QF Q400 Crew Forget Landing Gear

[PPRuNeUser0198]

Landing gear not retracted after take-off demonstrates how diverted attention or focus may result in errors of omission...

https://www.atsb.gov.au/media/news-items/2022/diverted-attention/

[601]

BN2 endorsed?

[megan]

as the aircraft was at an altitude of about 15,900 ft, this meant the aircraft had exceeded the maximum altitude at which the landing gear could remain extended, of 15,000 ftAny ideas on why the altitude limitation?

[Lead Balloon]

Intriguing. Seems like a question for the likes of john tullamarine.

Maybe the differences in the aerodynamic/stability/loss of an engine consequences of the drag of/turbulence in the wake of the undercarriage at altitude?

Intriguing.

[Ascend Charlie]

Was it a passenger who told the hostie to tell the pilot?

Didn't notice the extra drag reducing ROC? Didn't notice the handle in the Down position and three green lights looking at them?

[HappyBandit]

Any ideas on why the altitude limitation?
not an expert on aerodynamics but I'd imagine it has to do with increased drag and entering increased stall speed with altitude.

As for why they didn't notice roc or green lights. Expectancy bias for both. They were light on this flight but heavy in previous flights. The expectancy bias is something Qlink has been honing honing in on in c and t. It's not an isolated case though. Seen lots of read and not actually checking in checklists throughout my time.

[PoppaJo]

At least they avoided the knee jerk reaction when they noticed it and checked speed before raising. Instant reaction across many of these incidents is to go for the lever first. A similar example occurred inside my employer however flap related, and when they noticed at a significant height, pulled the lever immediately without checking they sat well over max retraction speed. Training Department was not happy.

[megan]

NASA did a study by riding jump seat and observing events on sixty flights, eight hundred ninety-nine deviations were observed (194 in checklist use, 391 in monitoring, and 314 in primary procedures). Included A320, 737, 757, 767, 777 and EMB 175/195.

Checklists and Monitoring in the Cockpit: Why Crucial Defenses Sometimes Fail

https://human-factors.arc.nasa.gov/publications/NASA-TM-2010-216396.pdf

[Lead Balloon]

So it's confirmed (again): Humans make mistakes.

But our laughably described political 'leaders' want the punters to believe that: "There's no margin for error in aviation."

That's why the powerless are beasted and over-regulated by CASA. CASA can get away with it, practically, and it makes the punters feel safe. If only they knew the reality.

[WillieTheWimp]

not an expert on aerodynamics but I'd imagine it has to do with increased drag and entering increased stall speed with altitude.

I think you will find its more to do with compressibility. Flap and gear will have limiting mach numbers. Not sure on the specifics of the q400 but I think you will find that its Vlo will crossover to its max mach number for the gear at 15,000. The mach number is probably not stated though, hence the altitude restriction.

[noclue]

Why can a gear down ferry be done up to a max of FL200 then?

[Lookleft]

FFS give it a rest That's why the powerless are beasted and over-regulated by CASA. CASA can get away with it, practically, and it makes the punters feel safe. If only they knew the reality.

NASA did a study by riding jump seat and observing events on sixty flights, eight hundred ninety-nine deviations were observed (194 in checklist use, 391 in monitoring, and 314 in primary procedures). Included A320, 737, 757, 767, 777 and EMB 175/195.

These observations continue under the heading of LOSA. The first LOSA conducted at Qantas was on the 747-400. The results caused a collective gasp of surprise.

I note the report dismisses the possible effect of a COVID related influence. During COVID LOSA was suspended so it will never be known what effect COVID might have had on operations.

[Lead Balloon]

Why can a gear down ferry be done up to a max of FL200 then?What would the passenger limitations, baggage limitations, fuel limitations, CofG limitations and other conditions of that ferry be, noclue?

[john_tullamarine]

the likes of john tullamarine

Afraid I have nil background on the aircraft and prefer not to get into too much in the way of speculation.

However, if this mishap indicates that humans make mistakes, then ......

