# NTSB LAX94LA030: Beech 200, N191FL, Reno, NV, October 28, 1993 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 27, 1993, 23:15 local (Oct 28, 1993, 06:15 UTC) - Place: Reno, NV - Coordinates: 39.479648, -119.739257 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4796&lon=-119.7393&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 5 uninjured - Status: Completed, report September 1, 1994 - Report: Approved by Office Director - Safety recommendations: Yes - NTSB case key (mKey): 28583 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA030 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28583/pdf - Page: https://openairdocs.org/ntsb/LAX94LA030 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - initial climb - landing gear,normal retraction/extension assembly - failure,partial (cause) - maintenance,overhaul - improper, other maintenance personnel (cause) - landing gear,normal retraction/extension assembly - jammed (cause) - Fire, takeoff - initial climb - electrical system,electric motor - overload (cause) - maintenance,service bulletin/letter - not performed, company/operator management (cause) - electrical system,electric motor - fire - electrical system,electric wiring - fire - Forced landing, landing - flare/touchdown - Main gear collapsed, landing - 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 (not matched to a registry record) - Reported make and model: BEECH 200 - Category: Airplane - Serial number: BB-107 - Airframe hours: 6420 - Engines: 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. - Pilot; age 29; 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 (OpenAirDocs). - [Accident 19931027041529A](https://openairdocs.org/incident/19931027041529A), Oct 27, 1993: Beech 200BEECH, Reno, NV, Substantial damage. Smoke in cabin on takeoff. Gear jammed. Fire in gear motor. Landed gear up. Motor improperly serviced on annual. 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.