Nose Wheel Detached from Lufthansa Cargo MD-11F D-ALCM after Maintenance Error
On 10 November 2016 Lufthansa Cargo McDonnell Douglas MD-11F D-ALCM suffered damage when the left-hand nose-wheel detached, bounced and repeatedly struck the underside of the fuselage on landing in Buenos Aires, Argentina on a flight from Curitiba, Brazil.
The JIAAC report the wheel had been changed by Lufthansa personnel one day and 5 sectors previously in Dakar, Senegal after damage caused by FOD had been found. The investigators determined that a fixing pin on a separator (fitted between the wheel and the wheel nut), designed to stop the separator rotating, had not been installed.
This omission allowed the wheel nut to back-off and detach, followed by the wheel.
Unfortunately no other information is provided on the circumstances of the wheel change.
The investigators raised one recommendation that Lufthansa “conduct a review of the procedures for quality control of the tasks of maintenance, particularly in remote bases”.
Other Safety Resources
Aerossurance has previously written on these associated topics:
- Airworthiness Matters: Next Generation Maintenance Human Factors Over the last 10-15 years, much attention has been focused on maintenance human factors training and reporting & investigating errors. While we could concentrate on simply doing more of these and certainly can find ways to do these things better, perhaps the next generation approach needs to include a much wider range of activities.
- Aircraft Maintenance: Going for Gold? Should we start treating maintenance personnel more like athletes who need to achieve peak performance every day?
- James Reason’s 12 Principles of Error Management
- B747 Landing Gear Failure Due to Omission of Rig Pin During Maintenance
- Maintenance Human Factors in Finnish F406 Landing Gear Collapse Safety investigators discuss the associated maintenance human factors and inadequacies in the type’s maintenance instructions.
- B1900D Emergency Landing: Maintenance Standards & Practices The TSB report posses many questions on the management and oversight of aircraft maintenance, competency and maintenance standards & practices after this serious incident. We look at opportunities for forward thinking MROs to improve their maintenance standards and practices.
- Singapore Airlines B777 41t Fuel Discrepancy Incident
Also see our review of The Field Guide to Understanding Human Error by Sidney Dekker presented to the Royal Aeronautical Society (RAeS): The Field Guide to Understanding Human Error – A Review
Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements: