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Old 2nd Nov 2012, 09:00
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haughtney1
 
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Gosh Blah, I wish I had your outstanding airmanship qualities, I find the conclusions of the report contradictory at best.
On the one hand..
3.1.5. The landing gear selector lever was left in the DOWN position and the captain directed the first officer to begin the “Landing gear fails to extend” checklist in the operator’s customised QRH (see Appendix 1).
Which is chapter and verse what I would hope we all would do

Followed further on by..
4.17. When the pilots moved the landing gear selector lever to DOWN on the approach to Woodbourne, the “Landing ear Inop” caution light did not illuminate, but the indicators on the landing gear panel told them that the nose landing gear was in an unsafe condition. The use of the “Landing gear fails to extend” procedure in the Air Nelson QRH was the appropriate action for the pilots to take. The procedure stated that if either the advisory indicator on the forward panel or the verification light under the alternate extension flap was green, the corresponding landing gear leg was down and locked. The 2 indication systems were independent of each other.
4.18. The text of the QRH removed any doubt for the pilots. It clearly stated that if either light was green, the relevant landing gear leg was down and locked. When the pilots saw the green verification light for all 3 landing gears, including the nose landing gear, the pilots had every right to believe the verification light, and halt the “Landing gear fails to extend” procedure.
4.19. The captain said that in his capacity as the airline’s flight operations representative at Bombardier customer seminars, he had heard the saying “a green is a green” used to emphasise the dependability of the verification system. His comment that “a green is a green”, made when he declined the first officer’s suggestion to fly past the control tower and have the nose landing gear position checked by the controller, reflected his confidence in the verification system. Most other pilots would have concluded at that point that all of the landing gear was down. Notwithstanding that confidence, shortly afterwards he requested a second check of the verification light, and both pilots confirmed that it was still green.
At this point there has been no reference to the operators operations manual as to whether a flypast is recommended or even allowable in this circumstance (please don't hit me with the airmanship argument...these days it's about avoiding culpability...which is why even QRH's are written the way the are)

Followed by the key findings in all of this..

Findings
With the nose landing gear stuck in a partially extended position, light from the taxi light was likely detected by the sensor for the down-lock verification system, causing it to give a false green light.
The false green light on the verification system misled the pilots of ZK-NEB into believing that the nose landing gear was fully down and locked.
The verification system for checking if the landing gear is down and locked on the Dash 8 series of aircraft is not reliable enough for pilots to place total trust in it when
trying to establish the status of the landing gear.
Quite simply the manufacturers recommendations hung these guys out to dry, yes they COULD have flown past the tower..but there is no guarantee of a successful outcome.
Then a further kick in the nuts for the crew..A none too subtle reference to the investigators opinion..as well as the standard get out clause..just in case it could be hung on him in a later incident...
4.40. A fly-by cannot confirm absolutely that a landing gear leg is locked down, especially at night, but an observer can report the landing gear appearance. In the case of the nose landing gear on the Q300, if the wheels appear down and the forward doors are closed, that is useful information, because the Proximity Switch Electronics Unit must sense that the landing gear is down and locked before it will signal the doors to close.
Followed by..A bit of 20/20 hindsight that supposes all that previously happened..didn't in fact happen and that the crew should have ignored the QRH...
4.41. The pilots could have sought technical advice from the operator and likely would have done so had they gone around in response to the aural warnings. If it had been confirmed that the nose landing gear was not locked down, the checklist would have led the pilots to silence the potentially distracting warnings and they would have instructed the flight attendant to prepare the cabin for an emergency landing.
And lastly....a statement indicative of an operator with potentially a few more deficiencies in its Ops spec....why the need to clarify? shouldn't the course of action be clear for all to see?
4.42. The operator later clarified the action it expected its pilots to take, including making use of an external observer, when there was a disagreement between landing gear position indications.
I wholly agree with the CRM aspects of the report, but these aspects in their isolation had no real bearing on the outcome.
The reality IMHO based on the report is that the Q300 concerned had a defective system that was deficient for the task with which it was designed to do..namely alert the crew as to the state of their landing gear...the fact that this system was given credence over and above the various other warning systems speaks volumes about the manufacturer, their "green is green philosophy"and its poorly concieved design.
The crew did everything that could be reasonably expected of them, notwithstanding the CRM issues...and the now "clarified" company procedure.
The manufacturer and operator however appear to have escaped any censure..other than a couple of recommendations

Last edited by haughtney1; 2nd Nov 2012 at 09:03.
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