Aviation safety investigations & reports

Aircraft preparation event involving A320, VH-FNP, Perth Airport, Western Australia, on 14 August 2018

Investigation number:
AO-2018-063
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 14 August 2018, a Virgin Australia Regional Airlines (VARA) A320, registered VH-FNP, was prepared for a scheduled passenger flight from Perth Airport, Western Australia, to Christmas Island. Landing gear ground locks (LGGL) were fitted to the landing gear of FNP during the preparation, and were not removed prior to pushback. A ground handler removed the locking pins from the LGGL, but did not remove the associated sleeves.

As the aircraft was pushed back, taxied and took off from Perth Airport, the LGGL sleeves fell from the landing gear, onto a taxiway and Runway 21. The remainder of the flight was uneventful and FNP landed safely at Christmas Island.

What the ATSB found

The ATSB found that a lack of documentation relating to installing and removing LGGL from VARA A320s, and an ineffective handover of responsibilities between two engineers, contributed to the engineers not detecting that the LGGL remained installed during the preparation for flight.

Although the flight crew aircraft exterior walk-around check identified the LGGL, this was at a time when the flight crew did not have access to the flight deck due to maintenance work on the flight deck. The disrupted pre-flight sequence for the flight crew contributed to the flight crew later not identifying that the LGGL were missing from the stowage compartment on-board.

There was no procedure for making maintenance log entries when LGGL were installed and removed. A maintenance log entry relating to LGGL would have provided another opportunity for both the flight crew and the on-board engineer to become aware that the LGGL had not been removed and stored on-board before flight.

Rather than inform an engineer or pilot as per procedures, the pushback driver removed the LGGL pins from the landing gear sleeves before pushback. This decision was affected by time pressure and prior experience removing pins from another aircraft type. However, as the lanyards attaching the pins to the sleeves was missing and the pushback driver did not understand the LGGL locking mechanism, he removed the pins and not the sleeves.

What's been done as a result

VARA introduced procedures requiring an authorised person to sign an Aircraft Readiness Log to certify that LGGL had been removed prior to flight. If the aircraft has been towed after the initial check, the check must be performed again. Towing procedures also now require the approved brake rider to ensure that LGGL have been removed after a positional tow.

VARA have also issued a notice to flight crews instructing them to use a standardised method for stowing LGGL pins and sleeves. A separate notice reminds ground handlers they should not remove pins themselves.

Safety message

This investigation highlights how a number of relatively small errors and/or omissions, associated with separate functional areas, can combine to potentially affect flight safety. In this case, the identification and rectification of any one factor would probably have significantly reduced the likelihood of the occurrence developing.

While all persons working in and around aircraft have specific roles, they also have a responsibility to notify the operating crew about any concerns they may have with the aircraft. It is imperative that any concerns are assessed and rectified by appropriately qualified personnel before flight.

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[Download  PDF: 340KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

General details
Date: 14 August 2018   Investigation status: Completed  
Time: 1338 WST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Perth Airport   Investigation phase: Final report: Dissemination  
State: Western Australia   Occurrence type: Aircraft preparation  
Release date: 11 September 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-231  
Aircraft registration VH-FNP  
Serial number 429  
Operator Virgin Australia Regional Airlines  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Perth Airport, Western Australia  
Destination Christmas Island, Western Australia  
Last update 11 September 2019