Aviation safety investigations & reports

Landing gear overspeed involving a Saab 340B, VH-ZRJ, near Sydney Airport, NSW on 4 December 2014

Investigation number:
AO-2014-189
Status: Completed
Investigation completed

Final Report

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What happened

On the evening of 4 December 2014, a Saab Aircraft Co. 340B aircraft, registered VH-ZRJ and operated by Regional Express, was on a scheduled passenger service from Sydney to Narrandera, New South Wales. After take-off from runway 34 Left the crew inadvertently did not retract the landing gear. The crew later identified this and instinctively retracted the gear whilst the aircraft was above the maximum landing gear retraction speed.

What the ATSB found

The ATSB found that at the time of the occurrence the first officer (FO) was experiencing a level of fatigue that affected performance. However, the FO’s ability to self-assess their level of fatigue was impeded by a lack of training and objective tools to determine their suitability to operate.

The ATSB also found that the FO did not recall hearing the captain’s ‘gear up’ call, which meant that the gear was inadvertently not retracted. The factors that influenced this omission and its non-detection included both crew focusing on departure procedures and the local weather, and the crew likely expecting that the landing gear was retracted as normal.

The crew detected the error when conducting the climb checklist. As this checklist was designed to confirm the configuration of the aircraft, the time that it was conducted coincided with a time when the aircraft’s speed was above the maximum gear retraction speed. Therefore, there was an increased risk that crew would react to the unexpected gear position before slowing the aircraft.

What's been done as a result

In March 2013, the Civil Aviation Safety Authority released new rules on fatigue management for flight crew. At the time of the occurrence, air operators that already held, or had applied for an air operator’s certificate after April 2013, had until April 2016 to transition to the new fatigue management rules. Consistent with this timeline, Regional Express was planning for their transition to meet those requirements at the time of the occurrence. In November 2015, this deadline was extended by the Civil Aviation Safety Authority to May 2017.

Safety message

This occurrence demonstrates some of the factors that increase the risk of making and not detecting errors of omission, particularly actions prompted by verbal cues. The use of a checklist helps identify errors, but they are most effective in this regard, if they are timed to be conducted before approaching aircraft limits.

Further, while this occurrence highlights the difficulties associated with assessing fatigue, operators and crew share responsibility for managing the risk of fatigue. Operators can reduce fatigue risk by providing crew with adequate rest opportunity, comprehensive training in fatigue management, and tools designed to support objective self-assessment of their alertness. Crew can then use the knowledge and tools to help identify when fatigue is present and may affect safety.

Download Final Report
[Download  PDF: 2.94MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

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General details
Date: 04 December 2014   Investigation status: Completed  
Time: 1720 EDT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Sydney Airport, west 19 km    
State: New South Wales   Occurrence type: Incorrect configuration  
Release date: 07 June 2016   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Saab Aircraft Co.  
Aircraft model 340B  
Aircraft registration VH-ZRJ  
Serial number 340B-396  
Operator Regional Express  
Type of operation Air Transport Low Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Narrandera, NSW  
Last update 14 November 2018