Aviation occurrence briefs

Landing gear failure involving Beech 1900D, Cairns Airport, Qld, on 18 July 2018

Number:
AB-2018-093
Status: Completed
Investigation completed

Brief

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On 18 July 2018, at about 0620 Eastern Standard Time, a Beech Aircraft Corp B1900D was conducting a charter flight from Cairns Airport, Queensland (Qld) to Skardon River Airport, Qld with two crew and 16 passengers on board.

Just after take-off from Cairns, the landing gear was selected up. The landing gear did not retract and remained down and locked with all green lights illuminated. The crew conducted a return to Cairns and the aircraft landed without incident.

Engineering Inspection

Following the incident, inspection of the landing gear revealed that the landing gear motor circuit breaker in the undercarriage had been pulled the previous day during maintenance and was not reset before the access panel was re-fitted after maintenance was completed. As a result, when the landing gear was selected up, the undercarriage system could not operate without the circuit breaker being reset.

Safety action

As a result of this incident, the maintenance organisation has advised the ATSB that they are taking the following ongoing safety actions:

  • improving prescribed paperwork methods
  • providing further human factors training
  • conducting Efficiency-Thoroughness Trade-Off (ETTO) training[1]
  • conducting more regular tool box talks
  • providing safety and quality awareness training.

Safety message

Where an aircraft has been out of service for maintenance, it is important to verify the functionality of all critical aircraft components before returning it to service. These checks should be conducted in addition to the routine, pre-flight checks.

It is important that pilots remain aware that despite conducting comprehensive pre-flight checks, unanticipated failures can still occur during flight. In this situation, the flight crew took all possible precautions by following non-normal procedures, conducting additional checks to assess the situation, providing clear communications to ATC and returning the aircraft to land.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

 

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  1. Erik Hollnagel, ETTO principles and rules that are applicable to the working environment. They compare the difference between efficiency and safety.
General details
Date: 18 July 2018   Investigation status: Completed  
Time: 0620 EST    
Location   (show map): Cairns    
State: Queensland    
Release Date: 05 November 2018   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 1900D  
Type of operation Charter  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Cairns, Qld  
Destination Skardon River, Qld  
Last update 12 December 2018