37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 533218 |
Time | |
Date | 200112 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : cyul.airport |
State Reference | PQ |
Altitude | msl single value : 1000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 12100 flight time type : 3000 |
ASRS Report | 533218 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 6700 flight time type : 2900 |
ASRS Report | 533076 |
Events | |
Anomaly | non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : lndg gear warning system other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance controller : provided flight assist flight crew : diverted to another airport none taken : detected after the fact other |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Company |
Narrative:
When departing montreal, canada, the nose landing gear failed to retract. We diverted back to montreal and landed without further incident. When inspecting the aircraft we found the nose gear safety pin still installed. Here are some factors that I think led to the incident. First, our company recently changed its policy concerning gear pin use during the pushback procedure. The old procedure called for a safety pin during push. The new procedure calls for no more use of gear pins since hydraulic pressure is more than sufficient to prevent collapse. I feel the station manager failed to notify its employees of the new policy since the ramp and maintenance personnel said they were not aware of the new policy. My first officer, the one who does the preflight, failed to inform me that a pin was installed in the nose gear or he missed it all together on the preflight inspection. In the future I will specifically ask the first officer what the status of the nose gear area -- is the pin in or out? I have suggested to our management that if maintenance personnel absolutely need to use a gear pin, to use the ones located in the cockpit only because the captain preflts the cockpit and makes sure all the safety pins are accounted for. Supplemental information from acn 533076: after departing runway 24L at cyul, I called for the gear up. The captain then selected the gear up and we noticed that the nose gear didn't retract. We then requested vectors back around to montreal. After running all appropriate checklists and briefing the passenger and cabin crew, we landed without further incident on runway 24R. The mechanic verified at the gate that the nose gear pin was still installed. The contributing factors are as follows. Our company changed polices just a few days prior on the usage of gear pins during push. They no longer require it, however it takes time for all stations to exercise this. I saw this pin installed during my preflight and safety inspection and assumed this station had not yet stopped using the pins for push, as was my experience at many other stations over the last several days. During the push I was in the process of coordinating clearance for deicing and taxi rtes as well as starting the engines. During this workload I didn't notice whether the ground crew removed the pin as they're supposed to when they disconnect. They obviously didn't. The captain assumed the pin wasn't installed per the new procedure. These events led us down a road I can assure you I will avoid in the future.
Original NASA ASRS Text
Title: CL65 PUSHBACK CREW DID NOT HAVE NOSE GEAR PIN REMOVED PRIOR TO TKOF AT CYUL.
Narrative: WHEN DEPARTING MONTREAL, CANADA, THE NOSE LNDG GEAR FAILED TO RETRACT. WE DIVERTED BACK TO MONTREAL AND LANDED WITHOUT FURTHER INCIDENT. WHEN INSPECTING THE ACFT WE FOUND THE NOSE GEAR SAFETY PIN STILL INSTALLED. HERE ARE SOME FACTORS THAT I THINK LED TO THE INCIDENT. FIRST, OUR COMPANY RECENTLY CHANGED ITS POLICY CONCERNING GEAR PIN USE DURING THE PUSHBACK PROC. THE OLD PROC CALLED FOR A SAFETY PIN DURING PUSH. THE NEW PROC CALLS FOR NO MORE USE OF GEAR PINS SINCE HYD PRESSURE IS MORE THAN SUFFICIENT TO PREVENT COLLAPSE. I FEEL THE STATION MGR FAILED TO NOTIFY ITS EMPLOYEES OF THE NEW POLICY SINCE THE RAMP AND MAINT PERSONNEL SAID THEY WERE NOT AWARE OF THE NEW POLICY. MY FO, THE ONE WHO DOES THE PREFLT, FAILED TO INFORM ME THAT A PIN WAS INSTALLED IN THE NOSE GEAR OR HE MISSED IT ALL TOGETHER ON THE PREFLT INSPECTION. IN THE FUTURE I WILL SPECIFICALLY ASK THE FO WHAT THE STATUS OF THE NOSE GEAR AREA -- IS THE PIN IN OR OUT? I HAVE SUGGESTED TO OUR MGMNT THAT IF MAINT PERSONNEL ABSOLUTELY NEED TO USE A GEAR PIN, TO USE THE ONES LOCATED IN THE COCKPIT ONLY BECAUSE THE CAPT PREFLTS THE COCKPIT AND MAKES SURE ALL THE SAFETY PINS ARE ACCOUNTED FOR. SUPPLEMENTAL INFO FROM ACN 533076: AFTER DEPARTING RWY 24L AT CYUL, I CALLED FOR THE GEAR UP. THE CAPT THEN SELECTED THE GEAR UP AND WE NOTICED THAT THE NOSE GEAR DIDN'T RETRACT. WE THEN REQUESTED VECTORS BACK AROUND TO MONTREAL. AFTER RUNNING ALL APPROPRIATE CHKLISTS AND BRIEFING THE PAX AND CABIN CREW, WE LANDED WITHOUT FURTHER INCIDENT ON RWY 24R. THE MECH VERIFIED AT THE GATE THAT THE NOSE GEAR PIN WAS STILL INSTALLED. THE CONTRIBUTING FACTORS ARE AS FOLLOWS. OUR COMPANY CHANGED POLICES JUST A FEW DAYS PRIOR ON THE USAGE OF GEAR PINS DURING PUSH. THEY NO LONGER REQUIRE IT, HOWEVER IT TAKES TIME FOR ALL STATIONS TO EXERCISE THIS. I SAW THIS PIN INSTALLED DURING MY PREFLT AND SAFETY INSPECTION AND ASSUMED THIS STATION HAD NOT YET STOPPED USING THE PINS FOR PUSH, AS WAS MY EXPERIENCE AT MANY OTHER STATIONS OVER THE LAST SEVERAL DAYS. DURING THE PUSH I WAS IN THE PROCESS OF COORDINATING CLRNC FOR DEICING AND TAXI RTES AS WELL AS STARTING THE ENGS. DURING THIS WORKLOAD I DIDN'T NOTICE WHETHER THE GND CREW REMOVED THE PIN AS THEY'RE SUPPOSED TO WHEN THEY DISCONNECT. THEY OBVIOUSLY DIDN'T. THE CAPT ASSUMED THE PIN WASN'T INSTALLED PER THE NEW PROC. THESE EVENTS LED US DOWN A ROAD I CAN ASSURE YOU I WILL AVOID IN THE FUTURE.
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.