Jetstar A320 at Sydney on Sep 20th 2018, thrust reversers did not deploy

Last Update: March 22, 2019 / 17:26:27 GMT/Zulu time

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Photo of Jetstar Airways VH-VGZ, Airbus A320 — Jetstar Airways VH-VGZ, Airbus A320 (Photo credit: mikecogh / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Sep 20, 2018

Classification
Report

Airline
Jetstar Airways

Flight number
JQ-827

Departure
Brisbane, Australia

Destination
Sydney, Australia

Aircraft Registration
VH-VGZ

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A Jetstar Airbus A320-200, registration VH-VGZ performing flight JQ-827 from Brisbane,QL to Sydney,NS (Australia) with 178 passenegers and 5 crew, landed on Sydney's runway 16L when the first officer, pilot flying, selected both engines into reverse thrust, however an ECAM indication "reverse fault" occurred. The captain, pilot monitoring, called "no reverse", the first officer completed the safe roll out without the use of thrust reversers and only on wheel brakes. A subsequent engineering inspection revealed both thrust reversers had been locked out with their MEL lock out pin, however, no entry was made in the tech logs.

Australia's ATSB released their final report concluding the probable causes of the incident was:

- Deviation from the required maintenance procedures resulted in the aircraft being returned to service with the thrust reverser system inadvertently deactivated.

- Operational pressure to expedite the maintenance probably influenced the engineers’ decision to deviate from the written procedures.

The ATSB analysed:

Following non-operation of the thrust reversers during the landing roll, an engineering check revealed that the MEL lockout pins were installed in the hydraulic control units (HCU) resulting in deactivation of the thrust reverser system. The pins were installed as part of required maintenance action and unintentionally not removed prior to flight.

Although the AMM procedure did not require a functional check of the thrust reversers following reactivation, the operator’s task card did. The task card was a supplemental procedure to the AMM and it was a requirement that a licenced engineer sign and certify that each step was completed. The task card specifically noted the importance of conducting the post-maintenance checks as stand-alone tasks. Contrary to the written procedure, the engineers did not follow the task card sequentially and signed off the operational check based on testing that they had completed earlier in the day. While that action was probably motivated by the desire to expedite the aircraft’s return to service, if the engineers had completed the functional check in sequence, they would have discovered that the thrust reverser was still de-activated.

Although the required operational check of the thrust reverser would have prevented this incident, other maintenance actions hampered detection of the HCU lockout. Thrust reverser de-activation required the use of a lockout pin with a red flag attached to provide a visual indication that the HCU was de-activated. The MEL lockout pin that was actually fitted was designed for in service use and was much less visually obvious than the pin used during maintenance.

The replacement of the horizontal stabiliser actuator and change to the revenue flight departure time had a compounding effect on the maintenance schedule. The engineering team probably felt pressure to expedite the maintenance, working through meal breaks in an effort to achieve this. The engineers stated that they felt pressured to return all tools to the tooling crib so that the CC could complete the paperwork, and that this was an influential factor in their decision to use the MEL lockout pin.

The AMM thrust reverser de-activation procedure also required the use of specific warning labels in the cockpit, stating that ‘thrust reverser HCU is de-activated’. However, it was reportedly common practice to only use a generic maintenance warning notice. That action, in combination with use of the MEL lockout pins, removed opportunities to identify the status of the thrust reverser system during the final inspection, and before the aircraft was returned to service.