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AIRBUS Central Entity
Abstract
At 1200 Eastern Standard Time on 26 October 2005, the outboard bead heel of the number-1
wheel tyre on the left main landing gear (MLG) of an Airbus A340-642 (A340) aircraft, registered
HS-TNA, separated from the outboard rim of the wheel assembly during a landing on runway 16
at Melbourne Airport, Vic. The landing was conducted during gusting crosswind conditions.
The number-1 wheel tyre deflated immediately after the bead heel separated from the wheel rim.
The tyre then partially disintegrated during the remainder of the landing roll, and the tyre tread
detached from the tyre casing. Following the number-1 wheel tyre deflation, the crew maintained
control of the aircraft and, apart from some minor deviations to the left and right of the runway
centreline, tracked along the centreline.
The aircraft touched down with 15-degrees of yaw as a result of its handling by the flight crew.
That yaw angle was greater than recommended by the aircraft manufacturer, and increased the
risk of damage to the MLG at touchdown. It also increased the risk that the resultant groundslip
angle of the MLG tyres would exceed the ‘saturation’ point at which they entered a fully-skidded
state.
The pilot in command made dual side stick inputs during the latter stages of the approach
intending to assist the copilot to maintain the attitude and trajectory of the aircraft. Those dual
inputs compounded the handling difficulties being experienced by the copilot and increased the
associated risks. Those risks could have been mitigated by the pilot in command taking control of
the aircraft and pressing the side stick priority pushbutton at the point where he appeared to have
become concerned about its attitude and trajectory, instead of making dual side stick inputs.
– iii –
THE AUSTRALIAN TRANSPORT SAFETY BUREAU
The Australian Transport Safety Bureau (ATSB) is an operationally independent
multi-modal Bureau within the Australian Government Department of Transport
and Regional Services. ATSB investigations are independent of regulatory, operator
or other external bodies.
The ATSB is responsible for investigating accidents and other transport safety
matters involving civil aviation, marine and rail operations in Australia that fall
within Commonwealth jurisdiction, as well as participating in overseas
investigations involving Australian registered aircraft and ships. A primary concern
is the safety of commercial transport, with particular regard to fare-paying
passenger operations. Accordingly, the ATSB also conducts investigations and
studies of the transport system to identify underlying factors and trends that have
the potential to adversely affect safety.
The ATSB performs its functions in accordance with the provisions of the
Transport Safety Investigation Act 2003 and, where applicable, relevant
international agreements. The object of a safety investigation is to determine the
circumstances in order to prevent other similar events. The results of these
determinations form the basis for safety action, including recommendations where
necessary. As with equivalent overseas organisations, the ATSB has no power to
implement its recommendations.
It is not the object of an investigation to determine blame or liability. However, it
should be recognised that an investigation report must include factual material of
sufficient weight to support the analysis and findings. That material will at times
contain information reflecting on the performance of individuals and organisations,
and how their actions may have contributed to the outcomes of the matter under
investigation. At all times the ATSB endeavours to balance the use of material that
could imply adverse comment with the need to properly explain what happened,
and why, in a fair and unbiased manner.
Central to the ATSB’s investigation of transport safety matters is the early
identification of safety issues in the transport environment. While the Bureau issues
recommendations to regulatory authorities, industry, or other agencies in order to
address safety issues, its preference is for organisations to make safety
enhancements during the course of an investigation. The Bureau prefers to report
positive safety action in its final reports rather than make formal recommendations.
Recommendations may be issued in conjunction with ATSB reports or
independently. A safety issue may lead to a number of similar recommendations,
each issued to a different agency.
The ATSB does not have the resources to carry out a full cost-benefit analysis of
each safety recommendation. The cost of a recommendation must be balanced
against its benefits to safety, and transport safety involves the whole community.
　
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