Aviation safety investigations & reports

Incorrect configuration involving Bombardier DHC-8-402, VH-QOY near Sydney, New South Wales, on 12 July 2021

Investigation number:
AO-2021-028
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 12 July 2021, a Bombardier DHC-8-402 (Q400), VH-QOY was being operated by QantasLink from Sydney to Albury, New South Wales and return. After take-off, the flight crew inadvertently omitted to retract the landing gear and did not identify this omission when completing the after-take-off checklist.

The cabin crew alerted the flight crew that the landing gear was still extended, and the flight crew retracted the landing gear when the aircraft was at about 15,900 ft. The aircraft had exceeded the maximum altitude with landing gear extended (15,000 ft).

What the ATSB found

The ATSB found that both pilots were heavily focused on aircraft performance after take-off, so the positive rate and subsequent gear-up calls were not made. Neither pilot identified these omissions.

When completing the after-take-off checklist, the pilot monitoring provided the ‘landing gear’ challenge and the pilot flying incorrectly called ‘up, no lights’ in response. Both pilots observed that the 3 green landing gear lights were illuminated but neither recognised that this was problematic for this stage of flight. It is likely that both pilots had a strong expectancy that the landing gear had been retracted after take-off.

What has been done as a result

QantasLink advised that both flight crew underwent additional training focused on threat and error management techniques. The occurrence was also included in a safety article, which discussed omissions, threat and error management and situational awareness.

QantasLink advised it had also initiated a program of focused risk monitoring for its operational ramp-up out of the COVID-19 pandemic. Metrics included human factors and performance, crewmember wellbeing, flight data and a return-to-work training program.  

Safety message

This occurrence demonstrates how diverted attention or focus may result in errors of omission, especially where a task may be reliant on standard verbal cues. Highly-repetitive, routine tasks may result in pilots developing strong expectations that a task has been completed, even if it has not been, and make it difficult for pilots to identify an omitted action. Accordingly, it is essential that when flight crews are completing checklists, they focus on confirming that the relevant conditions have been met.  

Download Final Report
[Download  PDF: 834KB]
 
 
 

The investigation

Summary

The ATSB is investigating an incorrect configuration involving Bombardier DHC-8-400, registered VH-QOY, near Sydney Airport, New South Wales, on 12 July 2021.

After take-off, the flight crew did not retract the landing gear. This was not identified during the after take-off checks but discovered later during the climb. After confirming it was safe to do so, the flight crew retracted the landing gear and returned the aircraft to Sydney.

The evidence collection phase of the investigation will include interviewing the flight crew and reviewing operator procedures, flight crew records and recorded data.

A final report will be released 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: 12 July 2021   Investigation status: Completed  
Time: 1630 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Sydney   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Incorrect configuration  
Release date: 23 March 2022   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Bombardier Inc  
Aircraft model DHC-8-402  
Aircraft registration VH-QOY  
Serial number 4288  
Operator Sunstate Airlines (Qld) Pty. Limited (operating as QantasLink)  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Sydney, New South Wales  
Destination Albury, New South Wales  
Last update 22 March 2022