Aviation safety investigations & reports

Airspeed indication failure on take-off involving Airbus A330, 9M-MTK Brisbane Airport, Queensland, 18 July 2018

Investigation number:
AO-2018-053
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On the night of 18 July 2018, a Malaysia Airlines Airbus A330, registered 9M-MTK, took off on a regular public transport flight from Brisbane, Queensland to Kuala Lumpur, Malaysia. There were 14 crew and 215 passengers on board. Covers had been left on the aircraft’s three pitot probes (airspeed sensors). The instruments showed a red speed flag in place of the airspeed indication from early in the take‑off, and unrealistically low airspeeds afterwards.

The flight crew did not respond to the speed flags until the aircraft’s speed was too high for a safe rejection of the take-off, and the take‑off was continued. The flight crew’s initial radio announcement of an urgency situation was not heard by the air traffic controller.

The flight crew climbed to 11,000 ft and circled while performing troubleshooting and other procedures, which led to the shutting down the aircraft’s air data systems. Doing so activated the back up speed scale (BUSS), a safety function that displayed safe flight envelope information to the flight crew in lieu of airspeed. Using this system, airspeed management procedures, and assistance from air traffic control, the flight crew conducted an approach and landing at Brisbane.

For technical reasons, the main landing gear doors did not retract and were slightly damaged on landing. Also, nose wheel steering was not available and the aircraft remained on the runway for a short period before being towed to the gate.

What the ATSB found

The ATSB identified safety factors across a range of subjects including flight deck and ground operations, aircraft warning systems, air traffic control, aerodrome charts, and risk and change management.

Ground operations and pre-flight walk-arounds

In accordance with a local informal procedure and recommended practice, a support engineer placed covers on the aircraft’s three pitot probes (airspeed sensors) to prevent them from becoming blocked by wasp nests (a particular hazard at Brisbane Airport). The operator’s certifying engineer, who was primarily responsible for the aircraft’s airworthiness, did not initially know about the covers due to a miscommunication with the support engineer who had fitted them.

The flight crew, engineers, and dispatch coordinator were required to conduct various pre‑departure checks, meant to identify aircraft damage or other unsafe conditions such as the fitment of pitot probe covers. However, these checks were omitted entirely or only partially completed, for a variety of reasons including inadequate communication and reduced diligence. On other turnarounds from the same operator, some flight crew, engineering, and dispatch walk-around checks were also omitted or incomplete.

The certifying engineer saw the covers early in the turnaround but later forgot about them, and there was ambiguity around the division of responsibilities with regard to the final walk-around portion of the transit check.

The support engineer who had fitted the pitot covers left to work on another aircraft and was unable to return before the occurrence aircraft was dispatched. There was no reliable method to ensure the return of tools and equipment before an aircraft departed.

The ATSB identified that the pitot probe covers used, which were different to those approved by the aircraft manufacturer, had streamers that were not prominent enough to be noticed by ground crews during incidental activities, including pushback, and so increased risk during turnarounds if other methods of ensuring their removal were not effective.

Flight operations

Surprise, uncertainty, time pressure, and ineffective communication between the two pilots during the take-off probably led to stress and high cognitive workload. The captain, as pilot monitoring, did not assertively announce the presence of a problem or clearly specify its nature when it was detected, delaying the first officer’s response. Then, although the captain and first officer attempted to convey information about the airspeed issues, there was limited coordination between them which reduced their capacity to interpret the situation and make a decision early enough to safely reject the take-off.

Pilots are trained to monitor airspeed on take-off, and Airbus recommends that pilots reject a take‑off if unreliable airspeed is identified early enough for this to be a safe action. However, take‑offs have sometimes been continued, or rejected at high speed, even with multiple airspeed anomalies. This suggests that the flight crews involved were not detecting unreliable airspeed early enough in the take-off, or if they did, other factors prevented or delayed a decision to reject the take-off.

Although the ATSB only examined Airbus occurrence statistics, these concerns are very likely to be relevant to other aircraft types. This is particularly important when aircraft and flight crews resume operations after a period of inactivity, due to increased likelihood of airspeed malfunction and limited flight crew recency.

