How Did EVERYONE Miss THIS!? | Malaysian Airlines Flight 134
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- Опубліковано 25 кві 2024
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On the 18th July 2018 an Airbus A330-300 was getting ready to depart from Brisbane International Airport in Queensland, Australia for Kuala Lumpur. Shortly after the take-off roll was initiated, the flight crew was suddenly aware that they had no indication of airspeed on their PFD’s (Primary Flight Display). What was the cause of this and how did the story unfold? Stay tuned.
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Below you will find the links to videos and sources used in this episode. Enjoy checking them out!
Sources
-----------------------------------------------------
Final Report:
www.atsb.gov.au/media/5780947...
Image Mud Dauber Wasp
i.redd.it/xoi0poca86o31.jpg
Dauber Wasp Nest:
upload.wikimedia.org/wikipedi...
Mud Wasp Nest:
tucson.com/dont-fear-the-mud-...
Pitot Tube A330:
aviation.stackexchange.com/qu...
Airspeed Gauge Cessna:
pilotworkshop.com/tips/pilot_...
Pitot Tube Schematic
safetyfirst.airbus.com/pitot-...
A330 and Pitot Cover:
safetyfirst.airbus.com/pitot-...
Infested Tubes:
avherald.com/h?article=46bd994d
ATSB Warning Letter:
www.atsb.gov.au/media/5774896/...
Brisbane Airport:UNKNOWN
www.passengerterminaltoday.co...
Malaysia Airlines 1: oneworld.com
www.oneworld.com/members/mala...
Malaysia Airlines 2: Reuters
www.bangkokpost.com/business/...
Inattentional Blindness 1: psychologytoday.com
www.psychologytoday.com/us/bl...
Inattentional Blindness Article: Daniel Simons / smithsonianmag.com
www.smithsonianmag.com/scienc...
Malaysia Airlines HQ: Foxy Who
commons.wikimedia.org/wiki/Fi...
Malaysia Fleet: Sky News
news.sky.com/story/malaysia-a...
A330 Schematic: flightglobal.com
i.pinimg.com/originals/08/7d/...
Aircraft used: JARDesign 330 Airliner:
store.x-plane.org/JARDesign-3...
CHAPTERS
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00:00 - Intro
00:26 - Airport Life
01:09 - An Itty-Bitty Threat
03:42 - Arriving On Stand
05:18 - Forgetfulness
08:03 - The Flight Crew
08:55 - Assumptions
09:57 - Gear Pins And Covers
13:04 - Pushback
15:24 - Dr Reason Was Right
16:56 - Takeoff Roll
19:43 - Rotation
20:37 - First Master Caution
22:01 - Hot Covers
23:05 - Confirming Adr 3
23:46 - Pan Pan!
26:09 - Troubleshooting The Problem
28:49 - The Backup Speed Scale
30:53 - Alerting The Cabin
31:50 - Long Final
32:41 - Wheels Down
33:35 - Findings
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What is your take on Mike Tyson punching a fellow passenger after he threw water over him?
Pitot tubes connect the real world with the virtual world inside a modern airplane's cabin. All the technology when properly aligned can't prevent nature with millions of years of experience from winning the bet.
Thanks Petter. 🙂👍
THEY COULDN'T USE A CELL PHONE GPS FOR SPEED????
@@B.C36 come on we all know what mentor pilot take on that would be
I was one of the Air Traffic Controllers in Brisbane that night, although thankfully it wasn't my airspace, I was sitting across from the departures controller. There was a lot of activity happening in the control room to get them as much information as we possibly could, ranging from RADAR feed data, to controllers using known winds and E6B flight computers to get an estimate of the actual airspeed of the aircraft. Interestingly we were able to get within about 3 knots of what the ATSB calculated the airspeed to be. Overall it was a good example of how a series of errors could lead to an uncomfortably close call, and also a good example of the system working to achieve the desired outcome. Still not an evening we will really forget.
How is it possible to have a story better than this with actual event hands personnel involved with the flight?
Pretty Darn Cool Captain @!
Cheers to entire crew..
People should have respect for you because you have one of the H A R D E S T jobs in the world. Like, you have to actually do SO much by managing air traffic. I would be a future pilot but I have hearing loss and I’m nearsighted.
I like to explain to whoever asks an aircraft is not a mere car : in order for that aircraft to fly, I tell them there are at least 200 people working together behind the scene, not just the pilots ... an movies are lies.
Just to express our gratitude to you guys, doing your part of the job while the outside world appear to have forgotten about you, at least, there are people fully aware of your role, just like so many others out there.
Thank you for your professionnalism.
@@StephenKarl_Integral on point bro. We Ils dme navaids engineers no one salutes us. Not even the air crew.
@@kasarachipeter8816 The pilots and aircraft owners likely salute their avionics shop for keeping the aircraft flying, but it's so rare to encounter someone maintaining the navaids. Your work is, indeed, appreciated by many. GPS LPV or LNAV/VNAV approaches are not everywhere, and even where they are available it's always nice to have a truly redundant backup approach when flying in the clouds.
The lack of ego on the part of the Captain is admirable. Deferring to the First Officer during the landing because the FO knows the plane better should be applauded. It may deviate from policy, but it was the right thing to do.
Real common sense. Thank goodness he had it too.
Good CRM in action, yeah.
CRM… best safety improvement that you seldom hear about except when it isn’t used.
Very good point
AF447 was lost in 2009 for the same reasons, choked pitot tubes. ( Ice) From the voice recorder we know that the younger co pilot guessed the situation right but was overridden by the older captain. 228 dead, no survivers. Back then I asked myself why airliner pilots are unable to do what every 14yo. glider pilot student is learning first: look out of the window, listen to the airflow, feel the aircraft moving. (Ass- o- meter) wikipedia lists a good handful of crashes caused by sensor failures resulting in the autopilot suddenly shutting off or doing crazy (the two 737crashes) and leaving the crew with a fuckin' mess.
This really reflects well on Airbus. That backup airspeed system likely saved the day.
Power + attitude = performance. Law of nature. But yes, clearly it was helpful to have a computer help doing those sums.
(As a PPL I'd read too many stories of people killing themselves because they were unable to fly with no airspeed indication - and this was before AF447! - so I got an instructor to fly circuits with me with the ASI covered up.)
Yes especially when you consider an engineer had to spend time writing the code and implementing it on the aircraft just for the highly unlikely situation where all other speed data was lost.
Is GPS ground speed not helpful at all?
@@BleakVision Sometimes. But you don't want to be relying on it near the ground at low speed in a light aircraft because it's having the right airspeed, not groundspeed, that stops you falling out of the sky.
@@BleakVisionAs the one below already commented but also as an engineering student we have also been thought that the calculation GPS uses approximated values that are calculated with the assumption that you are near the ground and give you your speed compared to the ground. The further away from the ground the further that speed is likely to differ from the actual airspeed they are looking for. Especially any vertical speed completely invalidates any Speed Gps gives you.
The fact that there exist a study on how a wasp will nest in pitot tube is simply fascinating and shows how far our aviation industry has advanced
It is believed that wasp nests in the pitot tubes of a Boeing 757 flying as Birgenair Flight 301 were part of the cause of the loss of that aircraft in 1996, with 189 on board.
wow, I did suspect so. THank you for the Info! @@mhfuzzball
@@mhfuzzball This. The study was performed entirely because of that crash to confirm if it was the cause of the captain's PITO tube becoming blocked.
That is called science. The advance in the aviation industry is due to science. You collect evidence and find the truth based on the evidence.
PS: Vaccine deniers also should not step in an airplane ever again. 🙂
Crazy.
Being called to the cockpit after emergency landing to explain your lack of walkaround inspection sounds...memorable.
I liked the blush animation, seemed appropriate for such an "aw sh*t!" moment of realization.
The captain did his sloppy walk around inspection after the engineer had already taken a seat. Lots of blame to go around for this.
Well it wasn't a lack of inspection, he just didn't follow up on his mental note.
I counted at least 5 people who were supposed to directly look at them & check...
