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NTSB: CV-440 in fatal 2019 crash stalled on approach to Toledo
3 September 2022

NTSB: CV-440 in fatal 2019 crash stalled on approach to Toledo

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ATSB publishes final report on A330 that took off with pitot covers attached

The Australian Transport Safety Bureau (ATSB) has released the final report from its investigation into a serious incident where a Malaysia Airlines Airbus A330 with 229 on board took off from Brisbane Airport with no airspeed information.
Shortly after the aircraft arrived in Brisbane from Kuala Lumpur on 18 July 2018, a support engineer placed covers on the aircraft’s three pitot probes (airspeed sensors) to prevent them from being blocked by mud wasps, a known hazard at Brisbane Airport.
However, during the turnaround and before the aircraft departed for the return flight to Kuala Lumpur the covers were not removed. This was despite there being requirements for multiple walk-around checks by the aircraft captain, engineer and dispatch coordinator, all intended to identify unsafe conditions such as the fitment of pitot probe covers.
Consequently, the aircraft’s primary instrument displays showed red speed flags in place of airspeed indications from early in the take-off, and the flight crew did not respond in time for the take-off to be safely aborted.
Once airborne the flight crew climbed the aircraft to 11,000 ft where they performed troubleshooting and other procedures, including shutting down the aircraft’s air data systems. This activated a system installed on some Airbus aircraft called the back up speed scale (BUSS), which displayed a safe flight envelope for flight crew to maintain.
Using the BUSS and airspeed management procedures, and assisted by air traffic control, the flight crew brought the aircraft safely back to Brisbane.

On the night, several individuals from different organisations had separate, key roles in detecting aircraft damage or other unsafe conditions such as the fitment of pitot probe covers. However, these checks were omitted entirely or only partially completed, for a variety of reasons including inadequate communication and reduced diligence.
Malaysia Airlines had recently reintroduced flights to Brisbane, and although the wasp risk was identified, the use of pitot probe covers was not required or controlled. Shortly after the occurrence, the ATSB issued a safety advisory notice (SAN) to operators who fly to Brisbane Airport to consider the use of pitot probe covers and, where they are used, ensure there are rigorous processes for confirming they are removed before flight.
The ATSB also uncovered a range of deeper issues, including coordination among the involved organisations, that allowed front-line problems to emerge.
For flight crew, the occurrence also highlights the importance of vigilance, communications, and decision-making in adverse circumstances.
The ATSB found that surprise, uncertainty, time pressure, and ineffective communication between the two pilots during the take-off probably led to stress and high cognitive workload. This reduced their capacity to interpret the situation and make a decision early enough to safely reject the take-off.

In response, the ATSB has issued a safety advisory notice (SAN) advising manufacturers and operators of all large transport aircraft to consider what types of unreliable airspeed events can occur, how the information is presented to pilots, and what responses are the safest in different phases of the take-off and in a range of potential situations.
All of the relevant organisations have contributed to the large number of safety actions taken in response to the incident and the ATSB’s investigation. For example, Malaysia Airlines now requires the placement of a placard on the flight deck as a visual alert that pitot probe covers are in place, and has introduced improvements to its change and risk management processes.
Airbus, meanwhile, has implemented additional flight crew training standards about unreliable airspeed on take-off, added guidance to the flight crew techniques manual on the importance of airspeed monitoring on take-off, and has commenced a review of airspeed indications in A330 and other aircraft types.
The ground handling and engineering companies involved in the incident have also made system and process improvements, and the airport information provided to pilots has been amended.

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