ASN Wikibase Occurrence # 364474
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| Date: | Friday 27 May 2022 |
| Time: | 09:20 |
| Type: |  Airbus A350-941 |
| Owner/operator: | Singapore Airlines |
| Registration: | 9V-SHH |
| MSN: | 316 |
| Year of manufacture: | 2019 |
| Engine model: | Rolls-Royce Trent XWB-84 |
| Fatalities: | Fatalities: 0 / Occupants: |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | Brisbane -
 Singapore
|
| Phase: | Standing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Brisbane International Airport, QLD (BNE/YBBN) |
| Singapore-Changi International Airport (SIN/WSSS) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
Singapore Airlines flight SQ256, an Airbus A350-941, was being prepared for a flight from Brisbane Airport to Changi Airport, Singapore. Just prior to the aircraft being pushed back for departure, a refueller on an adjacent bay informed the licenced aircraft maintenance engineer responsible for the aircraft turnaround that the pitot probe covers were still fitted. Subsequently, the covers were removed just before pushback.
Contributing factors
- The licenced aircraft maintenance engineer certified for the removal of the pitot covers in the technical log and removed a warning placard from the flight deck without visual or verbal confirmation that the pitot covers had been removed.
- Heston MRO had not yet implemented a previously proposed and accepted method to account for tooling and equipment (such as pitot probe covers) prior to aircraft pushback. (Safety issue)
- Maintenance personnel responsible for the aircraft departure did not conduct a final aircraft walk-around inspection. That inspection was the last procedural opportunity to identify that the pitot covers had not been removed.
Other factors that increased risk
- The licenced aircraft maintenance engineer was undertaking dual roles as both regional manager and engineer. This increased the risk of a fatigue-related maintenance error occurring as a result of a significantly expanded workload in the months that preceded this incident.
- Heston MRO did not track the work-related hours of personnel with dual management and operational roles (including the licenced aircraft maintenance engineer) for fatigue calculation purposes. Therefore, there was an increased risk of a fatigue‑related incident involving those personnel. (Safety issue)
- The majority of Singapore Airlines flight crews (observed around the time of the incident) did not fully complete the required pre-flight walk-around inspections. (Safety issue)
- Although suitable for use in most situations, the streamers attached to the pitot probe covers used for the Airbus A350 operations at Brisbane Airport provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds. (Safety issue)
Accident investigation:
 |
|
Sources:
ATSB
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 19-Mar-2024 15:26 | ASN | Added |
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