The ATSB found that aircraft alerts related to unreliable airspeed were either not available during take-off, or were not prominent enough to gain both the flight crew’s attention in a manner that the presence and importance of the problem were both immediately apparent.

In addition, there was limited guidance provided to flight crews to aid in the detection and decision-making processes in response to unreliable airspeed indications. For example, there was no clear guidance to flight crews whether the failure of a single airspeed display should result in a rejected take-off when below a nominal speed, which can leave the flight crew in a difficult position when identifying such a problem when approaching the decision speed.

During and after the take-off, the flight crew attempted to troubleshoot the airspeed problem without first completing the required memory items, and they did not complete the After take-off/Climb procedure. However, their coordination and management throughout the rest of the flight was effective.

Once activated, the aircraft’s back-up speed scale (available on some Airbus aircraft) was highly effective in reducing flight crew workload.

Risk and change management

The operator had recently reintroduced flights to Brisbane, and although relevant risks were identified, risk controls were not implemented, including some that might have prevented the occurrence through a more controlled use of pitot probe covers. This was likely due to a combination of factors, including:

  • errors in the risk assessment itself
  • incomplete and unclear processes and guidance, which probably resulted in erroneous risk information not being reviewed, and
  • the organisation’s risk and action monitoring processes not being applied in this instance.

The operator’s change and risk management processes had insufficient information to assure their effective application, which enabled the review and oversight processes to be inadvertently circumvented. The change management process also omitted many elements of established practices.

What has been done as a result

Shortly after the occurrence, the ATSB issued a safety advisory notice (SAN) advising all operators that conduct flights to Brisbane Airport to consider the use of pitot probe covers and, if covers are used, ensure there are rigorous processes for confirming that covers are removed before flight.

Alongside the publication of this final investigation report, the ATSB issued a SAN encouraging all manufacturers and operators of larger air transport aeroplanes to consider what types of unreliable airspeed events can occur, how the information is presented to flight crews, and what responses are the safest in different phases of the take-off and in a range of potential situations. Aircraft alerting systems, flight crew procedures, and flight crew training should be designed to provide sufficient assurance that flight crews become aware of and understand how to appropriately respond to unreliable airspeed on take-off in a timely manner.

All organisations directly involved in the occurrence implemented safety action to address safety issues identified by the ATSB:

  • Malaysia Airlines:
    • added procedures requiring the placement of a placard on the flight deck as a visual alert for flight crews when pitot probe covers are fitted
    • made changes to engineering arrangements at Brisbane, reducing the likelihood of error
    • published a flight safety bulletin to flight crew about vigilance during walk-arounds
    • made numerous changes to the change and risk management processes.
  • Airbus:
    • implemented additional flight crew training standards about unreliable airspeed on take-off, including walk-arounds, airspeed monitoring, systems knowledge, and non-technical skills
    • added guidance to the flight crew techniques manual on the importance of airspeed monitoring on take-off
    • commenced a review of airspeed indications in A330 and other aircraft types.
  • Heston MRO implemented procedures to improve the consistency of pitot probe cover use and tool control measures.
  • Menzies Aviation implemented improvements to its internal auditing programme.

Safety message

There are several key safety messages that arise from this occurrence.

Despite the efforts of Brisbane Airport to manage wasp populations and reduce the incidence of nest-building in aircraft, it is unlikely that these wasps, and the hazard that they bring, will be eliminated. The population of mud wasps in the Brisbane area has probably already spread beyond the limits of practical control.

The loss of airspeed data due to mud wasp ingress can occur even after brief periods, and the use of pitot probe covers for aircraft turnarounds at Brisbane is largely an effective defence. However, it introduces another risk, which is the potential for aircraft to commence a take-off with pitot probe covers still fitted.

In locations where pitot probe contamination is possible, operators need to consider the use of pitot probe covers, while addressing the potential unintended consequences of using them. Mud wasps generally affect only one pitot probe, which can be detected early in a take-off if the flight crew are vigilant. Risk is increased considerably if the flight crew does not detect the problem in time to safely reject the take-off, or if they continue the take-off.

It is rare to see multiple pitot probe contamination on the same aircraft due to mud wasps, but when pitot probe covers are left on all probes are likely to be affected. It is important to have preventative processes and equipment to alleviate the introduced risk when using covers for pitot probes or other sensors, and to recognise that their use does not completely eliminate the risk of mud wasp infestation.

