The ATSB's final report into a Boeing 747 brake fire accident that resulted in the serious injury of three passengers and one pilot found that incorrect grease had been applied to the aircraft's landing gear and that one of the over-wing evacuation slides had failed due to overload of its fabric fibres during the evacuation.

The aircraft had just arrived at the Sydney terminal after a flight from Singapore.

The factors that contributed to the three small brake fires included: the presence of incorrect and excessive amounts of grease on the aircraft's landing gear axles, the inadvertent de-selection of reverse thrust and the heat generated by the aircraft's brakes during the landing roll and subsequent taxiing.

The ATSB could not determine when the incorrect grease was applied to the aircraft axles, but a number of maintenance issues were identified that contributed to the incorrect grease being applied.

The ATSB also found that one of the over-wing evacuation slides failed during the passenger evacuation as a result of tearing of the slide's fabric fibres. The object that punctured the slide was not identified, but it was most likely a blunt edged item carried or worn by a passenger during the evacuation.

As a result of the investigation, the aircraft operator has made safety improvements in the quality control of maintenance equipment, flight and ground crew operating and handling procedures, as well as passenger and flight crew emergency procedures.

The ATSB has also issued recommendations to the operator and to the Civil Aviation Safety Authority (CASA) concerning the use of over-wing slides during known brake fires.

Copies of the final ATSB report ( Aviation Safety Investigation Report 200302980) can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6425 or 1800 020 616.

Media contact: 1800 020 616
Last update 01 April 2011