Oh....my
The "remove before flight" flags should have reflective tape on them. Our brains are hardwired to alert on a momentary flash of light like a predators eyes in firelight. This would bypass the inattentional blindness factor during a flashlight inspection
And jangly bells.....and a brick😃
Honestly, if they're going to install ribbons on them, why not just attach little windsocks too? Make them tear themselves off at flight speed, as one more layer of cheese in the stack.
@@henryptung Make them tear apart at higher speeds would be better, they are pulled over the Pitot tube, and a windsock would just pull them tighter.
An even better system would be for the pitot tubes to have some internal mechanism that closed up, when the plane was powered down and opened when powering up.
Offcourse with some sort of switch to sense if they were opened right. In this case, it would also be unrealistic for all 3 mechanisms to fail simultaniously.
They should be designed with a tearaway fault and a little sail to catch the wind, so when if they happen to get up to 100 knots it will catch the wind and rip off
Or how about a switch that triggers an audible warning in the cockpit if the aircraft is moved with the covers in place?
Really seems like those covers should be designed to easily tear off at high wind speeds, so that even if a situation like this happens, they'll just fall off.
Good idea!
Was just thinking something similar, though it could be the pitot tube heaters that melt a link, and use the wind to assist with clearing the tube.
Good idea. Also... why don't airplanes have a fourth, backup pitot that is sealed inside the airplane (thus inaccessible by wasps or anything else), but can be extracted (and afterwards retracted) in emergency situations so they have at least one "clean" pitot probe available at that point?
@@AniMageNeBy Maybe because of cost... I mean good Idea but the pilots have more than enough information to return safely. You have to remember, in an airplane there is atleast one backup system for any Sensor System to fail - I mean in this case - 3 Sensors have failed because of this error and I think they had 3 measures of speed - (1: their ground speed which is GPS 2: radar provided by the tower 3: this damn complicated calculated speed by the airplane)
@@olivers_bienenwelt it's different speeds. GPS and radar speeds are good and all, but difference between pitot tube pressure and static port pressure is the only way to acquire reading of an *airspeed*. That is, speed of the air around the wing. That is different to speed relative to ground (i.e. GPS speed). Airspeed is not so much speed measure per se, it is a simplified measurement of lift generated by wing. It can not be substituted by speed wrt ground fully.
The leading hand saying (around 14:10) he wasn’t sure if he had the proper training to do final inspec/ pushback showed true wisdom. Ironically, that type of person, if he would’ve done it, he would’ve most likely noticed the pitot tube covers.
Not noticing things you're not specifically looking for: Many years ago before everything went digital, I worked prepress at a newspaper. The content -- articles, ads, etc. -- were printed out and then applied to the layout pages with hot wax. One day I came in to work and the boss was very very not-happy. The phone had been ringing off the hook. Not only had they forgotten to put a rather large ad in, the space where the ad was supposed to be had "What the f*** is supposed to be here?" scrawled in it. Yup. A pasteup person had used a black marker instead of the blue cameral-invisible marker in the space where the ad belonged, then *hadn't noticed that the ad hadn't been put over it.* She then passed it along to the camera operator who put it on the rack and *didn't notice that there was some obscene writing scrawled on the page.* Then the negative for the page came out of the developer and the opaquer (the person who uses a dull, soft pencil to cover extraneous white marks) *didn't notice "What the f*** is supposed to be here?" scrawled in large white letters against the black background of the negative.* The person who burns the plates didn't notice. The pressman who loaded the plate onto the press didn't notice. And the guy who checks the paper after a short test run to make sure everything is okay didn't notice it. Pasteup, camera, opaquer, plate burner, pressman, and check person -- *all six people* failed to notice. You know who did notice? A lot of customers and advertisers.
I write for a magazine company and the amount of times something has gone to press and I’ve thought ‘how the hell did no one notice that?’ is bigger than I’d like! Luckily nothing that bad though 😆
It happens everywhere, we've had an electronic schematic with "glaringly obvious" (once you've noticed them) issues overlooked at at least half a dozen people (including myself) who checked those schematics for errors.
😆 Kinda reminds me of the "Wicked Bible".
Basically, in 1631, the Church of England ordered a new printing of the King James Bible. The typesetters left out a "not" in one of the Ten Commandments -- "Thou ſhalt not commit adultery" -- and _none_ of the proofreaders or printers caught it. They put extra attention into making sure all the long and complicated Hebrew names in the Old Testament were spelled correctly. But in the _very_ familiar Ten Commandments, it seems their brains kept autocorrecting the missing "not", so they didn't notice it was missing.
The Church _definitely_ noticed though ... _after_ the edition had already been bound and distributed. All copies of that printing were ordered to be recalled and destroyed. The publishers were fined and had their printing license revoked.
Only a handful of copies escaped the recall. 15 are owned by various libraries and museums (in the UK, US, Canada, and Australia), and a few more are in private hands.
No one notices things in front of their face. They’re always looking for a complicated solution when the answer is in front of them.
The police are a good example. They rarely notice the crime happening in front of them, it’s when you try to be clever and sneaky when they notice the crime.
I was in a pretty bad situation like this many years ago (in the pre-digital age) when some minor artwork changes were being made to a pharmaceutical product and the third-party artwork people re-set the whole artwork without telling us (and of course not intending to make any changes that we hadn't specified). Long story short, they made a mistake on the dosage information and we missed it because we were focusing on the bits we had asked to be changed and didn't properly proof-read the rest. Me and my boss both missed it and it was eventually picked up by a consumer long after the erroneous label was put into production. Fortunately (other than the commercial cost of a recall) there were no serious consequences (the product wasn't remotely dangerous even if you massively overdosed) but it could have been horrendous. Even now, labelling errors are by far the most common reason for product recalls in the pharmaceutical industry.
If it’s nobody’s job, it won’t get done. As a ramp rat training for lead hand, I was taught to COUNT all pins with streamers AND show them up to the pilots after pushback.
...and, if it's everybodies job it'll be nobodies job.
@@getahanddown Truth!
@@stellviahohenheim who asked you exactly? Its a comments Section nobody needs to ask genius
@@redchief94 , dude...
According to the video, the pins and streamers were supposed to be IN THE COCKPIT and verified on a checklist. It's inexcusable that they habitually violated this.
I was actually on this same flight! I was only 9 and I had no idea what was going on. We took off, circled Brisbane a couple of times and landed back at the airport. We were sitting on the runway for about an hour and there were also fire trucks on the side of the runway. I didn't even know the severity of the incident until now and it's quite harrowing to know that I could have died on that flight. It's also quite scary looking at images of the plane sitting there when the captain flashed his light on the side if the aircraft. I now finally know like 5 years later what actually happened. Thanks Mentour!
Did you get back on the same night? And on the same plane or not?
@@bgtcsjmWe had to stay in Brisbane for 2 nights, then fly down to Melbourne with Virgin Australia, then fly from Melbourne to Kuala Lumpur with MH.
@@hbaviation2008 So glad for a healthy outcome, although the voyage onward seems so fatiguing at least you were alive and uninjured. Some one was praying for you!!!
You didn't notice the pitot covers on, you should have told the gate agent😂
@@AwesomestGreatestMostestFunny Ahaha yes, I should've been paying more attention!
My RESPECTS to both pilots especially the CAPTAIN who relies and had faith with his first officer
Well the reason for this plane crashed because my ancestors the so called aliens you think captured the plane and taken them to their home planet in Alpha Centauri star system most of the people in the plane are experimented,eaten or ridiculed and kept as pets iam a species from this planet and disguised as human collected various intel they are gonna invade your planet by 2032 and iam the one who helped them
I mean... he probably doesn't want to die either 😀
The captain caused it
The captain caused this and the first officer who was supposed to confirm they have the pitot covers stowed lied.
What! Both pilots should have been fired as should the ground staff. If they cannot see a red flah what else would they miss. Oh, I was an aircraft engineer for 33 years so fully aware.
As an instructor in a flight club, I have experienced a blocked pitot tube. The story started when a student pilot was about to take off in a Cessna 172 on her first solo. The airspeed indicator didn't move, and she aborted the takeoff and stopped safely, albeit a little shaken. The mechanic identified insect eggs in the tubing, used compressed air to remove the eggs and released the aircraft. A test flight was not deemed necessary. Instead, the student pilot would fly with me. As we rolled down the runway, the speed indicator indicated normal speeds, and we took off. But shortly after becoming airborne, the indicated airspeed dropped to zero. This gave me the opportunity to teach the student how to fly with normal power settings, pitch and our senses. She flew the airplane nicely and landed safely. I never had to touch the controls.