At first glance, an observer might be puzzled as to how multiple checks can fail to detect the fitment of pitot probe covers before flight, or how a flight crew can complete a take-off without any valid airspeed being displayed. This occurrence illustrates how a range of individually straightforward factors can combine to nullify multiple critical safety barriers.

For all individuals working in the aviation industry, the occurrence shows that coordination and diligence can make a difference. Several individuals on the night—as well as their counterparts on other occasions—all acted as though the conduct of various external aircraft inspections was someone else’s responsibility; in fact, all had separate, key roles in detecting problems with the aircraft before departure. Had all such inspections been conducted diligently it is very likely that the pitot probe covers would have been seen and subsequently removed.

Most of these problems could have been resolved with better communication. Nevertheless, the working environment allowed errors and miscommunications to occur and propagate because individual responsibilities and work processes were not well-defined.

For flight crew, the occurrence also highlights the importance of vigilance, communications, and decision-making in adverse circumstances. Had the flight crew reacted more quickly, the take-off could have been rejected at low speed. Flight crews need to bear in mind the typical symptoms associated with unreliable airspeed on take-off in order to detect this situation as early as possible and reject the take-off if still safe. If uncertain of the aircraft’s proximity to the decision speed when an anomaly is detected, Airbus flight crews should immediately apply full take-off thrust and attain 15° pitch attitude when they feel that the aircraft is close to the rotation speed to maximise aircraft performance.

However, the flight crew’s delayed response vividly illustrates the falsity of the assumption that flight crews will always act as expected. Accordingly, the contribution of aircraft warning and indication systems design, combined with flight crew training and guidance, must be considered. Flight crews need to have information presented in a way that the importance of an adverse event, and possibly the right decision, is immediately apparent.

From an organisational perspective, the occurrence shows how inconsistent approaches between multiple interacting organisations can have safety implications that are hard to predict. As the ATSB has stated before, it is important to ensure that procedures are harmonised to increase the likelihood that potential problems or mistakes are detected before causing harm. Local variations to procedures should be formalised to reduce the risk of the inconsistent completion of tasks, and to improve the organisation’s ability to identify and address potential safety concerns. In addition, with operators increasingly relying on external engineering and ground handling support, the ATSB encourages anyone in the aviation industry to identify procedural problems for review and enhancement.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

Appendix A – Airworthiness bulletin AWB 02-052: Mud Wasp Infestation – Alert (Issue 6)

Appendix B - Personnel information

Appendix C - Recorded data

Preliminary report

Preliminary report published: 30 August 2018

Sequence of events

On 18 July 2018 Malaysia Airlines Airbus A330-300, registered 9M-MTK, was scheduled to operate on a regular public transport flight from Brisbane, Queensland to Kuala Lumpur, Malaysia. The scheduled departure time was 2320 Eastern Standard Time.[1]

The aircraft had landed at Brisbane Airport at 2011, after a flight from Kuala Lumpur. The captain, first officer and certifying maintenance engineer from the previous night’s flight, who had been resting at a Brisbane hotel, arrived at the airport to commence their duties for the 18 July outbound flight.

Soon after the aircraft had landed, covers were placed on the aircraft’s three pitot probes.[2] Subsequent inspections during the turnaround did not identify the presence of the pitot probe covers and they were not removed prior to the aircraft’s departure (Figure 1).

Figure 1: Aircraft about to be pushed back with pitot covers in place (two of three visible)
Figure 1: Aircraft about to be pushed back with pitot covers in place (two of three visible). Source: Brisbane Airport Corporation. Image annotated by ATSB.Source: Brisbane Airport Corporation. Image modified by ATSB.

The first officer was the pilot flying (PF) and the captain was the pilot monitoring (PM).[3] Prior to aircraft pushback, the captain and first officer calculated the aircraft’s ‘V’ (critical) speeds for the take-off.[4] For this flight, the decision speed V1 (the maximum speed at which a rejected take-off can be initiated in the event of an emergency) was 153 kt and the rotation speed VR (when rotation should be initiated) was 160 kt.

