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|
Attributes | |
ACN | 746497 |
Time | |
Date | 200707 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Weather Elements | other |
Light | Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 746497 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 746495 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency other |
Consequence | other |
Factors | |
Maintenance | performance deficiency : inspection performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Ambiguous |
Narrative:
1) in addition; to my error on the walkaround; I think it was a result of several layers of safety being missed. 2) lots of clues could have been drawn from the logbook had the missing pink pages been there. They would have showed gear pins being installed; removed and re-stowed. 3) maintenance left the pin installed although they said it was removed. 4) the rolled up nose pin flag in place of the main gear pin looked exactly like a main gear pin. 5) the pin installed on the gear was missing its red flag. 6) only 1 pin was installed instead of all 3. First flight of the day for this aircraft. Captain was the PF and I was the pilot monitoring. After takeoff our left main landing gear would not retract. We followed ECAM and recycled the landing gear. Left main landing gear would still not retract. We requested radar vectors with ATC to work out the issue. After a few mins and during a safe time I left my station to check the coat closest where the gear pins are stowed and found that 1 main landing gear pin was missing. However; the nose gear pin flag was new and was rolled up and in the place of the missing main landing gear pin; which made it look just like a main gear collar even when looking directly at through the plastic cover. In addition; when I returned to my station; captain assigned me flying and ATC duties and he opened the logbook to see if there were any write-ups for landing gear pins having been installed and/or removed. There were not. We then coordinated with ATC to return to ZZZ. We requested radar vectors and time from ATC to burn fuel; so we would be below landing weight upon our return. We got maintenance on the radio and they asked us to do a low pass by the tower to confirm that we indeed had the left main landing gear in the down position and all doors open while the gear handle was in the up position. They confirmed this for us and then we put the gear handle in the down position to check that all 3 gear were down and doors closed during the same fly-by. The tower confirmed that visually as well. We decided to leave the gear down and locked to aid in burning excess fuel for our landing and to preclude any other landing gear problems. We discussed our situation with the dispatcher and operations to arrange to return to the gate. We got all the flight attendants on the interphone and discussed our situation and that we would be returning to the airport with a precautionary landing. We also told them that we were anticipating a normal landing and would be taxiing to the gate under our own power. We asked them if they had any questions and told them that we anticipated flying for another 30 mins; or so before landing. We also accomplished the precautionary landing procedures specified in the fom. We made several announcements to the passenger informing them of our situation and emphasized that everything was safe and under control and that we would be making a normal landing and taxiing back to the gate. We also advised them that they would see emergency equipment upon clearing the runway and not to be alarmed because they were going to be there just as a precaution. At this point; we decided to declare an emergency with ATC and told them that at that time we anticipated a normal landing and rollout. Upon our arrival back at the gate; maintenance discovered that a gear pin was indeed still installed on the left main landing gear that was left installed from maintenance the night before. They brought it to the flight deck and stowed it back in its place. Of particular note; the gear pin they brought up did not have any flag at all on it. It was at this time that we were informed by maintenance that we were missing 4 previous pink pages from our logbook. This discrepancy would have been discovered by the captain had it not been for the fact that a new logbook had been installed with page number XXX1053 being the first new page in the logbook. The only thing that looked out of the ordinary was the fact the old logbook page number had not been recorded on the new log page that was in the book when preflight began. Maintenance had recorded the change in logbook page XXX1050; which we did not have and did not know we were missing. On page XXX1050 they recorded the last old logbook page as XXX2597; which was our last pink page that page showed the airplane terminating in ZZZ. With more investigation; we found that the missing pages showed flts from ZZZ back east; and back to ZZZ. On one of the missing pages; number XXX1051; there was a write-up showing the left gear pin being installed and removed and stowed back in the flight deck. We did not have that page in our possession either. Clearly maintenance did not remove and stow the landing gear pin. Only 1 of the 3 pins was removed from the flight deck and installed on the landing gear. After thinking about this situation and realizing that I had made an oversight on my walkaround that morning; I also realized that while starting my walkaround on the right side of the airplane I did not see a gear pin installed on the nose gear or the right main gear. On the left main gear I did notice that a brake had been changed and assumed that it was changed a day or so before; because there was no write-up in the logbook reflecting that work. The new brake drew my attention from the rest of the wheelwell area and that is when I made my mistake. In addition; with no gear pins being installed on any of the other gear and the fact that there was no flag on the left main gear pin also hampered my ability to see that the gear pin was still installed. When the left main gear did not retract it was fairly obvious. We spoke with maintenance immediately. They removed the pin and brought it to the flight deck. This is when we learned about the missing logbook pages with the write-up saying that the left main landing gear pin had been installed; removed and re-stowed. However; it was never removed and re-stowed. We refueled; got a new release and flew without further incident. First; if gear pins are installed make sure that all have red flags on them. Second; if one is installed; go ahead and install all three; not just one. Third; maintenance should make sure that any pages removed from the logbook get returned to the logbook. Fourth; when a new logbook is installed make a write-up on the first page of the new book; so the flight crew is aware of the change instead of a just a small line with a number from the last page of the old logbook. Lastly; I need to make certain that I do a thorough walkaround every time and not be complacent. You can rest assured that I will not let this happen again.
