Luxair DH8D at Saarbruecken on Sep 30th 2015, takeoff ending on belly, smoke in cabin
Last Update: August 27, 2017 / 18:54:27 GMT/Zulu time
The air accident was the result of an early retraction of the retractable landing gear during take-off, which was not prevented by the landing gear selector lever and the retracting control logic.
- Reduced concentration level
- A break in the callout process / task sequence on the part of the PNF
- Actuation of the landing gear lever to the UP Position too early
- Control logic design allows retraction of the landing gear with one wheel airborne
The BFU analysed that it had been a rather relaxed day for the crew, the crew was looking forward to an early conclusion of the working day with their last leg to Luxembourg.
The BFU wrote in their analysis:
During taxi they received take-off clearance. After a short stop in position at runway 09 acceleration for take-off was begun. The analysis of the recorders and the crew interviews showed that during take-off run, after reaching rotation speed, the landing gear lever was put into position UP and the landing gear retracted during rotation with lifted nose.
Without the support of the main landing gear the tail of the aircraft hit the runway. The recorded data of the FDR and the ground contact of the tail strike warner at about 5° nose up show that the main landing gear folded back and retracted before the airplane had reached the rotation pitch of approximately 8° nose up. Due to the tail strike the tail bounced off the ground. This reduced the pitch instantly even though the pulled control input of the PF still remained. Therefore the pitch was not sufficient to produce enough lift for the airplane to become airborne even though rotation speed had been reached and engine thrust remained unchanged.
Once the PF had realised the occurrence he reduced engine thrust and tried to keep the airplane on the runway and stop it.
The cabin crew stated that during the slide on the runway smoke and acrid metallic smell had developed which caused them to open the doors and evacuate the aircraft immediately after it had come to a standstill.
The BFU wrote with respect to human factors:
The early, not requested, grasp of the landing gear selector lever during the take-off callout procedure came suddenly and unexpectedly for the PF. After the event, the co-pilot could not explain her actions.
Publications on human performance and error management (see page 16 ff) describe such actions as Slip. It is a spurious action which occurs unintentional und unplanned in a correct, known, often trained and repeated course of action. Especially processes which are repeated quite often and therefore generate reduced concentration are susceptible for these kinds of errors.
With respect to the aircraft the BFU analysed:
The investigation also determined that the landing gear retracts in accordance with the control design logic if the cockpit commands it (lever in position UP) and at least one landing gear (nose wheel or main landing gear) is airborne according to the weight on wheels sensors. During rotation with lifted nose this is the case.
The BFU reported that Transport Canada released an Airworthiness Directive as result of the occurrence requiring that the gear does get only retracted when all weight on wheel sensors register no weight on the wheels. The aircraft manufacturer changed the PSEU accordingly.
Due to the safety actions already taken the BFU did not release any safety recommendation as result of the investigation.
On Aug 27th 2017 a reader made The Aviation Herald aware that Google Earth and Google Maps are currently using satellite images of Saarbruecken Airport, that were taken exactly on Sep 30th 2015 after the accident.
This article is published under license from Avherald.com. © of text by Avherald.com.
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