Network F100 at Karratha on Dec 27th 2017, thrust reverser failed to operate on landing
Last Update: December 18, 2019 / 15:24:49 GMT/Zulu time
Incident Facts
Date of incident
Dec 27, 2017
Classification
Incident
Airline
Network Aviation
Departure
Perth, Australia
Destination
Karratha, Australia
Aircraft Registration
VH-NHA
Aircraft Type
Fokker 100
ICAO Type Designator
F100
The aircraft was able to depart for the return flight QQ-1653 about 2 hours after landing.
Australia's TSB reported the right hand thrust reverser failed to deploy due to a thrust reverser lockout pin that had not been removed following previous maintenance activity. The occurrence was rated an incident and is being investigated.
On Dec 18th 2019 the ATSB released their final report concluding the probable causes of the incident were:
- The lockout bolt on the right engine thrust reverser was not removed after maintenance, resulting in the aircraft returning to service with it deactivated.
- The engineer used the in-service lockout bolt from the cockpit instead of the maintenance lockout bolt. As a result, the risk controls associated with using the maintenance bolt (red warning flag and tool store check-out procedure) were rendered ineffective.
The ATSB described the sequence of events:
After a normal descent and touchdown, the captain (pilot flying) selected both engine thrust reversers. 2 The left engine thrust reverser activated but the right engine thrust reverser did not. This was followed by an alert tone and a message on the multifunction display that the thrust reverser had not operated.
The flight crew 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 taxied to the gate without further incident and the passengers disembarked.
The flight crew reported the thrust reverser issue to engineering personnel for investigation. The subsequent engineering inspection found that the right engine thrust reverser had the ‘minimum equipment list’ (in-service) lockout bolt installed, effectively deactivating the reverser. The lockout bolt (Figure 1) was removed, normal operation of the thrust reverser was confirmed, and the aircraft returned to service.
The ATSB analysed:
The right engine thrust reverser did not activate after VH-NHA landed at the Karratha Airport, because its in-service lockout bolt was installed. The engineer who installed the bolt during the maintenance in Perth before the flight had mistakenly not removed the bolt after the maintenance was completed. The presence of the bolt was missed for a number of reasons.
The engineer used the lockout bolt during the maintenance task to safely isolate the thrust reverser mechanism. However, he used the bolt from the cockpit because it was conveniently located. Therefore, the risk controls associated with using the specified maintenance lockout bolt were rendered ineffective.
Specifically, there was no warning flag to alert the engineer, dispatch engineer and flight crew that the lockout bolt was still installed. Further, the tooling check that would have identified that the bolt had not been removed was circumvented. Additionally, there were no warning labels in the cockpit to warn the flight crew that the bolt may be installed. Consequently, the aircraft was returned to service with the thrust reverser deactivated, but that was not identified prior to flight.
Aircraft Registration Data
Incident Facts
Date of incident
Dec 27, 2017
Classification
Incident
Airline
Network Aviation
Departure
Perth, Australia
Destination
Karratha, Australia
Aircraft Registration
VH-NHA
Aircraft Type
Fokker 100
ICAO Type Designator
F100
This article is published under license from Avherald.com. © of text by Avherald.com.
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