No fatalities

2017-12-27: Fokker B.V. F28MK0100 (VH-NHA) — Network Aviation — Karratha Airport, Western Australia

Karratha Airport, Western Australia

On December 27, 2017, a Fokker B.V. F28MK0100 (registration VH-NHA) operated by Network Aviation was involved in an aviation accident near Karratha Airport, Western Australia. No fatalities were reported. Investigators recorded the probable cause as: The right engine thrust reverser did not activate because its lockout bolt was installed and not removed after maintenance, due to the engineer mistakenly using a cockpit bolt and multiple safeguards being missed. This summary draws on records from the Australian Transport Safety Bureau (ATSB); 5 related events involving the same aircraft type or operator are linked below.

Sourcesthe Australian Transport Safety Bureau (ATSB)Primary reportUpdated 1779789091Data APIEditorial standards

The right engine thrust reverser on VH-NHA failed to activate at Karratha Airport because a lockout bolt was left installed after maintenance in Perth, with multiple missed checks.

Incident Overview

During landing at Karratha Airport, the right engine thrust reverser on aircraft VH-NHA did not activate. The malfunction occurred because the in-service lockout bolt for the thrust reverser mechanism was still installed.

Maintenance Error

Before the flight, a maintenance engineer in Perth had installed the lockout bolt to safely isolate the thrust reverser during a maintenance task. Instead of using the specified maintenance lockout bolt, the engineer used a bolt from the cockpit because it was conveniently located. After completing the work, the engineer mistakenly did not remove the bolt.

Missed Detection

The presence of the bolt was not identified for several reasons. The usual risk controls associated with the specified lockout bolt were rendered ineffective because the wrong bolt was used. Specifically, there was no warning flag attached to the bolt to alert the engineer, dispatch engineer, or flight crew that the bolt was still installed. Additionally, the tooling check that would have identified the bolt had not been removed was circumvented. Furthermore, the cockpit lacked warning labels to inform the flight crew that the bolt might be installed.

Return to Service

As a result of these oversights, the aircraft was returned to service with the thrust reverser deactivated. This condition was not identified prior to the flight, leading to the inoperative thrust reverser upon landing.

Probable cause

The right engine thrust reverser did not activate because its lockout bolt was installed and not removed after maintenance, due to the engineer mistakenly using a cockpit bolt and multiple safeguards being missed.