# NTSB CEN15LA415: Beech 58, N4199S, Gary, IN, September 11, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 10, 2015, 20:35 local (Sep 11, 2015, 01:35 UTC) - Place: Gary, IN - Coordinates: 41.617221, -87.414443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.6172&lon=-87.4144&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 5, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA DuPage FSDO - NTSB case key (mKey): 91989 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA415 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91989/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91989 - Page: https://openairdocs.org/ntsb/CEN15LA415 ## Probable cause The pilot’s failure to ensure that the landing gear was down while on short final, his subsequent failure to conduct a go-around, and his loss of situational awareness of the airplane’s altitude above the runway while landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system](https://openairdocs.org/ntsb-findings/01023200): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech 58, 2 cases](https://openairdocs.org/ntsb-findings/01023200/cases.md?model=1152740), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/01023200/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 58, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1152740), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech 58, 1 case](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=1152740), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot; cases with it: [Beech 58, 4 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1152740), [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. - [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Beech 58, 8 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=1152740), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The pilot reported that he lowered the landing gear about 5 miles from the airport while flying an instrument approach. While on short final and as he was turning off the airplane's positioning lights so that the landing gear indicator lights would brighten, the propellers struck the runway, indicating that he likely loss situational awareness of the airplane's altitude above the runway. The airplane then skidded on its belly on the runway. The examination of the airplane revealed that the wing spar sustained substantial damage. The nose landing gear (NLG) doors sustained scraping damage consistent with the NLG being retracted upon touchdown. During postaccident examinations, the main landing gear and NLG lowered and raised normally, and the landing gear indicator lights operated normally. The landing checklist should be accomplished after the landing gear is lowered and the airplane is in the landing configuration. While on short final, if there are doubts about the landing gear configuration, a go-around should be accomplished. Given that the pilot had not ensured that the landing gear was down, he should have conducted a go-around. ## Factual narrative On September 10, 2015, about 2035 central daylight time, a Beech 58 twin-engine airplane, N4199S, sustained substantial damage while landing at Gary/Chicago International Airport (GYY), Gary, Indiana. The pilot, the sole occupant, was not injured. The airplane was registered to Charity Homes, Inc., and operated by Midwest Air Link under the provisions of the 14 Code of Federal Regulations Part 135 as a non-scheduled domestic cargo positioning flight. Night visual meteorological conditions prevailed at the time of the accident, and the flight operated on an activated instrument flight rules flight plan. The flight departed the Columbus Municipal Airport (BAK), Columbus, Indiana, about 2030 eastern daylight time en route to GYY. The pilot reported that he was flying the runway ILS 30 approach to GYY when he lowered the approach flaps about 5.5 miles from the airport and lowered the landing gear 5 miles from the airport. He reported that as he was turning off the positioning lights, so that the landing gear indicator lights would brighten, the propellers struck the runway and the airplane skidded on its belly on the runway. The pilot closed the throttles and mixture, and turned off the master switch. The air traffic controller who was in the GYY control tower reported seeing the nose landing light before the airplane touched down. The examination of the airplane revealed that the airplane's wing spar sustained substantial damage. The belly panels, flaps, and nose landing gear doors sustained scraping damage consistent with contact with the runway. The damage to the nose landing gear doors was consistent with the nose landing gear in the retracted position. There was no damage to the inner or outer landing gear doors. A Federal Aviation Administration airworthiness inspector provided oversight when the landing gear system was examined. The airplane was put on jacks and the system was checked by lowering and raising the landing gear handle in the cockpit. The main and nose landing gear lowered and raised normally, and the landing gear light indicators operated normally as well. At 2045, the surface weather observation at GYY was: wind 290 degrees at 5 kts, 20 miles visibility, sky clear, temperature 17 degrees C, dew point 14 degrees C, altimeter 29.92 inches of mercury. The landing checklist is accomplished after the landing gear is lowered and the airplane is in the landing configuration. While on short final and in the flare, if there are doubts about the landing gear configuration, a go-around should be accomplished. ## Aircraft - Registration: [N4199S](https://openairdocs.org/deregistered/N4199S-2018-02-05), registration cancelled 2018-02-05, S/N TH-736, built 1976 (OpenAirDocs) - Reported make and model: BEECH 58 - Registry model: [Beech 58](https://openairdocs.org/model/beech-58) (registry code 1152740) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: TH-736 - Year built: 1976 - Airframe hours: 3243 - Engines: CONT MOTOR IO-520-CB8B 285 horsepower reciprocating; CONT MOTOR IO-520-C 285 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Midwest Air Link, doing business as Midwest Air Link - Registered owner: Charity Homes Inc - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, August 10, 2015 - Departed: BAK, Columbus, IN - Destination: GYY, Gary, IN - Flight plan: IFR - Airport: GYY, Gary/Chicago International Air, runway 30, 8,859 × 150 ft, asphalt - Equipment: Stall warning system, Auto-pilot, Onboard weather, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review June 20, 2015; seat: left; restraint: 4-point; flight hours: 4,650 total, 2,358 in this make and model, 84 in the last 90 days, 36 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 290° at 5 knots - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 57 °F - Altimeter: 29.92 inHg - Observed at: GYY ## 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 20150910014709A](https://openairdocs.org/incident/20150910014709A), Sep 10, 2015: Beech 58, Gary, IN, Substantial damage. Flight was from columbus, IN (bak) to Gary, IN (gyy) to pick up cargo to be delivered. Pilot stated that it was his custom to fly to a final approach fix when… ## Other investigations on N4199S (2) 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. - [NTSB FTW79FPG21](https://openairdocs.org/ntsb/FTW79FPG21), Mar 5, 1979: Beech 58 (N4199S), Fort Smith, AR, substantial damage - [NTSB FTW78FPG40](https://openairdocs.org/ntsb/FTW78FPG40), May 31, 1978: Beech 58 (N4199S), Little Rock, AR, substantial damage ## Docket (2 files) The files NTSB released with the investigation on November 5, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91989. 1.3 MB in all. - Record of Conversation (item 1, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433688&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Photo Log (item 2, .PDF, 10 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433689&FileExtension=.PDF&FileName=Photo%20Log-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.