Aviation safety investigations & reports

Air data system failure involving Airbus A330-243, A6-EYJ, near Brisbane Airport, Qld on 21 November 2013

Investigation number:
AO-2013-212
Status: Completed
Investigation completed

Final Report

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What happened

On 21 November 2013, after a flight from Singapore, an Etihad Airways Airbus A330, A6-EYJ landed at Brisbane airport and was taxied to the terminal. Approximately 2 hours later, the aircraft was pushed-back from the gate for the return flight to Singapore.

The captain rejected the initial take-off attempt after observing an airspeed indication failure on his display. The aircraft taxied back to the terminal where troubleshooting was carried out, before being released back into service.

During the second take-off roll, the crew became aware of an airspeed discrepancy after the V1 decision speed and the take-off was continued. Once airborne, the crew declared a MAYDAY and decided to return to Brisbane where an overweight landing was carried out.

What the ATSB found

Engineering inspection after the overweight landing found that the Captain’s pitot probe was almost totally obstructed by an insect nest, consistent with mud-dauber wasp residue. The pitot obstruction had occurred during the 2 hour period that the aircraft was on the ground at Brisbane and was not detected during troubleshooting after the initial rejected take-off.

What's been done as a result

The aircraft operator has changed its policy on the use of pitot covers. They are now required to be used on all transits at Brisbane Airport, regardless of ground time.

The aircraft manufacturer has amended its maintenance troubleshooting manual to increase the likelihood that a blocked pitot probe will be detected.

The airport operator has extended its wasp inspection and eradication program and reviewed and updated its Wildlife Hazard Management Plan.

In addition, CASA has drawn attention to the safety implications of mud wasp activity through several publications.

Safety message

Operators can minimise the risk of pitot probe obstruction by consistently using pitot covers even during short transit periods.

Standard operating procedures include the cross-checking of airspeed during the take-off roll. These checks are an important last line of defence in preventing an aircraft from becoming airborne with airspeed indication problems.

Download Final Report
[Download  PDF: 2.39MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Photo

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Safety Issue

Go to AO-2013-212-SI-01 -

Identification of pitot probe in the trouble shooting manual

The relevant tasks in the trouble shooting manual did not specifically identify the pitot probe as a potential source of airspeed indication failure.

Safety issue details
Issue number: AO-2013-212-SI-01
Who it affects: Maintenance engineers
Status: Adequately addressed
General details
Date: 21 November 2013   Investigation status: Completed  
Time: 13:50 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Brisbane Airport    
State: Queensland   Occurrence type: Avionics/flight instruments  
Release date: 06 May 2016   Occurrence class: Technical  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A330  
Aircraft registration A6-EYJ  
Serial number 737  
Operator Etihad Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Brisbane, Qld  
Destination Singapore  
Last update 14 November 2018