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Qantas pilots forget to lower landing gear

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  • P3_Super_Bee
    replied
    Back in the Military our checklist was done as a to-do list.

    The checklist lists the step , then it also has who is responsible for the item and calls out the item's status. Also the checklist has the required response. That way say The F/E has an item, and calls out the wrong response, the Co-Pilot(who reads the checklist) can stop the checklist, and bring to all's attention something is amiss. Sometimes there is only one position required to call out a response, sometimes, both pilots must call out, and sometimes even all three are required to call out.

    Now for the landing gear item, on the approach checklist, which is done during approach, there is also a final approach checklist, which rechecks the biggies, IE Flaps, Landing gear, altimeter, etc..

    On the landing gear line, it is called out, Landing gear. The co-pilot selects landing gear, the co-pilot as he/she is selecting calls out "selected", then when they get down-n-locked, all three call out down-n-locked. Most of the co-pilots I have seen while the calling out for down-n-lock, he/she is also checking to ensure the handle is in the down detent position. (Detent for those that don't know is a form of a lock. With the handle in detent it simply can not be moved without pulling out on the handle prior to raising or lowering it. Thus prevents accidental movement.)

    I'm sure on an airliner, there is also what we have, "The Landing Gear Warning Horn". It goes off when landing gear is up, Flaps are going though or below a set angle of defection, and Power Levers, at or below a set, power setting(basically landing config), nothing to do with altitude, so even if you were at 10,000 feet and meet all the requirements for landing config, the warning horn would sound. I would think, this would pop prior to EGPWS popping, It did on ours. Even on the regular fleet birds that don't have EGPWS, and have RAWS (RADAR Altimeter Warning System - Old school EGPWS), the Warning horn sounds before RAWS does. RAWS/EGPWS is there for us not to run into the ground/water(we do sub prosecution at 200 feet above the water) not remind us the gear is up.

    Even now my current employer it is used as a "to do list" vice a a "Check to see if we remembered list"

    Might have been something else going on in the flight station to make the Pilots "forget" the landing gear. We have the horn because, there was a plane landed back in the early 80's without the gear down. In this case, they were going through the checklist, prior to getting to the landing gear portion, they had an in-flight emergency, where as the crew stopped the checklist, and preformed a go around to deal with the in-flight(it was determined that doing the go-around was the correct procedure vice continuing to land) During the go-around the crew got consumed with the in-flight, and forgot to resume the checklist, and ended up landing with the gear up.

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  • Evan
    replied
    Originally posted by Gabriel View Post
    Evan,

    I respect your opinion, but I don't agree.

    One can only guess how many times a pilot forgot to lower the gear and detected it in the checklist, either lowering it and going on with the approach or going around and landing, without anybody else knowing.
    I'd be interested to know how often that happens, but I doubt I am going to get any confessions. I think a few people would notice a go-around at 700 ft though.

    Anyway, it's not as much the forgetting part that irks me as the going around part. If pilots commonly forget the gear but catch it on the checklist, I guess that's fine with me, as long as the checklist is completed early enough to provide them a chance to catch the missed items without having to abandon the approach and give everyone an anxiety attack. Do you agree with that?

    Then, forgetting the gear never becomes an incident. Unless they skip or delay the checklist and then the GWPS saves the day and brings on the investigation.

    It's sensible checklist procedure that I'm focused on, because I completely acknowledge the human factor you speak of.

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  • cja
    replied
    Having just skimmed through this thread it seems that all are assuming that gear was not down beacuse the crew had not selected the gear to be depolyed and were therefore at fault. Surely we do not know that this was actually the case. The report is brief- it basically says that they selected TOGA and at at 700 feet the GPWS made an alert beacuase the aircraft was not configured for landing. Surely the rest is conjecture.

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  • Gabriel
    replied
    Originally posted by Evan View Post
    Gabriel, they forgot to lower the gear! I think that deserves to be called an incident, regardless of how it was detected. It has only become a larger story in the press because it doesn't sit well with the public when pilots forget the basics.

    Such incidents should foster investigation. Two questions I would ask:

    Q1: Why did they forget to lower the gear (or not get it down sooner)?
    Q2: What procedure need to be improved upon here?

    These little incidents are often symptoms of a larger issue and a greater threat to safety.
    Evan,

    I respect your opinion, but I don't agree.

    One can only guess how many times a pilot forgot to lower the gear and detected it in the checklist, either lowering it and going on with the approach or going around and landing, without anybody else knowing.

    The procedure is to lower the gear. They failed to do it, by mistake. Pilots have been doing sporadic mistakes from time zero and will keep doing them because... well, other than pilots they are humans.

    That's why everything critical that depends on the pilot NOT doing a mistake is safeguarded by several layers, to minimize the chance that a mistake causes an accident. I this case:

    Lower the gear by memory
    Check gear down during landing checklist
    Landing gear horn
    GPWS

    You don't call it an incident when an autopilot fails (there are two or three of them plus two human pilots), or when the COM1 radio fails, or when a tyre gets flat, unless an unsafe situation develops from that.

