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|
Attributes | |
ACN | 738568 |
Time | |
Date | 200705 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 738568 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : diverted to another airport flight crew : landed as precaution flight crew : declared emergency |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
While departing ZZZ on the noise abatement takeoff procedure; the landing gear was never retracted. Prior to flight; the procedure was briefed; and I was going to be the PF. During the takeoff; I focused on the higher than normal rotation to a pitch attitude of 19 degrees. At 700 ft the 19 degree pitch was reduced; the aircraft climbed to 3000 ft; and the flaps were retracted on speed. I called 'flaps zero; after takeoff checklist' and the checklist was completed by the pilot monitoring. Thinking back; I don't recall the pilot monitoring stating the callout 'positive rate.' I continued to concentrate on maintaining srs commands of the target pitch attitude; and should have commanded 'gear up' even without the positive rate callout. I think the pilot monitoring missed the call because; as I was rotating on takeoff; and adjusting the pitch; I recall hearing from the pilot monitoring say; 'ok rotating to 19; there's 700 ft' etc; thus verbalizing the profile as the pilot monitoring; even though the target pitch attitudes were achieved per the profile. I think that is the crux of why the landing gear was missed. Instead of hearing the standard takeoff profile callouts; I was hearing non-standard (extra verbiage) callouts during takeoff. During climb out; I thought the gear had been retracted. We did have a distraction immediately prior to takeoff. While on tower frequency; holding short of the runway; the flight attendant called and said there is a child over two as a lap child; and would have to be moved. We started to call ZZZ operations; and adjust the passenger count to reflect the change. Then; the flight attendant called back and stated that the child was in fact under 2; and would remain a lap child. Because it was interrupted; the takeoff briefing was started over; and the before takeoff checklist was completed. While climbing; it was thought the flaps were down; even though they were indicating up. The flight attendant checked and stated they looked down. Later; a commuting off-line airline pilot in the cabin looked; and advised that the flaps were up. It should have been apparent the gear was still down because of the decreased performance; decreased 280 KTS redline indication on the pfd (for maximum speed vle); and the ECAM remaining on the wheels page. I remained the PF; while maintenance was contacted. A diversion to ZZZ1 was made; with emergency declared. While configuring for landing; when I called; 'gear down' this is when it was realized the landing gear handle and landing gear was down; and illuminating 3 green triangles. A very bright afternoon sun on a clear day probably made the cockpit displays lighter; and did not help in seeing the gear down indications either. In sum; I will command gear up; irrespective of a missed positive rate call; make sure I hear the words 'after takeoff checklist complete' from the pilot monitoring; and suggest the after takeoff checklist be modified for the first 2 items to be changed to a verbal challenge and response checklist item rather than a silent (pm) pilot monitoring item.
Original NASA ASRS Text
Title: A319 FLT CREW SUSPECTED DEGRADED ACFT PERFORMANCE DURING CLIMBOUT. FLT CREW CONTACTED MAINT; AND DECIDED TO DIVERT; DECLARING EMER. FLT CREW DISCOVERED DURING APCH THAT LNDG GEAR HAD NEVER BEEN RETRACTED.