Damn that mechanic did you wrong
hope you gave the mechanic a stern talking to..
The first rule of Flight Club is you don’t talk about Flight Club.
@@PissBoys Nah, that's an important difference between Fight Club and Flight Club. You never talk about Fight Club, but you *always* talk about flying. :)
It sounds like you are a very competent instructor, with a student to be proud of!
As a retired B-767 captain, I was fascinated by this video. My sincere compliments to Petter for an outstanding presentation and for many others like it. I wish we had Mentour Pilot when I was still flying.
Enjoy retirement O.G!
✌😁👍 🎸🇺🇲💜
you deserve it. ✈
🛬👨✈️🇺🇲❤
@Farmer&Ganja malaysia Doesn't that shit get you sentenced to death in Malaysia?
@@redplanet7163
Yep, if you got this shit anywhere near Malaysia, Indonesia or singapore, you're pretty much dead.
@@PegimampooS dun forget brunei mah dude
Peter is a great narrator and he hired a superb animator who appears to be able to fly a flight sim! Even in the constraints of time and money he adds excellent animations and overalls on top of the sim's own content!
I am an A&P mechanic and did many aircraft walk around checks before releasing the aircraft for first flight of the day. To think these covers were missed SO MANY TIMES, blows my mind. I think how much you value your job/position factor into this as well. I took my job so very seriously and could only think, with EVERY CHECK, that peoples lives were at stake. Me doing a thorough job insured that someone’s mother, father and loved one made it to their destination safely. I expect nothing less from others who do this job. By the way I’ve read all of the wonderful comments …guess what I am a woman!! This is the female portion of TwisterChasers my name is Kat !!! I am the A&P mechanic/technician. I started as a Quality Assurance Inspector on F-16’s on a civilian level I think that is why I am so contentious!
As somebody who is scared to death to fly, has a wife that makes me fly often and has reoccurring plane crash dreams, I thank you for your diligence, it makes me feel a bit better knowing guys like you are keeping me safe.
Youre a good man and honest worker. I respect the likes of you in the service.
@@ZDiddy7777 Does your wife really make you fly?
@@ohdear2275 I don’t think he was (f) lying! ; )
I have nothing to do with aircraft (well, I did assist at the wreck site of Korean flight 801 in Guam, just putting up the temporary morgue tents), but my oldest friend who I've known for 40 years or so, was an aircraft mech in the Navy then he was an A&P mechanic for several years eventually managed a couple mechanic shops for vairous airlines for a couple years and has been with the FAA for several years now. I've hung out with him and his coworkers; mechanics, pilots, flight attendants back when he was still working commercial. I have heard some crazy stories from them over the years. One minor one I was actually envolved with was when I ended up getting laid over in Pittsburgh (where he was living/working at the time) on my way to New York many years ago. We ended up going out with some of his coworkers and were out pretty late. Its a bit strange when you are on a plane a bit hung over and recognize the mech doing the pre-flight checks as somebody who had just been drinking like a fish about 4-5 hours earlier till roughly 4 in the morning.
It is reassuring, despite this incident, to know that the pilot and engineers do a walkaround and inspect the aircraft. Passengers have no idea of the effort that goes into making flights safer and this video helps fill in that grey area for us. Thanks, Mentour.
Not this bunch
Very reassuring indeed that all these people, including the captain, miss a big red flag with REMOVE BEFORE FLIGHT fluttering in the air. The average trucker on the road checks his vehicle much better than all these "highly educated professionals".
@Daniel-hw2sb a truck isn't a plane
Have you watched any part of this video?
@@bellyrubs Yes, I have. What have I missed according to you?
@Daniel-hw2sb that the psychological part is what leads to mistakes
Also assumptions, I believe that's more dangerous than not paying attention or your brain tricking you, the assumption that someone else will double check your job
This one didn't end in a disaster but you can see in other accidents how pilots trained on what to do, do the complete opposite just because they can't fully grasp what's happening, because they're tired or they're not experienced in dealing with situations outside of what they're taught
Such things are rarely the fault of only one person and you can see just how many people made the same mistake in this one, and when the pressure to get as many planes into the air as quickly as possible is so high, everything else is rushed
One aspect you didn't mention that I thought was excellent from the pilot was his/her ability to check their ego and be completely on board with the 1st officer flying during the emergency since they had more experience with the particular aircraft. Too often I've seen less-experienced but superior ranked (in the organization) people argue for control of a situation because they wouldn't check their ego. Awesome job from that flight crew handling such a critical situation so well.
In the service permanent party work there every day. Reservists come as weekend warriors sparsely. Often a perm. Airman has more experience than a part timer sergeant. Time in service as opposed to time in title makes a difference. Rank has its privileges but knowledge is power. I'd prefer a younger more experienced person to guide me than a high ranking or older person just due to their age not skill.
I really enjoyed hearing a story where the crew was able to safely land the aircraft under unusual circumstances. I didn't know how this one was going to end.
I was worried.
.... thanks for the spoiler....
what I fail to understand is how they didn't abort the takeoff, they should have seen clearly that their airspeed was not increasing during the taxi or the takeoff.
@@dingdong2103 It was covered in the video. Not enough time to think clearly and make a snap decision when something unexpected happens. It's obvious to you because you've been prepped on what the problem is and what the pilots should be doing. Once they got in the air and had time to think, they did a great job.
Lmao this dude literally spoiled the entire episode, what a muderchowd!
This story 'fooled me at first. I was sure the crew would have lost control and crashed. GLAD the FO had so many hours flying and such detailed technical knowledge of the plane. ✈✈👍👍
There hasn't been a commercial jet aircraft crash in Australia for a very very long time.... so I wasn't surprised at all (can't remember last time there was an actual "crash" here, though we have had a few engine explosions, and a QANTAS jet that dropped altitude quickly injuring some people onboard)
i would think most pilots should be able to maintain control with no airspeed indicator. they knew it was unreliable. the real problem is when it is wrong but the pilots think it is correct.
@@crocodile2006 this was a Malaysian flight and pilots tho
There was another one that had this problem and crashed and everyone died
@@alexc4924 You are talking about Air France 447. The crew were so fixated on the pitot issue that they literally forgot to fly the airplane. It should be pilot training 101: if unsure of air speed, put all the controls in such and such configuration so that you will positively maintain a steady flight. They failed to do this in AF447.
I like these videos best, where everyone survived and the pilots are showing excellent situational awareness.
I used to be based in Brisbane on the A320 and the mud wasp problem is very real. The moment you shut-down and begin your walk around you can see them already beginning to investigate places to make a new home.
That's super fast. So the problem remains?
@@ohdear2275 They're common insects in Sydney where I live. I'd imagine that they're even more common in Brisbane.
@@carlramirez6339 Thank you for your reply. 🙂
I live about 30 miles from Dulles in VA and we definitely have mud wasps here. They liked my front porch until I sprayed the whole thing with an insect repellant. Now they are gone.
When you first started talking about the mud wasps, my immediate thought was, “How crazy is it that three different wasps went into three different pitot holes!”
And this is what happens when you jump to conclusions. You’d think I’d know better than that, after watching so many of these videos, but I already had the story all figured out🤣
The Sphex wasp's programmatic behavior has been a subject of numerous papers in philosophy of mind and cognitive science. Man, they sure get around!
I hadn't even watched the video yet, and I didn't even know it was colloquially known as a "mud wasp". Still, when I saw your comment, I immediately knew what was going on here. That is how much we spoke about this wasp when I was in college 20 years ago.
It actually isn't crazy at all. They all do the same thing, and so if you have multiple wasps and multiple holes, you're gonna end up with a wasp in each of them. This is what they live for--to do this one thing.
Mud wasps just plain love pitot tubes. I suspect heated tubes, in the process of cooling down, are even more attractive. We had problems with them (but not this bad) in the Arizona desert.
