Aviation safety investigations & reports

Landing gear retraction deactivation and return involving a Boeing 787, VH-ZNH near Sydney Airport, New South Wales, 21 June 2021

Investigation number:
AO-2021-026
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final Report
[Download  PDF: 617KB]
 

What happened

On 21 June 2021, a Boeing Company 787-9, registered VH-ZNH and operated by Qantas Airways, was prepared for a scheduled passenger flight from Sydney, New South Wales, to Perth, Western Australia. During initial climb, the flight crew selected the landing gear lever to UP. Shortly after, they received a warning, indicating that neither main landing gear had retracted to the ‘up and locked’ position. Despite consulting the aircraft’s electronic checklist, the flight crew were unable to resolve the retraction issue. The landing gear lever was then selected to DOWN, with positive gear extension indications, and the aircraft returned to Sydney for an uneventful landing.

What the ATSB found

The ATSB found that two of the five downlock pins, one in each main landing gear, had not been removed following towing of the aircraft to the domestic terminal aircraft bay. In addition, these gear pins were not identified during subsequent external inspections, prior to the departure. When the flight crew selected the landing gear to retract, the nose gear successfully retracted and locked in the up position. However, the two installed pins prevented any movement of the main landing gear. There was no damage to the main landing gear.

What has been done as a result

Following the occurrence, the operator distributed memos to engineering, flight and ramp crew, highlighting the quantity and location of the gear pins on the Boeing 787, and the importance of following the documented ramp, pre-flight and dispatch procedures.

The memo to engineering also emphasised the importance of checking the pin location, rather than relying on streamers for identification. In addition, training packages for engineering, ramp and flight crew were updated with additional detail. Further, the operator advised they were working to relocate the gear pin stowage to the flight deck, in line with other aircraft types, to enable ease of access to visually verify pin removal and stowage.

Safety message

‘Remove before flight’ streamers are a reminder to remove covers, or lockout devices, prior to flight. Failure to remove these devices and covers can prevent the functionality of certain aircraft systems. The streamers are subject to varying environmental conditions that can reduce their visibility.

Expectation can also affect identification of these warning devices. Put simply, the likelihood of detecting ‘remove before flight’ streamers is significantly reduced if they are not expected to be there. The same principle can also prevent the discovery of damaged and/or missing components.

 

Download Final Report
[Download  PDF: 617KB]
 
 
 

The investigation

Summary

The ATSB has commenced a transport safety investigation into a landing gear indication involving a Boeing 787, VH-ZNH, near Sydney Airport, NSW, on 21 June 2021.

During climb, the main landing gear did not retract and the crew received a gear disagree EICAS message. The crew returned the aircraft to Sydney for an uneventful landing. The engineering inspection revealed that the forward gear pins on the left and right main landing gear were not removed prior to the flight.

The evidence collection phase of the investigation will include a review and examination of maintenance records and the gathering of any other relevant evidence. 

A report will be published at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken. 

General details
Date: 21 June 2021   Investigation status: Completed  
Time: 11:00 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Sydney Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Landing gear/indication  
Release date: 16 November 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 787-9  
Aircraft registration VH-ZNH  
Serial number 36241  
Operator Qantas Airways Ltd  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Sydney Aerodrome  
Destination Perth Aerodrome  
Last update 16 November 2021