The operator’s standard operating procedures for take-off required the PM to announce when the airspeed reached 100 kt and for the PF to cross check this airspeed indication.

The wind was calm and there was no cloud. At 2324, the flight crew commenced taxi for a take-off on runway 01. Subsequent events included:

  • 2331:05: The flight crew commenced the take-off roll.
  • 2331:38: The cockpit voice recorder (CVR) recorded that the captain called ‘100 knots’. The the aircraft’s recorded groundspeed at this time was 100 kt.
  • 2331:47: The first officer initiated rotation. The recorded groundspeed at this time was 165 kt.

The flight crew recalled that they detected an airspeed anomaly during the take-off roll, including red speed (SPD) flags on both primary flight displays (PFD).

The standard operating procedures stated that the captain held responsibility for the decision to reject the take-off or continue. It stated that rejecting a take-off between 100 kt and V1 was a serious matter, that a captain should be ‘go-minded’, and that very few situations should lead to the decision to reject the take-off. There was no indication on the CVR recording that the captain or the first officer discussed rejecting the take-off.

After take-off the flight crew carried out actions for unreliable airspeed indications and made a PAN call[5] to air traffic control (ATC), advising they had unreliable airspeed indications.

The flight crew continued to climb above 10,000 ft and manoeuvred the aircraft to the north-east of Brisbane Airport where they carried out several checklists, troubleshooting and preparation for an approach and landing on runway 01 (Figure 2).

Figure 2: Flight path of 9M-MTK during turn-back
Figure 2: Flight path of 9M-MTK during turn-back. Source: Google Earth / ATSB.Source: Google Earth / ATSB.

In accordance with published procedures, the flight crew turned off the three air data reference systems (ADRs) at 1343. This activated the aircraft’s backup speed scale (BUSS) (Figure 3), which provided a colour-coded speed scale derived from angle of attack and other information, and altitude derived from GPS data.[6] The flight crew also obtained groundspeed information from ATC, and used the aircraft’s radar altimeter.

Figure 3: Example of the backup speed scale (BUSS), showing the colour-coded scale (left) that indicates derived speed, and a GPS altitude scale (right)
Figure 3: Example of the backup speed scale (BUSS), showing the colour-coded scale (left) that indicates derived speed, and a GPS altitude scale (right). Source: Airbus
Source: Airbus

Normal landing gear extension could not be accomplished with all three ADRs off.[7] The flight crew performed a landing gear gravity extension before conducting an overweight[8] landing on runway 01 at 0033.

After landing the flight crew stopped the aircraft on the runway as nose wheel steering was unavailable following a landing gear gravity extension. The main landing gear doors, which remain open following a gravity extension, had minor damage where they contacted the runway surface. The aircraft was towed to the gate where the passengers and crew disembarked. There were no reported injuries during the flight.

A subsequent inspection identified that the pitot probe covers were still fitted to the aircraft’s three pitot probes after it landed.

Recorded data

The ATSB recovered and downloaded data from the aircraft’s CVR and flight data recorder (FDR), and obtained data from the aircraft’s digital ACMS[9] recorder (DAR), used for routine monitoring by the operator.

The data from the CVR and FDR contained all of the occurrence flight, while the DAR included all data up to 2348 and intermittent data after that time.[10] At the time of publication, the ATSB had not fully validated the data and analysis is ongoing.

The aircraft had four sources of airspeed information:

  • ADR1, processing data for the captain’s pitot probe on the left side of the airframe, and usually presented on the captain’s PFD.
  • ADR2, processing data from the first officer’s pitot probe on the right side of the airframe, and usually presented on the first officer’s PFD.
  • ADR3, processing data from the standby pitot probe on the left side of the airframe, and not presented unless the flight crew selects it to be displayed on one of the PFDs.
  • Integrated standby instrument system, processing data from the standby pitot probe, and presented on the integrated standby instrument system to the right of the captain’s instruments.

Airspeed was not recorded or displayed to the flight crew when it had a calculated value below 30 kt.

