# NTSB CHI01FA084: Beech 1900D, N97UX, Chicago, IL, February 10, 2001 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: February 10, 2001, 16:53 local (22:53 UTC) - Place: Chicago, IL - Coordinates: 41.889266, -87.620567 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.8893&lon=-87.6206&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 7 minor, 10 uninjured - Status: Completed, report July 15, 2002 - Report: Approved by Office Director - Parties: Great Lakes Aviation, Ltd., International Brotherhood of Teamsters, Federal Aviation Administration, O'Hare FSDO - NTSB case key (mKey): 51704 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI01FA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51704/pdf - Page: https://openairdocs.org/ntsb/CHI01FA084 ## Probable cause The flightcrew not lowering the landing gear and/or verifying the landing gear position as required by three separate checklists, which resulted in an inadvertent gear-up landing. A factor to the accident was the flightcrew not complying with the required minimum equipment list placard that prohibited the silencing of the landing gear warning horn. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Wheels up landing, landing - flare/touchdown - wheels up landing - inadvertent, flightcrew (cause) - checklist - not complied with, flightcrew (cause) - procedures/directives - not followed, flightcrew (contributing factor) ## Analysis The crew unintentionally landed the airplane with the landing gear in the fully retracted position. The crew did not lower the landing gear or check the landing gear position as required on the flaps-up landing checklist, the normal landing checklist, and final checklist. According to the cockpit voice recorder (CVR), the landing gear unsafe warning horn did not sound during the entire recorded portion of the accident flight. The minimum equipment list (MEL) requires the installation of a placard that prohibits the silencing of the landing gear warning horn when the flap system is inoperative. The accident airplane had a placard that stated, "Do not silence gear warning horn." No anomalies were found with the landing gear system including the landing gear unsafe warning horn, the red landing gear control handle lighting, and the landing gear position lights. The flap system and ground proximity warning system (GPWS) were inoperative for the accident flight and were listed on the MEL as items that could be inoperative for revenue flight. ## Factual narrative HISTORY OF FLIGHT On February 10, 2001, at 1653 central standard time, a Beech 1900D, N97UX, owned and operated by Great Lakes Aviation, sustained substantial damage during a gear-up landing on runway 4R (8,071 feet by 150 feet, dry/asphalt) at the Chicago O'Hare International Airport, Chicago, Illinois. Visual meteorological conditions prevailed at the time of the accident. The flight was operating under the provisions of 14 CFR Part 121 as Great Lakes Flight 6798 and was on an active instrument flight plan. The captain and first officer (FO) reported no injuries. Eight passengers were released from the accident scene without treatment and seven passengers were transported to local area hospitals for evaluation and treatment of minor injuries. The flight originated at the Capital Airport, Springfield, Illinois at 1605. According to the captain, the crew had switched airplanes in Springfield, Illinois, in order to reposition the accident airplane to a maintenance facility in Spencer, Iowa. The captain reported that there were four maintenance discrepancies that were listed as Minimum Equipment List (MEL) items for the airplane. The MEL items were: Flap System inoperative, Ground Proximity Warning System (GPWS) Modes 1-4 inoperative, Altitude Function of the number two transponder inoperative, and Cockpit/Instrument Lights inoperative on the icing-panel. The captain reported that the crew preformed a preflight inspection of the airplane and a systems-check during an operational run-up. The captain determined the airplane to be in an airworthy condition. The captain reported that the crew used the "Abnormal Procedures: Flaps Up Landing Checklist" due to the flap system being inoperative. The captain stated that he had called for the checklist and that the FO verbally went through the checklist referencing a hard copy of the checklist. The captain stated that when on short final he called for the Final Checklist and the FO verbally went through the checklist. The captain reported that they crossed the runway threshold at 135 knots and were using 131 knots as the reference speed for the landing. The captain stated that he transitioned the airplane for landing, flared, and then the he heard a bang, loud scratching noises, and the airplane began to vibrate. The captain stated that he pushed the nose down, and retained aircraft directional control with rudder pedal inputs. The captain reported, "During the attempted landing the F.O. [first officer] stated that the gear might have collapsed, that is when I notice that the gear was in the UP position." The captain stated, "After the airplane was on the ground and after the F.O. stated that the gear might have collapsed ... I did notice that the gear handle was in the up position. During that time, I do not recall whether the red gear handle light was illuminated or not." The captain reported, "There was no warning of gear unsafe, GPWS disabled, and I did not recall the gear horn go off." The FO stated that during the approach and landing, "No gear horn sounded nor did we ever think the landing gear were not down." The FO reported that, "... A nonstandard note was affixed near the gear handle warning not to cancel the gear warning horn. Since it was not officially documented as an MEL item, its validity was questionable." Written crew statements and summaries of the crewmember interviews are appended to this factual report. The last six minutes of the cockpit voice recorder (CVR) were transcribed as follows: 1647:59 (Captain) Ok. and uh, lets go with the flaps up landing checklist. 