Aviation safety investigations & reports

Aircraft flight preparation occurrence involving Boeing 787-9, VH ZNJ Melbourne Airport, Victoria on 22 September 2021

Investigation number:
AO-2021-040
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
[Download  PDF: 872KB]
 

What happened

On the evening of 21 September 2021, a Boeing Company 787-9, registered VH-ZNJ and operated by Qantas Airways was prepared for a freight flight from Melbourne, Victoria, to Los Angeles, United States. This involved removing covers from the pitot probes and static ports, among other tasks, associated with restoring the aircraft to flight status following an aircraft ‘park’ procedure.

At about 0825 on 22 September 2021, a pre-flight exterior inspection was conducted by one of the flight crew, with no anomalies detected. The aircraft was also subject to a pre-departure exterior inspection by ground service dispatch personnel, before departing Melbourne at about 0900. The aircraft landed at Los Angeles about 14.5 hours later, following an uneventful flight. During the post-flight inspection, engineering identified that all 4 engine fan cowl static ports were covered with tape.

What the ATSB found

The ATSB found that tape covering the 4 fan cowl static ports was not removed by engineering, as per the manufacturer’s procedures, nor identified by flight crew or dispatch during pre‑departure checks. This resulted in the aircraft departing with reduced redundancy to the engine electronic control system. Despite that, the flight crew reported the flight was uneventful, and a review of the flight data confirmed there was no adverse effect to aircraft or its engine systems.

What has been done as a result

Following the occurrence, the operator distributed memos to engineering, flight and ramp crew, highlighting the location of the fan cowl static ports and that they may be covered when aircraft were parked for certain periods. The memos further reinforced the importance of following the documented engineering, pre-flight and dispatch procedures.

In addition, the operator has amended the aircraft ‘park’ and ‘restore’ engineering instructions to reference the manufacturer’s procedures. Further, these instructions will now identify the static port locations, to ensure consistency in maintenance practices.

Safety message

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.

‘Remove before flight’ streamers are a reminder to remove covers, or lockout devices, prior to flight. Failure to remove these devices and covers can prevent the functionality of certain aircraft systems. In certain circumstances, the streamers may be fixed to the aircraft and not hang freely, which can reduce their visibility. Targeted inspection of locations and components, rather than relying on streamers, which can detach, can help to identify when these covers or devices have not been removed.

Download Final report
[Download  PDF: 872KB]
 
 
 

The investigation

Summary

The ATSB has commenced a transport safety investigation into a flight preparation event involving a Boeing 787, VH-ZNJ, that departed Melbourne, Australia, on 22 September 2021

During the post-flight inspection following an uneventful flight to Los Angeles, United Sates, the engineer discovered that the static port vents on both engine fan cowls were covered with engineering tape.

The evidence collection phase of the investigation will include a review and examination of maintenance records and the gathering of any other relevant evidence.

A report will be published at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

General details
Date: 22 September 2021   Investigation status: Completed  
Time: 13:55 UTC   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Los Angeles, United States of America   Investigation phase: Final report: Dissemination  
State: International   Occurrence type: Flight Preparation / Navigation  
Release date: 17 May 2022   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 787-9  
Aircraft registration VH-ZNJ  
Serial number 66074  
Operator QANTAS AIRWAYS LIMITED  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Melbourne International Airport, Victoria  
Destination Los Angeles International Airport, California, USA  
Last update 17 May 2022