The FDR recorded airspeed from ADR3 once per second, and additionally from any one of the three ADRs twice per second depending on flight crew selection and data validity. Data from the FDR showed that ADR1 first sensed airspeed above 30 kt at 2331:39. At rotation, the FDR recorded 38 kt airspeed from ADR1 and the airspeed from ADR3 had not yet reached 30 kt. ADR3 first sensed airspeed above 30 kt at 2331:54.

The DAR sampled airspeed once per second and preliminary analysis shows broadly similar values as the FDR.

The maximum recorded airspeeds after take-off were 66 kt on the FDR and 57 kt on the DAR, prior to the ADRs being selected off when the data became invalid. These recorded airspeeds were consistent with the pitot probes being covered.

Preliminary analysis of the available groundspeed and angle of attack data indicated that the aircraft was flown within operational limits.

Further investigation is required to determine the airspeed indications and related warnings and cautions being displayed to the flight crew during the take-off roll.

Previous occurrences at Brisbane Airport

There have been multiple reports of insect activity disrupting aircraft systems at Brisbane Airport. These included blocked pitot probes, mainly from nests built by mud-dauber and other wasps, resulting in airspeed discrepancies and other effects.

A preliminary review of the ATSB database indicated that, from 2008 to 2018, there were at least 15 incidents involving high-capacity regular public transport aircraft departing from Brisbane Airport where one of the pitot probes had a partial or total blockage, at least four of which were identified as insect nests. These resulted in three rejected take-offs, four aircraft returning to Brisbane Airport after continuing the take-off and one aircraft that continued to its destination.

The ATSB investigated two rejected take-offs that involved A330 aircraft where one of the pitot probes had been blocked with wasp nests, one in 2006 and one in 2013.[11]

After the 2006 occurrence, the Brisbane Airport Corporation (BAC) commenced a monthly wasp eradication program, which was made weekly after the 2013 occurrence. BAC also undertook research to understand wasp behaviour and identify the pitot probe types at highest risk of contamination.

In May 2015, the Civil Aviation Safety Authority (CASA) issued Airworthiness Bulletin 02-052 ‘Wasp Nest Infestation – Alert’[12] to ‘urgently advise operators, maintainers and pilots of the dangers associated with undetected wasp infestation in aircraft, and the circumstances under which they can occur.’ It stated that wasps could build nests in aircraft that are stationary for more than 20 minutes with uncovered pitot probes.

From November 2015 onwards, the Airservices Australia produced publication En Route Supplement Australia (ERSA) entry for Brisbane Airport included a note that stated:

Significant mud wasp ACT WI AD VCY [activity within aerodrome vicinity] affecting pitot tubes [probes]. Pitot tube covers recommended.

Similarly, the Jeppesen aeronautical information publication Australia Airport Directory, used primarily by international pilots operating into Australia, also had the following in the Brisbane airport information section:

Significant mud wasp activity within apt [airport] vicinity affecting pilot tubes. Pitot tube covers recommended.

Some operators using Brisbane Airport use pitot probe covers for routine turnarounds.

Operator’s arrangements for ground handling at Brisbane Airport

Having previously ceased Brisbane operations in 2015, the aircraft operator recommenced flights to Brisbane on 6 June 2018. At the time of the occurrence arrangements had been made for the provision of services by a local ground handing provider and a local engineering support provider. On the day of the occurrence, aircraft turnaround duties were shared between:

  • a maintenance engineer from the operator who was rostered to return to Kuala Lumpur as a passenger on the departing aircraft
  • two non-certifying engineers from the engineering support provider
  • four ground handlers from the ground handling service provider.

The operator’s personnel and the ground handlers were both responsible for conducting pre-departure checks.

Use of pitot probe covers

The pitot probe covers were fitted on the aircraft’s three pitot probes by one of the engineering support personnel, as it was his understanding this was normal practice. He later reported that he advised the operator’s maintenance engineer that pitot probe covers were fitted during a brief exchange discussing turnaround tasks, but that the maintenance engineer did not directly respond. The maintenance engineer later reported that he did not recall hearing the advice, and he did not make an entry in the aircraft’s technical log to record that the covers had been fitted.

The presence of the pitot covers was not detected by the operator’s maintenance engineer or captain during separate external aircraft inspections. The operator’s maintenance engineer boarded the aircraft during turnaround, and the engineering support personnel left the bay to attend to other aircraft. The pitot covers were not detected by ground handlers during pushback.

