FTW99FA223

NTSB accident investigation · Swearingen SA-227-AC · San Antonio, TX · August 16, 1999

Accident · No injuriesField investigationFinal report
Date
August 16, 1999, 17:33 local (22:33 UTC)
Place
San Antonio, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N2671VSwearingen SA-227-AC
Weather
Visual (VMC) · Day
Status
Completed · report August 18, 2000
Report
Approved by Office Director
FAA report
19990816012299A
Case key
47081

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The instructor pilot's failure to complete the Emergency Gear Extension Checklist, resulting in the inadvertent wheels-up landing. A factor was the instructor pilot's fatigued condition.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Wheels up landingLanding
Checklist - not performedPilot in command(cfi)Cause
FatiguePilot in command(cfi)Factor
Wheels up landing - inadvertentPilot in command(cfi)Cause

Analysis

The airplane landed wheels up after the instructor pilot failed to lower the landing gear. The instructor told the student to execute 'a no flap landing due to a simulated hydraulic pump failure.' The student established the airplane on the approach and called for the 'Emergency Gear Extension Checklist.' The instructor delayed extending the gear in accordance with the operator's flight standards manual, which stated that the landing gear should not be extended until the landing was assured. Later in the approach, when the gear warning horn stopped sounding, due to the student's movement of the power levers forward, the instructor removed his hand from the gear handle without extending the gear. The instructor stated that 'because [the student] had already called for the [Emergency Gear Extension] checklist once before, in a split second thought process, [he] mistakenly thought it had been completed.' Following the accident, the landing gear system was tested and found to operate normally. Review of the maintenance records revealed no uncorrected discrepancies. At the time of the accident, the instructor pilot was completing a 9-hour work day, and did not have a lunch break.

Factual narrative

History of flight

On August 16, 1999, at 1733 central daylight time, a Swearingen SA-227-AC multi-engine airplane, N2671V, was substantially damaged when it landed gear-up at the San Antonio International Airport, San Antonio, Texas. The airline transport rated instructor pilot and the instrument-rated commercial pilot, who was receiving instruction, were not injured. The airplane was registered to General Interquip Inc., of Upland, California, and operated by Merlin Express of San Antonio, Texas. Visual meteorological conditions prevailed for the 14 Code of Federal Regulations Part 91 instructional flight and a company VFR flight plan was filed. The local flight originated from the San Antonio International Airport at 1530.

According to the instructor pilot and the pilot receiving instruction (student), the student was undergoing first officer training for the Swearingen SA-227-AC. The pilots stated that they were completing the last approach and landing for the flight. The instructor told the student to execute "a no flap landing due to a simulated hydraulic pump failure."

The student pilot maneuvered the airplane to intercept the ILS (instrument landing system) 12R approach at the San Antonio International Airport. The student established the airplane on the approach and called for the "Emergency Gear Extension Checklist." The instructor stated that the landing gear could not be extended until landing was assured. The landing gear was not extended. The student continued flying the approach and retarded the power levers to idle to reduce the airspeed, and the landing gear warning horn sounded. The instructor placed his right hand on the landing gear extension lever. As the airplane reached the target airspeed, the student moved the power levers forward to increase power, and the landing gear warning horn ceased. The instructor reported that "because [the student] had already called for the [Emergency Gear Extension] checklist once before, in a split second thought process, [he] mistakenly thought it had been completed." He removed his hand from the landing gear lever without extending the landing gear. Subsequently, the airplane landed on the runway with the landing gear in the up position.

Personnel information

The instructor pilot held an airline transport pilot certificate in multi-engine land airplanes, and a commercial certificate in single-engine airplanes and helicopters. The instructor pilot also held type ratings in the Lear Jet and the SA-227. According to Merlin Express company flight records, the instructor pilot was endorsed to operate as second-in-command (SIC) of the SA-227 on June 16, 1998. He was given his endorsement to act as pilot-in-command (PIC) in the SA-227 on July 16, 1998. On October 9, 1998, the pilot was endorsed by the chief of training for Merlin Express as a ground, simulator, and flight instructor for the SA-226 and SA-227 aircraft. On March 2, 1999, he completed an FAR 121/135 Airman Competency/Proficiency Check. According to the enclosed Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), the instructor pilot had accumulated a total of 3,400 flight hours, of which 490 hours were in the same make and model as the accident airplane. He had also accumulated 110 hours of instruction in the SA-227. The instructor pilot was issued a first class medical certificate, with no limitations, on February 22, 1999.

