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ASN Wikibase Occurrence # 186065
Last updated: 12 May 2019
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Date:31-MAR-2016
Time:01:00
Type:Silhouette image of generic A333 model; specific model in this crash may look slightly different
Airbus A330-323X
Owner/operator:Malaysia Airlines
Registration: 9M-MTB
C/n / msn: 1219
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: Minor
Category:Incident
Location:Melbourne International Airport, VIC (YMML) -   Australia
Phase: Standing
Nature:International Scheduled Passenger
Departure airport:YMML
Destination airport:WMKK
Investigating agency: ATSB
Narrative:
Malaysia Airlines flight MH128, an Airbus A330, was being prepared and boarded for a flight from Melbourne Airport, Australia, to Kuala Lumpur, Malaysia. The captain engaged the aircraft’s park brake before carrying out an external inspection of the aircraft. The resulting lit park brake indicator light on the nose landing gear led the aircraft maintenance engineer to assume that the park brake would remain on. Thinking that the aircraft would remain secure, the maintenance engineer removed the main landing gear chocks out of sequence with the relevant procedure and without informing the others in the ground crew. The ground crews did not check the main gear chocks before removing the nose gear chocks to attach the tow tractor to the nose gear. Unaware that no chocks were in place, and out of sequence with the relevant procedure, the captain released the park brake on return to the flight deck. The aircraft rolled back about 3 m and struck the aerobridge. The aircraft’s forward-left door and hinges, and the aerobridge were damaged. There were no injuries.

The ATSB found that the ground and flight crew procedures were not well harmonised, leading to reduced cohesion between the crews, and that the tractor operator’s procedures did not match the way tasks were carried out locally. These problems reduced the likelihood that the respective procedures would be followed correctly. In addition, the flight crew and engineers did not explicitly convey their actions and intentions to the others, resulting in a number of missed opportunities to discover the resulting procedural errors.

The engineering company, tractor operator and Malaysia Airlines each planned or initiated safety action in response to this occurrence. The engineering company introduced standard procedures and initiated periodic operational safety inspections at all ports. The tractor operator developed a written procedure to incorporate local differences in work practices and improve coordination. Malaysia Airlines reported that it was planning to amend its procedures so that flight crews advise ground crews whenever the park brake is about to be released. As an interim measure, Malaysia Airlines sent A330 flight crews a reminder to communicate with ground crews before releasing the park brake to verify that chocks are in place.

The aircraft was repaired and fflown back to Kuala Lumpur on April 21, 2016.

Sources:

http://www.atsb.gov.au/publications/investigation_reports/2016/aair/ao-2016-028/

Accident investigation:
cover
  
Investigating agency: ATSB
Status: Investigation completed
Duration:
Download report: Final report


Images:

Photo of 9M-MTB courtesy AirHistory.net


Adelaide - International (YPAD / ADL)
19 December 2011; (c) Andrei Bezmylov

Revision history:

Date/timeContributorUpdates
01-Apr-2016 06:56 Pineapple Added
01-Apr-2016 19:28 Aerossurance Updated [Damage, Narrative]
14-Sep-2016 10:45 harro Updated [Location, Narrative]
14-Sep-2016 10:46 harro Updated [Narrative]

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