History of the Flight
The crew reported for duty at 0515 hrs at their home base, Birmingham Airport, for a three-sector day. The first return flight was uneventful. After a scheduled break of 2 hours 35 minutes, which was reduced to 2 hours due to a delay, the pilots boarded the aircraft for the final sector to Stuttgart at about 1300 hrs. The before-flight checks were completed, and the crew briefed for a reduced thrust takeoff with Flap 18 from Runway 15. The ATIS valid at 1250 hrs reported the Honiley VOR out of service. Prior to pushback at about 1440 hrs, clearance was received for a COWLY 1E departure requiring reference to the Honiley VOR. The crew believed the VOR was out of service but considered they could proceed using the aircraft's Flight Management System (FMS).
Details of the Incident
The commander was the handling pilot. After a normal engine start, the aircraft taxied and lined up on Runway 15. Upon takeoff clearance, the commander advanced the thrust levers and engaged autothrust. The takeoff roll was normal. Once airborne, both pilots noted the Honiley VOR appeared serviceable as the beam bar on their navigation displays became active. The co-pilot called "positive climb" and the commander instructed him to raise the landing gear. The co-pilot believed he then pressed the VOR ident button on the communications selector to identify the Honiley beacon. As he did so, he saw the three green landing gear position indicator lights still illuminated and questioned the commander. The commander replied he thought he had already ordered the gear up. Almost immediately, the co-pilot advised the commander that he had retracted the flaps by mistake and reached forward to raise the gear lever. The commander immediately decreased pitch to accelerate the aircraft, at which point the stick shaker briefly activated. The commander estimated the aircraft descended by about 100 ft during the acceleration to zero flap speed (VFTO). The aircraft remained in visual meteorological conditions throughout, and the crew considered there was no risk of impact. After resuming the climb, the commander called for autopilot engagement and continued on the cleared departure. The rest of the flight was uneventful, and the aircraft landed safely at Stuttgart at 1515 hrs. The pilots later positioned back to Birmingham as passengers, and the commander filed a company air safety report and notified the base manager.
Flight Data
Data from the flight data recorder and enhanced ground proximity warning system showed that flap retraction started 5 to 6 seconds after takeoff at a computed airspeed of 157 kt and took 18 to 22 seconds to complete. Approximately 23.5 seconds after takeoff, the gear status changed from locked down to not locked down. About 24 seconds after takeoff, between 0.125 and 1.125 seconds after the landing gear was unlocked, the stick shaker warning was initiated at an airspeed of 154.5 to 155 kt, altitude approximately 800 ft above airfield level, height 750 ft above ground level, angle of attack (AOA) between 15.8 and 16.4 degrees, flaps at less than 1 degree, pitch attitude 16.6 degrees nose up, and wings level. The stick shaker operated for 1 to 2 seconds. After the stick shake, pitch was reduced by 9.8 degrees over 6 seconds. About 10 seconds after the stick shaker, the aircraft reached VFTO (186 kt) and the GPWS issued a mode 3 "Don't Sink" alert. Altitude loss was 110 ft, with terrain clearance reducing to 624 ft. Thrust levers were not moved during the event. The aircraft was fitted with a stall warning and identification system that activates the stick shaker at specific AOA thresholds depending on flap setting and speed.
Crew Factors
The co-pilot had flown 87 hours 50 minutes in the previous 28 days, with nine days off, many of which were single days off preceded by duty periods ending between 2035 and 2110 hrs local. He believed his roster left him generally fatigued, which he considered the major cause of the incident, stating he had failed to recognise a level of fatigue that would facilitate such an error. Additionally, both pilots had intended to eat during their break but the canteen closed before they went there, and they did not eat elsewhere, so they had not eaten since their crew meals on the first sector. The co-pilot believed this amplified his fatigue. Distraction also played a role: the ATIS used earlier reported the Honiley VOR out of service, but neither pilot checked for updates or questioned ATC about its status when given their clearance. Both pilots commented when the VOR appeared active shortly after rotation.