Aviation safety investigations & reports

Undetected engine thrust reverser deactivation involving Fokker F100, VH-NHA, Karratha Airport, Western Australia, on 27 December 2017

Investigation number:
AO-2018-001
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 253KB]
 

What happened

On the morning of 27 December 2017, a Network Aviation Fokker F100 aircraft, registered VH‑NHA was on final approach to Karratha Airport, Western Australia. The aircraft was operating as a scheduled passenger flight from Perth.

After a normal descent and touchdown, the captain selected both engine thrust reversers. The right engine thrust reverser did not activate. The aircraft decelerated using normal braking and taxied to the gate without further incident. There was no damage to the aircraft or injuries as a result of the incident. The captain reported the thrust reverser issue to maintenance personnel for investigation.

What the ATSB found

During maintenance the previous day in Perth, the right engine thrust reverser ‘minimum equipment list’ (in-service) lockout bolt had been installed instead of the maintenance lockout bolt. The maintenance bolt had a red warning flag and needed to be booked out from the tool store. Using the in-service bolt rendered ineffective the visual checks (warning flag) and procedural tooling check that were in place to ensure the bolt’s removal. Consequently, the aircraft was released to service with the bolt installed.

What's been done as a result

The aircraft’s maintenance organisation advised that in response to this incident it has taken safety action to highlight to maintenance staff the importance to follow the safety instructions and warnings contained in the aircraft maintenance manual. Further, the procedures for maintenance activities including task assessments, tooling and task procedures, have been reinforced.

Safety message

This investigation highlights the risk of varying procedures when performing maintenance tasks. It is important that, in all parts of the maintenance system, there is an awareness of human factors associated with completion of the task. An understanding of the demands associated with a task may help identify informal work practices that can then be aligned with the formal procedures (see Civil Aviation Safety Authority publication Safety Behaviours: Human Factors Resource Guide for Engineers).

Download final report
[Download  PDF: 253KB]
 
 
 

The occurrence

General details
Date: 27 December 2017   Investigation status: Completed  
Time: 10:42 WST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Karratha Airport   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: Engine failure or malfunction  
Release date: 18 December 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Fokker B.V.  
Aircraft model F28MK0100  
Aircraft registration VH-NHA  
Serial number 11490  
Operator Network Aviation  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Perth, Western Australia  
Destination Karratha, Western Australia  
Last update 18 December 2019