The flight crew and operator’s maintenance engineer later reported that they would not routinely use pitot probe covers on a turnaround. They advised that the operator did not normally fly to airports where the use of pitot probe covers was standard. Security video recordings of the operator’s three previous turnarounds at Brisbane Airport showed that pitot probe covers were not used.

The pitot covers fitted to the aircraft were provided by the engineering support provider and were manufactured to fit Airbus aircraft types including the A330. They consisted of a tightly woven Kevlar sheath about 12 cm long, with a 30 cm streamer.

Examination of the three covers fitted to the aircraft following the occurrence found that they were partially burned by the heated pitot probes. They each had a hole burned through where the cover folded around the probe in the airstream. The streamers were damaged by contact with the aircraft skin during the flight (Figure 4 and Figure 5).

Figure 4: Pitot probe covers removed from 9M-MTK after the incident flight
Figure 4: Pitot probe covers removed from 9M-MTK after the incident flight. Source: ATSB
Source: ATSB

Figure 5: Reconstruction of pitot probe covers on 9M-MTK, showing pitot cover damage and rub marks on aircraft skin from the streamer
Figure 5: Reconstruction of pitot probe covers on 9M-MTK, showing pitot cover damage and rub marks on aircraft skin from the streamer.  Source: ATSBSource: ATSB

Ongoing investigation

The ATSB has interviewed the flight and ground crews, and examined data from the aircraft’s FDR, CVR and DAR, as well as airport security video footage from before and after the flight.

The investigation will examine the:

  • procedures, arrangements and interactions between the operator’s maintenance engineers, flight crews, engineering support provider and ground handling service provider
  • procedures relating to ground and flight crew pre-flight checks, including walk-around procedures
  • training records for flight crew, engineers and ground handling personnel
  • warnings, cautions and other information displayed to the flight crew during the occurrence flight
  • ATC recordings
  • closed-circuit video recordings
  • FDR, CVR and DAR recordings.

The investigation will also interview the air traffic controllers who communicated with the flight crew during the flight.

Safety actions

Proactive safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

  • The aircraft operator provided a notice to all of its engineers and flight crew, which highlighted the need for pitot covers to be fitted to aircraft at Brisbane Airport during turnarounds or when parked, as well as the required procedures for their fitment and removal.
  • The aircraft operator and engineering support provider clarified and formalised more detailed service level arrangements.
  • The engineering support provider improved its procedures for conducting turnarounds, including improved inspection, documentation, and tool control.
  • The ground handling service provider provided all employees with a ‘read and sign’ bulletin emphasising its arrival and departure inspection procedures.

Safety advisory notice to all international operators using Brisbane Airport

Action number: AO-2018-053-SAN-003

The Australian Transport Safety Bureau advises all operators that conduct flights to Brisbane Airport to consider the use of pitot probe covers and, if covers are used, ensure there are rigorous procedures for confirming that covers are removed before flight.

 

___________

The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this report. As such, no analysis or findings are included in this report.

 

__________

  1. Eastern Standard Time (EST): Coordinated Universal Time (UTC) + 10 hours.
  2. Pitot probes provide air data computers and flight instruments with airspeed information, and are ineffective if covered or blocked.
  3. Pilot Flying (PF) and Pilot Monitoring (PM): procedurally assigned roles with specifically assigned duties at specific stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent, approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path.
  4. The V speeds are referenced using airspeed, which is indicated on the aircraft’s primary flight displays. Groundspeed is shown on the navigation displays and is not normally used other than for navigation.
  5. An internationally recognised radio call announcing an urgency condition which concerns the safety of an aircraft or its occupants but where the flight crew does not require immediate assistance.
  6. Pressure altitude is provided by the ADRs and became unavailable after they were switched off.
  7. A safety valve prevents landing gear extension above 280 kt, and must be overridden when airspeed is not available.
  8. An ‘overweight’ landing is conducted at an aircraft weight higher than certified maximum landing weight.
  9. Aircraft condition monitoring system.
  10. The DAR was set to only record information that met the operator’s flight data analysis capture criteria.
  11. ATSB investigation report 200601453, Rejected takeoff - Brisbane Airport, Qld - 19 March 2006 - VN-QPB, Airbus A330-303. ATSB investigation report AO-2013-212, Air data system failure involving Airbus A330-243, A6-EYJ, near Brisbane Airport, Qld on 21 November 2013.
  12. Issue 4 of Airworthiness Bulletin 02-052 was released on 3 May 2018.