Original NASA ASRS Text
Title: A320 FLT CREW MISSES SINGLE GEAR PIN ON PREFLIGHT AND LEFT MAIN GEAR WILL NOT RETRACT AFTER TKOF. FLT CREW DISCUSSES FACTORS THAT LED TO THIS OMISSION.
Narrative: 1) IN ADDITION; TO MY ERROR ON THE WALKAROUND; I THINK IT WAS A RESULT OF SEVERAL LAYERS OF SAFETY BEING MISSED. 2) LOTS OF CLUES COULD HAVE BEEN DRAWN FROM THE LOGBOOK HAD THE MISSING PINK PAGES BEEN THERE. THEY WOULD HAVE SHOWED GEAR PINS BEING INSTALLED; REMOVED AND RE-STOWED. 3) MAINT LEFT THE PIN INSTALLED ALTHOUGH THEY SAID IT WAS REMOVED. 4) THE ROLLED UP NOSE PIN FLAG IN PLACE OF THE MAIN GEAR PIN LOOKED EXACTLY LIKE A MAIN GEAR PIN. 5) THE PIN INSTALLED ON THE GEAR WAS MISSING ITS RED FLAG. 6) ONLY 1 PIN WAS INSTALLED INSTEAD OF ALL 3. FIRST FLT OF THE DAY FOR THIS ACFT. CAPT WAS THE PF AND I WAS THE PLT MONITORING. AFTER TKOF OUR L MAIN LNDG GEAR WOULD NOT RETRACT. WE FOLLOWED ECAM AND RECYCLED THE LNDG GEAR. L MAIN LNDG GEAR WOULD STILL NOT RETRACT. WE REQUESTED RADAR VECTORS WITH ATC TO WORK OUT THE ISSUE. AFTER A FEW MINS AND DURING A SAFE TIME I LEFT MY STATION TO CHK THE COAT CLOSEST WHERE THE GEAR PINS ARE STOWED AND FOUND THAT 1 MAIN LNDG GEAR PIN WAS MISSING. HOWEVER; THE NOSE GEAR PIN FLAG WAS NEW AND WAS ROLLED UP AND IN THE PLACE OF THE MISSING MAIN LNDG GEAR PIN; WHICH MADE IT LOOK JUST LIKE A MAIN GEAR COLLAR EVEN WHEN LOOKING DIRECTLY AT THROUGH THE PLASTIC COVER. IN ADDITION; WHEN I RETURNED TO MY STATION; CAPT ASSIGNED ME FLYING AND ATC DUTIES AND HE OPENED THE LOGBOOK TO SEE IF THERE WERE ANY WRITE-UPS FOR LNDG GEAR PINS HAVING BEEN INSTALLED AND/OR REMOVED. THERE WERE NOT. WE THEN COORDINATED WITH ATC TO RETURN TO ZZZ. WE REQUESTED RADAR VECTORS AND TIME FROM ATC TO BURN FUEL; SO WE WOULD BE BELOW LNDG WT UPON OUR RETURN. WE GOT MAINT ON THE RADIO AND THEY ASKED US TO DO A LOW PASS BY THE TWR TO CONFIRM THAT WE INDEED HAD THE L MAIN LNDG GEAR IN THE DOWN POS AND ALL DOORS OPEN WHILE THE GEAR HANDLE WAS IN THE UP POS. THEY CONFIRMED THIS FOR US AND THEN WE PUT THE GEAR HANDLE IN THE DOWN POS TO CHK THAT ALL 3 GEAR WERE DOWN AND DOORS CLOSED DURING THE SAME FLY-BY. THE TWR CONFIRMED THAT VISUALLY AS WELL. WE DECIDED TO LEAVE THE GEAR DOWN AND LOCKED TO AID