Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On 16 December 2018, at approximately 1545 Eastern Standard Time, a Fokker Aircraft B.V. F28MK0100 was conducting a regular public transport flight from Brisbane Airport, Queensland (Qld) to Rockhampton Airport, Qld with four crew and eighty-four passengers on board. During landing at Rockhampton, reverse thrust was selected by the crew, however both thrust reversers failed to deploy. The aircraft landed without incident. During taxi, the crew tested the reversers, which did not deploy.
Following non‑operation of the thrust reversers during the landing roll, an engineering check revealed that the reverse thrust lockout pins were installed, resulting in de-activation of the thrust reverser system. The lockout pins were installed as part of unscheduled maintenance action and unintentionally not removed prior to flight. It was also identified that the lockout pins did not have safety flags attached to them.
As a result of this incident, the maintenance organisation has advised the ATSB that they are taking the following ongoing safety actions:
- General Manager Aircraft Maintenance Organisation:
- Counsel LAME for effective oversight/management of shift task allocation and regulatory completion of associated documentation.
- Counsel AME to ensure any unscheduled maintenance is appropriately documented.
- Highlight to all AMO staff the requirement to record maintenance actions and to notify management and/or rectify any safety issues noted at the time.
- General Manager Airworthiness to review current TRP “Safety Flag” attachment management and associated reference documentation. Consideration should be given to:
- ensure all F100/70 aircraft TRP have “Safety Flags” attached
- update relevant Checklists and task references to include “TRP and Safety Flag”
- update appropriate MEL TRP removal/fitment steps to include “Safety Flag” references
- review management of Pre & Post maintenance safety tasks
- review of pre-flight procedures to include checking that pins are not installed and have been removed.
This incident serves as a reminder that a failure to follow procedures, such as functional checks, can result in unintended consequences. Functional checks are the last line of defence in maintenance work and can identify a range or errors that may have occurred during the job completion process. The extra few minutes taken to complete a functional check could detect an unsafe situation. This highlights the importance of ensuring that all pre-flight checks and procedures are carried out comprehensively and systematically. Where an aircraft has been out of service for maintenance, it is important to verify the functionality of all critical aircraft components before returning it to service. These checks should be conducted in addition to the routine, pre-flight checks. It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during flight.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
|Date:||16 December 2018||Investigation status:||Completed|
|Release Date:||30 April 2019||Occurrence category:||Incident|
|Aircraft manufacturer||Fokker B.V.|
|Type of operation||Air Transport High Capacity|
|Damage to aircraft||Nil|
|Departure point||Brisbane Airport, Qld|
|Destination||Rockhampton Airport, Qld|