Braking point

Canning Gazette - - NEWS -

A PLANE car­ry­ing 70 flight crew and pas­sen­gers left Perth Air­port with­out full stop­ping power af­ter main­te­nance was per­formed in­cor­rectly.

An Aus­tralian Trans­porta­tion Safety Bureau (ATSB) in­ves­ti­ga­tion found a wrong part used dur­ing work on an en­gine was left in when the Fokker F100 took off.

The in­cor­rect part ren­dered one of the two en­gine thrust re­versers – which help air­planes slow down on land­ing – in­op­er­a­tive. The Fokker was able to de­cel­er­ate us­ing nor­mal braking when it landed at Kar­ratha on De­cem­ber 27, 2017.

The ATSB found that dur­ing an in­spec­tion of the air­craft en­gines’ emer­gency fuel shut-off ca­bles, a main­te­nance engi­neer in­stalled the in­cor­rect lock­out bolt to safely iso­late the thrust re­verser mech­a­nism and then did not re­move it once the job was done.

Its in­ves­ti­ga­tion found the engi­neer used a more con­ve­niently lo­cated part from the air­craft’s flight deck for the task, in­stead of the ap­pro­pri­ate part, which had a large red warn­ing flag and had to be checked out of the tool store.

As a re­sult, the lock-out bolt did not show as miss­ing dur­ing an in­ven­tory check.

There were no warn­ing la­bels in the cock­pit to warn the flight crew that the bolt may be in­stalled.

“This in­ves­ti­ga­tion high­lights the risks of vary­ing from pro­ce­dures when per­form­ing main­te­nance tasks,” ATSB trans­port di­rec­tor Stu­art Macleod said.

“It is im­por­tant that in all parts of the main­te­nance sys­tem, there is an aware­ness of hu­man fac­tors. “

The main­te­nance or­gan­i­sa­tion has high­lighted to its staff at the Air­port the im­por­tance of fol­low­ing safety in­struc­tions and warn­ings in the air­craft main­te­nance man­ual.

It has also re­in­forced pro­ce­dures for main­te­nance ac­tiv­i­ties, in­clud­ing task as­sess­ments.

This is the third in­ci­dent in three years where main­te­nance en­gi­neers have in­ad­ver­tently left lock­out bolts in­stalled in pas­sen­ger air­craft en­gines af­ter main­te­nance.

An ATSB di­a­gram show­ing the lo­ca­tion of the lock­out bolt.

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