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system, and the pressure applied to the brakes must not exceed 1000 psi.
3.2. Causes
It is considered that the cause of this incident was the fact that, as a consequence of
the appearance of residual pressure in flight in the left brakes, due to the fact that the
left master cylinder P/N C 24592020, S/N H2121 was defective, and due to the lack of
a procedure to be applied in that case, the crew voluntarily disconnected the antiskid
system when the residual pressure was still present, which produced the burst of the
left tires at touchdown.
The following factors could have prevented the incident:
— The existence in the Operations Manual of instructions to be followed in the case of
residual pressure being observed in flight.
— The knowledge by the affected flight crew of similar cases that had been reported
as complaints during June 2002.
— A more comprehensive analysis of the previous squawks of residual pressure.
— A more detailed training on the brake system during the type rating courses.
Technical report IN-062/2002
54
4. SAFETY RECOMMENDATIONS
Airbus issued a telex to the operators in October 2002, and later on modified the
FCOM to include instructions to the crew in the event of appearance of residual pressure
in flight, and started a review of their procedures of checking the brake system
in the assembly line of the aircraft. They also started the study of a possible modification
of the design of the master cylinder to avoid the build-up of residual pressure
in flight.
Messier-Bugatti modified in December 2002 their procedures of quality control after
manufacture of master cylinders to include the checking and recording of the total
length of every cylinder. However, it could not be determined which subcomponent of
the cylinder, and the environmental conditions of operation, that ultimately produced
the residual pressure in flight. Therefore, it is possible that such a pressure can appear
again in aircraft A-340 equipped with this type of master cylinder, and it is considered
necessary to issue a safety recommendation regarding this fact.
Iberia stated that they had established the «Centro de Control de Mantenimiento»
(C.C.M.) with a view, among others, to improve the communication with remote maintenance
units.
REC 09/04. It is recommended to the DGAC of France that, in collaboration with Airbus
and Messier-Bugatti, conducts a deep evaluation of the characteristics
of design, manufacture and maintenance of the master cylinders of
the brake system of the A-340. This evaluation should have the goal of
preventing that cylinders accepted by the different quality controls of the
manufacturers at component manufacturer, final assembly, and flight testing,
might produce residual pressure on the brake system under certain
conditions of operation.
REC 10/04. It is recommended to the DGAC of Spain to encourage Iberia to take
action to improve the communication channels between their different
departments in a way that allows that flight crews and maintenance personnel
may, at any time and from any airport, seek quick and effective
engineering and operational support regarding situations not adequately
covered by the manuals available to them.
REC 11/04. It is recommended to the DGAC of Spain to encourage Iberia to improve
their methods of analysis of reports of abnormalities by the flight crews,
consulting with the manufacturer when needed, in such a way that it is
prevented the intermittent appearance of the same complaint, and that
the useful information resulting from that analysis is provided to flight
crews and maintenance personnel.
55
Technical report IN-062/2002
REC 12/04. It is recommended to the DGAC of Spain that the training methods provided
to the applicable maintenance personnel of Iberia are monitored in
order to assure that in the correction of the reports of intermittent malfunctions
provided by flight crews, all the available maintenance documentation,
as well as all the available clues, are used to analyse the causes
of the malfunctions.
REC 13/04. It is recommended to Airbus that they should revise the content of the
pertinent parts of the TSM in order to provide additional guidance regarding
the maintenance procedures to be applied in the event of intermittent
faults, taking into account the kind of fault and the available clues
before dispatching again the aircraft. All operators should be informed on
the results of that revision.
REC 14/04. It is recommended to Airbus that in the training they provide to maintenance
personnel there is enough information to deal with intermittent failures.
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