Yeah, I was yelling, "Oh no, they're gonna have wasps in the pitot tubes!" Then I realized and yelled "Oh no, they're gonna leave the covers on!"
Install thief tag on those "remove me" stripes and have the plane runing through a supermarket detection gate before allowing to take off 😀
But because they are stored inside the cabin after removal, they would likely be detected as well...
It's kind of amazing how pilots (and others) look right at them but sometimes don't register things like Pitot covers hanging off their plane's probes. I used to work at a municipal airport. Once I went out onto the ramp to marshal a private jet out - usually signaling to the pilots when they could start their engines, and indicating in what direction to turn in order to leave the ramp. But that time I had to stop the departure because of at least one Pitot cover still hanging off the plane. It happened in broad daylight and on a plane that's much smaller than a commercial passenger jet, so the pilot on their pre-flight walkaround really should have noticed it.
I guess it's the same thing as looking for your car keys and they're right in front of you, or looking for your glasses when you are wearing them.
Something I learned doing inspections of machinery: Try and find something wrong, in every case, no matter what. If you do an inspection with just getting the inspection done in mind, you have a good chance of missing a flaw.
it's also been said, look for something wrong, because if you look for something right, you are likely to see it even if it isn't there.
Yes!
Love this ⬆️
Good point
@@kenbrown2808 A very good lesson applicable across many other Industries and situations.
observation: this incident happened at night. The "tails" on the pitot tube covers appear to be red. Red is a hard colour to see at night. As Vokoder (previous poster) says the tails need to be reflectorised for night use.
Also as I needed reading glasses I found I became red blind at night,( literally I cannot see red instrument marking at night) no problem in daylight. A reflectorised pitot tube cover would bypass this problem for me and anyone else with this problem.
As long as you are emitting light.
@@stevecooper2873 Torch? As seen on the animations... But maybe bionic eyes would be better, let's get working on that!!
Maybe also add a compressed air nozzle inside the pitot tube so you can a) clear any foreign debris, or b) blow the pitot tube covers off.
very true, hope they will fix that
Good point, and some men are red/ green color blind.
I am a retired Chief Engineering Technical Instructor on MH, yes the problem is real and thanks for the videos. We do conduct ground handling training for all line station and the precautionary measures that goes with it.
Human Factors issue is always a concern, no matter how much we stress on these… still it can happen… a solid checklist and specific for the locality is much needed.
I work in the aviation industry and it is kinda scary how easy it is to become complacent and miss very, very simple things.
Never heard about this incident, but man- the swiss cheese is real with this one. Thanks for another entertaining and informative video. Always looking forward to these.
The final report of this was released only a few months back. I thought it was fascinating.
Thanks for watching!
another example of why humans need to be removed from aviation
if aviation is run by AI and not humans these errors would not happen
@@MentourPilot Can you shed some light in my comment below?
@@mortgageapprovals8933 Bold statement- however there are countless examples where human intervention has prevented automation from creating a disaster. Automation fails, and cannot account for every situation that might be encountered in day to day operation. A well trained crew with system knowledge, strong SOPs and CRM together with good automation is why aviation is as safe as it is.
Would you honestly put your family on an aircraft flown by a machine supervised by a guy sitting somewhere on the other side of the world?
@@mortgageapprovals8933 "AI" is only as good as the programming and the information given to it.
AI would need the same checklists, inputs, and hopefully LOTO (which aviation seems to lack) procedures humans need.
Way back in the 1980's when I was a student pilot I started to take off with my instructor in a Cessna 152. We had NO airspeed indication. He panicked... pulled the throttle and the the brakes. This was in the daytime. We taxied off... pulled off the pitot tube and there was an insect larva blocking airflow. NOTE... if one's needs an active airspeed indicator in a 152 to take off or land... you probable shouldn't be flying. A BIG jet is another story.
Thanks for sharing that story! 💕
You can just lick your winger and stick it out of the window, no?
I landed several times with no airspeed indicator in an M20E. Rather disconcerting. I knew what my usual approach rpm was. Practiced a couple of slow flight maneuvers at altitude without using my pitch trim so I knew how the controls would feel. Also I did not use full flaps on approach. Worked out fine. Replaced the airspeed indicator but I think there was some other issue in the pitot/static port plumbing.
When I worked in General Aviation as an avionics tech our shop in Arizona also had an instrument shop. We did a lot of pitot-static checks and many of the systems required repair. Leaks were most common (probably not an issue in transport aircraft) but there were plenty of pitot tubes with insect blockages. Usually they weren't blocked solid - yet - but I was dismayed how common it was. The airspeed indicator on the test set would rise normally while the indicator under test would lag.
The spookiest was a Beech Bonanza that had a crushed pitot housing. I found it leaked badly, so I went to the FBO to see if they had a replacement. They didn't, but while I was waiting their lead mechanic, Tony, came over and we discussed the situation. He suggested we recommend wrapping it with red vinyl tape, then completing the test, to get him back home. Tony said the guy would probably ask if we could just put chewing gum on it. Sure enough, the customer appeared and we gave him the lowdown on the problem. He asked if we could put chewing gum on it! He went with the red tape. The next year I saw he had painted the tape silver to hide it. Sigh....
Sounds as if the CFI did exactly what he should do in a situation like this, except to say that depending on the runway distance available a very experienced CFI might have instructed you to abort. I began a takeoff from KSQL in a light-single once with the pitot tube cover attached. As I accelerated I saw no airspeed, so I cut the throttle. It’s remarkable what your brain does in a situation like that, because before pulling the throttle I first tried to mentally explain to myself why that was happening rather than taking an immediate action. Fortunately this mental wrangling only took a split second as I immediately remembered getting distracted by another pilot during my preflight. The experience was impactful, because continuation bias is a real thing, and San Carlos has a fairly short runway. Had I not noticed the issue early I could have run out of runway. Small planes are slow and forgiving in a situation like this, jets less so. I now consider a preflight interruption grounds for starting over, and I’m much more conscious of not interrupting other pilots during their preflight procedures.
On the engineer side, to make a log entry is always the best way to avoid those incident. No matter you installed pitot/static port cover, landing gear safety pin or opened engine fan cowlings. Put it on the log, and never signoff until all covers, pins are on your hand and confirmed all latches under fan cowling have been locked and latched.
i like the part where the captain just says : "stop the checklist, i need to fly the aircraft"
Both the Captain and First Officer messed up bad on the inspection procedures, but after the incident happened they did remarkably well.
They remained cool headed throughout, got things under control after a hairy start to the flight, worked together diligently, discussed plans and listened to each other, focused intensely on the tasks at hand, were both assertive and willing to deviate from standard procedures when it was logical to do so, and finally got everyone safely onto the ground.
I would say they did _really_ _good_ after making a _really_ _bad_ mistake. I guess that kind of zeroes out to a neutral event.
It's upsetting that 5+ people all assumed that someone else had already done the inspection! I don't think it was laziness, more an issue of complacency, of everyone assuming things were going normally. This redundant safety check wasn't even a double check, it was a bloody quintuple check and still it slipped past them!
Crazy story.
As a former submariner, we typically “flew” our sub at about 20 kts. or so. Subs have a similar kind of potential problem.
We had little Cirripedia (barnacles) that would grow on the sub’s hull, and occasionally plug our depth sensor ports after we’d been submerged a month or two! The sea version of mud wasps plugging a pitot tube on aircraft!
One day, we found ourselves several hundred feet deeper than we thought we were!
It wasn’t a huge deal, but you ALWAYS want to know your true depth! Exciting!
How do you detect that it was deeper than you thought? Was it like echo-location off the seafloor, or is it like a pressure sensor, telling you that the sub is deeper than it should be? I'm curious on how you even detect that kinda problem, before something really bad happens.
@@weeveferrelaine6973 Hi Weeve. It’s nothing fancy. Every diving station has several depth gauges connected to different ports in the hull. This is called “redundancy”. The man who controls the sub’s depth has a main depth gauge right in front of him. But there is another gauge to the left or right (smaller) that gives the same info. We are taught to scan and compare duplicate gauges to prevent just such an event.
