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Pitot probe covers focus of safety advisory notice for operators at Brisbane Airport, Australia
30 August 2018

Pitot probe covers focus of safety advisory notice for operators at Brisbane Airport, Australia

The ATSB has issued a safety advisory notice to all operators flying to Brisbane Airport, Australia, to consider the use of pitot probe covers there and to have rigorous processes in place to confirm the covers are removed before flight.

The release of the safety advisory notice comes after the publication of the ATSB’s preliminary report into an airspeed indication failure on take-off involving a Malaysia Airlines Airbus A330-300 at Brisbane Airport on 18 July 2018.

The ATSB found that local engineering support crew placed covers on the pitot probes soon after the previous landing. Inspections during the aircraft’s turnaround did not identify their fitment and they remained on the aircraft for its departure. This resulted in unusable airspeed information being displayed to the flight crew. The flight crew continued the take-off and carried out several checklists before returning to Brisbane Airport.

Several high-capacity aircraft have departed from Brisbane with one of the pitot probes blocked by insect nests in recent years, including two that resulted in rejected take-offs investigated by the ATSB.

The airport has had a wasp eradication program since 2006 and the Civil Aviation Safety Authority and Airservices Australia have issued advice about the risk they pose, with some operators now using pitot probe covers for short turnarounds.

Aircraft about to be pushed back with pitot covers in place (two of three visible)

 

EASA issues safety bulletin on proper ground de-icing of aircraft following several incidents

The European Aviation Safety Agency (EASA) issued a safety bulletin to remind authorities and operators that personnel involved in the process of ground de-icing of aircraft should be aware of the importance of conducting effective de-icing procedures.

The bulletin was issued in response to several incidents where improper ground de-icing of the incident aircraft was a factor. One of those incidents occurred in November 2016 when a Swedish Avro RJ100 returned to land at Gothenburg Airport after encountering severe control issues after takeoff. It was concluded that the aircraft suffered vibrations due to the unbalance of the elevator system that arose due to ice contamination. As the report states: “It is apparent from the investigation that the personnel who were to inspect the aircraft prior to the flight did not detect all ice contamination, which meant the de-icing order did not cover all of the ice contamination, and that there were shortcomings in the de-icing actually carried out.
The incident was partly caused by the fact that the operator lacked enough detailed procedures for performing a complete contamination inspection, and that the existing routine’s was not fully applied, partly by the fact that the operator had not properly checked, evaluated and controlled the subcontractor’s working methods.
A contributing factor was that the de-icing operation had insufficient organisational support to help the staff to resist requests of departure on time and to ensure that the de-icing was properly executed despite actual or experienced time shortage.”

Consequently, EASA issued four recommendations to authorities and operators:

  1. EASA recommends that air operators take note of this SIB, ensure that training of the involved personnel is conducted in accordance with the applicable procedures, and check their competency.
  2. EASA recommends that air operators allow suitable time and ensure adequate visibility conditions for the de-icing personnel to properly conduct the de-icing of the aircraft, including the post de-icing checks.
  3. EASA recommends that air operators disseminate the SIB to their contracted ground de-/anti-icing service providers and pay particular attention to the above-mentioned recommendations during their audits by checking compliance of the ground de-icing service providers with their training syllabi and operations manuals. This process should be captured through the operator’s management system.
  4. EASA recommends that NAAs pay particular attention to the above-mentioned recommendations in their oversight programmes.

 

EASA warns airports after incidents: dark coloured aircraft may not be recognised by parking systems

The European Aviation Safety Agency (EASA) issued a bulletin, recommending airport operators to determine if the docking systems may encounter problems in identifying aircraft due to their colour.

This recommendation was issued in the light of an incident in Lisbon, Portugal in May 2015. An Airbus A320 operated by Brussels Airlines arrived at the parking stand at Lisbon Airport but was not identified by the automatic guidance system. The Aircraft Positioning and Information System (APIS) is a laser-based technology, which identifies and guides the aircraft to stop at the correct point corresponding to the aircraft type. The APIS system did not identify the aircraft and failed to give information to the pilot to stop at the position corresponding to the type of aircraft (A320).
The aircraft stopped a few meters ahead having struck the jetbridge with the nacelle of engine # 1.

An investigation showed that the APIS system did not recognize the aircraft because of the dark color of its painting. The aircraft carried a special Tintin colour scheme.

EASA states that Brussels Airlines after this occurrence, found that similar occurrences have happened around the world.

 

 

FAA issues safety alert on procedures for addressing odors, smoke and/or fumes in flight

The U.S. Federal Aviation Administration (FAA) issued a Safety Alert for Operators (SAFO) bulletin on procedures for addressing odors, smoke and/or fumes in flight.

The SAFO highlights the need to enhance flight crew procedures that mitigate the risk to passengers and crew in the event of odors, smoke and/or fumes.

More info:

EASA issues recommendations to operators on carriage of large Personal Electronic Devices

FAA fire test of laptop battery thermal runaway with aerosol can in suitcase.

On 5 April 2017, EASA published SIB 2017-04 to alert operators on the risks associated with the carriage of Portable Electronic Devices (PEDs) in the checked baggage, and to recommend mitigating actions when the carriage of large PEDs in the cabin is prohibited. PEDs containing lithium batteries carried by passengers should be carried in the passenger cabin, to enable the crew to react expeditiously in case an incident involving such a PED occurs.

Recent testing performed by the FAA showed that if a thermal runaway event occurs to a large PED carried in a checked baggage together with flammable materials, such as hair spray, there is a poor chance that a Class D cargo compartment could contain the resulting fire, and a fair to poor chance that a Class C cargo compartment could contain it.