    Does this event deserves being investigated?

    BY ALL MEANS YES!

    We don't know what happened yet. Maybe they were chatting about their lovers during the final approach (violation of the sterile cockpit rule). Maybe they were fatigued and had busted they rest time, or maybe everything was professional and by the SOPs except they simply forgot to lower the landing gear.

    IF that's what happened, and all the other safeguards worked as designed, THEN AFTER THE INVESTIGATION this event deserves being dismissed as an incident.

    It's of course just my opinion, and you don't need to agree.

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  • MCM
    replied
    And you can rest assured Evan that it is being fully investigated, particularly to the human factors/crm element that led to the situation. The ATSB are doing quite a thorough investigation, so it might take a while to see the final report, but it is being done as we speak.

    And it is confirmed that they were in the go around before the alarm went off.

    Leave a comment:


  • Evan
    replied
    Originally posted by Gabriel View Post
    this incident doesn't even deserves being called an incident.
    Gabriel, they forgot to lower the gear! I think that deserves to be called an incident, regardless of how it was detected. It has only become a larger story in the press because it doesn't sit well with the public when pilots forget the basics.

    Such incidents should foster investigation. Two questions I would ask:

    Q1: Why did they forget to lower the gear (or not get it down sooner)?
    Q2: What procedure need to be improved upon here?

    These little incidents are often symptoms of a larger issue and a greater threat to safety.

    Leave a comment:


  • EconomyClass
    replied
    I think the interest in such "incidents" springs from revelations that follow from investigations of fatal crashes. Example: Only a crash brought to light things like Alaska Airlines and AMR's risky maintenance practices. It makes the traveling public skeptical that the industry has integrity and that regulators are on the job. Its a legacy of past shocks.

    Leave a comment:


  • Gabriel
    replied
    My opinion is that if

    - the crew forgot to lower the landing gear in the first instance, and
    - they detected the mistake at 800ft as part of the landing checklist, and
    - started a go-around as a result and,
    - the GPWS went off as they were already starting the go-around, then

    this incident doesn't even deserves being called an incident.

    PS1: I don't know if that's what happened in this case.
    PS2: I don't mean it's not worth investigating, you can't know the above without investigating it.

    Leave a comment:


  • MCM
    replied
    I can completely understand your desire to avoid go-arounds, but unfortunately they are a part of aviation that is a necessity - and in fact you want to encourage them, not discourage.

    Although they frighten a few passengers, they are always a defensive manoeuvre, meaning the crew is taking the safe option.

    Sometimes they're caused by "unstable" approaches for whatever reason (such as outside limits... "not liking" the approach, etc), or they are just necessities (Aircraft ahead misses their taxiway exit, aircraft taking off needs to stop).

    Just for interest - I have gone around 3 times this year, and while we were perfectly within limits, and could have legally continued the approaches, we considered it less than desirable and went around, subsequently completing an approach we were much happier with. Some passengers were probably concerned, particularly as one go around was very low level, however our job is primarily to ensure the safety of the aircraft and passengers, and going around and making another approach was safer than continuing (Even though continuing would not have been unsafe). So while I sympathise that they can be startling, the vast majority of the time they are done for defensive reasons, and not due to drunk pilots .

    As to the checklist/warning issue - I think you'll find the system works pretty well as it is. How many times have you heard of this happening in thousands of flights? The current checklist philosophy has worked thousands upon thousands of times, and along with the GPWS backup the whole system is pretty good. When was the last time a heavy aircraft landed wheels up or without flaps?

    The checklist will, on some occasions, need to be done around 800ft. Thats the way the aircraft needs to be flown. In that occasion, the GPWS will go off before the checklist is completed - but there is no difference to the result. To ensure the GPWS is the last line of defence, you could lower the altitude to 200ft to align with the flaps... but that just means you end up lower to the ground before you are aware of the problem - not ideal.

    Note - at 800ft, crew from reputable airlines would, in most situations, go around and make another approach, however it IS sufficient time to put the gear down and continue the approach if you really wanted to. I guess thats why its at 800ft.

    I understand your concern, but the primary concern is making sure the checklist is workable and at an appropriate time, and if that results in one go around in every few hundreds of thousands of flights, then I think we just have to accept that.

    Note - this is a general philosophy, and doesn't necessarily relate directly to the Qantas incident.

    Leave a comment:


  • Evan
    replied
    Originally posted by MCM View Post
    G'day Evan,



    Just to explain a little, the checklist contains a number of items, not just the landing gear. It is often inappropriate to extend the Flaps at the same time as the landing gear (going by the Boeing procedure), and there is no point in doing the checklist until all the items have been completed.

    The last item, flaps, need to be set (in most airlines) prior to 500ft (although it is unusual to do it that late, however leaving 1000ft is sometimes required), and the "failsafe" warning for them is at 200/300ft (depending on model).

    Even though the gear warning is at 800ft, the checklist does not need to be completed until 500ft at the latest. This means occasionally, situations like this will occur... the checklist was completed above the minimum height, and the correct decision was made.

    I guess it just means that the GPWS isn't always the last line.
    Thanks MCM, I see what you are saying (where the checklist is not a to-do list), but let me make my purpose more clear: Apparently, in this instance, the GWPS warning necessitated a go-around (does it?), and therefore became an 'incident'. Perhaps the pilots would have caught it on the checklist anyway and no disaster was ever imminent.

    But here's the thing: go-arounds can really freak us passengers out, so we'd like to keep them down to a minimum. If the checklist is performed in a way that the gear extension item comes after the GWPS alert, we all get to go around (I'm assuming that is mandatory), wondering all the while what might be wrong with the aircraft or the pilot sobriety. So, for that reason, I would like the checklist to come earlier, far enough ahead of the GWPS. In other words, I think the GWPS should always be the last line.

    About two years ago, I was a passenger on a Sun Country flight coming into JFK from the Atlantic on a slow VOR (GPS?) approach to 13L, when suddenly, just after passing over Bennett Field, the plane surged forward and banked sharply off back out to the Atlantic. I will confess, this privately raised some hairs on my back. The Capt came on to explain that he "didn't like the approach", and maybe that's all it was, but when we eventually took up the same approach again, this time I distinctly heard the gear come down before Bennett Field. It occurred to me that I had not noticed the gear extension on the first approach. Perhaps I just didn't notice it on the first attempt. Or perhaps the GWPS scooped the checklist...

    I just would rather that didn't happen again.

    Leave a comment:


  • MCM
    replied
    G'day Evan,

    Uh... I don't know Gabriel... even if it's not a to-do list, I still think that checklist needs to happen well before you get the idiot light message.
    Just to explain a little, the checklist contains a number of items, not just the landing gear. It is often inappropriate to extend the Flaps at the same time as the landing gear (going by the Boeing procedure), and there is no point in doing the checklist until all the items have been completed.

    The last item, flaps, need to be set (in most airlines) prior to 500ft (although it is unusual to do it that late, however leaving 1000ft is sometimes required), and the "failsafe" warning for them is at 200/300ft (depending on model).

    Even though the gear warning is at 800ft, the checklist does not need to be completed until 500ft at the latest. This means occasionally, situations like this will occur... the checklist was completed above the minimum height, and the correct decision was made.

    I guess it just means that the GPWS isn't always the last line.

    Leave a comment:


  • SYDCBRWOD
    replied


    Oopps... Fast jet pilots aren't know to be stupid, suicidal or anything other than razor sharp. Unfortunately they are human however...

    Leave a comment:


  • Evan
    replied
    Originally posted by Gabriel View Post
    No it wouldn't be happening all the time because lamost always landing gear will be down before starting the checklist.
    Uh... I don't know Gabriel... even if it's not a to-do list, I still think that checklist needs to happen well before you get the idiot light message.

    Leave a comment:


  • brianw999
    replied
    Where work is done....mistakes and errors will occur.

    Monotony in work can be a killer because one day you will confirm something, but not actually check it.

    It's a bit like my job. I've been administering drugs for 27 years now. Annually I am required to re-classify by examination in my knowledge of the drugs that I use and the appropriate doseages. At one time it was considered to be cheating if I referred to my reference flip pad.....but....one line in one of the training manuals states "When administering drugs, never, NEVER, EVER rely on memory. Always cross refer to your checklist"
    It is now acceptable practise to refer to the checklist for doseages in the examinations...because that's how we do it on the road.

    The day that I don't bother to cross check is the day that I kill someone.

    I refer you now, back to the first line of this post.

    Leave a comment:


  • Gabriel
    replied
    Originally posted by Evan View Post
    unless the GA was initiated only moments before the GWPS floor...
    Well, I don't remember the exact warinig in the initial report but it was sometghing like "the GPWS landing gear warning activated as the crew was initiating the go-around"

    Why would the crew be doing a checklist for landing configuration that close to GWPS floor?
    Of course I don't know and the investigation might find out.
    Maybe they had been bussy doing something else, maybe it was a tight circling approach, etc.

    But I'm not sure if that's so low. They were at 700ft of altitude, which means about 1 minute from landing. They were in VFR and their sop called for a stabilized approach by 500ft. One criteria for the stabilized approach is that the plane is configured for landng and that the landing checklist is complete. To complete the landing checklist takes just a few seconds. So if they were doing it and there they detected the gear up problem, they were ok at least from a stabilized approach point of view.

    If that were SOP, this would be occurring all the time.
    No it wouldn't be happening all the time because lamost always landing gear will be down before starting the checklist.

    Oh, and the GPWS goes off pretty often during normal operations. The GPWS cannot know if the pilot didn't notice the 1500fpm sink rate or if he is intentionaly doing it, for examle. The GPWS has more than one level of warning. It can say "five hudred, four huncred..." or "minimums". It can also say "too low, gear", or "too low, flaps", or "sink rate". When things get really dangerous it says "woop woop pull up" (meaning ok now pull up and bother latter about whether the ofending item was the flaps, the gear, or the sink rate).

    Leave a comment:

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