LAX94LA030

NTSB accident investigation · Beech 200 · Reno, NV · October 28, 1993

Accident · No injuriesLimited investigationFinal report
Date
October 27, 1993, 23:15 local (Oct 28, 1993, 06:15 UTC)
Place
Reno, NV
Injuries
5 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N191FLBeech 200
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 1, 1994
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19931027041529A
Case key
28583

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 improper overhaul of the right main landing gear actuator by maintenance personnel, and the operator's failure to assure that the airplane manufacturer's mandatory service bulletin requiring modification of the gear motor circuit protection was accomplished.

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.

Airframe/component/system failure/malfunctionTakeoff - initial climb
Landing gear,normal retraction/extension assembly - failure,partialCause
Maintenance,overhaul - improperOther maintenance personnelCause
Landing gear,normal retraction/extension assembly - jammedCause
FireTakeoff - initial climb
Electrical system,electric motor - overloadCause
Maintenance,service bulletin/letter - not performedCompany/operator managementCause
Electrical system,electric motor - fire
Electrical system,electric wiring - fire
Forced landingLanding - flare/touchdown
Main gear collapsedLanding - roll

Analysis

After moving the landing gear handle to the up position, the cockpit began filling with smoke. The pilot noticed that the gear appeared to be hung in an intransit position. The smoke, which smelled of burning electrical insulation, became heavier, and heat could be felt on the cockpit floor. The pilot returned to the airport, and the gear collapsed during landing. Examination revealed that the landing gear motor and associated wiring were burned, and the cockpit flooring appeared to be partially melted. The right landing gear actuator was found to have been improperly overhauled, which resulted in three gear teeth breaking and jamming the actuator. Beech mandatory service bulletin no. 2035, rev. Ii, requiring replacement of the 200-AMP gear motor circuit breaker with a 60-AMP breaker to prevent gear motor damage, was not accomplished on this airplane.

Factual narrative

On October 27, 1993, at 2315 Pacific daylight time, a Beech 200, N191FL, incurred an electrical fire in the landing gear motor and associated wiring during the takeoff initial climb at Reno, Nevada. The aircraft returned to the Reno Cannon International Airport with the landing gear jammed in a partially retracted configuration and the gear collapsed on touchdown. The aircraft was operated by the pilot and was on a cross country personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the operation. The aircraft incurred substantial damage. The certificated private pilot and his four passengers were not injured. The flight was originating at the time of the mishap as a cross country flight to San Carlos, California.

In a verbal statement, the pilot reported that just after moving the landing gear handle to the up position in the initial climb, the cockpit began to fill with smoke. The pilot said he dumped the cabin in an attempt to clear the smoke. He noticed the landing gear appeared to be hung in an intransit position and he pulled the cockpit circuit breaker. The pilot stated that the smoke, which smelled of burning electrical insulation, appeared to get heavier and heat could be felt on the cockpit floor. The pilot said he requested and received a return to airport landing clearance from the control tower, and, just after touchdown, the right main landing gear collapsed.

An FAA airworthiness inspector from the Reno, Nevada, Flight Standards District Office, examined the aircraft. According to his report, the electrical landing gear motor and the associated wiring were burned and the cockpit flooring appeared to be partially melted from radiant heat exposure. The structural landing gear attach points and other bulkhead components in the fuselage sustained major damage.

The landing gear system electrical components, motor, main gear box, and the right main landing gear actuator were removed from the aircraft for detailed examination. The system electrical components examined consisted of: 1) landing gear motor relay K100, 2) landing gear remote circuit breaker CB100, and 3) landing gear remote circuit breaker relay K101.

The system electrical components were found to function within specifications for the 200 ampere gear motor circuit protection requirement. The test reports are attached to this report.

According to the examination report, disassembly of the landing gear motor revealed evidence of excessive current flow at the motor. Burned windings were found on the rotor. Loose balls of solder were noted on the commutator, which was distorted from heat. The motor brushes were within wear limits, but brittle from heat exposure.

The right main landing gear actuator was sent to the FAA Aircraft Certification Office in Wichita, Kansas, for disassembly and examination by Beech Aircraft. The actuator was found in an intermediate position and the shaft would only rotate one turn before encountering a hard stop. Disassembly revealed that two gear teeth had separated from the screw housing ring gear, with one lodged between the ring gear and the pinion gear. According to the Beech Aircraft report of the examination, the actuator was assembled with insufficient shims in place. The lack of shims resulted in insufficient end play and excessive side loads on the gear teeth, which ultimately caused the gear teeth separation and jamming of the actuator.

Review of the aircraft maintenance records revealed that the landing gear actuators were overhauled in September of 1993 at the last aircraft inspection event. The aircraft had accrued 12 operating hours since the landing gear actuators were reinstalled.

Beech Aircraft Service Bulletin 2035 (Rev II) was issued in 1985 and revised in August of 1990. The Bulletin concerns the replacement of the 200 ampere landing gear motor circuit breaker with a 60 ampere rated breaker to prevent motor damage due to excessive electrical current. Beech Aircraft considers the bulletin mandatory in nature. Examination of the aircraft maintenance records revealed that SB 2035 was not accomplished.

Aircraft

Registration
N191FL
Reported as
Beech 200
Category
Airplane
Serial number
BB-107
Airframe hours
6,420
Engine
P&W PT6A-42, 850 horsepower, turbo prop
Damage
Substantial damage
Fire
In-Flight
Flight
Personal · Part 91
Operator
Edward A. Mueller
Registered owner
Pacific Coast Leas Corp
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · September 16, 1993 · 12 hours before
Departed
RNO
Destination
SQL · San Carlos, CA
Airport
RNO · Reno Cannon Intl, runway 25, 6,101 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
29
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,000 total · 23 in this make and model · 60 in the last 90 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
250° at 3 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
43 °F

FAA reports on this event · 1

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