Qantas pilots forget to lower landing gear

[Spectator]

Looks like November is going to be the month of forgetful pilots... forgetting to land, forgetting landing gear, what next?

Two Qantas pilots were suspended on Wednesday after forgetting to lower landing gear as they came in to land at busy Sydney airport.

...

The airline today issued a statement saying the events around Monday's flight from Melbourne constituted a "serious incident" and would be subject to a full investigation by Qantas and the Australian Transport Safety Bureau.

There's also a small titbit about an airspeed issue similar to what is suggested may have affected AF447.

http://www.news24.com/Content/World/...o_lower_wheels

[Gabriel]

I just thought I'd mention that they noticed the gear-up condition and initiated a go-around when they were still at 700ft, so it's not that they were at seconds from landing (well, yes, like 60 seconds).

The "seriousness" of the incident is that they got to that point without realizing that the gear was not down.

The ground proximity warning system GPWS saved them with a "too low / gear" warning, and they initiated the go-around. The GPWS is exactly intended for these cases. Intended, yes. But not expected because the pilots are expected to lower the landing gear AND to perform the landing checklist effectively (which includes checking gear down and locked) AND to check that the plane meets the stabilized approach criteria (typically by 1000ft) which again includes that the plane is configured for landing, and are NOT expected to rely on the GPWS.

So the GPWS is the backup in case the pilots failed on all that. The pilots did fail on all that, and hence it's a serious incident that requires investigation.

But the news make it look like it was almost a total air disaster, and that's not right. A go around at 700 ft is not even considered a low altitude go around. A plane in an instrument approach that reaches the minimums without seeing the runway and goes around does it at some 200ft, something that happens everyday and it's not considered a close call.

[MCM]

Just some additional points to consider -

The pilots had already commenced the go around before the too low gear warning went off. (This is contained in the ATSB information). This means the GPWS did not "save" them.

From the official information we do not know if the go around was because they were not configured (which is certainly possible), or they selected the gear up too early in a go around for other reasons and that triggered the warning.

The operators requirement is to be stable (in VMC) by 500ft, although it is expected the gear will be down well before that.

[Gabriel]

Originally Posted by MCM

The pilots had already commenced the go around before the too low gear warning went off. (This is contained in the ATSB information).

Have a link?

[TeeVee]

just a quick query: is it possible that there was a gear malfunction and the pilots decided to continue the approach while trying to set gear down? or is there a minimum alt where gear must/should be confirmed down, and they had passed that min alt?

[AJ]

Originally Posted by Gabriel

Have a link?

http://www.atsb.gov.au/publications/...-2009-066.aspx

[EconomyClass]

Do pilots do risky things via a checklist? I've read about enough incidents where checklists were being followed that I wonder if SOP is to do a list, but often they perform from the MEMORY of what is on the list.

[Gabriel]

AJ, Thanks!

EC, check lists are written list and the crew is supposed to follow the written list while perfotming it.

Each airline has its own policies, but the current tendency is not to use the checklist as a to-do list. The procedures should be completed before, and the check list is just to check that you have actually done it right. In this way the probability that you both forget to press a button and then you mistakenly skip the line of that button in the list is minimized.

[Evan]

Originally Posted by Gabriel

Each airline has its own policies

I think I see the problem here.

[MCM]

The idea is that you accomplish the items as per your normal operations, without reference, and then you do the checklist at certain stages of flight, confirming that all of the required actions have been completed.

Airlines do have varying policies, but I can't think of one "recognized" airline carrier that does it differently... why? Because it is the accepted best practice for aviation, and is used by Boeing and Airbus in their checklist philosophies.

I can't see a problem with having minor variations in policy given that crews tend to remain with one carrier for a protracted time. They are only very minor differences anyway.

[Evan]

If an airline requires a checklist procedure for approach, I don't see how it is possible to overlook deployment of landing gear. One pilot reads out the item, the other confirms it. Therefore it gets done. Failsafe. What is so difficult about enforcing that? Why no universal checklist requirement? The checklist is there to protect us. It should be a universal requirement. Why isn't it? I'd really like to know.

