A QantasLink Dash 8 was diverted back to Sydney after its pilots forgot to retract the landing gear below the maximum altitude for safe retraction, an ATSB report has found.
The aviation safety investigation body noted that the issue was partially impacted by “skill degradation” of pilots, due to reduced flying capacity over the course of the COVID-19 pandemic.
According to the Australian Transport Safety Bureau’s final report into the matter, the “diverted attention” of both pilots contributed to neither of them realising that the landing gear had been missed in post-take-off procedures and checklists.
In fact, it wasn’t until a member of the cabin crew contacted the cockpit above 15,000 feet to ask about the landing gear, which can be seen from the cabin of the Dash 8 aircraft, that the pilots noticed the omission.
“When completing the after-take-off checklist, the pilot monitoring provided the ‘landing gear’ challenge and the pilot flying incorrectly called ‘up, no lights’ in response,” the report said.
Both pilots acknowledged that while they had sighted the landing gear indicator panel at various stages after take-off, which showed three green lights warning that the gear was still extended, neither pilot recognised that this was problematic at this stage of flight.
According to the report, after the cabin crew member alerted the flight crew of the landing gear position, they then “immediately looked at the landing gear panel and identified that the handle was down with three green lights illuminated”.
After confirming that the aircraft’s speed was below the maximum landing gear operating speed (of 200 knots), the flight crew retracted the landing gear at an altitude of 15,900 feet, the report said.
However, this was above the maximum altitude at which landing gear could remain extended, at 15,000 feet, according to the manufacturer’s manual.
While the ATSB noted that this likely had no effect on the serviceability of the aircraft, the flight was diverted back to its origin in Sydney for maintenance checks.
The report states that after take-off, the captain, who was pilot monitoring, recalled being “very focused” on the correct pitch altitude, while the first officer, who was pilot flying, was “very focused on airspeed and maintaining runway centre-line”.
The report claims this diverted focus caused both pilots to miss various opportunities to notice the landing gear still in the downwards position.
ATSB director, transport safety, Dr Michael Walker said the incident highlights how diverted attention can make it easier for pilots to make errors in routine procedures and assume a simple task has been completed.
“The ATSB found that both pilots were heavily focused on aircraft performance after take-off, so the positive rate and subsequent gear-up calls were not made, and neither pilot identified these omissions,” Dr Walker said.
“It is likely that both pilots had a strong expectancy that the landing gear had been retracted after take-off, and they probably conducted the after-take-off checklist with a high degree of automaticity, rather than consciously looking for what was required.
“Highly-repetitive, routine tasks may result in pilots developing strong expectations that a task has been completed, even if it has not been, and make it difficult for pilots to identify an omitted action,” he said.
“Accordingly, it is essential that when flight crews are completing checklists, they focus on confirming that the relevant conditions have been met.”
Dr Walker said the investigation did consider what, if any, impact reduced flying levels and skill degradation due to the COVID-19 pandemic may have had on this occurrence.
“While both pilots met minimum currency requirements, and both had recently undertaken a proficiency check, the first officer had conducted less than one-third of their normal amount of flying in the previous 90 days and had not conducted any flights for 11 days prior to the occurrence flight,” he noted.
“Overall, there was insufficient evidence to conclude that the first officer’s reduced flight recency contributed to the procedural errors made by the flight crew. The investigation also noted that the operator was aware of the potential issues associated with reduced flight recency and had introduced measures to mitigate the risk.”
The report also notes the cabin crew displayed a high level of vigilance regarding the aircraft state.
“Their willingness to bring the extended landing gear to the attention of the flight crew allowed the problem to be identified and for the landing gear to be retracted as soon as possible,” Dr Walker said.
“This highlights the strength of timely communications between crew members.”