IN BURNING EXCESS FUEL FOR OUR LNDG AND TO PRECLUDE ANY OTHER LNDG GEAR PROBS. WE DISCUSSED OUR SITUATION WITH THE DISPATCHER AND OPS TO ARRANGE TO RETURN TO THE GATE. WE GOT ALL THE FLT ATTENDANTS ON THE INTERPHONE AND DISCUSSED OUR SITUATION AND THAT WE WOULD BE RETURNING TO THE ARPT WITH A PRECAUTIONARY LNDG. WE ALSO TOLD THEM THAT WE WERE ANTICIPATING A NORMAL LNDG AND WOULD BE TAXIING TO THE GATE UNDER OUR OWN PWR. WE ASKED THEM IF THEY HAD ANY QUESTIONS AND TOLD THEM THAT WE ANTICIPATED FLYING FOR ANOTHER 30 MINS; OR SO BEFORE LNDG. WE ALSO ACCOMPLISHED THE PRECAUTIONARY LNDG PROCS SPECIFIED IN THE FOM. WE MADE SEVERAL ANNOUNCEMENTS TO THE PAX INFORMING THEM OF OUR SITUATION AND EMPHASIZED THAT EVERYTHING WAS SAFE AND UNDER CTL AND THAT WE WOULD BE MAKING A NORMAL LNDG AND TAXIING BACK TO THE GATE. WE ALSO ADVISED THEM THAT THEY WOULD SEE EMER EQUIP UPON CLRING THE RWY AND NOT TO BE ALARMED BECAUSE THEY WERE GOING TO BE THERE JUST AS A PRECAUTION. AT THIS POINT; WE DECIDED TO DECLARE AN EMER WITH ATC AND TOLD THEM THAT AT THAT TIME WE ANTICIPATED A NORMAL LNDG AND ROLLOUT. UPON OUR ARR BACK AT THE GATE; MAINT DISCOVERED THAT A GEAR PIN WAS INDEED STILL INSTALLED ON THE L MAIN LNDG GEAR THAT WAS LEFT INSTALLED FROM MAINT THE NIGHT BEFORE. THEY BROUGHT IT TO THE FLT DECK AND STOWED IT BACK IN ITS PLACE. OF PARTICULAR NOTE; THE GEAR PIN THEY BROUGHT UP DID NOT HAVE ANY FLAG AT ALL ON IT. IT WAS AT THIS TIME THAT WE WERE INFORMED BY MAINT THAT WE WERE MISSING 4 PREVIOUS PINK PAGES FROM OUR LOGBOOK. THIS DISCREPANCY WOULD HAVE BEEN DISCOVERED BY THE CAPT HAD IT NOT BEEN FOR THE FACT THAT A NEW LOGBOOK HAD BEEN INSTALLED WITH PAGE NUMBER XXX1053 BEING THE FIRST NEW PAGE IN THE LOGBOOK. THE ONLY THING THAT LOOKED OUT OF THE ORDINARY WAS THE FACT THE OLD LOGBOOK PAGE NUMBER HAD NOT BEEN RECORDED ON THE NEW LOG PAGE THAT WAS IN THE BOOK WHEN PREFLT BEGAN. MAINT HAD RECORDED THE CHANGE IN LOGBOOK PAGE XXX1050; WHICH WE DID NOT HAVE AND DID NOT KNOW WE WERE MISSING. ON PAGE XXX1050 THEY RECORDED THE LAST OLD LOGBOOK PAGE AS XXX2597; WHICH WAS OUR LAST PINK PAGE THAT PAGE SHOWED THE AIRPLANE TERMINATING IN ZZZ. WITH MORE INVESTIGATION; WE FOUND THAT THE MISSING PAGES SHOWED FLTS