The man at the diving station scanned the gauges and saw that they didn’t agree. Someone was being complacent! I’ve heard that it can happen quickly so I don’t want to pass judgement on my shipmate.
Anyway, they determined that the main depth gauge had failed by comparing other gauge readings. I believe we cross connected the ports to restore the main gauge but I’m not sure. It was a long time ago!
I’m sure someone got a nice a## chewing over the incident.
Seems like it could have been a big deal if you grounded though?
@@medwaystudios Yes, smashing your sub into the seafloor would definitely be a bad thing! That said, most of the ocean is quite deep. Suddenly finding out that you're at 800 feet instead of 500 feet isn't that big a deal when you know the section of ocean you're in is 10000 feet deep, for instance.
Thats so cool
Hello! I’m in 5th grade (almost 6th) and I just want to say the way you explain things make it easy for even someone as young as me to understand. Nice job, and thank you! :)
Best comment ever!!! ❤️
Go little Rockstar💖 :)
Go for it, Primrose! You're gonna be wonderful when you grow up. Keep learning! -- Salute to you from a retired U.S. Navy chief petty officer.
This is the friendliest response I've ever seen to someone on the internet saying they're a kid, this is so nice.
All the best to you!
Keep learning, little Primrose. As you get older don't let anyone tell you it's not cool to know stuff.
You show good judgement coming to this channel. Mentour Pilot is one of the most trustworthy sources of information on UA-cam.
when the pilots knew the air speed indicator is not working they can simply abort takeoff at the point when the aircraft reach 100kts，the easiest and safest way to solve the problem
exactly this decision making point is being discussed by the author in the video!
maybe watch it again.
The easiest and safest way of solving the problem is to put it in the tech log and have the 3 people who are meant to check the plane before take off actually use their eyes.
Pitot covers should have had some harness attached to the ground so they cant be missed as well as some part jutting out that causes air friction to pull them off as plane gathers speed
Yes. Or put some reflective tape on the red streamer. Even in low light conditions people would be able to see the flickering reflective tape.
This! Also make it so the front of the covers are a mesh that can allow air to flow through while still blocking wasps. Or heck even make the pitot tubes themselves have a grid or mesh built-in that blocks obstructions from entering.
I have binge watched the aviation accidents explained again all night and then this drops...sweet!! Absolutely fascinating!☺
Enjoy!
@@MentourPilot It makes so much sense.. unintentional blindness. Easy for anyone to understand how that happens. Btw...I love how the Captain was distracted by wondering about your Mentour Now channel...😂
Yep, regular TV loses its appeal when you have an algorithm that knows Exactly what you like, paired with Amazing content providers like @Mentor Pilot. I pay ~ $10.00 / month for UA-cam Red (no ads) & never looked back at regular TV.
Every 'nifty little backup safety system' that airplane have is like a hell of a plot twist in a mystery novel. Love it. Also, the pilot looks so badass wearing glasses at night in the cockpit while an emergency is happening, gotta be cool in the air at all times I guess? haha
🎶I wear my sunglasses at night...😎
A cheap and simple idea would be to also have some form of red clip saying ‘pitot cover’ which attaches to the throttles when these are fitted. Similar to when you have a disk lock on a motorbike, you have a clip on the ignition.
0:01 Intro
0:26 Airport Life
1:09 An Itty-Bitty Threat
3:42 Arriving On Stand
5:18 Forgetfulness
8:03 The Flight Crew
8:55 Assumptions
9:57 Gear Pins And Covers
13:04 Pushback
15:24 Dr Reason Was Right
16:56 Takeoff Roll
19:43 Rotation
20:37 First Master Caution (FAC)
22:01 Hot Covers
23:05 Confirming Adr 3
23:46 Pan Pan!
26:09 Troubleshooting The Problem
28:49 The Backup Speed Scale
30:53 Alerting The Cabin
31:50 Long Final
32:41 Wheels Down
33:35 Findings
Just came across this channel 2 days ago and I have been binge-watching it ever since. Really informative and entertaining, love the breakdowns and analyses as well!
Welcome aboard Martial Liam! Glad to have you with us. 😀
Same here!
If you run out of his content to watch, he has a second channel called MentourNow
@@dafeef5555 Subscribed
He holds my attention better than anyone
This is an absolutely brilliant explanation of a dangerous situation. I am 62 years old and my father worked to make aviation safe back in the 1970's. We looked at many accidents, including BE548 (the trident crash). I wish you good fortune with your endeavour as this kind of information really helps pilots.
So much respect for the pilots. Crew resource management was brilliant. I'm so glad they landed safely. There is so much to think about when preparing an aircraft for flight. I had no idea of how much is involved just to get us in the air safely until I started watching this channel. Petter explains things so well.
Zero respect for the captain who had multiple chances to pick up a problem prior to rotation.
It's awesome to hear how the crew worked the problem, they were true professionals.
I especially liked this video. Yeah, major mistakes made leading up to it. Including not rejecting the takeoff when they should have. But after that, the crew really came together and provided an almost textbook response to an emergency situation like that. This should be used as a training tool.
Never quit
@@M167A1 how so? Like never reject a takeoff quit? Or never throw up your hands and say it's all too hard I'm going to let the plane do what it wants quit?
Very interesting. Obviously there were serious mistakes in the preflight inspection phase, but that was top level professionalism from both pilots once they were in the air.
Yes, it really was.
This channel makes me want to be a pilot so badly lol
I'm likely too old now; truly a shame I never took any action toward that goal... growing up next to a commercial airport, a few miles from a university with an airport that offers aviation degrees, a few miles from an airforce base that several family members worked at over the years, and considering my grandfather was an aviator who rebuilt his own biplanes in his garage. I don't have many regrets, but this is one lol
Its relatively easy to become a private pilot. Where i live in ontario it can be done for roughly $7k Canadian all in. If you have the money ready to spend Its as easy as 40hrs ground school, 15 hours of instructor flight, 10 hours of solo flight, and a government test, provided you have first passed the medical exam you have a recreational pilot permit and can fly single engine planes that hold up to 4, although you can only carry 1 passenger with you.
Rental on a cessna 152/172 is under $200 an hour
It is easy to see you've trained as a pilot - that ad pitch maneuver was flawless.
really love how the airbus engineer (or just aircraft designer overall) make so many layered protection and redundant system for safety measures. first time i've seen aircraft videos that shows that visual aid for speed indicator when airspeed indicator no longer working at all. a very unusual situation, but the aircraft has backup/workaround to it just in case and glad they remembered it despite the heavy stress
My first thought when seeing this, was wondering why they didn't make one of the tubes unable to be covered, for the purpose of having a backup in the case of the covers being forgotten. Redundant systems that all suffer from the same possible failure modes sounds less desirable imo.
Wouldn’t the mud wasps just get into the uncovered tube?
@@aikaterineillt9876 Assuming that the wasps were at every airport, yeah. Looks like that airport had been consistently not using covers up to that point, so it's likely the covers were precautionary for it being a problem that could potentially occur.
So something like one coverless port would allow for the chance of a wasp not covering it, but the covers being left on mistakenly.
@@weeveferrelaine6973, how about this for a remedy: why not just get the employees to do their G'Damn job they're paid to do? I'm mean, they all saw the covers. How much more obvious do the covers have to be?
@@weeveferrelaine6973 yep, redundancy with a single point of failure is never good. Thought the same thing
As a mechanic for one of the two biggest cargo carriers, I’ll hold up a pushback to walk a plane off before I hook up the headset. Doors, gear pins, and pitot covers, and verify with the flight crew.
Lol
.
,T34. .....Right out of high school,I didn't know a Prop
From a jet.
L
A close to tragedy happened due to lack of attention to detail of ground inspection personnel. Respect to the Captain and first officer who saved the flight and returned the aircraft without air speed indicators. For next time I would do a walk under aircraft pre flight inspection if I were the captain. (If I see something red hanging it means Stop and Remove before starting the flight). Thanks for this great video.
Man, what a rough decade it was for Malaysia Airlines.
The pitot tube covers could be designed with an 'separating impedance cup' on the tail end that would rip them off the cover mount at or near a speed that would allow proper speed indication.
Yeah, but that would probably cost a few dollars...
