SA Airlink RJ85 at Johannesburg on Nov 10th 2011, landed without nosegear

Last Update: October 14, 2013 / 21:29:58 GMT/Zulu time

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Incident Facts

Date of incident
Nov 10, 2011

Classification
Accident

Airline
SA Airlink

ICAO Type Designator
RJ85

South Africa's Civil Aviation Authority (SACAA) released their final report concluding the probable cause of the accident was:

Nose landing gear failed to extend and lock down.

Contributory factor:

Nose landing gear doors were opened during maintenance by disconnecting the nose landing gear door operating rod at the lower attachment point for NDT inspection to be carried out. The operating rod was not re-connected back to normal after maintenance causing the operating rod to obstruct the nose landing from extending normally.

The SACAA reported the cockpit crew, captain (32, ATPL, 6,022 hours total, 2,064 hours on type) and first officer (30, ATPL, 4,106 hours total, 1,602 hours on type), arrived on a different aircraft about 40 minutes prior to the departure 4Z-8739. That aircraft was assigned to carry out 4Z-8739 but could not perform the flight due to a pressurization issue. ZS-SSH, which was about to get ready after maintenance tasks were carried out, was thus assigned to carry out the flight.

The crew performed a walk around and found no anomalies, the tech log did not contain any entries about anomalies in effect.

While preparing for departure a ramp controller notified the crew that the nose landing gear doors were still open, the flight crew however did not consider this to be of concern as there were no tech log entries and proceeded with the takeoff operations.

After the aircraft had become airborne on runway 03L the crew was selected up, the gear retracted with no abnormal indication, the wind noise and vibrations from the nose landing gear area however remained to be excessive. The crew selected the gear down and up again, but the wind noise remained excessive. The crew therefore decided to return to Johannesburg.

On final approach the crew selected the gear down but received down and locked indications only for the main gear, the nose gear remained retracted. The crew aborted the approach and performed all relevant checklist procedures to no avail. The crew performed a low approach to Johannesburg to have the landing gear inspected from the ground, emergency services and tower reported the nose gear was retracted. A number of high G maneouvers were performed without getting the nose gear down.

The crew finally commenced an emergency landing on just the main gear keeping the nose up as long as possible before permitting the aircraft to settle on its nose. The aircraft came to a stop about 2500 meters down runway 03R. The passengers disembarked through the front left hand door, the tail doors were too high above ground to conduct an evacuation.

7 passengers were taken to hospitals for observation however discharged without injuries shortly after. The aircraft sustained damage to the nose lower area and nose landing gear doors.

Prior to the accident flight the aircraft was to undergo a non-destructive test, an ultrasonic inspection of the upper part of the main fitting of the nose landing gear. An external contractor was assigned and work cards issued to carry out the task amongst other tasks to be carried out that night and morning.

The licensed maintenance engineer (LAME) opened the nose gear doors by disconnecting the nose landing gear operating rod and conducted the inspection. After the test was finished the LAME reported to the shift supervisor that the non destructive test was finished, the aircraft was left unattended due to other tasks still pending and aircraft needing to be towed to a hangar for further maintenance tasks.

When later in the day, after completion of other maintenance tasks, the originally assigned aircraft went tec, the day maintenance supervisor checked the technical logs, found no outstanding defects and maintenance tasks, concluded the aircraft was fit to conduct the flight and released the aircraft to service.

The SACAA annotated that there is no evidence that the LAME opening the nose gear doors made an according tech log entry, there was no flag "maintenance in progress" attached to the nose landing gear door(s).

The SACAA further reported that the external contractor had left the aerodrome with the documentation of the non destructive test still with them, so that the maintenance supervisor could not certify the documentation. As result the aircraft was dispatched without the work having been certified. There is no evidence that a pre-flight inspection was carried out by maintenance prior to returning the aircraft to service.

There is also no evidence that the captain or first officer completed their walk around prior to commencing the flight.

The SACAA analysed that as result of the LAME failing to enter the fact of opening the nose landing gear doors by disconnecting the rod into the tech log, failing to apply the flag "maintenance in progress" and failing to reconnect the rod, as well as the failure to conduct a pre flight check by maintenance and failure to complete a pre-flight check by the flight crew resulted in the nose landing gear doors remaining open although they should have been closed. The notification of the open nose landing gear doors by the ramp controller was discarded as being of no concern.
Incident Facts

Date of incident
Nov 10, 2011

Classification
Accident

Airline
SA Airlink

ICAO Type Designator
RJ85

This article is published under license from Avherald.com. © of text by Avherald.com.
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