A Qantas Boeing 787-9 Dreamliner flew from Melbourne to Los Angeles in 2021 with tape covering four fan cowl static ports. This was despite a Qantas engineer placing “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).
Four static probes left covered on Qantas Dreamliner
On Tuesday, the ATSB released its findings concerning the September 22, 2021, incident. The aviation safety agency found the aircraft departed with reduced redundancy to the engine electronic control system because the coverings were left intact. 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.
Locations of the various static ports on the Boeing 787-0 Dreamliner. Photo: Cooper Simmons/ATSB
Luckily, an uneventful flight to LAX
Around 09:00 the Dreamliner took off and set course for LAX. Flying time across the Pacific was 14 and half hours. The flight was described as “uneventful.” 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.
Before flying out of Melbourne, VH-ZNJ 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, nor did they check.
The static ports were still covered however, the remains of the ‘tail’ can be seen in the images. In addition, the images show that the inboard port covers had the tail oriented up with the outboard covers oriented down. Photo: Qantas/ATSB
Second officer fails to see covered static ports
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. Further, 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 either 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 on Tuesday. “While the flight was uneventful, the covered ports meant redundancy for the engine electronic control system was reduced.”
A Qantas diagram detailing the pre-flight exterior Boeing 787-9 inspection route. Image: Qantas/ATSB
The ATSB strikes a benign tone in its findings
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.
The ATSB made several findings regarding September’s incident. 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.
Boeing static port cover procedure. Source: Boeing/ATSB
Action taken by Qantas
The ATSB reserved somewhat harsher judgment for the unfortunate second pilot and Dnata dispatcher. The ATSB said the second officer’s inspection was “non-normal.” The safety agency also said the dispatcher did not conduct their exterior inspections per the documented procedures.
“This was a missed opportunity to assist engineers to readily access the current procedures and determine which ports were covered, and also allowed for different interpretations of which ports could be covered,” Mr Macleod said.
“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.’
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