Incident
The left engine thrust reverser did not activate when VH-VQG landed at the Gold Coast Airport because its lockout pin was still installed. Engineers had installed the pin during maintenance in Adelaide before the flight but missed removing it due to several contributing conditions.
Maintenance Conditions
The maintenance in Adelaide was carried out at night under artificial lighting on the tarmac. The lighting significantly reduced at midnight when the tarmac lights automatically dimmed (half extinguished). Additionally, it was raining when engineer 1 conducted a visual inspection before closing the engine cowling. These conditions made it difficult to see the lockout pin’s red warning flag. The red colour of the flag was harder to see in the artificial lighting, and the flag was not fitted with reflective material. The lockout pin was located at the top of the engine, where its 1-metre flag was not as conspicuous as other longer flags that would have hung below the engine to the tarmac. Furthermore, the stand used to install the pin, which might have served as a reminder, had been removed.
Procedural Issues
Procedures aimed at ensuring the lockout pin’s removal were not followed. These procedures included booking items out on the tool store’s computer system. As the pin was not booked out, its return to the store could not be checked. Further, the pin’s installation was not recorded in the technical log, which meant its removal went unnoticed and unrecorded. Finally, the required cockpit warnings associated with thrust reverser deactivation were not used, thereby removing an opportunity to identify that the pin had not been removed before the aircraft was returned to service.