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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.”
Tony Ryan
says:One must question the apparent lack of observation of the aircraft configuration displayed by the crew. To climb above FL150 and not notice the position of the gear lever or the three green annubciators begs the question “Just what did this crew monitor”? The additional drag must have impacted the climb performance of the aircraft. Qantas can offer all the excuses they like but at the end of the day it all adds up to poor performance by the crew involved.
Neil Boulton
says:Tony Ryan, you are totally correct!
Retracting the gear and checking for three green lights is a basic action for pilots who are personally responsible for physically checking that the gear is safely locked up.
Missing that check is absolutely inexcusable and the pilots should be downgraded!
Peter Raffels
says:At least the pilot did not forget to lower the landing gear before landing!
Dick wesseling
says:One wonders if the aggressive noise abatement procedures causing pilots to spend undue focus on correct pitch, airspeed and maintaining centre line .
Adrian P
says:Retracting undercarriage ASAP is beneficial to noise abatement because it reduces drag which reduces thrust required which reduces fuel burn and noise. So blaming noise abatement procedure, bit of a furphy.
Perhaps crews should do some warm up exercises to stimulate the heart and lungs (get some blood and oxygen to the brain) prior to flight.
peter
says:You have to be kidding me. Over nearly 22 months I and some 16 others did not set foot in any aircraft andf after minimal retraining were turned loose to fly again as normal line pilots. Not one made simple errors though I am not trying to be particularly critical of the crew in this instance.
It is the authority attitude that is trying to find silly excuses for what very well might be a deeper issue in Australian aviation if these sorts of incidences are now occurring. the idea that some lack of recent flying experience is behind such basic errors is tenuous at best and appears more of a quick grab at anything than a well considered approach to what needs deeper thinking than this.
Bernie
says:That is highly un-professional behavior IMHO. No excuses, that sort of a casual approach to checklists has brought many a flight undone. I hope serious lessons have been learnt. Lucky it was not much more serious.
Al
says:Not surprised coming from a airline that cut costs by getting rid of the best of the best only to replace them by others who will work for peanuts
Lowflying
says:Lots to do on the flight deck. Easy to make a mistake. There’s nothing so simple that you can’t mess it up! Pilots are humans. Humans make errors.
The crew on the day are to be commended for admitting to their error. They didn’t pretend it didn’t happen and returned for maintenance action. Sometimes crew try to “bury” mistakes such as this.
We all learned from this and nobody got hurt.
On the scale of bad things that can happen, this rates pretty low. IMHO.
chris
says:Lucky they didn’t experience an engine failure at V1 or just above. The near certainty of them forgetting the gear in that loaded up scenario would have invalidated the aircraft’s certified OEI climb gradient performance.
Gautam Kastha
says:The outcome from the investigating team is unclear and shocking that no action had been taken on the erring pilots. Following the safety guidelines they should be immediately stood down and retrained and tested before putting back the pilots back on air.
Not doing this is compromising the safety of the passengers and the crew.
The actions of the flight attendants were commendable nevertheless.
John Tait
says:Don’t go up in the plane Daddy ,it’s safer to stay on the ground. I’m off to Norfolk Island later this month , would it be rude of me to have the Air Hostess check with the pilot that he has put the landing wheels away.?