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|
Attributes | |
ACN | 627977 |
Time | |
Date | 200408 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | Cessna 210 Centurion / Turbo Centurion 210C, 210D |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : maintenance landing : roll |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector maintenance : technician |
Qualification | technician : airframe technician : inspection authority technician : powerplant |
Experience | maintenance technician : 16 |
ASRS Report | 627977 |
Person 2 | |
Affiliation | other |
Function | flight crew : single pilot |
Events | |
Anomaly | aircraft equipment problem : critical ground encounters : gear up landing maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : nose gear position indicator other flight crewa |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
This aircraft was released to the owner after completion of an annual inspection and repairs found during the inspection. The owner later contacted me by cell phone that he was in the air attempting to land at ZZZ1 airport and that the nose landing gear would not extend. He requested if I had any ideas as to how to get the gear down. Several attempts were made to extend the nose gear. He performed several 'G' maneuvers and flew down the runway and touched down on the main gear to try and free the gear to come down. He then departed ZZZ1 airspace and returned to the ZZZ airport. We flew in another aircraft and intercepted him to have a look at the aircraft from the air. We saw that the nose gear door was slightly open by about 2-3 inches. He then attempted more flight maneuvers to free the gear and another attempt at touching down on the runway. This was unsuccessful. He was now low on fuel and from the aircraft checklist performed a nose gear up landing. The engine was shut down on touchdown and the aircraft rotated down onto the runway and came to a stop. The pilot exited the aircraft with no injury. We raised the aircraft nose up and freed the gear and extended it to a down and locked position. After getting the aircraft back into the hangar, we looked for the problem. The side turbo access panel had been removed during the inspection. It was noted that all of the screws securing this panel along the side of the nose gear wheel well were missing. We feel that the problem was that during the final inspection of the aircraft, these screws were missed to see if they were actually installed at all or installed and tight. We feel these screws were missed due to the fact that the screws are under the nose gear door when the gear is down in its normal condition. Visibility is limited, so due to a lack of visibility they did not get noticed during this final inspection that they were going to be a problem with interference with the gear not extending. To correct this problem we are going to start using a worksheet checklist for panels removed and installed with dual inspections. We have also shut down this shop for the time being. Callback conversation with reporter revealed the following information: the reporter stated the aircraft damage was limited to the propeller, nose gear doors and surrounding skin. The reporter said control paperwork has been introduced to track panels removed and installed and dual inspection procedure. The reporter stated the pilot did not declare an emergency.
Original NASA ASRS Text
Title: A C210 FIRST FLT OUT OF ANNUAL INSPECTION EXPERIENCED NOSE LNDG GEAR THAT FAILED TO EXTEND. LANDED NOSE GEAR UP INCURRING ACFT DAMAGE.
Narrative: THIS ACFT WAS RELEASED TO THE OWNER AFTER COMPLETION OF AN ANNUAL INSPECTION AND REPAIRS FOUND DURING THE INSPECTION. THE OWNER LATER CONTACTED ME BY CELL PHONE THAT HE WAS IN THE AIR ATTEMPTING TO LAND AT ZZZ1 ARPT AND THAT THE NOSE LNDG GEAR WOULD NOT EXTEND. HE REQUESTED IF I HAD ANY IDEAS AS TO HOW TO GET THE GEAR DOWN. SEVERAL ATTEMPTS WERE MADE TO EXTEND THE NOSE GEAR. HE PERFORMED SEVERAL 'G' MANEUVERS AND FLEW DOWN THE RWY AND TOUCHED DOWN ON THE MAIN GEAR TO TRY AND FREE THE GEAR TO COME DOWN. HE THEN DEPARTED ZZZ1 AIRSPACE AND RETURNED TO THE ZZZ ARPT. WE FLEW IN ANOTHER ACFT AND INTERCEPTED HIM TO HAVE A LOOK AT THE ACFT FROM THE AIR. WE SAW THAT THE NOSE GEAR DOOR WAS SLIGHTLY OPEN BY ABOUT 2-3 INCHES. HE THEN ATTEMPTED MORE FLT MANEUVERS TO FREE THE GEAR AND ANOTHER ATTEMPT AT TOUCHING DOWN ON THE RWY. THIS WAS UNSUCCESSFUL. HE WAS NOW LOW ON FUEL AND FROM THE ACFT CHKLIST PERFORMED A NOSE GEAR UP LNDG. THE ENG WAS SHUT DOWN ON TOUCHDOWN AND THE ACFT ROTATED DOWN ONTO THE RWY AND CAME TO A STOP. THE PLT EXITED THE ACFT WITH NO INJURY. WE RAISED THE ACFT NOSE UP AND FREED THE GEAR AND EXTENDED IT TO A DOWN AND LOCKED POS. AFTER GETTING THE ACFT BACK INTO THE HANGAR, WE LOOKED FOR THE PROB. THE SIDE TURBO ACCESS PANEL HAD BEEN REMOVED DURING THE INSPECTION. IT WAS NOTED THAT ALL OF THE SCREWS SECURING THIS PANEL ALONG THE SIDE OF THE NOSE GEAR WHEEL WELL WERE MISSING. WE FEEL THAT THE PROB WAS THAT DURING THE FINAL INSPECTION OF THE ACFT, THESE SCREWS WERE MISSED TO SEE IF THEY WERE ACTUALLY INSTALLED AT ALL OR INSTALLED AND TIGHT. WE FEEL THESE SCREWS WERE MISSED DUE TO THE FACT THAT THE SCREWS ARE UNDER THE NOSE GEAR DOOR WHEN THE GEAR IS DOWN IN ITS NORMAL CONDITION. VISIBILITY IS LIMITED, SO DUE TO A LACK OF VISIBILITY THEY DID NOT GET NOTICED DURING THIS FINAL INSPECTION THAT THEY WERE GOING TO BE A PROB WITH INTERFERENCE WITH THE GEAR NOT EXTENDING. TO CORRECT THIS PROB WE ARE GOING TO START USING A WORKSHEET CHKLIST FOR PANELS REMOVED AND INSTALLED WITH DUAL INSPECTIONS. WE HAVE ALSO SHUT DOWN THIS SHOP FOR THE TIME BEING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACFT DAMAGE WAS LIMITED TO THE PROP, NOSE GEAR DOORS AND SURROUNDING SKIN. THE RPTR SAID CTL PAPERWORK HAS BEEN INTRODUCED TO TRACK PANELS REMOVED AND INSTALLED AND DUAL INSPECTION PROC. THE RPTR STATED THE PLT DID NOT DECLARE AN EMER.
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.