The 787 Covered Cowl Fan Static Ports Emphasize the Importance of Clear and Unambiguous Procedures


Key points:

  • The Boeing 787 used for cargo operations flew from Melbourne to Los Angeles with tape covering the static vents of its engine cowl fan;
  • The work instruction card for the return to service of a 787 was not linked to the procedures recommended by Boeing;
  • Qantas has amended its Technical Instructions to correctly reference Boeing’s recommended procedures.

A Boeing 787 used for a cargo flight flew from Melbourne to Los Angeles with four of its static ports taped, details a new ATSB investigation report.

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

Static ports provide important atmospheric pressure data to aircraft systems. Boeing recommends that they be covered, to prevent contamination, when the aircraft is parked for periods of up to 7 days, and Qantas has incorporated this instruction into its “normal” parking procedure.

The ATSB investigation details that the day before the incident flight, an engineer undertook the parking procedure on the aircraft, which included covering the engine cowl static ports with barricade streamer tape “to remove before the flight”.

“Later in the day, another engineer was assigned to conduct the ‘restoration’ procedure to return the aircraft to airworthy condition,” explained ATSB Director of Transportation Safety Stuart Macleod.

“The tape on the engine fan cowls was not removed by this engineer, in accordance with the manufacturer’s procedures, and it was not identified by the flight crew or dispatch during pre-departure checks .”

VH-ZNJ then took off with the tape still on the engine fan cowl static ports.

“Although the flight was uneventful, the covered ports meant that the redundancy of the electronic engine control system was reduced,” Mr Macleod noted.

The ATSB found that while the work instruction card (JIC) developed by Qantas for parking a 787 was linked to the procedures recommended by Boeing, the JIC for returning it to service was not.

“It was a missed opportunity to help engineers easily access current procedures and determine which ports were covered, and also allowed for different interpretations of which ports might be covered,” Macleod said.

“When performing safety-critical tasks such as aircraft maintenance, it is very important that procedures are clear and unambiguous to avoid misinterpretations and errors such as those that occurred during this incident.”

During maintenance, the second flight crew officer, who performed a pre-flight exterior inspection of VH-ZNJ, stated that he was aware of the vents in the fan cowl, but not that they could be covered with tape.

The second officer also reported that they had been somewhat distracted during the inspection as they had found a pitot tube cover on the floor and were trying to hand it over to a member of the engineering staff at the time. .

“The second officer also believed that Qantas engineering had carried out a pre-flight inspection before the flight crew arrived at the aircraft,” Mr Macleod added.

Following the event, Qantas distributed memos to engineering, flight and ground crew outlining the location of the fan cowl static ports and indicating that they could be covered.

In addition, the airline changed its “park” and “restoration” engineering instructions to reference Boeing procedures.

The investigation report also notes that the meter-long tail of the ‘remove before flight’ tape covering the static ports was taped on, to prevent it from being torn from the fuselage in high winds, in accordance the procedure recommended by Boeing.

“It probably reduced the visibility of it covering the fan cowl static port covers,” Macleod said.

“A targeted inspection of locations and components, rather than relying on streamers, which can come loose, can help identify when these covers or devices have not been removed.”

You can find the report here: AO-2021-040 Aircraft Flight Readiness Event involving a Boeing 787-9, VH‑ZNJ Melbourne Airport, Victoria, September 22, 2021

Last updated May 17, 2022

/Public release. This material from the original organization/authors may be ad hoc in nature, edited for clarity, style and length. The views and opinions expressed are those of the author or authors.View Full here.
Previous Chiefs warn of shortage of invigilators for GCSE and A-level exams
Next Digital transformation is a cultural issue, not a technological one