# NTSB LAX91LA277: Fairchild SA227-AC, N348AE, Visalia, CA, June 11, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: June 11, 1991, 03:45 local (10:45 UTC)
- Place: Visalia, CA
- Coordinates: 36.290767, -119.379364 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=36.2908&lon=-119.3794&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report January 22, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27263
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91LA277
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27263/pdf
- Page: https://openairdocs.org/ntsb/LAX91LA277

## Probable cause

THE INSTRUCTOR/PILOT-IN-COMMAND'S FAILURE TO ADEQUATELY SUPERVISE THE FLIGHT AND THE SECOND PILOT'S IMPROPER USE OF THE CHECKLIST AND FAILURE TO MAINTAIN CREW COORDINATION TO ENSURE THAT THE LANDING GEAR WAS EXTENDED. CONTRIBUTING TO THE ACCIDENT WAS THE SILENCING OF THE LANDING GEAR WARNING HORN BY POSITIONING GO THE ENGINE POWER LEVERS.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Gear not extended, landing - flare/touchdown
  - warning system(other) - disabled (contributing factor)
  - supervision - inadequate, pilot in command (cause)
  - checklist - improper use of, copilot/second pilot (cause)
  - crew/group coordination - not maintained, pilot in command (cause)

## Analysis

THE CERTIFICATED AIRPLANE TRANSPORT PILOT, THE PILOT-IN-COMMAND AND INSTRUCTOR PILOT, WAS CONDUCTING COMPANY TRAINING WITH TWO CAPTAIN CANDIDATES. THE SECOND-IN-COMMAND, A DUAL STUDENT, WAS FLYING FROM THE LEFT SEAT.  THE INSTRUCTOR REQUESTED A NO FLAP, SINGLE ENGINE CIRCLING APPROACH, WHICH REQUIRES THAT THE LANDING GEAR NOT BE EXTENDED UNTIL A SAFE LANDING IS ASSURED.  THE LANDING GEAR WARNING HORN DID NOT SOUND DUE TO THE POSITION OF THE FLAPS AND ENGINE POWER LEVERS.  THE STUDENT MADE A CHECKLIST CALL OUT AT A TIME IN THE LANDING SEQUENCE THAT OCCURS AFTER THE LANDING GEAR IS LOWERED. NEITHER PILOT RECALLED CALLING FOR THE LANDING GEAR DOWN.  THE INSTRUCTOR RECALLED NOTING THAT THE STUDENT DID NOT CALL FOR GEAR DOWN.  HE STATED THAT HE WAS GIVING THE STUDENT AN OPPORTUNITY TO LOWER THE GEAR WITHOUT BEING PROMPTED TO DO SO.  THE AIRPLANE CONTACTED THE RUNWAY WITH THE LANDING GEAR UP, CAUSING SUBSTANTIAL DAMAGE.  THE THREE PILOTS WERE NOT INJURED.

## Aircraft

- Registration: N348AE (not matched to a registry record)
- Reported make and model: FAIRCHILD SA227-AC
- Category: Airplane
- Serial number: 613
- Airframe hours: 11148
- Engines: GARRETT TPE331-11 1000 horsepower turbo prop
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Wings West Airlines Inc
- Registered owner: First Security Bank Utah
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, June 2, 1991, 372 hours before
- Airport: VIS, Visalia, runway 3, 6,556 × 150 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 39; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: valid medical--no waivers/lim.; seat: front; flight hours: 4,785 total, 879 in this make and model, 3,767 as pilot in command, 124 in the last 90 days, 33 in the last 30 days, 4 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: calm
- Visibility: 5 statute miles
- Lowest ceiling: none

## 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 19910611024109A](https://openairdocs.org/incident/19910611024109A), Jun 11, 1991: Swrngn SA227AC, Visalia, CA, Substantial damage. CFI gave pilot engine out ILS approach and added no flap landing. Landed gear up. CFI waited for student lower gear

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.

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