That's why we do our individual and systems best to trap errors before they get out of the cockpit.

I could list some of mine over the years but the bandwidth load would be a tad gross. Fortunately, very few made it outside the cockpit .... see the previous line.

[Lead Balloon]

Of course…

But the context of my response that mentioned you was not the mistake, but rather the altitude limitation on the undercarriage remaining extended on this aircraft type. I’d hoped you’d be able to shed some light on why that limitation exists.

[43Inches]

Maybe Bombardier calculated the likely altitude that passengers and FA would notice that the gear should not be down, so make sure it's retracted by then. Looks like they were spot on and crew were alerted right as they passed that altitude. What was the altitude of the other one that reached cruise altitude and exceeded max gear speed?

[john_tullamarine]

I could only hazard a guess as I have no knowledge of the aircraft's certification.

My guesses might include door/structure airloads at the max gear speed, for the limiting height, perhaps Mach related compressibility problems, perhaps something as simple as the OEM's determining that there was no design/operational need for the gear to be qualified for higher levels in a manner similar to the usual F200 flap limit on jets.

Sometimes one needs to dig deeply into the design standards to tease out some of these sorts of conflicting requirements.

[noclue]

LB-How would not having pax or bags loaded affect a “compressibility” speed/Mach limit on the gear.

The report stated there was “no effect on serviceability of the aircraft” with having the gear extended above the FL150 limit? So what’s the limit for?

[john_tullamarine]

How would not having pax or bags loaded affect a “compressibility” speed/Mach limit on the gear.

I think the question was more a case of "tell us all the details of the supplement, rather than just the height limit" ?

The report stated there was “no effect on serviceability of the aircraft” with having the gear extended above the FL150 limit?

I think you may have misinterpreted the statement. More a case, I suggest, of the minor exceedance not causing any associated damage .... as one would expect to be the case. There are very few occasions in certification where the aircraft is left near a cliff in the event of minor limit exceedances.

So what’s the limit for?

As suggested before, one would really need to be familiar with the certification reports, which usually are held quite proprietary by the OEM. Alternatively, one can engage in an extensive ferreting exercise in the design standards to see what possibilities might present.

[Capt Fathom]

Like most limits, there can be lot of excess margin built in. But you have to set it somewhere.
Would not have taken a Q400 long to get to FL159!

[KAPAC]

Why can a gear down ferry be done up to a max of FL200 then?
Maybe gear down speed limit is higher than gear extension / retraction speed as there are lots of doors opening and closing during gear not locked and air loads on hydraulics during transit . Only a guess .

[Uplinker]

It has been many many years since I flew the Q400, so I cannot remember if there is an after take-off checklist?

[deja vu]

It has been many many years since I flew the Q400, so I cannot remember if there is an after take-off checklist?
I'm surprised, since your recent remarks regarding pitot covers, you are not calling for this crew"s heads.
Unbelievable that you would not know about the A/TO checklist.

[Uplinker]

Oh, grow up.

[minigundiplomat]

Another couple of posts and will have become managements fault.

[Capn Bloggs]

I'm surprised, since your recent remarks regarding pitot covers, you are not calling for this crew"s heads.
Seriously?

[FPDO]

Cadets !

Such poindexters, too busy taking selfies......

[FullOppositeRudder]

Whatever the circumstances and side issues, the report has offered up a new word - at least for me.

Quote:
"... they probably conducted the after-take-off checklist with a high degree of automaticity,"

I must try and work that into a conversation - once I can manage to pronounce it correctly.

