Background
On 27 May 2022, a Singapore Airlines Airbus A350-941, registered 9V-SHH, was being prepared for a regular public transport flight from Brisbane Airport, Queensland to Changi Airport, Singapore. Just prior to pushback, a refueller on an adjacent bay noticed that the pitot probe covers were still fitted and informed the licenced aircraft maintenance engineer (LAME) responsible for the turnaround. The covers were subsequently removed just before pushback.
Findings
The Australian Transport Safety Bureau (ATSB) found that procedural risk controls for the removal of the pitot probe covers were circumvented. A LAME certified the removal of the covers in the technical log and removed a warning placard from the flight deck without visual or verbal confirmation that the covers had been removed. The LAME reported having assumed, rather than verified, that the covers were removed by an aircraft maintenance engineer (AME). The AME, new to the organisation, had been instructed not to remove the covers without direction from a LAME. No such direction or visual check occurred. Closed-circuit television footage showed the LAME removing the placard and placing it in their work vehicle while the covers remained on the aircraft.
A final walk-around of the aircraft by maintenance personnel to ensure correct configuration for flight was also not conducted. The ATSB also found that the majority of flight crew pre-flight inspections observed around the time of the occurrence, including for the occurrence flight, were truncated and not undertaken in accordance with company procedures.
The Heston MRO tool control requirements for the transit toolbox were not an effective method for accounting for tooling prior to aircraft dispatch. Checks were performed at the end of a shift rather than before pushback. This safety issue had been previously identified in ATSB investigation AO-2018-053, and although Heston MRO had advised the ATSB of a procedural change, it had not been implemented by May 2022.
Heston MRO did not track the work hours of personnel with dual roles for fatigue management purposes, despite a policy requirement to do so.
The pitot probe covers were fitted approximately 3 m above eye height and had relatively short streamers, making them inconspicuous and limiting the chance of incidental detection.
Actions Taken
Heston MRO no longer requires the Brisbane regional manager position to undertake dual responsibilities that included aircraft maintenance certification. The company now tracks the work hours of all employees for fatigue management purposes. Singapore Airlines communicated with flight crew about the requirements of their pre-flight walk-around checks and provided Heston MRO at Brisbane with pitot probe covers with longer streamers for better conspicuity.