A “restructure” of Qantas’ engineering personnel off the back of COVID-19 standdowns and redundancies has been labelled as a factor in a recent flight incident where a 787’s landing gear remained stuck in place after take-off.
On 21 June 2021, a Qantas 787-9, registration VH-ZNH, departed Sydney at 10:30am as flight QF645 to Perth. However, it was diverted back to Sydney when the flight crew realised that the landing gear was not retracting to the “up and locked” position.
According to the Australian Transport Safety Bureau, the flight had an “uneventful landing” around 40 minutes after take-off.
The ATSB’s final report into the incident found that two of the 787’s five downlock pins, which keep the landing gear in place during maintenance and towing, had not been removed from the aircraft’s main landing gear by ground crew.
The presence of the pins was not picked up during any of the pre-flight inspections, despite bearing red “remove before flight” streamers that adorn every pin.
According to the ATSB, all except one of the ground crew responsible for towing and performing the pre-flight procedures on this aircraft, including the removal of these downlock pins, had never worked on a Boeing 787 aircraft before.
Notably, the 787 contains five downlock pins – one in its nose gear and two in each of its main landing gear – whereas smaller aircraft, including Boeing 737s and Airbus A330s, only have three pins to remove – one in the nose gear, and just one in each of the main landing gears.
It was therefore quite easy for the crew to not realise that two of the pins were still in place.
“As a result of the COVID-19 pandemic travel restrictions, voluntary redundancies were offered to affected personnel. A subsequent restructure of Qantas engineering took place in February 2021, which resulted in certain engineers being transitioned into new roles, on new aircraft types,” the report noted.
The safety investigator stated that only one of the Qantas ground crew that it spoke to advised they were aware that a 787 contained five gear pins. While all of the other ground crew was found to have experience, none had previously worked specifically on a Boeing 787.
“Pins are inserted into the nose and main landing gear when the aircraft is on the ground to prevent inadvertent gear retraction during maintenance or towing,” ATSB director of Transport Safety Stuart Macleod explained.
“In this case, two of the pins – one of the two for each main landing gear – had not been removed after towing and prior to the flight. In addition, subsequent preflight inspections by the flight and dispatch crew did not identify that the pins remained in place prior to departure.”
As noted, the gear pins have bright red “remove before flight” streamers. However, the report stated, “the missed gear pin streamers may have been stuck on the gear, from a combination of grime and the recent wet and windy conditions”.
“‘Remove before flight’ streamers are visual reminders to remove covers and lockout devices prior to flight but can be subject to varying environmental conditions that can reduce their visibility,” Mr Macleod said.
“Expectation can also affect your ability to identify these warning devices. If you are not expecting to see a ‘remove before flight’ streamer, you are significantly less likely to detect one that is present.
“The same principle can also prevent the discovery of damaged and/or missing components.”
Since the incident, Qantas has reportedly distributed a memo to its engineering, flight and ramp staff to highlight the quantity and location of the gear pins on the Boeing 787, and the importance of following the documented ramp, pre-flight and dispatch procedures.
The memo also reportedly emphasised the importance of checking the pin locations, rather than relying on “remove before flight” streamers for identification of pins, after towing.