BTW The gliding world has many historical instances of undercarriage stuff-ups. It became an issue when a whole generation of pilots learnt to fly in gliders with a fixed undercarriage, but then in the 1970s when the higher performance fiberglass types arrived with a retractable wheel, the old way of doing things (or perhaps rather not doing things) still remained deep in the subconscious. Forgetting to put the wheel down for landing became the new trap. Then there were those who were in the air for longer flights, but forgot to retract the wheel after launch, and then mechanically operated the lever during the in circuit pre-landing checks thus retracting the wheel and landing on the aircraft's nicely polished belly - usually only with mild abrasions to the aircraft, but always with acute embarrassment for the pilot. The standard penalty was to shout a complete round of drinks at the bar when ops concluded. Micro switches and warning buzzers were installed to warn the operator of serious oversight and potential embarrassment when the dive brakes were opened with the wheel still retracted, but the more ingenious types still found ways to ignore or overlook the warning (what the hell is that strange noise??). I was once showing a visiting government VIP around the field when one of our most experienced pilots performed this astonishing feat right there in front of us. Since I had been building up the qualities of the pilot - one of our best - and all the exciting features of the borrowed aircraft - new, shiny and expensive - to our visitor, I also shared in the acute embarrassment of the pilot as I did my best to explain this quite unusual variation from standard landing procedure to our visitor :uhoh:.

[cooperplace]

I agree with Full Opposite. How many of us have forgotten stuff like retracting flaps? I'm lucky I fly a plane with fixed u/carriage. My sympathy is with this crew.

[Fuel-Off]

I agree with Full Opposite. How many of us have forgotten stuff like retracting flaps?
There was an incident many moons ago (think 2008?) in a Qlink Q400 which managed a decent flap overspeed on departure. Recall something like IAS was 235 and the flap speed limit was 200kts until the crew realised they forgot the flaps and returned back to base (no load relief like Boeing types have)

I have done a few gear down ferries in the Q400 and the subsequent buffet is definately noticeable. How the crew seemingly missed this is a bit perplexing.

[601]

Any ideas on why the altitude limitation?
While doing a sim course in Montreal and visiting the Canadair factory, one of the class asked a similar question.
The Canadair engineer indicated that altitude limits such as this one was the result of flight testing.
It was simply the highest altitude that the aircraft was flown at with the gear down during flight testing.

[hobbit1983]

Frank Borman (test pilot, engineer, astronaut, commander of the first lunar orbital mission) relates his autobiography that he once forgot to raise the gear on a test flight. And only noticed some time into the flight.

If it can happen to him, it can happen to anyone!

(Granted, only one pair of eyes in the cockpit, but still)

[lucille]

Most of these “oddball” limitations are simply there because that’s the limit to which they were light tested for certification.

15,000 ft for one thing or another appears in quite a few places in different aircraft. I have long suspected it’s because La Paz in Bolivia is at 13,500(ish) which brings one to 15,000 if you’re mooching around the circuit at 1500 AGL. But, as always, happy to be corrected.

(As an aside, SLLP is a tricky place for some O2 systems.)

[Down and Welded]

Potential tyre-burst?

[Ascend Charlie]

Potential tyre-burst?

Hmmm... yes, of course, wheel wells are normally pressurised to prevent this happening...

[Lead Balloon]

But AC, you've overlooked the extra number of air molecules hitting the tyres due to prolonged, unintended exposure. Those things are pointy.

[Ascend Charlie]

Oh, Leady, everybody knows that the higher you go, the thicker the air gets. That's why the planes that fly fast and high have to really pointy, but those down lower in the thinner air can be big and blunt.
And the higher you get, the more trouble the light has getting through, so it looks darker - and space is just black.
Rockets need to be pointy to get through that thick air, the failures just bounce off it and fall down again.

And it's true, I read it on the internet.

[StudentInDebt]

Frank Borman (test pilot, engineer, astronaut, commander of the first lunar orbital mission) relates his autobiography that he once forgot to raise the gear on a test flight. And only noticed some time into the flight.

If it can happen to him, it can happen to anyone!

(Granted, only one pair of eyes in the cockpit, but still)”Two kinds of pilot, those who have forgotten to raise the gear after take-off and those who haven’t yet” - Anonymous

[Kenny]

This thread encapsulates everything that’s wrong with aviation in Oz. For the love of god, everyone of us has done something dumb at some point in our careers. It’s not a case of if but when. Someone left the gear down, were told about it and put the gear up. Yet here we are with a two page thread and ensuing debate about it.