We can also make it larger, like, a huge flag. lol Cost nothing, but will be impossible to missed.
You would think.
Sounds like a good pat right there bro get on it before someone else does
you would risk them getting sucked into the engines.
Hey Mentour Pilot, just wanna say, the way you structured the video and how you speak to the viewers, it feels like you’re telling a story. And there was no spoilers, the suspense all the way to the end to find out everyone was save. Amazing video man
No suspense for me due to reading your comment!
So you decided to provide the spoiler…
@@brentfodera377 hahahahaa I didn’t think it through, You’re absolutely right
@@genericcommenter2676 It's not your fault, they should watch the video before reading the comments. Lesson learned for them.
I love this channel so much. Those 35 minutes just went by like nothing, great video!! I thought this would be ending in disaster, but always nice when such major lessons can be learned and no one died in order to learn them.
I am happy to see everyone safely landed,,,, well done to both of the pilots.
I always like it when Aircraft with serious problems ultimatly land safe and sound .
Me too
The mistakes and tragedies happen where you don't take something seriously.
How ironic that the measure taken to prevent one problem actually caused the same problem they were trying to avoid!
Agreed. Shakespeare himself couldn't outdo this one
I'm wondering if installing a fine mesh at the inlet of the pitot tube would be able to stop insect infestation. Hmm...
I mean by the time 4 people all over over looked something, the weather itself played tricks on them and even the freaking plane was like "hold up guys, think something wrong" It really really gets embarrassing.
Human error at its finest
@@BillAnt the plane should have a way of "spiting out" anything stuck inside there. Thats why nature rules with bodys that natruly rejects and kills intruders and heals damge.
We nee planes made of living-metal that can correct mistake in air and heal and build itself if damaged XD
This is a good illustration of human systems with "multiple safeguards" that so diffuse the responsibility for a crucial task that the task can easily be overlooked. This is found in such places as nuclear plants, pipeline operations, chemical plant operations, explosive plant operations, etc. The people who design the safety procedures for such systems often designate several crew members with the responsibility to ensure that a particular safety step is taken. Redundancy is intended to build in safety. But redundancy can lead to problems:
1. Some in the chain of responsibility start skipping their step, since there is always someone else who will look after it - "I thought Joe was gonna do it";
2. A bean counter, or a new manager who wants to impress the higher ups with cost savings, reviews the cost of all these steps and decides to save money by eliminating a step or two;
3. If everyone is responsible, then no one person is responsible;
4. It is easy for people in the checklist chain to stop paying attention because there is always someone else who has looked after the crucial step before, and there has not been a problem with it for a long time - normalcy bias takes over;
5. Training on proper procedures gets lax because there has not been a problem in such a long time and someone else has always looked after the crucial step; and
6. If the crucial safety step is built into many crew member''s assigned tasks, then each crew member tends to be assigned too many tasks, and it becomes easier to overlook any one task.
A perfect storm of course. It might be possible to design the pitot tube covers to tear away above a certain wind speed? For example a small drag parachute on the end of the covers and stiches which give under a certain loading? It would be a fail safe. . .
sounds like a great idea, it just need to block the wasp, not to be durable
I’m thinking they may be design to not come off during flight !they could get sucked in the engines and ruin them! They appear to be in front of the engines! And a pigeon are any bird can destroy an engine ! So I’m sure they could also? Just thinking out loud hear but it definitely is possible!
@@thuss5162 Good point, a cover ending up in one of the engines is a huge risk of turning a non-emergency issue into an emergency. The pitot covers should just be designed to still allow air flow through the front while blocking access to the wasps. Would that not be possible with a grid-like structure?
We always made a tech log entry stating the pitot and static covers were installed. This then required another entry to have them removed before the aircraft was issued with a Certificate of Release to Service for the next flight. Same goes for landing gear ground lock pins.
I managed 35yrs with a ‘national’ airline that deeply invested in operational flight safety. Your analysis of this Malaysian 134 event is a stand-out example that drills into the ‘soft’ side of aviation especially human factors,CRM, swiss cheeses et al. Well done. Dave Hawkins
Hello David
Peter, John's worker whom you met at Bentley. 😊
QANTAS?
Absolutely shocking when a simple oversight turns into far more serious situation because everyone assumed someone else was doing the job. Human error because of human laziness and distraction!
If they had rejected this takeoff I would expect only internal review. Once airborne it became an incident.
It turned out several people did the job but only saw what they expected to see.
Malaysian has been known for its laziness
Maybe it's just because I've seen so many bad examples on your channel lately, but that's such a wholesome story. And that captain is a prime example in keeping situational awareness and generally great airmanship.
Everyone has good ideas about this. I was in law enforcement for a long time, and honestly, it is very difficult to overcome human nature of getting into a rut of things you have done a thousand times before. Trouble is, we'd have a close call, and then have a meeting, and 99% of the time the result would be-- Let's try to be more careful next time.
Malaysian Airlines had a rough few years over the last decade or so.
Will I ever fly Malaysian Airlines ? No!
@@peterw4338 it's okay, even most of the locals won't fly on it again.
@@nix294 Yep. Locals here prefer cheap flights like AirAsia 😂
Given how they handled the situation rather well and professionally despite the mistakes made, I wouldn't be too worried. The other incidents I wouldn't say were the airline's fault in the first place, a pilot going rogue with little warning or insurgents firing at a civilian airliner isn't something anybody would be normally prepared for.
Malaysian airlines at this point might be really bad luck. Dont fly with them!
The Japanese Shinkansen procedure of ‘pointing and calling’ could possibly have helped here. If the checklist had been verbalised during the walk-around perhaps the Captain would have seen the probe covers. I’m cabin crew and I have my own pointing and calling procedures (for arming and disarming slides, for example) and often share the idea with my colleagues.
The "Point and call" mentality is really fucking good and I can't believe my instructor never drilled this in.
They should have pesticided those mud wasps.... spray them and you're good.
I LOVE the "pointing and calling" system. I do it sometimes when I drive. I point in the direction I could possibly be "t-boned," and then it gives me confidence to proceed onwards. Simple little thing I do. I learned that in Japan
@@metalmike570 I'm from Brisbane, mud wasps are almost as common as the housefly and while pesticides could help to some degree the wasps are flying insects native to the area(including pretty much the entire country) so not only will they come back but you can't be sure they will come into contact with the pesticide rather than fly over it.
That was very stressful to watch I didn’t know what the outcome would be. Thankfully it had a very great ending due to the skill of all involved. Thank you for a wonderful and informative video.
An interesting story, with lots of learning points, and an admirable recovery by the flight crew.
10:47 It's fantastic that the captain was thinking about Petter's wonderful second channel, however, I think he should have more closely paid attention to what he was doing.
I just smiled when I saw the part about the A330 having an emergency speed indicator. Engineers never seize to amaze me with their engunuity
Haha yeah thats some proper engineering. Like, 'we have 3 indicators already, why not create a backup for a backup of a redundant system?' Those engineers are also heroes in this and possibly future stories.
It's never cease, not seize
@@behindthen0thing We've never seized anyone... not yet, at least...
@@behindthen0thing Okay atleast you understood, English unfortunately isn't my mother tongue
Before that was mentioned, I was thinking it would be nice if the plane had some lower precision backup speed indication that infered the airspeed from the groundspeed, AOA, vertical speed, pitch angle, ... so it was nice hearing it actually existed
been watching many of your videos, thank you for your respect for the cabin crew. 34 years with Delta here.
For us aviation fascinated enthusiasts your page is heaven , thanks 🙏
Hey Petter, I live in on the Gold Coast with my home airport being roughly a 40 minute drive from Brisbane Intl. , I do mainly GA flights but a similar thing has happened to me however luckly I noticed on the take-off roll and not in the air, I was able to stop, checked the pitot probes, they looked okay so I took my plane into the hangar and took apart the probes, the little buggers didnt like me doing that and stung the hell out of my arms but yeah, lesson learnt, use pitot probe covers whenever youre not in the air!
Interesting! I don't think I've heard of those things actually stinging anyone before (unlike regular wasps, which tend to be quite aggressive, but build completely different types of nests.) Maybe the Australian species of mud daubers / mud wasps are more aggressive than the ones in Southeastern North America that I'm used to, though.
