TSB releases final report into July 2016 nose landing gear failure in Calgary, Alberta
Edmonton, Alberta, 29 May 2018 – The Transportation Safety Board of Canada (TSB) investigation (A16W0092) into an occurrence where the nose wheel failed to extend on an Air Georgian flight found several maintenance-related deficiencies that went undetected by the company's safety management system (SMS). These issues also went undetected by Transport Canada oversight activities.
On 12 July 2016, an Air Georgian Ltd. Beechcraft 1900D turboprop aircraft was operating as Air Canada Express flight 7212 from Lethbridge, Alberta, to Calgary, Alberta, with 2 flight crew members and 15 passengers on board. When the flight crew lowered the landing gear for the approach into Calgary, they noticed that there was no gear-safe indication for the nose landing gear. The flight circled for about one hour while the flight crew attempted to fix the problem. An emergency was declared and the aircraft landed with the nose gear partially extended. There was minimal damage to the aircraft, no fire, and there were no injuries.
The investigation found that the nose landing gear did not fully extend because of a lack of lubrication to certain landing gear components. These components were not properly lubricated because maintenance personnel were not adequately trained on lubrication techniques and the use of lubrication equipment. The company's quality control program also contributed to ineffective lubrication activities going undetected for an extended period of time prior to the occurrence.
Safety management and oversight is a TSB Watchlist issue. This investigation found that Air Georgian's SMS was ineffective at identifying and correcting improper and unsafe practices related to nose landing gear lubrication tasks.
Transport Canada's (TC) surveillance of Air Georgian focused primarily on its SMS rather than on regulatory compliance. As a result, ineffective lubrication processes went undetected during three TC inspections prior to the occurrence. If TC does not adopt a balanced approach to oversight that combines inspections for compliance with SMS audits, there is a risk that improper maintenance practices will not be identified, which may lead to incidents and accidents.
Following the occurrence, Air Georgian carried out a fleet campaign to address the greasing issue and reduced the inspection interval for the affected component. The company also hired a manager for maintenance training, and provided human factors training to its staff on distraction, including the need to track and document steps in the workflow.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada