CEN11IA615

NTSB incident investigation · Bombardier CL-600-2B19 · Baton Rouge, LA · September 1, 2011

Incident · No injuriesIncident investigationFinal report
Date
September 1, 2011, 17:25 local (22:25 UTC)
Place
Baton Rouge, LA
Injuries
53 uninjured
Damage
Minor damage
Phase of flight
Landing
Aircraft
N875ASBombardier CL-600-2B19
Defining event
Landing: Landing gear not configured
Weather
Visual (VMC) · Day
Status
Completed · report January 30, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Atlantic Southeast Airlines
FAA report
20110901023769I
Case key
81683

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The improperly installed upper attachment bolt in the left main landing gear uplock assembly, which led to the failure of the left main landing gear to extend before landing. Contributing to the accident was maintenance personnel's lack of training on the installation and inspection of the uplock assembly.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBombardier CL-600-2B19: 1 caseAll aircraft: 371 casesProbable cause
Experience/qualifications: total experience w/ equipmentPersonnel issues › Experience/knowledge · Maintenance personnelBombardier CL-600-2B19: 1 caseAll aircraft: 269 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelBombardier CL-600-2B19: 1 caseAll aircraft: 57 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

While configuring the airplane for landing, the flight crew observed a landing gear disagree message and an indication that the left main landing gear was not down and locked. The flight crewmembers followed procedures to address the landing gear disagree message; however, they were unable to get the left landing gear to extend. The captain declared an emergency and chose to land the airplane with only the right main landing gear and nose landing gear extended. The airplane came to rest in an upright, left-wing-low position. Postincident examination of the left main landing gear system revealed that the upper attachment bolt for the left main landing gear uplock assembly, which is designed to be attached to both the uplock mechanism and the structure, was attached only to the airplane structure. The left main landing gear uplock assembly had been removed and reinstalled the day before the incident flight. The mechanic who performed the maintenance did not have training on nor prior experience performing the installation of the uplock assembly, and the maintenance inspector who inspected its installation did not have training on inspecting the uplock assembly. Neither the mechanic nor the maintenance inspector observed any problems during the postinstallation inspection. Thus, it is likely that the uplock assembly was installed incorrectly due to the lack of training in both the installation by the mechanic and the inspection by the inspector.

Factual narrative

On September 1, 2011, about 1725 central daylight time, a Bombardier CL-600-2B19 airplane, N875AS, operated as Delta Connection flight 5058, landed at the Baton Rouge Metropolitan Airport (BTR), Baton Rouge, Louisiana, with the left main landing gear in the retracted position. The airline transport pilot captain, first officer, flight attendant, and 50 passengers were not injured. The airplane received minor damage. Visual meteorological conditions prevailed for the landing and an instrument flight rules flight plan was filed for the 14 Code of Federal Regulations Part 121 flight. The flight originated from the Hartsfield Jackson Atlanta International Airport (ATL), Atlanta, Georgia, at 1409. While configuring the airplane for landing, the flight crew observed a landing gear disagree message, and the left main gear indicated that it was not down and locked. The Quick Reference Handbook (QRH) procedures were accomplished, which included cycling the landing gear handle and the use of the alternate gear extension (manual release) system; however, the crew was unable to get the left landing gear to extend. The captain declared an emergency and elected to land the airplane with the right main landing gear and nose gear extended. The airplane came to rest in an upright and left wing low position. The captain commanded an evacuation, and all passengers departed the airplane using the left forward door. Post-incident inspection of the airplane revealed minor damage to the left wing. There was no other damage to the airplane as a result of the left main landing gear being retracted at the time of landing. Examination of the left main landing gear assembly revealed that the upper attachment bolt for the left main landing gear uplock assembly, which is designed to be attached to both the uplock mechanism and the structure, was attached to the airplane structure only. Maintenance had been performed on both the left and right main landing gear systems prior to the incident flight. The mechanic who performed the maintenance did not have prior experience performing the installation of the uplock assembly. Following the incident, Atlantic Southeast Airlines changed their maintenance requirements and procedures to prevent future accidents. In addition, Bombardier issued Service Letter ATA:3230 to address this maintenance discrepancy and prevent future accidents.

Aircraft

Registration
N875AS
Reported as
Bombardier CL-600-2B19
Category
Airplane
Serial number
7559
Airframe hours
30,563
Engines
General Electric CF34-3B1, 9,140 lbs thrust, turbo fanGeneral Electric CF34-3B1, 9,140 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Atlantic Southeast Airlines Inc
Registered owner
Atlantic Southeast Airlines Inc
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · August 31, 2011
Departed
ATL · Atlanta, GA
Destination
BTR · Baton Rouge, LA
Flight plan
IFR
Airport
BTR · Baton Rouge Metropolitan, runway 13, 6,407 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
March 18, 2011
Seat
Left
Toxicology
Performed
Flight hours
5,305 total · 4,312 in this make and model · 198 in the last 90 days
Role
Co-pilot
Age
27
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
998 total · 715 in this make and model · 175 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 75 °F
Altimeter
29.94 inHg
Observed at
BTR

Docket · 6

The files NTSB released with the investigation on November 21, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.