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|
Attributes | |
ACN | 453353 |
Time | |
Date | 199910 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : esn.airport |
State Reference | MD |
Altitude | agl bound lower : 0 agl bound upper : 75 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | M-20 J (201) |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | landing : missed approach landing : roll |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | instruction : instructor |
Qualification | pilot : instrument pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 46 flight time total : 1560 flight time type : 400 |
ASRS Report | 435353 |
Person 2 | |
Affiliation | other |
Function | instruction : trainee |
Qualification | pilot : private |
Events | |
Anomaly | aircraft equipment problem : critical ground encounters : gear up landing non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
2 pilots were on board the incident flight. There were no other aircraft involved or even in the vicinity. I was acting as flight instructor (I am a CFI-ia). I was conducting a flight review with the other pilot who is an instrument rated private pilot and who has many hundred of hours in the M20. It was nighttime, the WX was clear and there was bright moonlight. In preparation for a landing on runway 22 at esn, I had observed the PF perform the prelndg check and I confirmed then that the landing gear was down. When the flight was on short final for runway 22 I again confirmed that the landing gear was down. At about 1/2 mi from the approach end of the runway, I said 'you can make a touch-and-go or a full stop.' the PF executed a go around. Immediately after the PF established a climb attitude with full power, I retarded the throttle to simulate a loss of power on takeoff/go around. At that moment the aircraft was at about 75 ft AGL and 85 KIAS. The PF immediately lowered the nose to maintain flying speed and then established a speed appropriate for landing (about 70-75 KIAS). He maintained excellent lateral control and airspeed control with the throttle at idle. I believe I split my time between observing the airspeed indicator and the aircraft's attitude, and judging if there was sufficient remaining runway to land. Although I observed the PF lower the flaps to full, I failed to check that the landing gear was still extended. The propeller and then parts of the underside of the aircraft struck the runway, the engine stopped, and the aircraft slid to a stop directly on the centerline of the runway about 1000 ft from the end of runway 22. The 2 pilots shut off the fuel, engine, ignition and electrical system and switches and exited the aircraft within less than 30 seconds. After a few moments we observed that there was no sign or smell of fuel, and we saw that the wings had never touched the ground (we had 1 flashlight at this point). A few mins later we returned to the aircraft to confirm that the aircraft was properly shut down and to retrieve additional flashlights and a hand-held transceiver. As soon as possible we contacted the police/fire auths (via 911) and the airport manager, notifying them of the incident and stating that runway 22 was blocked. We monitored the esn unicom frequency to notify any aircraft that runway 22 was closed (none approached or departed) until the airport auths arrived and our aircraft was removed. I believe that almost every accident/incident is the result of a definite chain of events. While most events occur in a sequential order, some run parallel. Proper action at any one of the key links will almost always break the chain and the accident/incident will not occur. Although the chain of events in the above incident appears to be relatively short, both in time and in sequence, it still required several distinct lapses on my part before I wound up at the wrong end of that chain. Proper action by me anywhere or anytime along the chain would have kept me and my student off the asphalt that evening. How the problem arose: I used bad judgement by simulating an engine-out emergency at night. It was also poor judgement to simulate an emergency following the PF's go around. It was obvious that he was uncertain about something, and my adding a simulated emergency must have contributed to his uncertainty. The final, and most inexcusable, link in this chain was my failure to check that the landing gear was down. Contributing factors: human performance considerations: contributing factors affecting the quality of perceptions, judgements and decisions: in retrospect, my perceptions, judgements and decisions were influenced by the following contributing factors, but they do not in any way excuse my actions or inactions: 1) the PF is one of the better, safest pilots I fly with. I would not simulate an engine failure on takeoff, at night or during the day, with most of the pilots I fly with. I did so in this case because I believed the PF would be able to handle the transition from a full power climb to a power off glide and landing. 2) I was not terribly concerned that it was night because the visibility was superb and there was a very bright (almost full) moon. 3) I wasunder the false impression/perception that the landing gear was down. I had checked that the landing gear was down just a few moments before the go around. I did not see the PF raise the landing gear, but I did see him lower the flaps. Moreover, since I had reduced the throttle immediately after the PF had established a climb, I did not anticipate that he would have raised the gear. This was the key, though false, impression/perception, that may have caused me not to rechk that the landing gear was down. All of these thoughts and inactions were incorrect. The landing gear position was, of course, displayed on the annunciator panel at all times throughout this incident.
Original NASA ASRS Text
Title: AN INSTRUCTOR AND FLT REVIEW PLT LANDED A MOONEY M20 WITH THE GEAR UP AT ESN.
Narrative: 2 PLTS WERE ON BOARD THE INCIDENT FLT. THERE WERE NO OTHER ACFT INVOLVED OR EVEN IN THE VICINITY. I WAS ACTING AS FLT INSTRUCTOR (I AM A CFI-IA). I WAS CONDUCTING A FLT REVIEW WITH THE OTHER PLT WHO IS AN INST RATED PVT PLT AND WHO HAS MANY HUNDRED OF HRS IN THE M20. IT WAS NIGHTTIME, THE WX WAS CLR AND THERE WAS BRIGHT MOONLIGHT. IN PREPARATION FOR A LNDG ON RWY 22 AT ESN, I HAD OBSERVED THE PF PERFORM THE PRELNDG CHK AND I CONFIRMED THEN THAT THE LNDG GEAR WAS DOWN. WHEN THE FLT WAS ON SHORT FINAL FOR RWY 22 I AGAIN CONFIRMED THAT THE LNDG GEAR WAS DOWN. AT ABOUT 1/2 MI FROM THE APCH END OF THE RWY, I SAID 'YOU CAN MAKE A TOUCH-AND-GO OR A FULL STOP.' THE PF EXECUTED A GAR. IMMEDIATELY AFTER THE PF ESTABLISHED A CLB ATTITUDE WITH FULL PWR, I RETARDED THE THROTTLE TO SIMULATE A LOSS OF PWR ON TKOF/GAR. AT THAT MOMENT THE ACFT WAS AT ABOUT 75 FT AGL AND 85 KIAS. THE PF IMMEDIATELY LOWERED THE NOSE TO MAINTAIN FLYING SPD AND THEN ESTABLISHED A SPD APPROPRIATE FOR LNDG (ABOUT 70-75 KIAS). HE MAINTAINED EXCELLENT LATERAL CTL AND AIRSPD CTL WITH THE THROTTLE AT IDLE. I BELIEVE I SPLIT MY TIME BTWN OBSERVING THE AIRSPD INDICATOR AND THE ACFT'S ATTITUDE, AND JUDGING IF THERE WAS SUFFICIENT REMAINING RWY TO LAND. ALTHOUGH I OBSERVED THE PF LOWER THE FLAPS TO FULL, I FAILED TO CHK THAT THE LNDG GEAR WAS STILL EXTENDED. THE PROP AND THEN PARTS OF THE UNDERSIDE OF THE ACFT STRUCK THE RWY, THE ENG STOPPED, AND THE ACFT SLID TO A STOP DIRECTLY ON THE CTRLINE OF THE RWY ABOUT 1000 FT FROM THE END OF RWY 22. THE 2 PLTS SHUT OFF THE FUEL, ENG, IGNITION AND ELECTRICAL SYS AND SWITCHES AND EXITED THE ACFT WITHIN LESS THAN 30 SECONDS. AFTER A FEW MOMENTS WE OBSERVED THAT THERE WAS NO SIGN OR SMELL OF FUEL, AND WE SAW THAT THE WINGS HAD NEVER TOUCHED THE GND (WE HAD 1 FLASHLIGHT AT THIS POINT). A FEW MINS LATER WE RETURNED TO THE ACFT TO CONFIRM THAT THE ACFT WAS PROPERLY SHUT DOWN AND TO RETRIEVE ADDITIONAL FLASHLIGHTS AND A HAND-HELD TRANSCEIVER. ASAP WE CONTACTED THE POLICE/FIRE AUTHS (VIA 911) AND THE ARPT MGR, NOTIFYING THEM OF THE INCIDENT AND STATING THAT RWY 22 WAS BLOCKED. WE MONITORED THE ESN UNICOM FREQ TO NOTIFY ANY ACFT THAT RWY 22 WAS CLOSED (NONE APCHED OR DEPARTED) UNTIL THE ARPT AUTHS ARRIVED AND OUR ACFT WAS REMOVED. I BELIEVE THAT ALMOST EVERY ACCIDENT/INCIDENT IS THE RESULT OF A DEFINITE CHAIN OF EVENTS. WHILE MOST EVENTS OCCUR IN A SEQUENTIAL ORDER, SOME RUN PARALLEL. PROPER ACTION AT ANY ONE OF THE KEY LINKS WILL ALMOST ALWAYS BREAK THE CHAIN AND THE ACCIDENT/INCIDENT WILL NOT OCCUR. ALTHOUGH THE CHAIN OF EVENTS IN THE ABOVE INCIDENT APPEARS TO BE RELATIVELY SHORT, BOTH IN TIME AND IN SEQUENCE, IT STILL REQUIRED SEVERAL DISTINCT LAPSES ON MY PART BEFORE I WOUND UP AT THE WRONG END OF THAT CHAIN. PROPER ACTION BY ME ANYWHERE OR ANYTIME ALONG THE CHAIN WOULD HAVE KEPT ME AND MY STUDENT OFF THE ASPHALT THAT EVENING. HOW THE PROB AROSE: I USED BAD JUDGEMENT BY SIMULATING AN ENG-OUT EMER AT NIGHT. IT WAS ALSO POOR JUDGEMENT TO SIMULATE AN EMER FOLLOWING THE PF'S GAR. IT WAS OBVIOUS THAT HE WAS UNCERTAIN ABOUT SOMETHING, AND MY ADDING A SIMULATED EMER MUST HAVE CONTRIBUTED TO HIS UNCERTAINTY. THE FINAL, AND MOST INEXCUSABLE, LINK IN THIS CHAIN WAS MY FAILURE TO CHK THAT THE LNDG GEAR WAS DOWN. CONTRIBUTING FACTORS: HUMAN PERFORMANCE CONSIDERATIONS: CONTRIBUTING FACTORS AFFECTING THE QUALITY OF PERCEPTIONS, JUDGEMENTS AND DECISIONS: IN RETROSPECT, MY PERCEPTIONS, JUDGEMENTS AND DECISIONS WERE INFLUENCED BY THE FOLLOWING CONTRIBUTING FACTORS, BUT THEY DO NOT IN ANY WAY EXCUSE MY ACTIONS OR INACTIONS: 1) THE PF IS ONE OF THE BETTER, SAFEST PLTS I FLY WITH. I WOULD NOT SIMULATE AN ENG FAILURE ON TKOF, AT NIGHT OR DURING THE DAY, WITH MOST OF THE PLTS I FLY WITH. I DID SO IN THIS CASE BECAUSE I BELIEVED THE PF WOULD BE ABLE TO HANDLE THE TRANSITION FROM A FULL PWR CLB TO A PWR OFF GLIDE AND LNDG. 2) I WAS NOT TERRIBLY CONCERNED THAT IT WAS NIGHT BECAUSE THE VISIBILITY WAS SUPERB AND THERE WAS A VERY BRIGHT (ALMOST FULL) MOON. 3) I WASUNDER THE FALSE IMPRESSION/PERCEPTION THAT THE LNDG GEAR WAS DOWN. I HAD CHKED THAT THE LNDG GEAR WAS DOWN JUST A FEW MOMENTS BEFORE THE GAR. I DID NOT SEE THE PF RAISE THE LNDG GEAR, BUT I DID SEE HIM LOWER THE FLAPS. MOREOVER, SINCE I HAD REDUCED THE THROTTLE IMMEDIATELY AFTER THE PF HAD ESTABLISHED A CLB, I DID NOT ANTICIPATE THAT HE WOULD HAVE RAISED THE GEAR. THIS WAS THE KEY, THOUGH FALSE, IMPRESSION/PERCEPTION, THAT MAY HAVE CAUSED ME NOT TO RECHK THAT THE LNDG GEAR WAS DOWN. ALL OF THESE THOUGHTS AND INACTIONS WERE INCORRECT. THE LNDG GEAR POS WAS, OF COURSE, DISPLAYED ON THE ANNUNCIATOR PANEL AT ALL TIMES THROUGHOUT THIS INCIDENT.
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.