[Lead Balloon]

The 'debate' is mostly a discussion is about why the limitation exists. It appears that it exists merely because the manufacturer didn't see a need to do any flight testing with the gear extended above - pick a number - 10,000'. A mundane and reasonable explanation.

I don't see too much criticism of the crew.

Relax.

[Chronic Snoozer]

Like 'demonstrated crosswind limit' you mean?

[Lead Balloon]

Spot on, CS.

[CDRW]

This thread encapsulates everything that’s wrong with aviation in Oz. For the love of god, everyone of us has done something dumb at some point in our careers. It’s not a case of if but when. Someone left the gear down, were told about it and put the gear up. Yet here we are with a two page thread and ensuing debate about it.
Some one left the gear down in the rain! Sounds like a line out MacArthurs Park.

well its not so simple as " they left it down- were told about it and then they put it up"
The debate is what were the factors that allowed them to get to 15000+ft. From lift off and the not hearing or not calling positive rate, the after takeoff checklist, the extra vibration and noise, the fact that three green lights were illuminated when normally the would not be and the fact that a lever that normally points to the roof was pointing at the floor.
we all cock up - we got to to learn from it.

[VH-FTS]

The event also happened around the time Sydney was going into lock down again with the threat of more stand downs. That on top of reduced flying all year, no wonder crew like this made mistakes during 2021.

[Derfred]

There are 2 categories of pilots:

1. those who criticise the errors of others; and
2. those who think “that could be me tomorrow”, and continually strive to learn and improve.

I occasionally fall into category 1. When I do, I try to recognise it and push myself into category 2. I know I’m not perfect. I thought I was, once, but it turned out I was mistaken.

Which category do each of you fall into?

[VH-FTS]

There are 2 categories of pilots:

1. those who criticise the errors of others; and
2. those who think “that could be me tomorrow”, and continually strive to learn and improve.

I occasionally fall into category 1. When I do, I try to recognise it and push myself into category 2. I know I’m not perfect. I thought I was, once, but it turned out I was mistaken.

Which category do each of you fall into?

Probably one of the best posts I've seen on here for a while.

[No Idea Either]

Yes, well said Derfred…

[megan]

I know I’m not perfect. I thought I was, once, but it turned out I was mistaken.

Which category do each of you fall into?Far, far from perfect Derfred, could fill a book on errors made. Once had a CP who acknowledged he made a mistake once, that was when he thought he made a mistake. Was of a demeanor where you weren't sure if he was joking or not.

[Down and Welded]

It's all very well for pilots on here to be reminding themselves of how fallible they might be: 'There but for the grace of God go I'... etc. But the famed (and perhaps overstated) Qantas reputation for safety is on a knife-edge here. The challenges visited by COVID on flight crew recency-of-experience notwithstanding, operational checklists have to stand for something, and if the SLF cannot rely on our storied Qantas aircrew to treat checklists seriously, then who can they have confidence in? This small lapse (made less small by the fact that the mistake got past not one pilot, but both) amounts to a frightening derangement of process and a diminution of the general view (whatever it might be) of QF flight crew competence. Deserves to be stated.

[Derfred]

It's all very well for pilots on here to be reminding themselves of how fallible they might be: 'There but for the grace of God go I'... etc. But the famed (and perhaps overstated) Qantas reputation for safety is on a knife-edge here. The challenges visited by COVID on flight crew recency-of-experience notwithstanding, operational checklists have to stand for something, and if the SLF cannot rely on our storied Qantas aircrew to treat checklists seriously, then who can they have confidence in? This small lapse (made less small by the fact that the mistake got past not one pilot, but both) amounts to a frightening derangement of process and a diminution of the general view (whatever it might be) of QF flight crew competence. Deserves to be stated.

I agree with your post except for these last 2 bits:

a frightening derangement of process
- an error got through a few slices of swiss cheese. That probably happens more often than most realise in all professional safety-critical outfits, not just aviation. We have learned to learn from these mistakes rather than criticise (e.g. Threat and Error management training). The organisation will learn from the final ATSB report (when it comes), and in the meantime, pilots who recognise that “it could happen to me tomorrow” stay on their toes and reinvigorate their defences.

