# NTSB CEN10LA076: Beech 200, N411BL, St. Louis, MO, December 11, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 10, 2009, 18:56 local (Dec 11, 2009, 00:56 UTC) - Place: St. Louis, MO - Coordinates: 38.748611, -90.370002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.7486&lon=-90.3700&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Landing gear not configured](https://openairdocs.org/ntsb-events/095) - Highest injury: No injuries - Injuries: 7 uninjured - Status: Completed, report May 28, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA-St Louis FSDO - NTSB case key (mKey): 75173 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75173/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75173 - Page: https://openairdocs.org/ntsb/CEN10LA076 ## Probable cause The pilot's failure to properly follow the manual landing gear extension procedure, resulting in a gear-up landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Inoperative; cases with it: [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md) - [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot; cases with it: [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing: Landing gear not configured](https://openairdocs.org/ntsb-events/095) (defining event); cases with it: [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing-flare/touchdown: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## Analysis The pilot reported that the landing gear failed to extend prior to landing. His attempts to manually extend the landing gear in accordance with the manual extension procedure from the airplane flight manual were not successful. He subsequently executed an emergency gear-up landing. A postaccident inspection revealed that the emergency gear engagement handle was not in the engaged position. When the handle was engaged, subsequent movement of the extension lever manually lowered the landing gear. Further examination revealed that the landing gear motor circuit breaker was open (popped). The landing gear motor and circuit breaker were located under the cabin floor aft of the forward wing spar. When the circuit breaker was reset and electrical power applied to the airplane, the landing gear was successfully extended using the normal procedure. ## Factual narrative On December 10, 2009, at 1856 central standard time, a Beech model 200 airplane, N411BL, piloted by an airline transport pilot, was substantially damaged during an emergency gear-up landing on runway 24 (7,602 feet by 150 feet, concrete) at Lambert-St. Louis International Airport (STL), St. Louis, Missouri. The pilot reported that the landing gear failed to extend properly on initial approach. His subsequent attempts to lower the landing gear with the manual extension procedure were unsuccessful. The flight was being conducted under 14 Code of Federal Regulations Part 135 on an instrument flight rules flight plan. Night visual meteorological conditions prevailed. The pilot and 6 passengers on-board were not injured. The flight departed Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The intended destination was STL. The pilot stated that he attempted to lower the landing gear on final approach about six miles from the runway. He reported that when he selected gear down nothing happened. He attempted to cycle the landing gear a few times with no effect. The pilot subsequently executed a missed approach in order to troubleshoot the problem. His efforts to lower the landing gear normally were not successful. The pilot stated: “I then followed the check list for gear malfunction and manual gear extension. I pulled the gear circuit breaker, pulled the lever out, rotated it 90 degrees clock wise to engage the system and started pumping. I felt no pressure as I was pumping; I pumped about 40 or 50 times.” During several low approaches, air traffic controllers confirmed that the landing gear was not extended. The pilot then set-up up for and executed a gear up emergency landing. The pilot and passengers exited through the main cabin door. A post accident inspection revealed that the landing lever was in the down position, the extension lever was unstowed, and the emergency engagement handle was in the down position (not engaged). Movement of the extension lever at that time did not produce any corresponding movement of the landing gear torque shafts. The engagement handle was subsequently pulled up and rotated to lock it in the engaged position. At that time, movement of the extension lever produced corresponding movement in the torque shafts. In that configuration, with the airplane supported on jacks, manual extension of the landing gear was successful. Further examination revealed that the landing gear motor circuit breaker was open (popped). The circuit breaker was located adjacent to the motor under the cabin floor panel, aft of the forward wing spar. The circuit breaker was reset and electrical power was applied to the airplane. The landing gear was operated using both the normal and manual systems with no anomalies observed. The airplane flight manual provided a procedure for manual extension of the landing gear. The procedure noted: Establish 130 knots airspeed, pull (open) the landing gear relay circuit breaker on the pilot’ssub-panel, place the landing gear handle in the down position, lift and turn the emergency engagement handle to engage the system, and pump the extension lever until all three green gear down instrument panel lights are illuminated. Maintenance records indicated that the most recent continuous airworthiness phase inspection was completed on August 25, 2009. At the time of the accident, the airframe total time was approximately 9,648 hours, with 9,670 total cycles. ## Aircraft - Registration: N411BL (not matched to a registry record) - Reported make and model: BEECH 200 - Category: Airplane - Serial number: BB-448 - Airframe hours: 9648 - Engines: P&W CANADA PT6A-60A 1050 horsepower turbo prop; P&W CANADA PT6A-60A 1050 horsepower turbo prop - Damage: Substantial damage - Flight: Part 135 - Operator: Butler Aviation Inc - Registered owner: Butler Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, August 25, 2009, 81 hours before - Departed: MKC, Kansas City, MO - Destination: STL, St. Louis, MO - Flight plan: IFR - Airport: STL, Lambert-St Louis International, runway 24, 7,602 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 20, 2009; seat: left; flight hours: 8,000 total, 500 in this make and model, 7,900 as pilot in command, 72 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 210° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 25 °F, dew point 5 °F - Altimeter: 30.23 inHg - Observed at: STL, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20091210025979A](https://openairdocs.org/incident/20091210025979A), Dec 10, 2009: Beech 200, St. Louis, MO, Substantial damage. Pilot reported to ATC he could not get the landing gear extended on approach to stl. He aborted the landing and tried to get the gear extended. After thirty… ## Docket (5 files) The files NTSB released with the investigation on April 1, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75173. 2.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 951 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327462&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327463&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Mechanic Statement (item 3, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327465&FileExtension=.PDF&FileName=Mechanic%20Statement-Redacted.PDF - Maintenance Summary Log (item 4, .PDF, 636 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327466&FileExtension=.PDF&FileName=Maintenance%20Summary%20Log-Master.PDF - Airplane Flight Manual -- Excerpt (item 5, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327468&FileExtension=.PDF&FileName=Airplane%20Flight%20Manual%20--%20Excerpt-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.