FROM ZZZ BACK E; AND BACK TO ZZZ. ON ONE OF THE MISSING PAGES; NUMBER XXX1051; THERE WAS A WRITE-UP SHOWING THE L GEAR PIN BEING INSTALLED AND REMOVED AND STOWED BACK IN THE FLT DECK. WE DID NOT HAVE THAT PAGE IN OUR POSSESSION EITHER. CLRLY MAINT DID NOT REMOVE AND STOW THE LNDG GEAR PIN. ONLY 1 OF THE 3 PINS WAS REMOVED FROM THE FLT DECK AND INSTALLED ON THE LNDG GEAR. AFTER THINKING ABOUT THIS SITUATION AND REALIZING THAT I HAD MADE AN OVERSIGHT ON MY WALKAROUND THAT MORNING; I ALSO REALIZED THAT WHILE STARTING MY WALKAROUND ON THE R SIDE OF THE AIRPLANE I DID NOT SEE A GEAR PIN INSTALLED ON THE NOSE GEAR OR THE R MAIN GEAR. ON THE L MAIN GEAR I DID NOTICE THAT A BRAKE HAD BEEN CHANGED AND ASSUMED THAT IT WAS CHANGED A DAY OR SO BEFORE; BECAUSE THERE WAS NO WRITE-UP IN THE LOGBOOK REFLECTING THAT WORK. THE NEW BRAKE DREW MY ATTENTION FROM THE REST OF THE WHEELWELL AREA AND THAT IS WHEN I MADE MY MISTAKE. IN ADDITION; WITH NO GEAR PINS BEING INSTALLED ON ANY OF THE OTHER GEAR AND THE FACT THAT THERE WAS NO FLAG ON THE L MAIN GEAR PIN ALSO HAMPERED MY ABILITY TO SEE THAT THE GEAR PIN WAS STILL INSTALLED. WHEN THE L MAIN GEAR DID NOT RETRACT IT WAS FAIRLY OBVIOUS. WE SPOKE WITH MAINT IMMEDIATELY. THEY REMOVED THE PIN AND BROUGHT IT TO THE FLT DECK. THIS IS WHEN WE LEARNED ABOUT THE MISSING LOGBOOK PAGES WITH THE WRITE-UP SAYING THAT THE L MAIN LNDG GEAR PIN HAD BEEN INSTALLED; REMOVED AND RE-STOWED. HOWEVER; IT WAS NEVER REMOVED AND RE-STOWED. WE REFUELED; GOT A NEW RELEASE AND FLEW WITHOUT FURTHER INCIDENT. FIRST; IF GEAR PINS ARE INSTALLED MAKE SURE THAT ALL HAVE RED FLAGS ON THEM. SECOND; IF ONE IS INSTALLED; GO AHEAD AND INSTALL ALL THREE; NOT JUST ONE. THIRD; MAINT SHOULD MAKE SURE THAT ANY PAGES REMOVED FROM THE LOGBOOK GET RETURNED TO THE LOGBOOK. FOURTH; WHEN A NEW LOGBOOK IS INSTALLED MAKE A WRITE-UP ON THE FIRST PAGE OF THE NEW BOOK; SO THE FLT CREW IS AWARE OF THE CHANGE INSTEAD OF A JUST A SMALL LINE WITH A NUMBER FROM THE LAST PAGE OF THE OLD LOGBOOK. LASTLY; I NEED TO MAKE CERTAIN THAT I DO A THOROUGH WALKAROUND EVERY TIME AND NOT BE COMPLACENT. YOU CAN REST ASSURED THAT I WILL NOT LET THIS HAPPEN AGAIN.
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.