@@vbscript2 I just think they didn’t like me taking apart their home haha
that gotta hurt like hell. I got stung on my right thumb when it was chilling on the lower part of my bike throttle
@@vbscript2 Australia seams to lean towards the nastier than anywhere else forms of wildlife with a few exceptions.
Australia has tornados on fire. Its not a unforgiving place.
Among this long stack of Swiss cheese slides that had all its holes aligned, there are 2 unforgivable ones:
- Missing the pitot tube covers and their streamers in the pre-flight walkaround by the pilot. All the pre-flight is important but the probes is possibly the most critical area because their importance for the safe operation of the plane and because they are very well known and documented to be prone to accidental damage, operational mistakes, and natural events affecting them.
- "Below 80 knots (or 100 knots depending on the airline) we abort for any alarm or abnormal condition". The red "speed" flag comes in the airspeed indicator while at low speed, you abort. And that dot is a period. The only attempt of an excuse not to do so would be "I thought we were already at high speed". But the flag appeared at 50 knots, that's slow highway speed (58 MPH). The airspeed indication had remained in zero until then. The groundspeed was showing 50 knots, they had just started the takeoff roll some 5 to 10 seconds ago. they were OBVIOUSLY in the slow speed regime to abort immediately at the first sign of any alarm or abnormal condition. The captain, instead of saying "the speeds, the speeds!!!" should have just said "abort". That a captain in not mentally programmed to face every take-off assuming that something will go wrong and they will abort is mind boggling, and dangerous.
I mean, a lot of people did things wrong here, starting from the airline management. But come on Captain, you are the ultimate responsible for the safety of the flight to which, by the way, you yourself are going to be strapped in. You are not allowed to not see these 3 red covers with red flags hanging from the 3 very critical pitot tubes during the walk around, and you are not allowed not to command an immediate abort when receiving an alarm at low speed. Unacceptable.
Yes! The Swiss cheese was between their ears.
indeed, take-off would never happen. rto. period.
The operation of the pitot tubes and static ports are crucial to safe flight. So why don’t people address the real problem? That problem is why can’t crews know if pitot tubes or static ports are operational BEFORE takeoff? The answer is simple. Have a feedback loop that lets crews know if there is a free flow of air through those sensors. If there isn’t free flow their should be loud alarms and the ability to even power up engines could be stopped.
I could design a feedback loop in an afternoon that would allow crews to know if pitot tubes and static ports are blocked. Why can’t aircraft designers even think about feedback loops that would save countless people’s lives and the losses of many half billion dollar aircraft?
@@MovieMakingMan the feedack loop was a comparator diff between gs and ias. red RED it was. that is a RTO. these pilots should have executed an RTO as you don't know the v1/v2/vr speeds. stupid if the covers were forgotten. not executing an RTO is unforgivable
@@MovieMakingMan ... Well, the problem is that there is no free flow of air through a pitot tube, by design. A pitot tube is open on the front but closed in the back because it measures the pressure of the stagnation point, which is equal to the pressure inside the tube, and which is proportional to the speed squared (differential pressure over the local atmospheric pressure). That is why the function of the pitot tubes is checked when the airplane is moving at some speed. The airspeed indication starts at 30 to 40 knots. At that point, in some airlines, the pilot monitoring (who is looking at the instruments) will call "speed alive" and the pilot flying (who is mostly looking outside) will look at his airspeed indicator and confirm "check". In ALL airlines, at 80 knots (could be 60 knots for smaller and slower airplanes) the PM will call "80 knots" and the PF will verify that his side is also indicating 80 and call "check". ELSE YOU ABORT, PERIOD. Note that the system in this airbus did a crosscheck between the airspeed and ground speed and gave them a visual alarm (both in the shape of a master caution light and the red flag in all airspeed indicators) and an aural alarm + an ECAM message at 50 knots. That they didn't abort immediately at that point is unbelievable. The captain was the PM, the captain was looking at the instrument, the captain saw the red flag and instead of saying "reject" he said "the speeds, the speeds!!!".
All that said, talking about feedback loop, the pitot cover can have an element that interacts with a sensor in the pitot tube to detect when the cover is installed and relay that information to the cockpit and sound an alarm if the thrust is advanced past a certain point with the covers installed.
As always, thank you for the beautiful production!
Not even an amateur pilot, barely have a day of air-time in total, yet, enthused by your channel! TY!
This was fascinating. I have zero experience flying but have logged thousand’s of hours as a passenger. Never realized how complex piloting is. Have a new respect for flight crews.
Can't believe that pilot that's done walk round to ensure aircraft fit to fly can mis seeing peto covers that's why they have ribbons on them so you've got visual feed back! Crew did brilliant job getting aircraft down safely without asi, could have turned out so very bad! Just show the importance of walk round not to take anything for granted, your making sure it's fit for flight!
Correct! This was likely a very good wake up call.
Even a bright red streamer -- or even a neon green one -- can be surprisingly easy to _not_ see in low-light conditions. Especially if you aren't really looking for it.
I input bills into an accounting system. Certain bills are identical and I copy them. It takes almost supernatural attention to detail to catch the minimal changes that need to be made when everything basically matches your experience.
Peto covers must be pitot covers.
You lose colour vision at night- worse than that, if using a yellow flashlight might make it look black or grey. But regardless, its cognitive dissonance. They didn't know about the wasps, they were on a short turnaround, there is no way there would be covers on them.
There's some research into this, your mind is perfectly willing to erase the impossible, in fact that is why you forget weirder dreams fast.
Our brains just aren't that switched on in the dark.
I am not a pilot of any kind IRL. However, I am an aviation enthusiast. I found your channel a few days ago and have been binge watching ever since. Your delivery of information is not only very detailed and informative but is also very calming. My wife has also started watching. My wife is a VERY nervous flyer and usually has to take medication to fly. Your analysis of these incidents has helped her flying anxiety greatly. Thank you for your videos and we look forward to continue watching!
My 1947 Cessna 140 has a simple bent aluminum pitot tube with a hinged flapper that covers the pitot tube hole. It opens as airspeed builds up on takeoff. Not saying it is a better system, but it sure keeps the bugs out. 👍🏻.
Pitot tubes have been a feature of several incidents, including disastrous crashes, over the years. This fact should make it a priority check for those doing walk-arounds. It's astonishing that the covers were missed in this case.
Plus training to fly without them ...
07:58 I just studied prospective memory (remembering to remember) for psychology and there's been lots of studies done in the airline industry. In one paper, the researchers noted that 74 out of 75 incidents were a result of prospective memory failure. Pilots in general have really good retrospective memory and quite good prospective memory but interruptions can severely degrade the memory. When the engineer was interrupted he forgot about the tube covers. The best way to avoid this is as Mentour Pilot says, keep a note: make overt lists and always check - have explicit cues to check.
What you describe actually brings home day to day events. I have a routine to get ready in the morning to go to work. If my wife starts talking about non related stuff or asking me a series questions I almost always leave something at home or forget to do something that needed to be done on a daily basis. I've told her not to do that until I am about ready to head out the door but that hasn't always been effective :). On the job a company policy in IT was to not interrupt people even if they appear to be doing nothing at their desks since they may be concentrating on solving a problem. Instead co-workers were supposed to send a message to see when people had time to discuss something.
I forgot to turn the water off to the garden hose in my vegetable garden last night. So easy for stuff to slip the mind.
@@kjisnot perfect handling of the situation.
Lesson here: always pay attention to detail. If you see something out of the ordinary, make a written note and ask someone, and never forget, there is no such thing as a dumb question.
That First Officer is my hero ❤
And also how they worked as a team to bring everyone safe on the ground 🙏😍
So sad that small mistakes like this can have fatal results 🥺
So many lives were taken when tape was not removed from sensors or timy small parts of the plane were not properly checked or repaired 🥺
Kudos to all the personnel that triple checks everything is right and they are true professionals on their jobs ❤
A flex takeoff with no airspeed reference, the computers then dropping back into Alternate Law while the pilots are still confused and radio comms are flailing all over the place. Yet everyone lived! Time for another scotch.
