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Old 07-16-2008, 12:03 PM   #1  
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Default NTSB report from the Eagle BOS gear up problem

Aviation Week and Space Technology, July 14, 2008
Seeing Green
American Eagle crew averts a gear-up accident with a just-in-time go-around
FRANCES FIORINO/WASHINGTON

Human-machine interface, crew decision-making and the value of "seat-of-the pants" flying will likely be discussed late this summer when the NTSB determines the probable cause of an American Eagle incident in 2007.

The event-an attempt to land with the gear retracted-nearly became one of aviation's fatal statistics. NTSB documents made available to Aviation Week & Space Technology reveal what transpired in the cockpit the morning of June 20, 2007,when the Embraer 135 regional jet (Flight 4539)was on approach to Boston Logan International Airport with 37 passengers and three crew on board. The crew told investigators that the flight was normal from pre-flight and takeoff from Toronto Pearson International Airport at 7:04 a.m, through en route and final approach to Runway 22L.

The first sign of trouble came when the crew noticed the "landing-gear lever disagree" light appear shortly after the first officer (the pilot flying) had pulled down the landing-gear lever. At this point, the aircraft was at about 1,500 ft. and on close-in final approach.

The cockpit voice recorder transcript (see excerpts) shows that the captain and first officer discussed the meaning of the gear lever indication. The captain was opting to continue the approach and the first officer concurred, although they continued the approach without following the checklist for the landing-gear lever disagree alert.

The flight crew said their decision was based on having "overwhelming indications "that the gear was down: Those indications included seeing a "three green" light on the lever and a written "three-green" on the radio management unit.The pilots also heard the gear doors opening.In addition, none of the normal alerts sounded in the cockpit to indicate the gear was not down-not the "landing-gear' warning when the aircraft was below 1,200 ft., nor the "too low gear" warning below 500 ft.

The first officer told investigators that he would not have continued the approach if there had been another sign that something was wrong.
Even the landing felt normal until just prior to touchdown, the crew told the NTSB. The first officer,with "seat-of-the-pants" flying instincts emerging, repeatedly remarked that "something feels weird ... it doesn't feel right," before calling for and executing a go around.

At this point, the aircraft fuselage scraped the runway, and controllers advised the crew that sparks were observed when the aircraft touched down, according to the NTSB. When the captain raised the landing gear during the go-around-he noted an immediate three-green landing-gear-up indication, which does not normally appear so quickly. Then, following the flight manual, the crew performed the checklist for the landing-gear lever disagree alert, which calls for recycling the landing gear. With the recycle, the crew noted a "three-green," indicating that the gear was extended. The crew, agreeing that "something was not right," then performed the Abnormal Landing Gear Extension checklist. After using the electrical override system, the crew said they felt three "clunks," which led them to believe the gear had extended normally.

The captain said he informed the first officer that he did not need to perform the emergency landing checklist because they were time-limited and he was familiar with the procedures on the checklist, according to the NTSB.

The crew discussed the situation with American Eagle maintenance operational control, and performed a flyby for a visual check of the gear extension by tower controllers. The tower advised that a pilot on the ground thought the gears to be canted at a 45-deg. angle. When extending flaps for the flyby, a "flaps fail" indication appeared, and flaps remained retracted for the remainder of the flight.The pilots executed a second fly by at lower altitude, at which time the tower observed that the extended gear position looked normal. The crew of Flight 4539 then decided to proceed with a second approach, with the captain flying. The crew debated whether to declare an emergency, then did so. Controllers vectored the flight to a longer runway, 33L, while passengers were briefed for a "brace-brace" landing. This time the aircraft touched down safely,and no injuries were reported.

The day after the incident, American Eagle issued a Safety Message to operators that reads in part: "Whenever the EICAS [engine indicating and crew alert system] warning 'LG/Lever Disagree' message is shown after gear extension, the landing gear should be considered unsafe, regardless of gear position indications on the EICAS or radio management unit. An immediate go-around must be initiated and the 'emerge/abnorm procedures LG/Lever Disagree' must be followed."

The NTSB, which has been engaged in more incident investigations in recent years, is likely to issue incident-related safety recommendations along with probable cause.

Excerpts from
NTSB Cockpit Voice Recorder Transcript

Recording Span 07:37:48 - 9:38:59am

08:18:06 [Boston Logan tower clears Flight 4539 to land Runway 22L.]
08:18:36 [Sound similar to altitude alerter)
08:18:48 [Sound of click and roar similar to landing gear operation)
08:19:10 [Sound similar to aural warning)
08:19:12 HOT-2 Landing gear disagree. We can't land with that, can we?
08:19:12 HOT-1 [Unintelligible) the[expletive) does that mean?
08:19:21 HOT-2 I don't know, but we can't land with that...got 22 ...What do you want to do?
08:19:33 HOT-1 We got three green
08:19:34 HOT-2 We do, but it's a discrepancy. What do you think?
08:19:38-08:19:40 HOT-l Keep going I think... I think we're alright with three green.
08:20:09·08:20:15. [Before-landing checklist is completed, aircraft approaching minimums.]
08:20:13 HOT-2 I hope that light's not broke.
08:20:34 HOT·2 If it doesn't feel right, tell me to go around.
08:20:51 HOT-2 Doesn't feel right, doesn't feel right (sound of impact)

Crew initiates go-around, consults with airline maintenance, performs two flybys and runs through abnormal emergency landing procedures, attempts second landing.

09:29:32 HOT-2 Brace, brace, brace
09:30:00 [Sound similar to aircraft touchdown on runway]


Legend: HOT-1: Captain; HOT-2: First Officer
Source: National Transportation Safety Board, cockpit
Voice Recorder Transcript from the Group Chairman
Factuol Report (June 25, 2008)
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Old 07-16-2008, 01:14 PM   #2  
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08:19:12 HOT-2 Landing gear disagree. We can't land with that, can we?


08:20:13 HOT-2 I hope that light's not broke.
08:20:34 HOT·2 If it doesn't feel right, tell me to go around.
This FO went from "Left-seat worthy" to "just along for the ride" in approximately 60 seconds, probably because of the Captain's hunch and somewhat unconvincing argument that there was a strong possibility, despite considerable doubt, that just maybe, all would be OK.

Two words that jump out at me are professionalism and get-there-itis.

I'm sure there's a little bit of these guys in each of us.

Wanna bet we examine this series of events (the Captain - FO conversation) in our CRM courses for the next couple years?
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Old 07-16-2008, 01:38 PM   #3  
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At this point, the aircraft fuselage scraped the runway, and controllers advised the crew that sparks were observed when the aircraft touched down.

then

The captain said he informed the first officer that he did not need to perform the emergency landing checklist because they were time-limited and he was familiar with the procedures on the checklist, according to the NTSB.
i would think that once the controllers tell you, you got sparks coming out the rear, that the CVR is probably going to be looked at
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Old 07-16-2008, 06:30 PM   #4  
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this is a totally unfortunate situation. I would have thought the gear was down based on the sound of the gear doors as well. But thats because every airplane Ive ever flown has a mechanical link with the door, meaning if the doors open, the gear is coming down with it. how does the ERJ work?
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Old 07-16-2008, 07:42 PM   #5  
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meaning if the doors open, the gear is coming down with it. how does the ERJ work?
When it doesn't work, it works like this:





Doors open, three green, gear not down and locked.
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Old 07-16-2008, 07:49 PM   #6  
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this is a totally unfortunate situation. I would have thought the gear was down based on the sound of the gear doors as well. But thats because every airplane Ive ever flown has a mechanical link with the door, meaning if the doors open, the gear is coming down with it. how does the ERJ work?
I've been flying the thing for almost 3 years now but I am by no means an expert. To the best of my knowledge there is no linkage between the landing gear themselves and the doors (the nose gear is the only one with a door). I've had the exact opposite situation happen where the landing gear was retracted on climbout and the nose gear door stayed open.
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Old 07-16-2008, 10:20 PM   #7  
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I can't help but wonder if it really was the best idea to go around after contacting the ground. Ah, hindsight. Glad everything turned out fine though!
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Old 07-16-2008, 10:27 PM   #8  
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I'm simply surprised they even got off the ground again! He'd be at idle thrust right as he was touching the ground, so unless he was landing with thrust that was a real feat.
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Old 07-16-2008, 10:39 PM   #9  
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Well at least we all learned something good to take from CRM class next time and no one died because of it. I'll chop that one as a positive.
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Old 07-17-2008, 05:48 AM   #10  
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I can't help but wonder if it really was the best idea to go around after contacting the ground. Ah, hindsight. Glad everything turned out fine though!
They were in the process of going around when they struck the ground. The scenario was attempted in the sim many times and each time they were unable to keep the aircraft flying. The NTSB and the FAA were very impressed with the actions of the crew considering the situation. You guys can arm chair quarterback all you want they did a great job.
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