1648:03 (FO) Standby. 1648:12 (FO) Flaps up landing checklist... approach speed... one thirty one 1648:16 (Captain) Ok. 1648:16 (FO) That's confirmed... pressurization... checked. 1648:21 (Captain) Yeah it's-. 1648:24 (FO) We're good. 1648:26 (FO) Autofeather switch to arm. GPWS flap override switch, push to activate... surface de-ice cycle as required. Negative required. Landing gear, will go to down, lights will be as required. When landing is assured, yaw damp off, power levers to idle, propellers full forward. 1648:47 (Captain) Bring my power back to fifteen hundred. 1648:53 (Captain) Thank you. 1649:00 (FO) After touchdown, power levers lift and select ground fine. Brakes, as required, to achieve stopping performance. All set? 1649:17 (FO) All set? 1649:18 (Captain) All set. 1649:19 (FO) Ok. I'll put the uh props full forward, you wanna call for that, or you want me to do it. 1649:23 (Captain) Yeah I'll - I'll say short final, props full forward. 1649:25 (FO) Ok. All right. All set. 1649:27 (Approach) Lakes Air seven ninety eight maintain speed one eight zero knots or greater till REKKS, tower at REKKS is twenty seventy five. 1649:33 (Captain) One eighty or greater, tower at REKKS one twenty seventy five Lakes Air seven ninety eight. 1649:38 (Captain) Need to get back here. One eighty to REKKS or greater and ta-tower at REKKS twenty seventy five. 1649:45 (Captain) You- 1649:45 (FO) Do I need to answer? 1649:46 (Captain) I already, I got it. 1649:50 (Captain) All right... where is REKKS? 1649:56 (FO) Uhh six... even... four miles to REKKS. 1650:00 (Captain) All right. 1650:37 (Captain) And... bring me to a thousand please. 1650:42 (Captain) Thank you. 1650:58 (Captain) And there's REKKS coming up, lets go five hundred. 1651:04 (Captain) Thank you. 1651:15 (FO) O'Hare tower Lakes Air seven niner eight, REKKS inbound. 1651:20 (Tower) Lakes Air seven ninety eight O'Hare tower, runway four right cleared to land, wind three one zero at eight. 1651:26 (FO) Roger the winds. Cleared to land Lakes Air seven niner eight. 1651:28 (FO) You are cleared to land captain. 1651:30 (Captain) Thank you. 1651:33 (FO) Three zero zero at eight. 1651:42 (FO) Everybody's down in back the aisle's clear. 1651:56 (Tower) Eagle one fifty all the way down to the end, with a left turn off on delta, ground point nine on delta. 1652:00 (Eagle 150) Point nine on delta we'll see ya, Eagle one fifty. 1652:03 (FO) Aircraft on the runway. 1652:10 (Captain) No delay freaking #. 1652:14 (GPWS) Five hundred. [at an extremely low volume on both the Captain's and First Officer's CVR channels] 1652:16 (FO) Still on the runway, is he taking off? 1652:17 (Captain) Its Ameri- its Eagle. 1652:20 (FO) Is he landing? 1652:23 (Captain) No de-[sound similar to interruption in recording due to tape splice] # do you know what that means? 1652:24 (FO) I got him turning I got him turning. 1652:26 (Captain) [sound of laughter] Lets go props full forward, final check. 1652:30 [sound similar to change in prop speed] 1652:31 (FO) Woah. That's normal. [sound of laughter] 1652:36 (GPWS) (too low), gear. [appears to repeat until impact, at an extremely low volume on both the captain's and FO's CVR channels] 1652:36 (FO) [sound of laughter] I'm so used to (pushing). OK he's clear. 1652:44 (FO) All right, Ref and uh... Ref. 1652:50 (FO) There we go, Ref and ten... Ref. 1653:00 [sound similar to impact] 1653:01 [sound similar to CVR power interruption] 1653:02 [sound similar to landing gear warning horns begins and continues to end of recording] 1653:02 (Captain) Gear down look at the # gear oh #. 1653:04 (FO) Emergency emergency emergency. 1653:07 (FO) Ok everybody stay seated stay seated... stay seated 1653:12 (FO) Stay seated shut down, shut it down. 1653:17 (FO) Emergency emergency Lakes Air seven ninety eight. The gear's failed. 1653:18 [sound similar to stall warning horn begins and continues to end of recording] The landing gear unsafe warning horn did not sound during the entire recorded portion of the accident flight. The entire CVR transcript is appended to this factual repor ## Aircraft - Registration: [N97UX](https://openairdocs.org/deregistered/N97UX-2005-03-07), registration cancelled 2005-03-07, S/N UE-97, built 1994 (OpenAirDocs) - Reported make and model: Beech 1900D - Registry model: [Beech 1900D](https://openairdocs.org/model/beech-1900d) (registry code 1154162) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: UE-97 - Airframe hours: 16997 - Engines: Pratt & Whitney Canada PT6A-67D 1279 horsepower turbo prop; Pratt & Whitney Canada PT6A-67D 1279 horsepower turbo prop - Damage: Substantial damage - Flight: Part 121 - Registered owner: Great Lakes Aviation, Ltd. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, February 5, 2001, 16.5 hours before - Departed: SPI, Springfield, IL - Destination: ORD, Chicago, IL - Flight plan: IFR - Airport: ORD, Chicago O'Hare International, runway 4R, 8,071 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: none; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review January 28, 2001; seat: left; flight hours: 2,450 total, 600 in this make and model, 2,240 as pilot in command, 302 in the last 90 days, 97 in the last 30 days, 4 in the last 24 hours - Co-pilot; age 44; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review November 4, 2000; seat: right; flight hours: 1,449 total, 191 in this make and model, 171 as pilot in command, 138 in the last 90 days, 83 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 18 °F, dew point 9 °F - Altimeter: 30.48 inHg - Observed at: ORD ## 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 20010210014589A](https://openairdocs.org/incident/20010210014589A), Feb 10, 2001: Beech 1900D, Chicago, IL, No damage. (-23) This part 121 revenje flight was conducted as united express flight no. 6798, from springfield, IL to Chicago o'Hare airport with VFR weather prevailing.… 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.