[Fear_of_Flying]

Originally Posted by Evan

If an airline requires a checklist procedure for approach, I don't see how it is possible to overlook deployment of landing gear. One pilot reads out the item, the other confirms it. Therefore it gets done. Failsafe. What is so difficult about enforcing that? Why no universal checklist requirement? The checklist is there to protect us. It should be a universal requirement. Why isn't it? I'd really like to know.

I don't think you understood MCM's answer. The checklist is used universally, and these pilots should have used it properly. Is it failsafe? Not when you have human beings who have to lower the landing gear, and human beings who then have to check to ensure they lowered it. With a zillion flights, sooner or later someone's going to mess up on both counts. Luckily, there's yet another safeguard, the ground proximity alarm, when this occurs.

I hope I haven't misstated the situation.

[Leftseat86]

Come on AJ you can fess up

[Simpleboy]

Originally Posted by Fear_of_Flying

I don't think you understood MCM's answer. The checklist is used universally, and these pilots should have used it properly. Is it failsafe? Not when you have human beings who have to lower the landing gear, and human beings who then have to check to ensure they lowered it. With a zillion flights, sooner or later someone's going to mess up on both counts. Luckily, there's yet another safeguard, the ground proximity alarm, when this occurs.

I hope I haven't misstated the situation.

Thats my take on it as well, and as we know, they had already commenced a go around, perhaps they were using the checklist when it happened? A little late, but still, we just dont know. The ATSB info reads very differently to that of the newspaper article.

[EconomyClass]

Time for a clarification. If they did normal SOP for landing, then they had aborted the landing before the spot where they would expect to lower the wheels and were in the middle of go-around which doesn't required the wheels to be down and locked? Is this what we are now expecting? Whatever log there is would show a go-around decision had interrupted the landing checklist?

[Evan]

Originally Posted by Fear_of_Flying

I don't think you understood MCM's answer. The checklist is used universally, and these pilots should have used it properly. Is it failsafe? Not when you have human beings who have to lower the landing gear, and human beings who then have to check to ensure they lowered it. With a zillion flights, sooner or later someone's going to mess up on both counts. Luckily, there's yet another safeguard, the ground proximity alarm, when this occurs.

I hope I haven't misstated the situation.

Actually, I was responding to Gabriel's answer, but in any case, I don't see how you can overlook gear extension if you are using a checklist as a to-do list. You call it out, you move the lever, you check it off. Done. So I'm asking why this isn't a universal requirement.

And, once again, this technological complacency issue keeps coming up at the heart of things. Disasters are often the result of multiple failures of equipment and pilot procedure. Will the GWPS always have your back? What happens if the GWPS fails to alert you for some unforeseen reason—faulty RA input or something? I don't think GWPS alone is a failsafe, but along with a strict checklist requirement it certainly is.

Why doesn't the GWPS drop the gear automatically at the alert level (provided there is a guarded override switch)? Or would this breed further complacency?

[Curtis Malone]

Originally Posted by Evan

Why doesn't the GWPS drop the gear automatically at the alert level (provided there is a guarded override switch)? Or would this breed further complacency?

Because the gear in transit (either up or down) may degrade go-around performance.

[MCM]

Evan, because basically it is a flight control, and isn't always deployed at the same point. And even if it was... what is the difference between saying "Gear Down", or

"Gear Down Checklist"... then the other pilot going "Gear Down Checklist - Gear Lever - Down... Gear Down Checklist Complete".

You can miss either one just as much as the other.

The point is there is a checklist that needs to be completed prior to landing, the landing checklist... and it has on it all the items that are required. There IS a strict checklist requirement, and it must be completed prior to landing. In this case, the checklist needs to have been completed by 500ft... they were well above that when they went around.

Aviation happens too fast, and things need to be done in different timeframes, to do EVERYTHING from a "to do list"... which is of course different from non-normal checklists which are done as "to do" lists.

If you read the ATSB initial comments it looks like they didn't need GPWS to "have their back"... they'd already started going around.

As to an automatic gear drop? Probably the worst thing you could have. The GPWS is designed to stop you hitting terrain, and you need the best performance the aircraft can give you, which is with the wheels safely tucked up inside the jet. The "Too Low Gear" is a very small subset of the GPWS, and in certain situations may actually preceed a full blown Terrain warning, when gear down would hinder rather than help.

Also, of what benefit is dropping the gear? If a "Too Low Gear" warning sounds, then the crew should go around... as it is possible the gear isn't the only thing in the incorrect position.

[Gabriel]

Evan,

Checklists have been mandatory for very long. And they have to read it, not to make it by heart.

What I meant is that, there was a time when checklists were used as to-do list. That is, one pilot calls each item and the other one DOES IT and confirm it. For example:

NFP: "Spoilers"
FP: (arms the spoilers and then says) "Armed"
NFP: (if the correct status for "spoilers" is "armed" he moves to the next line)

The current practice (I think some airlines still use the old one, but I'm not sure) is to do the things BEFORE the checklist. By when you get to the point where you do the checklist it is expected that all items on it are already done. Then one pilot calls each item and the other pilot just CONFIRMS that the item is already in the status. For example:

FP: Arms the spoilers (at an earlier time, before the checklist)

During the checklist:
NFP: "Spoilers"
FP: (verifies the status of the spoilers and then says) "Armed"
NFP: (if the correct status for "spoilers" is "armed" he moves to the next line)

In this second case, any event where the status of the item is not what it's supposed to be is an "Oops!". It's too late already to fix it. I mean, may be they do fix it (for example, they arm the spoilers), but the mistake is already done.

Written checklists are much safer than memory cehcklists and let alone than no checklist. But they are not fail-safe. Several things can go wrong:

They can fail to do the checklist (either intentionally or because they forget in the rush of the situation)
They can skip a line (not so uncommon)
They can do it by inertia and call an item's status just what it's supposed to be, or what "I remember I did", instead of actually checking it status.
They can, for some reason or another (including mistake), undo an item AFTER the checklist.

The advantage of the current practice of first do then check is clear. If pilots act professionally doing all items correctly most of the times and then doing the checklist correctly most of the times, the probability to fail on both instances are orders of magnitude lower than if you use the checklist as a to-do list (where one single mistake leaves an item undone).

For example, say that 95% of the times you don't forget to lower the gear before the checklist and that 95% of the times you effectively do the checklist (yo do it AND don't miss the "landing gear" item AND you do it consciously checking its actual status): You will make one mistake (wither one or the other) in 1 out of 10 flights. You'll make both in 1 out of 500 flights (there the GPWS will save you).

With the old practice, if you only lower the landing gear when the checklist is effectively done, the GPWS will have to save you in 1 out of 20 flights, or about 20 times more often.

[Evan]

I hear what you are saying but...

Originally Posted by Gabriel

They can do it by inertia and call an item's status just what it's supposed to be, or what "I remember I did", instead of actually checking it status.

So, actually checking its status by moving the eyeballs from the checklist to the three green lights on the panel is how difficult exactly...? I think "inertia" is putting it too kindly. The indication couldn't be designed more clearly.

But by then, in the case of do-it-first, check-it-later, if you get to the item and find that you didn't do it, you have to go-around, effectively freaking out the passengers and stressing out the traffic controllers, whereas if you do the checklist as a to-do checklist earlier on, you avoid this scenario (and there is no way, if a PNF calls out a checklist action, that the PF is going to fail to do it and then immediately confirm that he has done it; that would be definitively psychotic), and if you can manage to skip even one item on a relatively short checklist like that, you should probably have a job drilling holes in sheet metal instead.

Overshooting airports, falling asleep on the job, landing on taxiways, forgetting to extend landing gear despite having a checklist you really shouldn't even need to have...

Are truly qualified pilots in such short supply? Are they not properly screened for basic attentative skills? Or are pilots simply over-extended to the point that they behave psychotically? This seems epidemic lately.

One day, when I drive into my garage door because I forgot to open it, I will begin to understand, but despite having worked a lot of long hours and ridiculous schedules that definitely exceed what I am hearing from pilots, and not having had a co-pilot or checklist to back me up, or a hundred souls in my backseat to worry about, this has never happened.