Aviation safety investigations & reports

Boeing Co 747-438, VH-OJU

Investigation number:
200302980
Status: Completed
Investigation completed

Summary

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On 2 July 2003, the Boeing 747-438 aircraft, registered VH-OJU, operating on a scheduled flight from Singapore, arrived at Sydney at 0511 Eastern Standard Time, during the airport's curfew period. There was a tailwind of around 12 knots when the aircraft landed. The pilot flying selected auto brake setting three and idle reverse thrust in accordance with the curfew requirement. However, during the landing roll the reverse thrust was inadvertently de-selected.

On arrival at the terminal, the pilot in command (PIC) observed a BRAKE TEMP advisory message and notified the ground engineers. At that point, a fire ignited on the right wing landing gear. The flight crew were advised and the PIC ordered an evacuation of the aircraft. On receiving the evacuation announcement, the cabin crew commenced the evacuation drill deploying the aircraft's escape slides. The upper deck left (UDL) door and doors 2 left (L2) and 4 right (R4) escape slides, did not deploy. During the evacuation, the over-wing slide at door right 3 (R3) deflated while in use. As a result of the evacuation, one flight crew member and three passengers were seriously injured. Some passengers evacuated down the slides with their cabin baggage.

During the accident, an additional two brake fires ignited on the right body landing gear, one of which was extinguished by the Aerodrome Rescue and Fire Fighting Service (ARFFS). A subsequent inspection found that the aircraft's landing gear contained an excessive amount of grease with the presence of inappropriate grease on all of the landing gear axles. The three brake units that had caught fire were found to be serviceable but in a worn condition.

The investigation determined that slide R3 did not have any pre-existing defects that contributed to its failure. The nature of the failure was found to be overload of the fabric fibres during the evacuation. The inappropriate grease found on the landing gear axles was general purpose grease used on other components of the landing gear. The time and point of its application to the aircraft axles could not be determined.

The investigation found deficiencies in the operator's maintenance, flight crew and cabin crew procedures. As a result, the operator has issued maintenance memos to its engineering staff clarifying aircraft landing gear lubrication procedures, amended its Aircrew Emergency Procedures Manual, and reviewed cabin crew and flight crew emergency procedures.

As a result of this investigation, the ATSB is issuing safety recommendations to the operator and the Civil Aviation Safety Authority concerning the use of over-wing slides during known brake fires.

Related Documents: | Media Release |

Download Final Report
[Download  PDF: 1.35MB]
 
 
 
General details
Date: 02 July 2003   Investigation status: Completed  
Time: 0511 hours EST    
Location   (show map): Sydney, Aero.    
State: New South Wales   Occurrence type: Fire  
Release date: 17 March 2005   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 747  
Aircraft registration VH-OJU  
Serial number 25566  
Type of operation Air Transport High Capacity  
Damage to aircraft Minor  
Departure point Singapore  
Destination Sydney, NSW  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 2400 15133
Co-Pilot/1st Officer ATPL 300 19500
 
Injuries
  Crew Passenger Ground Total
Serious: 1 3 0 4
Minor: 1 4 0 5
Total: 2 7 0 9
Last update 13 May 2014