37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 175881 |
Time | |
Date | 199104 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bos |
State Reference | MA |
Altitude | msl bound lower : 1000 msl bound upper : 5000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : takeoff climbout : initial landing other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 120 flight time total : 24000 flight time type : 8900 |
ASRS Report | 175881 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 204 flight time total : 4577 flight time type : 1207 |
ASRS Report | 176040 |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After takeoff we got a nose red unsafe light when we attempted to retract gear. The nose gear sounded like it did not move. On recycling we got an immediate green light when gear handle placed down and no change in sound. We immediately suspected that the nose gear safety pin was in place. Returned for landing. No fuel dumped, no emergency declared or equipment required. Mechanic found nose gear pin still in place with red streamer attached. Gear pins are rarely used and are never seen by flight crews in a normal operation. This aircraft had been towed to the gate from a remote site which did require the use of pins. They failed to remove the nose pin. Our second officer failed to see the pin on his walk around inspection. Company procedures require him to personally observe the removal of any gear pins found before returning to the cockpit. Probable cause of the incident was the second officer failure to use a flashlight to look directly at the down lock pins location. He relied on ambient light which was enough for him to see other required items in the nose well area. Contributing was the good possibility that the red streamer had blown up and become entangled so it was not hanging down below the nose gear doors where it could be seen. This would explain why maintenance also missed it. Sometimes a little paranoia can be a good thing. Supplemental information from acn 176040. The procedure is that whenever any gear pins are installed, an entry is made into the aircraft logbook by the mechanic installing the gear pins. This was not accomplished this time. My guess is that the red streamer attached to the nose gear pin was tangled up above the down lock arm and not hanging down as it should have been because I missed the pin on my walk around preflight, and at least four other maintenance personnel did not notice the red 'remove before flight' streamer in the accomplishment of their normal duties ie, hooking up and disconnecting ground power, pushing the aircraft back and disconnecting the steering bypass pin etc. The widebody transport probably had the hardest to see nose gear pin of all major aircraft therefore should have a system that insures that the pin and streamer is visible regardless of wind conditions, such as an attachment point at the bottom and of the streamer. In addition, a different color or type of material for the streamer could be used (as red nylon tends to look black after constant use).
Original NASA ASRS Text
Title: AFTER TKOF, WDB UNABLE RETRACT NOSE GEAR. RETURN LAND.
Narrative: AFTER TKOF WE GOT A NOSE RED UNSAFE LIGHT WHEN WE ATTEMPTED TO RETRACT GEAR. THE NOSE GEAR SOUNDED LIKE IT DID NOT MOVE. ON RECYCLING WE GOT AN IMMEDIATE GREEN LIGHT WHEN GEAR HANDLE PLACED DOWN AND NO CHANGE IN SOUND. WE IMMEDIATELY SUSPECTED THAT THE NOSE GEAR SAFETY PIN WAS IN PLACE. RETURNED FOR LNDG. NO FUEL DUMPED, NO EMER DECLARED OR EQUIP REQUIRED. MECH FOUND NOSE GEAR PIN STILL IN PLACE WITH RED STREAMER ATTACHED. GEAR PINS ARE RARELY USED AND ARE NEVER SEEN BY FLT CREWS IN A NORMAL OPERATION. THIS ACFT HAD BEEN TOWED TO THE GATE FROM A REMOTE SITE WHICH DID REQUIRE THE USE OF PINS. THEY FAILED TO REMOVE THE NOSE PIN. OUR S/O FAILED TO SEE THE PIN ON HIS WALK AROUND INSPECTION. COMPANY PROCS REQUIRE HIM TO PERSONALLY OBSERVE THE REMOVAL OF ANY GEAR PINS FOUND BEFORE RETURNING TO THE COCKPIT. PROBABLE CAUSE OF THE INCIDENT WAS THE S/O FAILURE TO USE A FLASHLIGHT TO LOOK DIRECTLY AT THE DOWN LOCK PINS LOCATION. HE RELIED ON AMBIENT LIGHT WHICH WAS ENOUGH FOR HIM TO SEE OTHER REQUIRED ITEMS IN THE NOSE WELL AREA. CONTRIBUTING WAS THE GOOD POSSIBILITY THAT THE RED STREAMER HAD BLOWN UP AND BECOME ENTANGLED SO IT WAS NOT HANGING DOWN BELOW THE NOSE GEAR DOORS WHERE IT COULD BE SEEN. THIS WOULD EXPLAIN WHY MAINT ALSO MISSED IT. SOMETIMES A LITTLE PARANOIA CAN BE A GOOD THING. SUPPLEMENTAL INFO FROM ACN 176040. THE PROC IS THAT WHENEVER ANY GEAR PINS ARE INSTALLED, AN ENTRY IS MADE INTO THE ACFT LOGBOOK BY THE MECH INSTALLING THE GEAR PINS. THIS WAS NOT ACCOMPLISHED THIS TIME. MY GUESS IS THAT THE RED STREAMER ATTACHED TO THE NOSE GEAR PIN WAS TANGLED UP ABOVE THE DOWN LOCK ARM AND NOT HANGING DOWN AS IT SHOULD HAVE BEEN BECAUSE I MISSED THE PIN ON MY WALK AROUND PREFLT, AND AT LEAST FOUR OTHER MAINT PERSONNEL DID NOT NOTICE THE RED 'REMOVE BEFORE FLT' STREAMER IN THE ACCOMPLISHMENT OF THEIR NORMAL DUTIES IE, HOOKING UP AND DISCONNECTING GND PWR, PUSHING THE ACFT BACK AND DISCONNECTING THE STEERING BYPASS PIN ETC. THE WDB PROBABLY HAD THE HARDEST TO SEE NOSE GEAR PIN OF ALL MAJOR ACFT THEREFORE SHOULD HAVE A SYS THAT INSURES THAT THE PIN AND STREAMER IS VISIBLE REGARDLESS OF WIND CONDITIONS, SUCH AS AN ATTACHMENT POINT AT THE BOTTOM AND OF THE STREAMER. IN ADDITION, A DIFFERENT COLOR OR TYPE OF MATERIAL FOR THE STREAMER COULD BE USED (AS RED NYLON TENDS TO LOOK BLACK AFTER CONSTANT USE).
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.