REPORT: An engineer forgot tape on a Qantas Boeing 787 which flew to Los Angeles

[HS-TQE]

ATSB Report incident from 22 September 2021.

REPORT An engineer forgot tape on a Qantas Boeing 787 which flew to Los Angeles - AIRLIVE

A Boeing 787 being used for a freight flight flew from Melbourne to Los Angeles with tape over four of its static ports, a new ATSB investigation report details. After the Qantas 787-9 aircraft, registered VH-ZNJ, landed in Los Angeles on the morning of 22 September 2021, a Qantas engineer found...

www.airlive.net

(snippet below)

A Boeing 787 being used for a freight flight flew from Melbourne to Los Angeles with tape over four of its static ports, a new ATSB investigation report details.​

After the Qantas 787-9 aircraft, registered VH-ZNJ, landed in Los Angeles on the morning of 22 September 2021, a Qantas engineer found tape covering the four static ports on the aircraft’s engine fan cowls.

Static ports provide important air pressure data to aircraft systems. Boeing recommends they be covered, to avoid contamination, when the aircraft is parked for periods up to 7 days, and Qantas incorporated this instruction into its ‘normal’ parking procedure.

 

[Quickstatus]

Not just the Flight engineer

 

[TheInsider]

Not just the Flight engineer

It was DNATAs responsibility in a way. QF engineering don't push back the aircraft anymore.

 

[jb747]

Not just the Flight engineer

I presume you mean the flight's engineer. Flight engineers are long gone, though their knowledge is missed.

But, yes, the SO who did the preflight did a very poor job. Whilst it's normal for the Captain to delegate this to the SOs, you do need to ensure that they're actually doing the complete job. For that reason, getting them to show you the external preflight every now and then, as if you were a new pilot, is a good idea.

It was DNATAs responsibility in a way. QF engineering don't push back the aircraft anymore.

Whilst the people doing the pushback may spot things like this, it's up to the engineer who signed it out to not only remove these covers, but also to check that any ports are uncovered, whether or not they may have had a cover.

Interesting that the engines didn't throw up any messages.

 

[TheInsider]

Whilst the people doing the pushback may spot things like this, it's up to the engineer who signed it out to not only remove these covers, but also to check that any ports are uncovered, whether or not they may have had a cover.

Interesting that the engines didn't throw up any messages.

Of course, but I guess the point I was making was engineering have no dispatch or receipt duties anymore on 787s. In which case it could've had a higher chance of been noticed if QFE still had these duties instead of being outsourced.

 

[jb747]

Of course, but I guess the point I was making was engineering have no dispatch or receipt duties anymore on 787s. In which case it could've had a higher chance of been noticed if QFE still had these duties instead of being outsourced.

Boeing are the ones who have removed engineering actions from arrivals and departures. The airlines (or at least their management) just gleefully jump onto every one of these exercises in boiling a frog. DNATA have no real engineering responsibility, and it would just be good luck if they happened to spot something. Having said that, the engineers do come back into play at various points, and it was an engineer who failed to remove the tape. And a pilot who failed to complete a proper preflight.

 

[Quickstatus]

I presume you mean the flight's engineer

Yes, the LAME

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DNATAs responsibility

SO who did the preflight

Boeing are the ones who have removed engineering actions

boiling a frog

An excellent book/audiobook about failures in complex systems involving human-technological interactions is by Sidney Dekker:

Drift into Failure: From Hunting Broken Components to Understanding Complex Systems

On a superficial analysis, there were multiple layers of responsibility, each level had the ability to ensure the tapes were removed.
However there are a lot more layers involved and when you look closer its a web of interdependencies:
LAME, SO, Pilots, DNATA, Organisational, Employer, Shareholders, Customers, Passengers, Aircraft manufacturer, Safety Regulator
Each of these groups are responsible to some degree, even indirectly. Some more directly than others.

It is very easy to point a finger at the culprit/s but understanding the real reason for failure in a complex system require a lot more than just finding people accountable or just finding that particular check routine was weak and needed to be augmented. Failure in a complex system like an airline is much more complex and require a different analysis. This book/audiobook is highly recommended.

.......

For that reason, getting them to show you the external preflight every now

Yes. The more routine the check/procedure the higher the risk that the check/procedure is not done correctly - and a good example of "Drift into failure".