Incident Overview
On 30 July 2005, a Boeing 757-236 (registration G-BMRE) operated by an airline was conducting training circuits at Nottingham East Midlands Airport. The aircraft had been positioned earlier that morning for maintenance, including replacement of the No 3 wheel brake unit. The flight crew consisted of four members: the commander, two student co-pilots, and a safety pilot. There were no passengers.
History of Flight
The aircraft took off for training circuits. During the second touch-and-go, the control tower alerted the crew that flames were visible from the right main landing gear. The commander decided to continue the touch-and-go and fly a circuit with the landing gear down to assess the situation. He was concerned about stopping distance remaining on the runway. The landing was successful, and after stopping on the runway, the fire service inspected the aircraft. A hydraulic leak and damage to the right main landing gear were found, but there was no evidence of smoke or flames affecting the wheels. The aircraft was towed to a stand.
Maintenance Error
The fire was later attributed to a failure in the No 3 brake unit. The end cap of the brake torque rod had not been refitted during the maintenance activity. This allowed the brake torque rod to become detached at one end and scrape along the ground during landing. The brake unit rotated with the wheel during rollout, causing damage to the wheel, severing the brake hose, and damaging brake temperature monitoring components.
Investigation Findings
The operator's Safety Department used Boeing's Maintenance Error Decision Aid (MEDA) to investigate. Interviews with the maintenance engineers revealed that the work was carried out at night using torchlight. They were subjected to numerous interruptions, and neither engineer realized the end cap was missing because the lockbolt did not rotate when tightened—contrary to their past experience. Contributory factors identified included repetitive task familiarity, inadequate task planning, peer and time pressure. The shift supervisor had allocated extra teams to complete tasks within the shift, and the change of the brake unit was recommended to be done in daylight but this was overruled.
Safety Actions
The operator implemented safety actions: reviewing authority to change maintenance programs, reminding personnel to review procedures before tasks, considering independent checks after brake unit changes, and providing additional training for supervisors on proper procedures and the risks of poor environmental conditions. Safety training days were organized using this incident as a case study. No formal safety recommendations were deemed necessary.