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
- UPDATE 3 June 2020: Beechcraft 1900C Landing Gear Collapse at San Antonio, TX
- UPDATE 12 October 2020: Frozen Dash 8-100 Landing Gear After ‘Improper Maintenance Practices’ Say NTSB
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: