# NTSB WPR09LA189: Beech A36TC, N333HP, Roseburg, OR, April 8, 2009

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: April 8, 2009, 15:13 local (22:13 UTC)
- Place: Roseburg, OR
- Coordinates: 43.238887, -123.355834 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=43.2389&lon=-123.3558&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing-flare/touchdown: Landing gear not configured](https://openairdocs.org/ntsb-events/095)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report December 29, 2009
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Administration
- NTSB case key (mKey): 73634
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA189
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73634/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73634
- Page: https://openairdocs.org/ntsb/WPR09LA189

## Probable cause

The pilot's failure to follow the landing checklist, which resulted in a gear up landing. Contributing to the accident was the pilot's diverted attention.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Beech A56TC, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1152738), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md)
- [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Beech A56TC, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=1152738), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md)
- [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Beech A56TC, 1 case](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=1152738), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-VFR pattern downwind: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech A56TC, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=1152738), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Landing-flare/touchdown: Landing gear not configured](https://openairdocs.org/ntsb-events/095) (defining event); cases with it: [Beech A56TC, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=1152738), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md)

## Analysis

According to the pilot, while on the downwind leg for landing he used the airplane's checklist. However, his attention was "focused outside the cockpit," and he apparently "forgot" to lower the landing gear. No mechanical malfunctions or failures occurred with the airplane, and it slid to a stop with retracted landing gear.

## Factual narrative

On April 8, 2009, about 1513 Pacific daylight time, a Beech A36TC, N333HP, landed with its landing gear retracted at the Roseburg Regional Airport, Roseburg, Oregon. The commercial certificated pilot owned and operated the airplane, and was not injured. The airplane was substantially damaged. Visual meteorological conditions prevailed, and no flight plan was filed. The personal flight was performed under the provisions of 14 Code of Federal Regulations Part 91, and it originated from the airport about 1508. The pilot reported that as he was approaching the airport for landing on the downwind leg, and completing the airplane's checklist, his attention was "focused outside the cockpit." The pilot stated that he "apparently forgot to lower [the airplane's] landing gear." An examination of the airplane by a Federal Aviation Administration (FAA) airworthiness inspector revealed that at least 5.5 feet of belly skin was damaged and was partially ground off to the rivet lines. Two belly ribs were broken. The damage also was evaluated by Hawker Beechcraft personnel who reported that in several locations "the underlying fuselage structure was abraded to the point where there [was] no remaining structure to attach the skin." The FAA coordinator reported that a major airframe repair would be required to restore airworthiness to the airplane's fuselage. In the pilot's National Transportation Safety Board "Pilot/Operator Aircraft Accident" report form, #6120.1, he indicated that during the flight he had not experienced any mechanical malfunction or failure with his airplane. The pilot did not report the date of his last flight review or the date of the airplane's last annual inspection.

## Aircraft

- Registration: [N333HP](https://openairdocs.org/deregistered/N333HP-2017-02-22), registration cancelled 2017-02-22, S/N TG-89, built 1970 (OpenAirDocs)
- Reported make and model: BEECH A36TC
- Registry model: [Beech A56TC](https://openairdocs.org/model/beech-a56tc) (registry code 1152738) (OpenAirDocs)
- Registry engine: [Lycoming TI0-541 series](https://openairdocs.org/engine/lycoming-ti0-541-series) (registry code 41536, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: TG-89
- Airframe hours: 3971
- Engines: Lycoming TIO-541-E1B4 380 horsepower reciprocating; Lycoming TIO-541-E1B4 380 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Fred J. Brandenfels
- Registered owner: Fred J. Brandenfels
- Airworthiness certificate: Standard, Normal
- Departed: RBG, Roseburg, OR
- Destination: RBG, Roseburg, OR
- Airport: RBG, Roseburg Regional, runway 34, 4,602 × 100 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 72; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; flight hours: 3,200 total, 1 in the last 90 days, 1 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 250° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: 5,000 ft overcast
- Temperature: 55 °F, dew point 43 °F
- Altimeter: 29.92 inHg
- Observed at: RBG

## 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 20090408004539A](https://openairdocs.org/incident/20090408004539A), Apr 8, 2009: Beech A56TC, Roseburg, OR, Substantial damage. (-23) Pilot stated he completed his downwind checklist but failed to bring down the landing gear. The aircraft landed gear up, sliding on the runway 800-900…

## Docket (15 files)

The files NTSB released with the investigation on October 29, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73634. 18.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320671&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Pilot's Statement (item 2, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320672&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Redacted.PDF
- FAA Damage Evaluation Statements (item 3, .PDF, 763 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320673&FileExtension=.PDF&FileName=FAA%20Damage%20Evaluation%20Statements-Redacted.PDF
- Letter from Pilot's Attorney Regarding Damage (item 4, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320674&FileExtension=.PDF&FileName=Letter%20from%20Pilot%27s%20Attorney%20Regarding%20Damage-Redacted.PDF
- Attachment to Pilot's Attorney Letter (item 5, .PDF, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320675&FileExtension=.PDF&FileName=Attachment%20to%20Pilot%27s%20Attorney%20Letter-Redacted.PDF
- NTSB IIC's Memo to File (item 6, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320676&FileExtension=.PDF&FileName=NTSB%20IIC%27s%20Memo%20to%20File-Master.PDF
- Photo 1. Airplane, front view on runway. (item 7, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320680&FileExtension=.PDF&FileName=Photo%201.%20%20Airplane,%20front%20view%20on%20runway.-Master.PDF
- Photo 2. Airplane, left side. (item 8, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320681&FileExtension=.PDF&FileName=Photo%202.%20%20Airplane,%20left%20side.-Master.PDF
- Photo 3. Checklist on airplane seat. (item 9, .PDF, 632 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320682&FileExtension=.PDF&FileName=Photo%203.%20%20Checklist%20on%20airplane%20seat.-Master.PDF
- Photo 4. Airplane, hoisted up. Belly. (item 10, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320683&FileExtension=.PDF&FileName=Photo%204.%20%20Airplane,%20hoisted%20up.%20Belly.-Master.PDF
- Photo 5. Bottom view of airplane. (item 11, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320684&FileExtension=.PDF&FileName=Photo%205.%20%20Bottom%20view%20of%20airplane.-Master.PDF
- Photo 6. Airplane's belly damage. (item 12, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320685&FileExtension=.PDF&FileName=Photo%206.%20%20Airplane%27s%20belly%20damage.-Master.PDF
- Photo 7. Airplane's belly damage. (item 13, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320686&FileExtension=.PDF&FileName=Photo%207.%20%20Airplane%27s%20belly%20damage.%20-Master.PDF
- Photo 8. Airplane's belly damage. (item 14, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320687&FileExtension=.PDF&FileName=Photo%208.%20%20Airplane%27s%20belly%20damage.-Master.PDF
- Photo 9. Airplane's belly damage. (item 15, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320688&FileExtension=.PDF&FileName=Photo%209.%20%20Airplane%27s%20belly%20damage.-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.

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