The ATSB's final report into a Boeing 747 brake fire accident
that resulted in the serious injury of three passengers and one
pilot found that incorrect grease had been applied to the
aircraft's landing gear and that one of the over-wing evacuation
slides had failed due to overload of its fabric fibres during the
evacuation.
The aircraft had just arrived at the Sydney terminal after a
flight from Singapore.
The factors that contributed to the three small brake fires
included: the presence of incorrect and excessive amounts of grease
on the aircraft's landing gear axles, the inadvertent de-selection
of reverse thrust and the heat generated by the aircraft's brakes
during the landing roll and subsequent taxiing.
The ATSB could not determine when the incorrect grease was
applied to the aircraft axles, but a number of maintenance issues
were identified that contributed to the incorrect grease being
applied.
The ATSB also found that one of the over-wing evacuation slides
failed during the passenger evacuation as a result of tearing of
the slide's fabric fibres. The object that punctured the slide was
not identified, but it was most likely a blunt edged item carried
or worn by a passenger during the evacuation.
As a result of the investigation, the aircraft operator has made
safety improvements in the quality control of maintenance
equipment, flight and ground crew operating and handling
procedures, as well as passenger and flight crew emergency
procedures.
The ATSB has also issued recommendations to the operator and to
the Civil Aviation Safety Authority (CASA) concerning the use of
over-wing slides during known brake fires.
Copies of the final ATSB report (
Aviation Safety Investigation Report 200302980) can be
downloaded from the website, or obtained from the ATSB by
telephoning (02) 6274 6425 or 1800 020 616.