- so I disagree with your language of “a frightening derangement of process” - unless you are trying to get a sound-bite in the media, this is a gross overstatement of the risk matrix. A far more “frightening derangement of process” was the contributing factors leading to the A330 departing with pitot covers, for example.

a diminution of the general view (whatever it might be) of QF flight crew competence
- well yes, any publicity of an aviation screw-up diminishes the general view, and of course tall-poppy syndrome makes Qantas (including it’s wholly owned but independently operated subsidiaries) particularly susceptible. Rain Man was awesome PR for Qantas, but also created a rod for their back with increased public scrutiny of any stuff-ups.

- Joe Public probably won’t get too excited if “a Qantas pilot forgot to put the wheels up”. It’s not the main news story of the day. The aircraft stayed safely away from Primary Schools and Orphanages.

If genuine risks to aviation safety in Australia are to be discussed, I would suggest directing attention to the real threats, such as fatigue management, bean-counters running ATC (Ballina), bean-counters running airlines (all of them, and including cost pressures on pilot training, engineering, aircraft purchasing, and outsourcing everything), bean counters running manufacturing (Boeing), self-funded “cadet” schemes, cheap pilot labour (to avoid costly training) via “critical work shortage visas” for pilots, and the general plummeting work conditions and pay for pilots in general.

A Q400 missing “gear up”, and the checklist supposed to catch it (if that’s what happened) is not insignificant, and I look forward to learning from the report in 3 or 4 years’ time (there’s another problem right there!). But let’s keep things in perspective. And more importantly, let’s focus on the fix rather than the criticism, particularly before anyone knows what really happened.

Drawing general conclusions about the state of the industry (or a company) from one event like this is not likely to be accurate nor helpful.

[C441]

…...The challenges visited by COVID on flight crew recency-of-experience notwithstanding, operational checklists have to stand for something, and if the SLF cannot rely on our storied Qantas aircrew to treat checklists seriously, then who can they have confidence in?
One crew on one aircraft overlooked a checklist item; hardly a reason to lose confidence in the entire crew cohort of Qantas or any other airline that has an ATSB report published about a single, relatively non-critical omission. Not ideal but airlines like Qantas and the manufacturers of the aircraft have numerous lines of defence to cover omissions, ramping up as the error becomes more critical.

Most reputable airlines are ensuring that crew returning from long Covid induced lay-offs are trained to the pre-Covid standard, albeit with unavoidably less recent line operational experience.

[HappyBandit]

I agree with your post except for these last 2 bits:


- an error got through a few slices of swiss cheese. That probably happens more often than most realise in all professional safety-critical outfits, not just aviation. We have learned to learn from these mistakes rather than criticise (e.g. Threat and Error management training). The organisation will learn from the final ATSB report (when it comes), and in the meantime, pilots who recognise that “it could happen to me tomorrow” stay on their toes and reinvigorate their defences.

- so I disagree with your language of “a frightening derangement of process” - unless you are trying to get a sound-bite in the media, this is a gross overstatement of the risk matrix. A far more “frightening derangement of process” was the contributing factors leading to the A330 departing with pitot covers, for example.


- well yes, any publicity of an aviation screw-up diminishes the general view, and of course tall-poppy syndrome makes Qantas (including it’s wholly owned but independently operated subsidiaries) particularly susceptible. Rain Man was awesome PR for Qantas, but also created a rod for their back with increased public scrutiny of any stuff-ups.

- Joe Public probably won’t get too excited if “a Qantas pilot forgot to put the wheels up”. It’s not the main news story of the day. The aircraft stayed safely away from Primary Schools and Orphanages.