Really interesting incident, amazing how so many people missed seeing the covers for a variety of reasons. Also interesting how many systems you lose when you turn off all the ADRs - can understand the speed brakes, but the cabin pressurisation control, landing gear extension and nose wheel steering were a surprise!
It's actually pretty surprising how many systems are interconnected.
Adirus are one of those systems that if they don't work right all of other computers that use that data from the adiru gets messed up. Thankfully that's why they have three independent systems on most planes. So if one or two go bad they still have a third. Sadly a mistake like this takes all three out.
Cabin pressurisation needs to know the current altitude so it depressurises slowly during the descent.
The landing gear computer needs to know the airspeed so the gear cannot be lowered if it’s too high. No data then it prevent lowering by conventional means so the gear is gravity dropped. But doing this means having to shut off hydraulic fluid to the gear. The NWS operates on the same system as the landing gear on the A330
One species of Mud wasps are now evolving into a new species called the "Pitot Tube Wasp"
@@tomstravels520 ... Doesn't make sense. Why not give the pilots an override option for the normal extension? If they extend manually there is no overspeed protection either, so let me extend with the normal system and let me have the gear doors closed and nosewheel steering available.
Why is the turn off method for pitot tube failure limited to turn off the entire ADI box attached to that pitot tube. A lot of things would keep working if the ADI box remained active with all the other sensors it handles.
It's great to see that the less experienced captain gave the lead to the more experienced on aircraft type 1st officer. It shows the Captain had absolutely no ego at all...... this saved the aircraft and all on board in my opinion.
Clever old Airbus as well
@Mentour you definitely have a gift for telling a good story and also to make complex technical concepts consumable for lay man audience like myself.
Absolutely terrifying situation. Reminded me of Aeroperu's Flight 603 disaster back in 1996, when a ground technician put tape on the Static Ports to protect them during a stopover and forgot to remove them. That 757 crashed on the sea, all 70 souls on board lost.
The static ports were taped over for an exterior washing. Most unfortunate accident 😔
Birgenair Flight 301 was earlier that year. Another 757, but instead of tape a mud wasp entered the captains pitot tube and the plane stalled and crashed after the captain trusted his obviously faulty airspeed indicator.
I have occasionally wondered why there was not an emergency static port - less accurate but better than none at all - that could be selected with a manual valve. Perhaps the variable errors could make it more dangerous than none at all.
"Mud wasps" are a thing on just about every continent it seems (except Antarctica probably).
Here in Texas, we call them "mud daubers" or "dirt daubers" and they will indiscriminately glob dirt anywhere and everywhere that is not exposed to direct sunlight.
Those little tubes they build can solidify in to brick and can be a pain in the ass to remove, even with a pressure washer!
We had ours full of a nest inside of a few hours while on the 'ramp' at a little grass strip in regional VIC, Australia. Aborted takeoff when no positive airspeed showing on takeoff. Piper Arrow IV Turbo. Simple pitot tube cover with remove before flight ribbon essential.
That's neat BigRalphSmith.
I'm from indiana. They are here too, although slightly different.
I made similar comment before stumbling upon yours. "Dauber"...
Cool. I've never read that word before. I thought it was "dobber." 😁
I've got some daubers living the lap of luxury in our garage, here in Tomball.
In Missouri we also call them mud daubers
Louisiana we call them dirt daubers.
The pro shows again that flying is a teamwork..
Good stuff..
I love this kind of video so much! Where things could be rectified and everybody is safe. ✨️
Given how many accidents were once caused ultimately because of the ego of the most senior pilot, this was an excellent example of how knocking egos out of the cockpit has saved lives.
IIRC an insect nest of some sort in a pitot tube caused a terrible crash in the Caribbean region. This current knowledge was hard won.
Birgenair flight 301 in 1996. You are 100% correct.
Yes, exactly. And I thought to Birgenair flight 301 in 1996, too. In that case the pilots were unable to deal with the similar situation and they crashed the plane. At least in this direction this Malaysian Crew performed fortunately much better.
Aeroperú Flight 603...
@@michaela7100 the Aeroperu accident, while similar, was caused by taped-over static ports, rather than blocked pitot tubes. That took out not only airspeed indicators, but the altimeters and vertical speed indicators.
@@stephenp448 very true Stephen. Yet while the minute details maybe different the premise remains the same
Im going to have my employees watch a few of your videos. It's so difficult to train out complacency once it gets an established foothold, and your videos so often demonstrate why it's important to continually defend against it. In my industry the number of catastrophic failures overall tends to be very low, but fatalities are basically assured if one happens. Skipping one check is so easy to get accustomed to doing as a time saving measure, and can so easily cost lives in an unlucky chain of events.
A few years ago we had an employee burning waste det cord in a burn barrel to dispose of unwanted scraps. This is an acceptable and safe way to dispose of unused portions if done correctly. We have three people run through a checklist at the shop to ensure nothing unwanted goes into the burn. On this occasion a field crew had taped up their scraps with electrical tape to make handling more convenient.
Unbeknownst to everyone involved there was a detonator in the middle of the tape ball. Procedures were very clear on visual checks, which would have included unwrapping and visually inspecting the scrap prior to the burn. This also means that the field crew had multiple people sign off on an incorrect detonator count prior to departure of their operations location. All three people in the shop also pencil whipped the paperwork, and the end result was catastrophic.
Oh my! How are the injured? I hope they all survived! I can't imagine how bad this was
@@dawnaquick3329 Incidents with explosives in an industrial setting are rarely survivable, and this one was no exception. There was only one person present when it initiated, and he had no chance. The vast majority of us will go an entire career without witnessing an unplanned initiation, so it's incredibly easy to develop a complacent attitude and never pay the price for it.
@@whitenoise509 I'm sorry for your loss. I'm understanding your point and it's true that safety regulations are written in blood.
May I suggest a "double check" system, that's two personal checking to reconfirm safety.
@@mikehoh1719 That was already in place at the time. We just use the term "two sets of eyes" for basically every process involving non negligible risk. However, in the states the ATF actually mandates a sign off procedure on every movement of primaries. So not only did we have your suggestion in place, but there was a paper trail to follow it happening.
This was in place in the field as mandated by law with our detonators, and then in the shop because we felt it was the correct way to ensure safety standards were being observed. We also have regular audits of all our safety procedures. Some of these are required by law, and some we have implemented on top of what is legally required. The ATF also audits operations like ours somewhat regularly.
Our taproot determined the problems branched from multiple actions directly counter to accepted procedure. We try really hard to hammer home how dangerous this stuff can be. It sucks so freaking bad when you find out everything you've done to try and mitigate the risk fails because of negligence.
I've been binge watching your videos, and somehow this is the first where I was able to draw a connection to my own work. It's office work, but involves attention to detail in reviewing applications with a manual process.
I have spent years trying to figure out why we often see the same sorts "inattention" mistakes over and over again, and now I'm starting to see the swiss cheese holes align. A lot of the areas are the same information over and over again, so people expect certain responses, and will miss when they deviate. Much like everyone missing the covers over and over again.
Now that I understand this more, I can start filling in the holes.
those "leading hand" guys are pure genius
with such an approach and communication levels should be allowed nowhere near the airplane
The pilots did great here. The first officer especially seemed to be thinking fast at every step and coming to the right conclusion, at least the scenarios mentioned. Exceptional outcome too, no injuries, not even shaken passengers, and a little inevitable scratched paint plus potential scorched pitot covers. Its important to cover mistakes with both loss of life and good outcomes rather than focusing on the former, there's a lot to learn from all problems and this is a great example of good and bad to remember.
Recommendation for improved flying safety: Attach little bells to all flapping attachments.
I was thinking led blinking lights
Imagine a windy day and many planes standing still, ringing all day long like herd of cows in the ears of engineers. That make you crazy
Add some tiny reflective mirrors on the ribbon too.
I think our comment section engineering crew has solved a problem.
Considering the amount of noise at airports, the bells would have to be quite big in order to be heard.
@@mballer" remove before flight" on the streamer didn't give 4 people a clue
Great presentation. You amaze me and it makes me happy that you are such a good representative of our profession! Thank you!