Podcast
Questions and Answers
What was a significant failure in the maintenance process observed during the incident?
What was a significant failure in the maintenance process observed during the incident?
- Technicians communicated effectively between shifts.
- All maintenance personnel followed established protocols.
- The maintenance shift supervisor failed to remove deactivation pins. (correct)
- The maintenance shift supervisor removed deactivation pins.
Which factor contributed to shortcuts and deviations from procedures?
Which factor contributed to shortcuts and deviations from procedures?
- Adequate training of all technicians.
- Full compliance with AMM procedures.
- Pressure to minimize open tasks. (correct)
- Thorough communication between teams.
What human factor indicates a failure in teamwork during the incident?
What human factor indicates a failure in teamwork during the incident?
- Proper delegation of tasks.
- Effective collaboration among team members.
- Bypassing of the regular supervisory chain. (correct)
- Optimal resource allocation.
Which of the following is a corrective action that was implemented following the incident?
Which of the following is a corrective action that was implemented following the incident?
What led to a misunderstanding about the status of thrust reverser systems?
What led to a misunderstanding about the status of thrust reverser systems?
Which of the following describes a lack of knowledge among the maintenance team?
Which of the following describes a lack of knowledge among the maintenance team?
Which of the following factors is NOT one of the 'Dirty Dozen' that contributed to the incident?
Which of the following factors is NOT one of the 'Dirty Dozen' that contributed to the incident?
What consequence might result from workers feeling stressed during maintenance tasks?
What consequence might result from workers feeling stressed during maintenance tasks?
What did the technician wrongly assume about the task completion?
What did the technician wrongly assume about the task completion?
What issue was identified regarding resource management during the maintenance incident?
What issue was identified regarding resource management during the maintenance incident?
What failure occurred with the Airbus A320's thrust reversers during the incident?
What failure occurred with the Airbus A320's thrust reversers during the incident?
What were the crew alerted by after the thrust reverser failure?
What were the crew alerted by after the thrust reverser failure?
What was a significant error made during the maintenance of the thrust reversers?
What was a significant error made during the maintenance of the thrust reversers?
What type of supervision failure occurred in the maintenance section?
What type of supervision failure occurred in the maintenance section?
What was the reason the fitters used the incorrect deactivation pins?
What was the reason the fitters used the incorrect deactivation pins?
What incorrect action did the A320 qualified technician take?
What incorrect action did the A320 qualified technician take?
Which of the following was available to the maintenance team but not utilized?
Which of the following was available to the maintenance team but not utilized?
Why did the technician falsely indicate that the TR systems were reactivated?
Why did the technician falsely indicate that the TR systems were reactivated?
Flashcards
System Failure
System Failure
A situation where a system, process, or procedure fails to meet its intended purpose, leading to an undesirable outcome. In this case, the failure of the thrust reversers upon landing resulted in a significant safety risk.
Thrust Reverser
Thrust Reverser
An aircraft system that helps slow down the aircraft during landing by redirecting the engine exhaust forward, reducing the landing roll distance.
Deactivation Pin
Deactivation Pin
A device used to deactivate the thrust reverser system, allowing access for inspection or maintenance.
Quick Release Deactivation Pin
Quick Release Deactivation Pin
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Safety Deactivation Pin
Safety Deactivation Pin
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Aircraft Maintenance Manual (AMM)
Aircraft Maintenance Manual (AMM)
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Task Sign-Off
Task Sign-Off
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Supervision
Supervision
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Complacency in aircraft maintenance
Complacency in aircraft maintenance
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Communication breakdown
Communication breakdown
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Unqualified technicians in aircraft maintenance
Unqualified technicians in aircraft maintenance
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Pressure to minimize open tasks
Pressure to minimize open tasks
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Dirty Dozen in Aircraft Maintenance
Dirty Dozen in Aircraft Maintenance
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Lack of Assertiveness
Lack of Assertiveness
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Distraction in Aircraft Maintenance
Distraction in Aircraft Maintenance
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Undefined roles and responsibilities
Undefined roles and responsibilities
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Failure to follow AMM procedures
Failure to follow AMM procedures
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Lack of Resources in Aircraft Maintenance
Lack of Resources in Aircraft Maintenance
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Study Notes
Airbus A320 Thrust Reverser Failure - Study Notes
- Incident Date: January 21, 2024
- Aircraft: Airbus A320 (HZ-XXXX), operating flight SV-XXX
- Route: Riyadh (RUH) to Jeddah (JED)
- Problem: Both engine thrust reversers failed upon landing
- Cause: Deactivation pins mistakenly left installed in the engines
Key Findings and Maintenance Failures
- Incorrect Pins: Maintenance installed quick release deactivation pins instead of correct procedure pins (HIX3008 with red streamers) and didn't remove them before release. Tools were available, but not used.
- Insufficient Oversight: Supervisor bypassed normal process, assigning an inexperienced team of three fitters to the task.
- Incorrect Task Sign-Off: A qualified A320 technician falsely signed off on the EWIS inspection task card—the task wasn't completed correctly.
- Non-Compliance with AMM: Maintenance supervisor failed to remove deactivation pins and ensure the Thrust Reversers were in a functional state.
- Lack of Clear Communication: Insufficient communication between shifts.
- Minimization of Open Tasks: Pressures to minimize open tasks likely contributed to shortcuts and error in the maintenance process.
Human Factors Contributing to the Incident ("Dirty Dozen")
- Poor Communication: Between maintenance shifts
- Complacency: Technician falsely signing off on tasks.
- Lack of Knowledge: Inexperienced maintenance team.
- Distraction: Focus on minimizing open tasks.
- Lack of Teamwork: Bypass of supervisor procedures.
- Pressure: Pressures to complete tasks led to shortcuts.
- Lack of Resources: Correct pins were available but not ordered.
- Stress: The pressure of tasks contributing to errors.
- Lack of Assertiveness: Team did not challenge the use of improper pins.
Corrective Actions
- Technical Bulletin: Issuing to personnel on proper procedures.
- Team Assignment Protocol: Implemented for better supervision.
- Unqualified Technician Policy: Prohibiting unqualified technicians from unsupervised work.
- Sign-Off Policy: Prohibiting incorrect sign-off.
- Training and Feedback: Training to personnel involved and incident incorporated into training materials.
- Lesson Learned Report: Disseminating a detailed report on the incident.
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Description
Explore the critical incident involving the Airbus A320 thrust reverser failure that occurred on January 21, 2024. This quiz covers the maintenance failures, incorrect procedures, and key findings that led to this aviation incident. Test your knowledge on aviation safety and maintenance protocols.
