WHAT INVESTIGATIONS FOUND
In the incident involving SIA’s jet, it was found that the airline’s contracted engineering provider at Brisbane, Heston MRO, had yet to implement “an acceptable method for accounting for tooling and equipment prior to aircraft pushback”.
“Additionally, the procedural risk controls which were in place for the removal of the pitot probe covers were circumvented when the licensed aircraft maintenance engineer 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 engineer or headset operator also did not perform the final walk-around inspection of the aircraft to ensure that it was correctly configured for flight with all panels and doors closed, and 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,” Mr Mitchell said.
The investigation also noted that the engineer had reported that his workload in his dual role as an aircraft maintenance engineer and regional manager had become “considerably more demanding” following the COVID-19 pandemic.
Heston MRO did not track the work-related hours of personnel with dual roles like the engineer involved in this incident for fatigue calculation purposes, Mr Mitchell said.
“This meant there was an increased risk of a fatigue-related incident with these personnel,” he added.
However, the bureau was unable to formally establish that fatigue contributed to what happened.
It also found that the pitot probe covers fitted to the aircraft were about 3m above eye level and had relatively short streamers that were not clearly visible. Streamers are flags or ribbons attached to pitot covers and are intended to alert personnel of their presence.
