Jetstar A320 at Coolangatta on Dec 18th 2017, failure of thrust reverser
Last Update: September 5, 2019 / 15:07:05 GMT/Zulu time
Australia's TSB reported a post flight examination revealed previous maintenance had not removed a hydraulic lockout pin and opened an investigation into the occurrence rated an incident.
On Sep 5th 2019 the ATSB released their final report concluding the probable causes of the incident were:
- The lockout pin on the left engine thrust reverser was not removed after maintenance, resulting in the aircraft returning to service with the thrust reverser deactivated.
- The location of the thrust reverser lockout pin at the top of the engine meant that its 1 m red warning flag was difficult to see in the prevailing low-light conditions. This probably led to the engineer not seeing the flag and removing the pin.
- The lockout pin was not booked out of the tool store nor was its installation recorded in the technical log. As a result, the checks that these procedures provided to ensure the pin's removal were missed. Additionally, the required cockpit warnings associated with thrust reverser deactivation were not used, removing an opportunity to identify that the thrust reverser was disabled.
The ATSB described the sequence of events:
At about 0845 Eastern Standard Time,1 air traffic control cleared VQG to land. After a normal descent and touchdown, the captain (pilot flying) selected both engine thrust reversers.2 The right engine thrust reverser activated but the left engine reverser did not, and the flight crew received a ‘reverse fault’ alert. They continued with the landing and the aircraft decelerated to a taxi speed using normal braking. The captain moved the thrust reverser controls to the stowed position, the aircraft was taxied to the gate without further incident and the passengers disembarked.
While taxiing, the captain cycled the thrust reverser levers and the alert extinguished. Nevertheless, the captain reported the thrust reverser issue for investigation by engineering personnel.
The subsequent engineering inspection found the left engine thrust reverser lockout pin installed, effectively deactivating the reverser. The lockout pin was removed, the thrust reverser confirmed to be operating normally and the aircraft returned to service.
The ATSB described the maintenance activities the night preceeding the occurrence flight:
One of the engineers (engineer 1) began his scheduled night shift at about 1900 on 17 December, and he described the weather that evening as hot and humid. He initially thought he was the only engineer on that shift to carry out maintenance certification on four A320 aircraft, and stated that he felt ‘stressed’ and under pressure. The other engineer (engineer 2) had been called in to work overtime that evening. He started his shift at 1830, carrying out other tasks before being assigned to assist engineer 1 with VQG later that evening.
At about 2300, after completing their other tasks, the engineers commenced maintenance on VQG. This maintenance was unscheduled and involved investigating an engine bleed air issue. Jetstar had not provided paperwork for this task. Engineer 2 began collecting the consumables required for the task. Engineer 1 went to the tarmac tool store to get a lockout pin, required to be installed on the engine to prevent inadvertent activation of the thrust reverser.
After locating the lockout pin with some difficulty, engineer 1 hurried back to the aircraft without booking out the pin on the store’s computer system. He opened the left engine cowling and, using a stand to access the top of the engine, installed the pin. Procedures required the pin’s installation to be entered in the aircraft’s technical log. The log was located in the line office, and the engineer decided to record it in the log later.
A couple of hours later, the engineers completed investigating the bleed air issue. By this time, it had started raining. Engineer 1 made a visual inspection around the engine in preparation to close the cowling. The available lighting had reduced as half the tarmac lights automatically turn off at midnight. Engineer 1 missed seeing the lockout pin and its 1 m long red warning flag, and closed the cowling (Figure 1). The flag was shorter than those on the pins in the hangar tool store at Adelaide, which had been lengthened to 4m after a previous incident to make them more obvious. Additionally, the stand that engineer 1 had used to install the pin, and which may have reminded him about it, had been removed for another task.
The aircraft maintenance manual thrust reverser de-activation procedure also required the use of specific warning labels in the cockpit, stating that ‘thrust reverser HCU [hydraulic control unit] is de-activated’. This procedure was not used during this maintenance task.
The ATSB analysed:
The left engine thrust reverser did not activate when VH-VQG landed at the Gold Coast Airport because its lockout pin was installed. Engineers had installed the pin during maintenance in Adelaide before the flight, but missed removing it due to a number of reasons.
The maintenance in Adelaide was carried out in the night under artificial lighting on the tarmac. The lighting significantly reduced at midnight when the tarmac lights automatically dimmed (half extinguished). In addition, it was raining when engineer 1 carried out a visual inspection before closing the engine cowling. These conditions made it difficult to see the lockout pin’s red warning flag.
The red colour of the flag was also harder to see in the artificial lighting,4 and the flag was not fitted with reflective material. The lockout pin was located at the top of the engine, where its 1 m flag was not as conspicuous as other longer flags, which would have hung below the engine to the tarmac. Further, the stand used to install the pin, which might have served as a reminder, had been removed. The combination of these factors probably led to the pin not being removed.
Procedures aimed at ensuring the lockout pin’s removal were not followed. These procedures included booking items out on the tool store’s computer system. As the pin was not booked out, its return to the store could not be checked. Further, the pin’s installation was not recorded in the technical log, which meant its removal went unnoticed and unrecorded.
Finally, the required cockpit warnings associated with thrust reverser deactivation were not used, thereby removing an opportunity to identify that the pin had not been removed before the aircraft was returned to service.
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This article is published under license from Avherald.com. © of text by Avherald.com.
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