Aviation safety investigations & reports

Flight control system event - 520km NW of Gold Coast Aerodrome, Qld, 18 May 2009, VH-VNC, Airbus A320-232

Investigation number:
AO-2009-021
Status: Completed
Investigation completed

Summary

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On 18 May 2009, an Airbus Industrie A320-232 aircraft, registered VH-VNC was on a regular public transport flight from Mackay, Queensland (Qld) to Melbourne, Victoria when at about 1249 Eastern Standard Time, the aircraft started to vibrate. Cockpit indications showed that the left aileron was oscillating. The crew diverted the aircraft to the Gold Coast Aerodrome, Qld and landed.

The source of the aileron oscillation was an internal fault in one of the left aileron's hydraulic servos. The fault was introduced during manufacture by an incorrect adjustment of the servo, which caused internal wear in a number of the servo's hydraulic control components. The aileron servo manufacturer has incorporated a new method of adjusting the aileron servos during assembly to minimise the likelihood of a recurrence of the problem.

During the investigation, it was found that an identical fault had occurred to the same aircraft 8 months prior to this incident. The previous incident was not reported to the Australian Transport Safety Bureau by the operator as required by the Transport Safety Investigation Act 2003. The operator has improved the training of its staff and the reportable event requirements in its safety management system manual in an effort to address the non-reporting risk.

Download Final Report
[Download  PDF: 964KB]
 
 
 

Safety Issues

Go to AO-2009-021-SI-01 - Go to AO-2009-021-SI-02 -

Aileron servo valve adjustment

The servo valve within the left green aileron servo was incorrectly adjusted during manufacture.

Safety issue details
Issue number: AO-2009-021-SI-01
Who it affects: The aircraft manufacturer and aircraft type operators
Status: Adequately addressed

Reporting of incidents

The aircraft operator did not comply with the reporting requirements of the Transport Safety Investigation Act 2003.

Safety issue details
Issue number: AO-2009-021-SI-02
Who it affects: The aircraft operator
Status: Adequately addressed
General details
Date: 18 May 2009   Investigation status: Completed  
Time: 1300 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 520km NW Gold Coast Aerodrome    
State: Queensland   Occurrence type: Flight control systems  
Release date: 24 August 2010   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus Industrie  
Aircraft model A320  
Aircraft registration VH-VNC  
Serial number 3275  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Mackay, Qld  
Departure time 1249 EST  
Destination Melbourne, Vic  
Last update 14 November 2018