# NTSB GAA17CA023: North American Navion, N8895H, Palmer, AK, October 5, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 5, 2016, 11:45 local (19:45 UTC) - Place: Palmer, AK - Coordinates: 61.595001, -149.088607 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=61.5950&lon=-149.0886&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: 1 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - SAIBs cited in the narratives: [SAIB CE-16-08](https://openairdocs.org/saib/CE-16-08) (OpenAirDocs) - NTSB case key (mKey): 94219 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94219/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94219 - Page: https://openairdocs.org/ntsb/GAA17CA023 ## Probable cause The pilot's failure to extend the landing gear for landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [North American NAVION, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=6150130), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Landing gear system: landing gear selector](https://openairdocs.org/ntsb-findings/01023234): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [North American NAVION, 1 case](https://openairdocs.org/ntsb-findings/01023234/cases.md?model=6150130), [All aircraft, 54 cases](https://openairdocs.org/ntsb-findings/01023234/cases.md) - [Physical workspace: noise](https://openairdocs.org/ntsb-findings/03041040): Environmental issues › Task environment · Awareness of condition; cases with it: [North American NAVION, 1 case](https://openairdocs.org/ntsb-findings/03041040/cases.md?model=6150130), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/03041040/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot; cases with it: [North American NAVION, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=6150130), [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 not configured](https://openairdocs.org/ntsb-events/095) (defining event); cases with it: [North American NAVION, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=6150130), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing-landing roll: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [North American NAVION, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=6150130), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [North American NAVION, 2 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=6150130), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot of a retractable landing gear equipped airplane reported that he landed with the landing gear retracted. He further reported that the airplane slid about 100 feet to a stop near the right edge of the runway. The fuselage sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration (FAA) Aviation Safety Inspector assigned to the accident, by coincidence, was already at the accident airport for an unrelated event. The inspector observed the landing gear retracted into the wheel wells and observed the landing gear handle in the up position. He further reported that the pilot was using a "noise cancelling headset." According to the inspector, the landing gear warning horn was not designed to sound through the headset/ intercom system, but would be audible in the cockpit. He reported that during the airplane recovery process the landing gear handle was moved to the down position and the landing gear extended and locked normally. The FAA Special Airworthiness Information Bulletin (SAIB), CE-16-08, Noise Cancelling Headsets, in part states: "In many cases, pilots are using the noise cancelling headsets as supplementary equipment during operations. When wearing these headsets, the pilot may be unaware of environmental sounds and audible warning annunciations in the cockpit that do not come through the intercom system." The FAA SAIB recommends that general aviation pilots and operators: • Become familiar with the safety information in FAA InFO 0700 • Elect to find other solutions to discern such alarms or sounds, or discontinue using these headsets if any audible alarms or environmental sounds cannot be discerned while wearing a noise cancelling headset. The pilot did not report whether or not he had heard the landing gear warning horn prior to landing. ## Factual narrative The pilot of a retractable landing gear equipped airplane reported that he landed with the landing gear retracted. He further reported that the airplane slid about 100 feet to a stop near the right edge of the runway. The fuselage sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Federal Aviation Administration (FAA) Aviation Safety Inspector assigned to the accident, by coincidence, was already at the accident airport for an unrelated event. The inspector observed the landing gear retracted into the wheel wells and observed the landing gear handle in the up position. He further reported that the pilot was using a "noise cancelling headset." According to the inspector, the landing gear warning horn was not designed to sound through the headset/ intercom system, but would be audible in the cockpit. He reported that during the airplane recovery process the landing gear handle was moved to the down position and the landing gear extended and locked normally. The FAA Special Airworthiness Information Bulletin (SAIB), CE-16-08, Noise Cancelling Headsets, in part states: "In many cases, pilots are using the noise cancelling headsets as supplementary equipment during operations. When wearing these headsets, the pilot may be unaware of environmental sounds and audible warning annunciations in the cockpit that do not come through the intercom system." The FAA SAIB recommends that general aviation pilots and operators: • Become familiar with the safety information in FAA InFO 0700 • Elect to find other solutions to discern such alarms or sounds, or discontinue using these headsets if any audible alarms or environmental sounds cannot be discerned while wearing a noise cancelling headset. The pilot did not report whether or not he had heard the landing gear warning horn prior to landing. ## Aircraft - Registration: [N8895H](https://openairdocs.org/aircraft/N8895H), registered now, S/N NAV-4-895, built 1947 (OpenAirDocs) - Reported make and model: NORTH AMERICAN NAVION (A) - Registry model: [North American NAVION](https://openairdocs.org/model/north-american-navion) (registry code 6150130) (OpenAirDocs) - Registry engine: [Continental E225 series](https://openairdocs.org/engine/continental-e225-series) (registry code 17015, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-895 - Year built: 1947 - Airframe hours: 4174 - Engines: Continental IO-470-C 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 2, 2016 - Departed: BCV, BIRCHWOOD, AK - Destination: PAQ, Palmer, AK - Flight plan: Company VFR - Airport: PAQ, Palmer Muni, runway 34, 6,009 × 100 ft, asphalt - Equipment: Electronic flight bag or handheld device, Electronic multifunction display, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: none; private; airplane ratings: single-engine sea, single-engine land; medical: class 3, with waivers/limitations; last flight review June 9, 2015; seat: left; flight hours: 2,227 total, 1,190 in this make and model, 35 in the last 90 days, 23 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 46 °F, dew point 27 °F - Altimeter: 30.12 inHg - Observed at: PAAQ ## 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 20161005021749A](https://openairdocs.org/incident/20161005021749A), Oct 5, 2016: North American NAVION, Palmer, AK, Substantial damage. Aircraft was observed by FAA inspectors immediately after the occurrence. A/c was found on r/h side of runway approximately 800' from the approach end with… ## Other investigations on N8895H (1) 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 UNK65X1417](https://openairdocs.org/ntsb/UNK65X1417), Feb 13, 1965: Navion A (N8895H), Taylor, TX, substantial damage ## Docket (5 files) The files NTSB released with the investigation on December 1, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94219. 2.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 474 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446932&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (FAA Inspector) (item 2, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446933&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(FAA%20Inspector)-Master.PDF - FAA SAIB Noise Cancelling Headsets (item 3, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446934&FileExtension=.PDF&FileName=FAA%20SAIB%20Noise%20Cancelling%20Headsets-Master.PDF - FAA Info 0700 Noise Cancelling Headset (item 4, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446935&FileExtension=.PDF&FileName=FAA%20Info%200700%20Noise%20Cancelling%20Headset-Master.PDF - Accident Photos (Courtesy of FAA) (item 5, .PDF, 3 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446936&FileExtension=.PDF&FileName=Accident%20Photos%20(Courtesy%20of%20FAA)-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.