Discussions with the instructor pilot revealed that he started his work day at 0830 with two hours of ground instruction, followed by an instructional flight with a student initiating at 1100, and returning at 1330. The instructor debriefed the first student until 1430, and then briefed the next student (who was the student involved in the accident) prior to the accident flight. The second flight originated at 1530 and was supposed to finish with the accident approach (at 1730). Additionally, the instructor stated that he had not eaten lunch prior to the second flight.

The pilot receiving instruction was issued a commercial pilot certificate, with single and multi-engine land airplane, and instrument ratings on January 4, 1995. On March 24, 1999, he was issued a flight instructor certificate. At the time of the accident, he was receiving instruction to operate as SIC of the SA-227. According to company records, he had completed the aircraft ground training on July 9, 1999. According to the enclosed NTSB Form 6120.1/2, he had accumulated a total of 2,050 flight hours, of which 9 hours were in the SA-227. He was issued a first class medical certificate, with no limitations, on March 5, 1999.

Aircraft information

The airplane was manufactured in 1981 and had accumulated a total airframe time of 19,317 hours. According to the enclosed NTSB Form 6120.1/2, the last maintenance inspection was completed on August 4, 1999. According to Merlin Express maintenance records, the last "light" inspection of the landing gear was completed on April 11, 1999. The last "heavy" inspection of the landing gear was completed on December 12 and 13, 1999. Review of the maintenance records did not reveal any uncorrected maintenance discrepancies during those inspections. (See the enclosed excerpts from the maintenance records for more details.)

According to the SA-227 pilot training manual, the landing gear is "normally controlled electrically and actuated by the two hydraulic actuators attached to the gear." All of the landing gear doors are mechanically attached to and operated by movement of the landing gear. The landing gear position indication is provided by six lights (two for each gear) mounted on the instrument panel. Additionally, there is a landing gear warning horn, which sounds intermittently if all three landing gear are not down and locked when the flaps are extended more that half way, or either engine power lever is moved to flight idle. There is an emergency extension system provided in the event of an electrical and/or hydraulic failure. The system, when utilized mechanically releases the landing gear uplocks and positions the landing gear selector valve to allow the landing gear to free-fall to the down position, with the aid of the airstream.

At the time of the accident, the Merlin Express flight standards and training manuals for the SA-227 stated that when the airplane experiences a loss of hydraulic power, the landing gear should only be extended when landing on the runway is assured. A recommendation for a manual revision was submitted (by the instructor pilot prior to the accident) to the Director of Flight Standards for Merlin Express. The recommendation was to allow for the extension of the landing gear at the final approach fix to ensure a stabilized approach. The revision has since been approved by Merlin Express' Flight Standards and the FAA.

Medical and pathological information

Toxicological tests for drugs and alcohol were ordered by Merlin Express, and were performed on the flight crew. The results of the tests were negative.

Wreckage and impact information

Examination of the airplane and the runway revealed that the airplane traveled 1,827.7 feet from the approach end of the runway, and came to rest upright on a measured magnetic heading of 124 degrees. The airplanes resting position was 22 feet to the left of the runway centerline. A few of the propeller blade tips were separated, and all of the propeller blades displayed severe curling with chordwise scraping and leading edge gouges. The airplane was lifted off of the runway with the aid of a crane. As the airplane was lifted, the landing gear emergency extension was activated, allowing the landing gear to extend. The landing gear was locked in the extended position, and the airplane was towed to a hangar located on the airport for further examination.

Examination of the airplane revealed that the main spar was structurally damaged and a three

Aircraft

Registration
N2671V
Reported as
Swearingen SA-227-AC
Category
Airplane
Serial number
AC-437
Airframe hours
19,317
Engine
Garrett TPE331-11U, 1,000 horsepower, turbo prop
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Merlin Express, doing business as N/A
Registered owner
General Interquip Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 4, 1999 · 24 hours before
Departed
SAT · San Antonio, TX
Flight plan
Company VFR
Airport
SAT · San Antonio International, runway 12R, 8,502 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
3,400 total · 490 in this make and model · 2,400 as pilot in command · 40 in the last 90 days · 27 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
97 °F, dew point 61 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N2671V · 1

Matched to the same aircraft by N-number and date.