Aviation safety investigations & reports

Landing gear wheel failure involving Saab 340, VH-ZLX, Adelaide Airport, South Australia, on 20 August 2019

Investigation number:
AO-2019-047
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 20 August 2019 a Regional Express, Saab Aircraft Company 340B, registration VH-ZLX, departed Adelaide, for a regular public transport flight to Port Lincoln, South Australia. During the post flight walk around, the first officer noted that the left main outboard landing gear tyre was deflated and that a piece of the wheel was missing.

Ground support personnel at Adelaide Airport subsequently located the missing section of wheel on the runway strip.

What the ATSB found

An area of fatigue cracking had initiated in the bead seat region of the wheel and progressed 86 mm around the circumference prior to final overstress fracture. Information obtained from the manufacturer and a previous ATSB investigation indicated that fatigue cracking of the bead seat area in this wheel type was a known issue with previously updated maintenance schedules and practices.

It was considered likely that the fatigue crack was present at the most recent maintenance visit, however, it had not been detected. Insufficient guidance in the operator’s maintenance procedures meant that inspections required by the component maintenance manual that might have identified the developing fatigue crack were not carried out.

What's been done as a result

The operator advised that, as a result of this incident, they have implemented new measures to prevent a recurrence. These include:

  • Updating wheel maintenance procedures to ensure that non normal inspections are identified and carried out.
  • Making the component maintenance manual for tyres more readily available to personnel by adding it to their engineering website.
  • Providing additional advisory material to maintenance personnel on the requirements of completing unserviceable tags to ensure that other maintenance personnel performing subsequent work fully understand the defect.
  • Providing additional training to personnel on wheel maintenance techniques.

Safety message

When situations or issues arise that do not fit into standard operating procedures, maintenance personnel should always be prepared to consult or request further guidance. This guidance can come from internal support materials, such as procedures, or external materials such as maintenance manuals or the manufacturer.

Download final report
[Download  PDF: 755KB]
 
 
 

The occurrence

General details
Date: 20 August 2019   Investigation status: Completed  
Time: 1935 CST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Adelaide Airport   Investigation phase: Final report: Dissemination  
State: South Australia   Occurrence type: Landing gear/indication  
Release date: 26 August 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Saab Aircraft Co.  
Aircraft model 340B  
Aircraft registration VH-ZLX  
Serial number 340B-182  
Operator Regional Express  
Type of operation Air Transport Low Capacity  
Sector Turboprop  
Damage to aircraft Minor  
Departure point Adelaide, South Australia  
Destination Port Lincoln, South Australia  
Last update 26 August 2020