Narrative: WHILE DEPARTING ZZZ ON THE NOISE ABATEMENT TKOF PROC; THE LNDG GEAR WAS NEVER RETRACTED. PRIOR TO FLT; THE PROC WAS BRIEFED; AND I WAS GOING TO BE THE PF. DURING THE TKOF; I FOCUSED ON THE HIGHER THAN NORMAL ROTATION TO A PITCH ATTITUDE OF 19 DEGS. AT 700 FT THE 19 DEG PITCH WAS REDUCED; THE ACFT CLBED TO 3000 FT; AND THE FLAPS WERE RETRACTED ON SPD. I CALLED 'FLAPS ZERO; AFTER TKOF CHKLIST' AND THE CHKLIST WAS COMPLETED BY THE PLT MONITORING. THINKING BACK; I DON'T RECALL THE PLT MONITORING STATING THE CALLOUT 'POSITIVE RATE.' I CONTINUED TO CONCENTRATE ON MAINTAINING SRS COMMANDS OF THE TARGET PITCH ATTITUDE; AND SHOULD HAVE COMMANDED 'GEAR UP' EVEN WITHOUT THE POSITIVE RATE CALLOUT. I THINK THE PLT MONITORING MISSED THE CALL BECAUSE; AS I WAS ROTATING ON TKOF; AND ADJUSTING THE PITCH; I RECALL HEARING FROM THE PLT MONITORING SAY; 'OK ROTATING TO 19; THERE'S 700 FT' ETC; THUS VERBALIZING THE PROFILE AS THE PLT MONITORING; EVEN THOUGH THE TARGET PITCH ATTITUDES WERE ACHIEVED PER THE PROFILE. I THINK THAT IS THE CRUX OF WHY THE LNDG GEAR WAS MISSED. INSTEAD OF HEARING THE STANDARD TKOF PROFILE CALLOUTS; I WAS HEARING NON-STANDARD (EXTRA VERBIAGE) CALLOUTS DURING TKOF. DURING CLBOUT; I THOUGHT THE GEAR HAD BEEN RETRACTED. WE DID HAVE A DISTR IMMEDIATELY PRIOR TO TKOF. WHILE ON TWR FREQ; HOLDING SHORT OF THE RWY; THE FLT ATTENDANT CALLED AND SAID THERE IS A CHILD OVER TWO AS A LAP CHILD; AND WOULD HAVE TO BE MOVED. WE STARTED TO CALL ZZZ OPS; AND ADJUST THE PAX COUNT TO REFLECT THE CHANGE. THEN; THE FLT ATTENDANT CALLED BACK AND STATED THAT THE CHILD WAS IN FACT UNDER 2; AND WOULD REMAIN A LAP CHILD. BECAUSE IT WAS INTERRUPTED; THE TKOF BRIEFING WAS STARTED OVER; AND THE BEFORE TKOF CHKLIST WAS COMPLETED. WHILE CLBING; IT WAS THOUGHT THE FLAPS WERE DOWN; EVEN THOUGH THEY WERE INDICATING UP. THE FLT ATTENDANT CHKED AND STATED THEY LOOKED DOWN. LATER; A COMMUTING OFF-LINE AIRLINE PLT IN THE CABIN LOOKED; AND ADVISED THAT THE FLAPS WERE UP. IT SHOULD HAVE BEEN APPARENT THE GEAR WAS STILL DOWN BECAUSE OF THE DECREASED PERFORMANCE; DECREASED 280 KTS REDLINE INDICATION ON THE PFD (FOR MAX SPD VLE); AND THE ECAM REMAINING ON THE WHEELS PAGE. I REMAINED THE PF; WHILE MAINT WAS CONTACTED. A DIVERSION TO ZZZ1 WAS MADE; WITH EMER DECLARED. WHILE CONFIGURING FOR LNDG; WHEN I CALLED; 'GEAR DOWN' THIS IS WHEN IT WAS REALIZED THE LNDG GEAR HANDLE AND LNDG GEAR WAS DOWN; AND ILLUMINATING 3 GREEN TRIANGLES. A VERY BRIGHT AFTERNOON SUN ON A CLR DAY PROBABLY MADE THE COCKPIT DISPLAYS LIGHTER; AND DID NOT HELP IN SEEING THE GEAR DOWN INDICATIONS EITHER. IN SUM; I WILL COMMAND GEAR UP; IRRESPECTIVE OF A MISSED POSITIVE RATE CALL; MAKE SURE I HEAR THE WORDS 'AFTER TKOF CHKLIST COMPLETE' FROM THE PLT MONITORING; AND SUGGEST THE AFTER TKOF CHKLIST BE MODIFIED FOR THE FIRST 2 ITEMS TO BE CHANGED TO A VERBAL CHALLENGE AND RESPONSE CHKLIST ITEM RATHER THAN A SILENT (PM) PLT MONITORING ITEM.
Data retrieved from NASA's ASRS site as of January 2009 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.