Based on this, EASA now recommends operators to:

  • Inform passengers that large PEDs should be carried in the passenger cabin whenever possible;
  • Request passengers to ensure that any large PED that cannot be carried in the passenger cabin (e.g. due to its size), and therefore has to be carried in checked baggage, is:
    – Completely switched off and effectively protected from accidental activation. To ensure the device is never powered on during its transport, any application, alarm or pre-set configuration that may activate it shall be disabled or deactivated;
    – Protected from the risk of accidental damage by applying suitable packaging or casing or by being placed in a rigid bag protected by adequate cushioning (e.g. clothing);
    – Not carried in the same baggage together with flammable material (e.g. perfumes, aerosols, etc.);
  • Make the carriage of large PEDs in checked baggage in Class D cargo compartments subject to measures effectively mitigating the associated risks.

Furthermore, where carry-on bags are put in the hold (e.g. due to the lack of space) operators are reminded to ensure that passengers are requested to remove from the bag any spare batteries or e-cigarettes.

More info:

 

Busy phone lines, poor coordination factors in Aeroflot A321 serious airprox incident, Venice, Italy

Loss of situational awareness after intrument failure cited in fatal Swedish CRJ-200 accident

Italian safety agency issues safety recommendations for drones

The Italian National Agency for Flight Safety (ANSV)  issued five safety recommendations to reduced the safety risks of the operation of drones in Italian airspace.

Over the year 2015 the ANSV received 18 reports of unmanned vehicles interfering with flight operations in civil airspace, a sharp increase compared to previous years.

As a result of further investigation of these cases and meetings with aviation industry stakeholders, ANSV published five safety recommendations:

  1. The Italian Civil Aviation Authority (ENAC) should create a register for all small unmanned aircraft, comparable to the register recently initiated by the U.S. Federal Aviation Administration,
  2. ENAC should start an information campaign, aimed at encouraging the development of an aeronautical culture among drone users,
  3. The Interior Ministry and Italian Municipalities should raise awareness among local police forces to sanction in an effective, fair and prompt way those drone operators who violate existing legislation.
  4. ENAC should, in coordination with the Ministry of Economic Development, consider the installation of geofencing software on drones, which automatically limits in areas where the use of drones is not allowed.
  5. ENAC should, in coordination with the Ministry of Economic Development, and the Aero Club of Italy, evaluate the possibility of identifying specific frequency bands to be allocated for professional drone use.

More information:

EASA recommends MD-11 operators to install system to prevent bounced landings

The European Aviation Safety Agency (EASA) recommends MD-11 operators to install a landing gear Struts Extended Annunciation System (SEAS) to prevent bounced landing accidents.

In the light of several bounced landing accidents involving MD-11 aircraft, Boeing developed a system which gives additional information about the aeroplane’s air/ground status to pilots during landing. The so called landing gear Struts Extended Annunciation System (SEAS) illuminates dedicated lights on the glare shield in front of both pilots when the main landing gear struts are close to, or are at full extension. In this way, pilots are more aware if a bounce has occurred, and control inputs can be made which will avoid the bounce developing into a more serious event.

EASA recommends operators to install the Landing Gear SEAS per Boeing SB MD11-32-093 (or its equivalent which matches the specific aeroplane cockpit) as mitigation for the risk of inappropriate control inputs after bounced landings. This should be combined with enhanced training using amended FCOM procedures and special maintenance tasks provided by the Boeing Company.

A system to show the landing/strut gear touchdown status was first recommended by the Japanese TSB in April 2013. This recommendation followed the investigation into a fatal MD-11F accident at Tokyo-Narita Airport, Japan, in March 2009. Both pilots died when the left wing fractured following a bounced landing. The airplane rolled over and a fire erupted.

More information:

MD-11F accident sequence at Tokyo-Narita, 2009 (JTSB)

MD-11F accident sequence at Tokyo-Narita, 2009 (JTSB)

FAA urges airlines to assess lithium battery risks

A DC-8 cargo fire in 2006 was likely caused by lithium batteries

A DC-8 cargo fire in 2006 was likely caused by lithium batteries

The U.S. Federal Aviation Administration (FAA) issued a safety alert to U.S. and foreign commercial passenger and cargo airlines, urging them to conduct a safety risk assessment to manage the risks associated with transporting lithium batteries as cargo.

The FAA also is issuing guidance to its own inspectors to help them determine whether the airlines have adequately assessed the risk of handling and carrying lithium batteries as cargo.

FAA battery fire testing has highlighted the potential risk of a catastrophic aircraft loss due to damage resulting from a lithium battery fire or explosion. Current cargo fire suppression systems cannot effectively control a lithium battery fire. As a result of those tests, the International Civil Aviation Organization (ICAO) and aircraft manufacturers Boeing and Airbus have advised airlines about the dangers associated with carrying lithium batteries as cargo and also have encouraged them to conduct safety risk assessments.

Hazardous materials rules currently ban passenger airlines from carrying lithium-metal batteries as cargo. In addition, a number of large commercial passenger airlines have decided voluntarily not to carry rechargeable, lithium-ion batteries. The safety risk assessment process is designed to identify and mitigate risks for the airlines that still carry lithium batteries and to help those that don’t carry them from inadvertently accepting them for transport.

The SAFO  encourages airlines that previously conducted safety assessments to reevaluate them in light of new evidence from the agency’s recent lithium battery fire tests.

More information: