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Cases › CEN11IA615 · Part 121 airline

BOMBARDIER INC CL-600-2B19ATLANTIC SOUTHEAST AIRLINES INC

Baton Rouge, LA, USA · 2011-09-01·N875AS

0
fatal
0
serious
No injury
highest injury
Minor
damage

What happened

NTSB summary, verbatim

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.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
Contour Airlines Bombardier CRJ-200 N875AS BWI MD1
Acroterion · CC BY-SA 4.0 · Wikimedia Commons

Probable cause

the Board's determination
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.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Landing
    Landing gear not configured
    defining event

Findings

3 causal · 0 contributing
  • CAUSE
    Personnel issues › Task performance › Maintenance › Installation — Maintenance personnel
  • CAUSE
    Personnel issues › Experience/knowledge › Experience/qualifications › Total experience w/ equipment — Maintenance personnel
  • CAUSE
    Personnel issues › Task performance › Inspection › Post maintenance inspection — Maintenance personnel

NTSB analysis

from the final report

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.