Airbus A320 Thrust Reverser Failure Study Notes

Airbus A320 Thrust Reverser Failure - Study Notes

• Incident Date: January 21, 2024
• Aircraft: Airbus A320 (HZ-XXXX)
• Flight: SV-XXX from Riyadh (RUH) to Jeddah (JED)
• Failure: Both engine thrust reversers failed upon landing.
• ECAM Messages: "ENG 1 reverser fault" and "ENG 2 reverser fault" received in the cockpit.
• Cause: Incorrect deactivation pins (PN: HIX3008) were used, and necessary safety pins with red streamers (Remove Before Flight) were not employed.

Maintenance Failures

• Incorrect Deactivation Pins: Maintenance team used quick-release pins, instead of the required safety pins (PN: HIX3008).
  • Quick-release pins were readily available in the thrust reverser assembly.
  • Correct, safety pins with “Remove Before Flight” streamers were available but not used.
• Improper Supervision: The Section Manager bypassed the standard supervisory chain, which removed oversight for the unqualified fitter team. A team of three unqualified fitters was assigned.
• Falsified Task Sign-Off: A qualified A320 technician falsified an EWIS inspection task card, inaccurately stating the TR systems were reactivated.
  • The technician likely did this to reduce open tasks and work orders. The TRs were intended to remain deactivated for a subsequent maintenance task. This highlights the danger of assumptions in aircraft maintenance and the importance of clear communication.
• Failure to Follow AMM Procedures: The maintenance shift supervisor failed to remove the deactivation pins prior to releasing the aircraft for service. This oversight was a critical failure to meet established protocols.
  • The supervisor also conducted a final engine leak check without removing the safety pins.

Root Causes: "Dirty Dozen" Human Factors

• Lack of Communication: Poor communication between maintenance teams and shifts.
• Complacency: Technician falsified a sign-off with assumptions.
• Lack of Knowledge: Unqualified fitter team lacked necessary expertise.
• Distraction: Minimizing open tasks may have distracted the maintenance team from proper procedures.
• Lack of Teamwork: Bypassing the supervisory chain and assigning an unqualified team impacted teamwork.
• Pressure: Pressure to minimize open tasks may have contributed to shortcuts and procedural violations.
• Lack of Resources: Needed deactivation pins were not secured, highlighting a deficiency in resource management.
• Stress: Pressure to meet time constraints can lead to mistakes.
• Lack of Assertiveness: Team members failed to challenge improper procedures or use of inadequate pins.

Systemic Issues

• Unclear Roles and Responsibilities: Maintenance department roles and responsibilities were poorly defined. This resulted in the Section Manager overriding the shift supervisor's authority.
• Ineffective Communication: Lack of communication between maintenance teams and shifts prevented crucial information from being relayed, leading to the incident.

This study note quiz covers the incident of the Airbus A320 thrust reverser failure that occurred on January 21, 2024. It details the maintenance failures, incorrect equipment use, and the absence of proper supervision during the incident. Test your knowledge on aviation safety protocols and maintenance procedures.