
pre-flight aircraft preparation, a June 2021 incident resulted in a Qantas 787
being unable to retract its main landing gear on a flight from Sydney to Perth.
The subsequent ATSB investigation found the failure to remove two of the five downlock
pins before departure prevented the main landing gear from retracting after takeoff. Furthermore,
the pins were also not identified during subsequent preflight inspections.
The results of the investigation of this incident found that it was due
to a combination of miscommunication, inexperience, & misunderstandings.
One issue included incomplete checks of the pins and their storage in the 787’s electrical
equipment center, using a ladder that was too short to visually check the presence of all five
pins! Instead of confirming visually, crews simply reached up into the electrical equipment center
and felt around to ensure all pins were present. Clearly counting and “feeling around” incorrectly.
Going back to the September 2021 incident, the ATSB made several findings. The agency
noted the meter-long tail of the 'remove before flight' tape covering the static ports
was stuck down to prevent it from being torn from the fuselage in strong winds,
as per Boeing's recommended procedure.
"This likely reduced the visibility of it covering the fan cowl static port covers,"said
Mr Macleod. The ATSB notes Qantas' maintenance procedures required the static ports to be covered
but did not specify the locations, allowing potentially different
interpretations of the procedure between LAMEs/engineers. In addition,
the emphasis of the warnings was more in line with the fuselage static ports,
rather than possible issues associated with the fan cowl or vertical fin covers not being removed.
"When performing safety‑critical tasks like aircraft maintenance,
it is very important that procedures are clear and unambiguous to avoid misinterpretation and
error such as occurred in this incident." Qantas has since made some changes to how
their engineers and flight crews deal with aircraft inspections,
including issuing an internal memo issued to flight operations
detailing the fan cowl static ports and that they may be covered during parking. In addition,
the memo noted that engineering may not necessarily conduct an exterior
inspection before dispatch and highlighted the importance of flight crew vigilance 'to ensure
they are an effective last line of defense in assessing the aircraft's readiness for flight.'
At the start of this year, Australian media outlet
7News reported that Qantas had lost its top rank as one of the world’s safest airlines.
Qantas held the title of world’s safest airline from 2014 to 2017,
as well as 2019 to 2021. The most recent ranking for Qantas had the airline come in seventh place,
reportedly due to a “slight increase in incidents coupled with the fleet age.”
The media outlet noted that in October 2021, a Qantas jet traveling from Perth
to Adelaide in Western Australia was diverted due to a fuel imbalance- an
occurrence classified as a “serious incident”. It’s uncertain if the other incidents in 2021
factored in to the airline’s most recent ranking on AirlineRatings.com. However, due
to the presence of human error in many of these situations, it wouldn’t be surprising if they did.
Qantas currently operates a fleet of 11 Boeing 787-9 Dreamliner aircraft.
These have an average age of just over three and a half years. And although the airline is
expecting an additional three more 787s, the arrival of these additional aircraft
won’t exactly lower this sub-fleet’s average age. That’s because the three undelivered 787s
have already been built but are undeliverable due to Boeing’s production and delivery issues-
issues that are being worked through with the Federal Aviation Administration- or FAA.
What do you think of this incident? Does this affect your opinion of Qantas
and their safety record? Share your opinion with us by leaving a comment!