Myanmar e190 accident

“Myanmar E190 nose-gear jammed after poor maintenance”

Investigators in Myanmar believe improper maintenance meant an Embraer 190’s intermittent nose-gear fault was not rectified before the aircraft landed at Mandalay without its nose-wheels deployed.

The Myanmar National Airlines jet (XY-AGQ) suffered substantial damage to its forward fuselage underside, nose-gear doors, avionics access hatch and other systems during the landing on Mandalay’s runway 17, as it arrived from Yangon on 12 May last year. None of the 89 occupants was injured.

Analysis of flight-data recorder information showed that the weight-off-wheels sensors on the nose-gear and main landing-gear had correctly registered ‘true’ as the jet lifted off from Yangon. But just after the command to retract the landing gear, the nose-wheel switch signal changed back to ‘false’. This indicates that the nose-gear shock absorber had compressed during the transit, enough to disengage a self-centring cam which normally keeps the nose-wheels from turning in the gear bay.

Source: AAIB of Myanmar

Analysis of flight-data recorder information revealed that, on 23 previous flights, the weight-off-wheels switch signal had similarly changed from ‘true’ to ‘false’ as the nose-gear retracted. “While all these flights were operated uneventfully, the risk of the nose-gear tyre rotating beyond the limit and getting stuck in the wheel well was present,” the inquiry says. It points out that the aircraft had previously undergone nose-gear servicing in an attempt to rectify a failure message relating to the weight-on-wheels system.

The failure message had appeared on 8 May, four days before the accident, as the jet operated the same Yangon-Mandalay route. It returned to Yangon and, after maintenance on the nose-gear sensors, was put back into service. But during another flight, from Yangon to Sittwe on 11 May, the crew felt the nose-gear was “shaking” during the take-off roll and gear retraction, and further maintenance was performed overnight. The accident occurred on the first flight subsequent to the work.

Source: AAIB of Myanmar

Investigators believe maintenance fault isolation work was “not properly done” and that “poor workmanship” had been carried out during nose-gear servicing.

“This event highlights the importance for maintenance crew to follow the maintenance and troubleshooting guidance from the aircraft manufacturer,” the inquiry says. “This will allow defects to be rectified as soon as possible, to eliminate potential flight safety consequences.”

Source: Flightglobal

Taking the Just Culture/systems perspective

Assuming the article is factual…

  • Why was the fault isolation work ‘not properly done’?
  • Was the procedure correct?
  • Was the tooling available?
  • What kind of information did maintenance receive from the pilots, from automatic data recording sources, form colleagues in other stations where maintenance was done?
  • What training did the maintenance crew receive?
  • Was there proper tooling, equipment provided?
  • What are the circumstances maintenance staff have to work in (shift patterns, working conditions…)?
  • What is the safety culture in this company?
  • How is the company/maintenance overseen by the authorities?

In short: why did the maintenance crew do what they did? Probably not, because they intended to put passengers and colleagues in danger…