Aviation safety investigations & reports

Undetected engine thrust reverser deactivation involving Airbus A320, VH-VQG, Gold Coast Airport, Queensland on 18 December 2017

Investigation number:
AO-2017-117
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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[Download  PDF: 143KB]
 

What happened

On the morning of 18 December 2017, a Jetstar Airways Airbus A320 aircraft, registered VH‑VQG was on final approach for Gold Coast Airport, Queensland. The aircraft was operating as a scheduled passenger flight, from Adelaide, South Australia.

After a normal descent and touchdown, the captain selected both engine thrust reversers. The left 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, and the captain reported the thrust reverser issue for investigation.

What the ATSB found

During overnight maintenance in Adelaide, the left engine thrust reverser lockout pin had been installed. However, the pin was not removed after the maintenance, resulting in the aircraft returning to service with the thrust reverser deactivated.

The lockout pin was located at the top of the engine and its 1 m red warning flag was difficult to see in the prevailing low‑light conditions. This probably led to the engineer not seeing the flag and removing the pin.

Further, the lockout pin was not booked out of the tool store nor was its installation recorded in the technical log. As a result, the checks that these procedures provided to ensure the pin's removal were missed.

What's been done as a result

The aircraft’s maintenance organisation, Qantas, advised that it is taking safety action that includes the following:

  • Highlighting the importance of the aircraft maintenance manual precautions to maintenance staff at Adelaide.
  • Lengthening all thrust reverser lockout pin warning flags to hang past the closed engine cowls. The pin will also have a warning notice attached for placement on the engine thrust reverser controls during maintenance.

The aircraft manufacturer, Airbus, advised that the August 2019 revision of the aircraft maintenance manual introduced an operational test of the thrust reverser system to confirm its re‑activation after maintenance tasks.

Safety message

This investigation highlights the importance of considering the environmental conditions in which equipment and tools will potentially be used, as well as the importance of following procedures that in this instance should have resulted in detecting the error.

When considering the effectiveness of equipment, tooling and procedures that aim to minimise the likelihood and/or consequences of an error, an engineered solution is generally more effective than relying on procedural compliance. Further, a functional check is generally more effective within procedural compliance than a self-check of work. See the ATSB research report, An overview of human factors in aviation maintenance (AR-2008-055), available from the ATSB website.

Download final report
[Download  PDF: 143KB]
 
 
 

The occurrence

General details
Date: 18 December 2017   Investigation status: Completed  
Time: 0847 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Gold Coast Airport   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Warning devices  
Release date: 05 September 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VQG  
Serial number 2787  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Adelaide, South Australia  
Destination Gold Coast, Queensland  
Last update 16 September 2019