If genuine risks to aviation safety in Australia are to be discussed, I would suggest directing attention to the real threats, such as fatigue management, bean-counters running ATC (Ballina), bean-counters running airlines (all of them, and including cost pressures on pilot training, engineering, aircraft purchasing, and outsourcing everything), bean counters running manufacturing (Boeing), self-funded “cadet” schemes, cheap pilot labour (to avoid costly training) via “critical work shortage visas” for pilots, and the general plummeting work conditions and pay for pilots in general.

A Q400 missing “gear up”, and the checklist supposed to catch it (if that’s what happened) is not insignificant, and I look forward to learning from the report in 3 or 4 years’ time (there’s another problem right there!). But let’s keep things in perspective. And more importantly, let’s focus on the fix rather than the criticism, particularly before anyone knows what really happened.

Drawing general conclusions about the state of the industry (or a company) from one event like this is not likely to be accurate nor helpful.

I can tell you a very thorough internal investigation was completed far quicker than that and some solid learnings came out of it.

As with most incidences in aviation the incident was multifactorial.

[compressor stall]

Expect more of this in the future... Airbus have removed Gear Up from the checklist. Rationale is that there is an VLE overspeed alert and increased fuel consumption.

[Roj approved]

Airbus have removed Gear Up from the checklist. .

Actually at my company, they have removed the "After T/O Climb Checklist". it is now just a PM scan.

[Chronic Snoozer]

Actually at my company, they have removed the "After T/O Climb Checklist". it is now just a PM scan.

So has the company’s fuel bill increased?

[Lead Balloon]

So has the company’s fuel bill increased?
That right there is funny. Thanks for the belly laugh, CS!

[Mach E Avelli]

Actually at my company, they have removed the "After T/O Climb Checklist". it is now just a PM scan.

...and probably more safe because of it. Checklists are no insurance and in fact, if overdone, an embuggerance.
Back in my days as a trainer I would notice some pilots rattling off checklist responses without really checking. To confirm my suspicion, I would challenge with the before landing checklist at the after take-off stage, or before take-off checklist on final approach. Plenty of suckers would give responses to the checklist being read, not the one actually executed - to earn themselves a tick in the 'below average' box for 'situational awareness' on the training form for the day.

A very long time ago I did a Type Rating on the MU2 with a European operator. This is a complex aeroplane and was being flown single pilot in a demanding environment. Their checklist policy was to use it up until engine start, then again after shutdown. Everything in between was done by methodical scanning, the philosophy being that head-down reading to one-self was not as effective as keeping eyes and ears open, minding the store.

[compressor stall]

That's exactly why Airbus did it. In the name of safety. The basic philosophy is that the only things on the checklist are things that will kill or hurt you or the aircraft. They are trying to reengage the pilot with the aircraft by forcing them to think about their actions. There was a lot of operator pushback pre roll out (some certain corners of the planet more than others apparently) but the new changes eventually rolled out a few months ago.

[neville_nobody]

The reality is in this day and age checklists on new airliners should be very minimal. However manufacturers do not innovate and are obsessed with common type ratings and that includes the Dash 8-400. Hence the need for long and persistent checklist as the pilot has to make up for the lack of technology.

[Uplinker]

I have done many stupid things or forgotten things in my career. We once flew Toulouse to Heathrow with the APU running. It was only when the other pilot went to the loo, and I did a casual cockpit scan - an hour+ into the flight - when I noticed the APU was still running ! Ooopps !

Hence checklists.

But they must be taken seriously. A couple of times at my ATPL flight school, I witnessed instructors in piston twins landing with the gear up, which bent the props and all sorts. I now have a personal checklist when on very short finals, when I say under my breath "Fly. By. Wire":

F = Flaps set?
B = Brakes: Auto brake selected and no residual pressure?
W = Wheels down and locked?

The key is to use checklists properly; They are not there to be gotten out of the way as quickly as possible, they are there to check stuff and prevent death. For example, I deliberately do my (Airbus) control checks in a different order to the book, because it is too easy to give the expected vocal response rather than actually looking properly at the flight control page and stating what is seen. More than once I have been holding full right, when the response has been "full left". My response is "Are you sure?".