Narrative:

It was xxoo pm and near the end of a very long day. I was completing a 3 hour flight on an aircraft with a total of 6 hours since major overhaul and 3 hours since annual inspection. The last 1.5 hours of the flight was at night and over rough terrain. There was no moon out, and therefore it was very dark. Although the WX was VMC, I had to keep a close eye on the gauges due to the lack of horizon. Needless to say, the last leg of this trip was very stressful. Once dark, I contacted center for flight following. Since I had not filed a flight plan, I thought this was prudent knowing I had just picked up an aircraft with a new overhaul. When I finally saw my destination airport, I felt relaxed and relieved. As I approached the airport, I noticed that my descent from cruise was going to leave me too high and fast for a straight in approach. Therefore, I slowed the aircraft down to flap extension speed, and lowered the gear and flaps nearly simultaneously. Knowing I needed to lose altitude quickly, I immediately sideslipped the aircraft. I held the slip in until short final. Once there, I noticed another aircraft taxiing. I heard him on the unicom frequency after I had announced my final approach position. At that time he indicated he would take off on the second runway at the airport. However, he was not doing so, instead he was taxiing toward the runway I was about to land on. I kept a close watch on him until he stopped. At this time, I was approaching the runway threshold and initiating my flare for landing. The next thing I heard was the ticking of the propeller and the scratching of the airplane fuselage on concrete. My initial thought was that I did not put my gear down. However, I remembered doing so, I needed the drag. I checked the gear selector. It was in the down position. Then I remembered that I had never verified that the gear had actually come down. How could this have happened? Later that morning after the aircraft was secure I had a chance to analyze the final phase of the flight. Like most accidents/incidents, there was no single point of failure. I realized that 3 system must have failed for this incident to have occurred. First, the actual gear system must fail. This mechanical system is not foolproof. And indeed, on this night, the electric motor which drives the hydraulic pump did fail. Therefore the gear was only partly extended. Second, the pilot must fail. This is the only human element of the 3 system. It was a long day, I was tired, stressed, and hungry (I had not taken the time to eat), and I was trying to salvage a poorly planned approach. On long final when I put the gear switch down, I was concentrating on losing altitude. Instead of watching for the gear down light, I was watching the airspeed indicator, waiting for flap speed. Once the flaps were down, I was busy flying the airplane in an uncoordinated attitude. And once on short final, instead of verifying the gear indication for a second time like I normally do, I was concentrating on another aircraft. I never verified the position of the gear. And finally, the gear warning system must fail. This is another mechanical system which is prone to failure. And as unfortunate as it may seem, this final system failed along with the previous system, on the same approach. As a pilot, and not a mechanic, I can only improve on the second system. I've determined that the most important element which could have avoided the human error, was to have flown a complete landing pattern. To fly a pattern appropriately and successfully, I would have lost altitude before entering the landing phase (not descending into the pattern). Therefore, the tasks required for landing is accomplished in a routine and orderly manner. I would have extended the gear abeam of the touchdown zone, and immediately verified it was down and locked. I would have extended the flaps if needed, and once on short final, verify the gear position once more. Before this incident, I flew the pattern only if other traffic was in the area. However, I now realize that the pattern serves a purpose other than keeping aircraft sequenced: it helps to distribute and organize tasks required for landing. Each element has its proper place. Once an element is skipped (due to distrs or other actions) another approach is needed. Also, identification did not mention checklists. I did complete the 'gump' checklist. However, I rushed through the list. Instead of verifying each action, I performed the task almost simultaneously. A checklist is no good if performed in this manner. It is not only important to perform the actions but the action must be accomplished correctly and verified.

Related reports:

Google
 

Original NASA ASRS Text

Title: ACFT EQUIP PROB MALFUNCTION COMPOUNDED BY PLT TECHNIQUE FLYING. GEAR UP LNDG ENSUES.

Narrative: IT WAS XXOO PM AND NEAR THE END OF A VERY LONG DAY. I WAS COMPLETING A 3 HR FLT ON AN ACFT WITH A TOTAL OF 6 HRS SINCE MAJOR OVERHAUL AND 3 HRS SINCE ANNUAL INSPECTION. THE LAST 1.5 HRS OF THE FLT WAS AT NIGHT AND OVER ROUGH TERRAIN. THERE WAS NO MOON OUT, AND THEREFORE IT WAS VERY DARK. ALTHOUGH THE WX WAS VMC, I HAD TO KEEP A CLOSE EYE ON THE GAUGES DUE TO THE LACK OF HORIZON. NEEDLESS TO SAY, THE LAST LEG OF THIS TRIP WAS VERY STRESSFUL. ONCE DARK, I CONTACTED CTR FOR FLT FOLLOWING. SINCE I HAD NOT FILED A FLT PLAN, I THOUGHT THIS WAS PRUDENT KNOWING I HAD JUST PICKED UP AN ACFT WITH A NEW OVERHAUL. WHEN I FINALLY SAW MY DEST ARPT, I FELT RELAXED AND RELIEVED. AS I APCHED THE ARPT, I NOTICED THAT MY DSCNT FROM CRUISE WAS GOING TO LEAVE ME TOO HIGH AND FAST FOR A STRAIGHT IN APCH. THEREFORE, I SLOWED THE ACFT DOWN TO FLAP EXTENSION SPD, AND LOWERED THE GEAR AND FLAPS NEARLY SIMULTANEOUSLY. KNOWING I NEEDED TO LOSE ALT QUICKLY, I IMMEDIATELY SIDESLIPPED THE ACFT. I HELD THE SLIP IN UNTIL SHORT FINAL. ONCE THERE, I NOTICED ANOTHER ACFT TAXIING. I HEARD HIM ON THE UNICOM FREQ AFTER I HAD ANNOUNCED MY FINAL APCH POS. AT THAT TIME HE INDICATED HE WOULD TAKE OFF ON THE SECOND RWY AT THE ARPT. HOWEVER, HE WAS NOT DOING SO, INSTEAD HE WAS TAXIING TOWARD THE RWY I WAS ABOUT TO LAND ON. I KEPT A CLOSE WATCH ON HIM UNTIL HE STOPPED. AT THIS TIME, I WAS APCHING THE RWY THRESHOLD AND INITIATING MY FLARE FOR LNDG. THE NEXT THING I HEARD WAS THE TICKING OF THE PROP AND THE SCRATCHING OF THE AIRPLANE FUSELAGE ON CONCRETE. MY INITIAL THOUGHT WAS THAT I DID NOT PUT MY GEAR DOWN. HOWEVER, I REMEMBERED DOING SO, I NEEDED THE DRAG. I CHKED THE GEAR SELECTOR. IT WAS IN THE DOWN POS. THEN I REMEMBERED THAT I HAD NEVER VERIFIED THAT THE GEAR HAD ACTUALLY COME DOWN. HOW COULD THIS HAVE HAPPENED? LATER THAT MORNING AFTER THE ACFT WAS SECURE I HAD A CHANCE TO ANALYZE THE FINAL PHASE OF THE FLT. LIKE MOST ACCIDENTS/INCIDENTS, THERE WAS NO SINGLE POINT OF FAILURE. I REALIZED THAT 3 SYS MUST HAVE FAILED FOR THIS INCIDENT TO HAVE OCCURRED. FIRST, THE ACTUAL GEAR SYS MUST FAIL. THIS MECHANICAL SYS IS NOT FOOLPROOF. AND INDEED, ON THIS NIGHT, THE ELECTRIC MOTOR WHICH DRIVES THE HYD PUMP DID FAIL. THEREFORE THE GEAR WAS ONLY PARTLY EXTENDED. SECOND, THE PLT MUST FAIL. THIS IS THE ONLY HUMAN ELEMENT OF THE 3 SYS. IT WAS A LONG DAY, I WAS TIRED, STRESSED, AND HUNGRY (I HAD NOT TAKEN THE TIME TO EAT), AND I WAS TRYING TO SALVAGE A POORLY PLANNED APCH. ON LONG FINAL WHEN I PUT THE GEAR SWITCH DOWN, I WAS CONCENTRATING ON LOSING ALT. INSTEAD OF WATCHING FOR THE GEAR DOWN LIGHT, I WAS WATCHING THE AIRSPD INDICATOR, WAITING FOR FLAP SPD. ONCE THE FLAPS WERE DOWN, I WAS BUSY FLYING THE AIRPLANE IN AN UNCOORDINATED ATTITUDE. AND ONCE ON SHORT FINAL, INSTEAD OF VERIFYING THE GEAR INDICATION FOR A SECOND TIME LIKE I NORMALLY DO, I WAS CONCENTRATING ON ANOTHER ACFT. I NEVER VERIFIED THE POS OF THE GEAR. AND FINALLY, THE GEAR WARNING SYS MUST FAIL. THIS IS ANOTHER MECHANICAL SYS WHICH IS PRONE TO FAILURE. AND AS UNFORTUNATE AS IT MAY SEEM, THIS FINAL SYS FAILED ALONG WITH THE PREVIOUS SYS, ON THE SAME APCH. AS A PLT, AND NOT A MECH, I CAN ONLY IMPROVE ON THE SECOND SYS. I'VE DETERMINED THAT THE MOST IMPORTANT ELEMENT WHICH COULD HAVE AVOIDED THE HUMAN ERROR, WAS TO HAVE FLOWN A COMPLETE LNDG PATTERN. TO FLY A PATTERN APPROPRIATELY AND SUCCESSFULLY, I WOULD HAVE LOST ALT BEFORE ENTERING THE LNDG PHASE (NOT DSNDING INTO THE PATTERN). THEREFORE, THE TASKS REQUIRED FOR LNDG IS ACCOMPLISHED IN A ROUTINE AND ORDERLY MANNER. I WOULD HAVE EXTENDED THE GEAR ABEAM OF THE TOUCHDOWN ZONE, AND IMMEDIATELY VERIFIED IT WAS DOWN AND LOCKED. I WOULD HAVE EXTENDED THE FLAPS IF NEEDED, AND ONCE ON SHORT FINAL, VERIFY THE GEAR POS ONCE MORE. BEFORE THIS INCIDENT, I FLEW THE PATTERN ONLY IF OTHER TFC WAS IN THE AREA. HOWEVER, I NOW REALIZE THAT THE PATTERN SERVES A PURPOSE OTHER THAN KEEPING ACFT SEQUENCED: IT HELPS TO DISTRIBUTE AND ORGANIZE TASKS REQUIRED FOR LNDG. EACH ELEMENT HAS ITS PROPER PLACE. ONCE AN ELEMENT IS SKIPPED (DUE TO DISTRS OR OTHER ACTIONS) ANOTHER APCH IS NEEDED. ALSO, ID DID NOT MENTION CHKLISTS. I DID COMPLETE THE 'GUMP' CHKLIST. HOWEVER, I RUSHED THROUGH THE LIST. INSTEAD OF VERIFYING EACH ACTION, I PERFORMED THE TASK ALMOST SIMULTANEOUSLY. A CHKLIST IS NO GOOD IF PERFORMED IN THIS MANNER. IT IS NOT ONLY IMPORTANT TO PERFORM THE ACTIONS BUT THE ACTION MUST BE ACCOMPLISHED CORRECTLY AND VERIFIED.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.