Safety Issues

Go to AO-2018-053-SI-16 - Go to AO-2018-053-SI-10 - Go to AO-2018-053-SI-09 - Go to AO-2018-053-SI-01 - Go to AO-2018-053-SI-07 - Go to AO-2018-053-SI-18 - Go to AO-2018-053-SI-12 - Go to AO-2018-053-SI-02 - Go to AO-2018-053-SI-14 - Go to AO-2018-053-SI-05 - Go to AO-2018-053-SI-03 -

Instruction and guidance for unreliable airspeed on take-off

The Airbus guidance provided in the flight crew techniques manual and other manuals for helping A330 flight crews decide whether to continue or reject a take-off did not refer to unreliable airspeed indications.

Safety issue details
Issue number: AO-2018-053-SI-16
Status: Closed – Adequately addressed

Alerts associated with nil or unreliable airspeed during take-off

In the Airbus A330, there was no auditory alert associated with nil or unreliable airspeed from two or more sources during take-off (a high workload, critical phase of flight). Comparatively, other critical failures provide both visual and auditory indications.

Safety issue details
Issue number: AO-2018-053-SI-10
Status: Open – Safety action pending

Pitot probe cover characteristics

Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A330 operations by Aircraft Maintenance Services Australia 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 details
Issue number: AO-2018-053-SI-09
Status: Closed – Adequately addressed

Aircraft Maintenance Services Australia use of pitot covers

Some Aircraft Maintenance Services Australia (AMSA) engineers extended the use of pitot probe covers (to mitigate the threat of wasp infestation) to operators that did not explicitly require it, including Malaysia Airlines. This increased the likelihood of error associated with the use of pitot probe covers was because AMSA engineers were not controlling or conducting all of the engineering activities and were not permitted to make technical log entries.

Safety issue details
Issue number: AO-2018-053-SI-01
Status: Closed – Adequately addressed

Aircraft Maintenance Services Australia tool control

Aircraft Maintenance Services Australia did not have a reliable method to account for tooling and equipment (such as pitot probe covers) prior to aircraft dispatch when providing non-certifying engineering support.

Safety issue details
Issue number: AO-2018-053-SI-07
Status: Closed – Adequately addressed

Menzies audits of dispatch coordination tasks

Menzies Aviation staff did not consistently carry out the required arrival and pre-departure aircraft checks of Malaysia Airlines aircraft, and Menzies Aviation audit processes were not effective at evaluating compliance with these requirements.

Safety issue details
Issue number: AO-2018-053-SI-18
Status: Closed – Adequately addressed

Malaysia Airlines inconsistent walk-arounds

Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections.

Safety issue details
Issue number: AO-2018-053-SI-12
Status: Closed – Adequately addressed

Interim engineering arrangements

Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights to Brisbane with interim ground handling and engineering arrangements that varied from

Safety issue details
Issue number: AO-2018-053-SI-02
Status: Closed – Adequately addressed

Guidance about the use of pitot covers

Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.

Safety issue details
Issue number: AO-2018-053-SI-14
Status: Closed – Adequately addressed

Change and risk management processes

Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:

  • the appropriate level of involvement of subject matter expertise and safety groups
  • that risk controls were implemented and monitored.
Safety issue details
Issue number: AO-2018-053-SI-05
Status: Closed – Adequately addressed

Lido airport operational information

The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information.

Safety issue details
Issue number: AO-2018-053-SI-03
Status: Closed – Adequately addressed
General details
Date: 18 July 2018   Investigation status: Completed  
Time: 2231 EST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Brisbane Airport   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Aircraft preparation  
Release date: 16 March 2022   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A330-323XZ  
Aircraft registration 9M-MTK  
Serial number 1388  
Operator Malaysia Airlines  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Minor  
Departure point Brisbane, Queensland  
Destination Kuala Lumpur, Malaysia  
Last update 16 March 2022