# NTSB WPR10LA219: Rogers Rutan Defiant 40, N23TR, Phoenix, AZ, April 29, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 28, 2010, 17:40 local (Apr 29, 2010, 00:40 UTC) - Place: Phoenix, AZ - Coordinates: 33.688331, -112.082496 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6883&lon=-112.0825&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 7, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 75892 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA219 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75892/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75892 - Page: https://openairdocs.org/ntsb/WPR10LA219 ## Probable cause The failure of the pilot to ensure that the landing gear extension handle was firmly placed in the down position prior to landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Rogers Ted RUTAN DEFIANT 40, 1 case](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=05690K4), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md) - [Landing gear system: gear position and warning](https://openairdocs.org/ntsb-findings/01023260): Aircraft › Aircraft systems · Design (probable cause); cases with it: [Rogers Ted RUTAN DEFIANT 40, 1 case](https://openairdocs.org/ntsb-findings/01023260/cases.md?model=05690K4), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01023260/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Rogers Ted RUTAN DEFIANT 40, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=05690K4), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The pilot reported that while on base leg he initiated a landing check and lowered the nose landing gear. Following initial touchdown and immediately upon placing weight on the nose gear, the nose of the airplane settled to the ground and the nose gear handle quickly popped out of the down position. During a postaccident examination of the airplane, a Federal Aviation Administration airworthiness inspector reported that the nose gear may not have been "positively" down and locked as witnessed by the alignment/witness marks. The inspector stated that when placing the gear handle down, but not “hard,” the gear indication could appear to be down and locked, but the gear could actually not be in the down and locked position. The inspector added that during the examination the gear system was operated several times. Each time if the gear handle was not placed down “firmly and hard” the alignment marks were not indicating a “SAFE” condition. The pilot further added that the mechanical alignment arrows are down by the right ankle of the pilot. In this location, an arrow misalignment is extremely difficult to perceive and the nose gear could easily be placed in "transition" vice down and locked. The pilot reported that he has since redesigned the nose gear down-and-locked indicator to be more easily viewed. ## Factual narrative On April 28, 2010, about 1740 mountain standard time, a Rogers Rutan Defiant 40 multi-engine airplane, N23TR, sustained substantial damage following a nose landing gear collapse during landing roll at the Phoenix Deer Valley Airport (DVT), Phoenix, Arizona. The certificated airline transport pilot, the sole occupant of the airplane, was not injured. Visual meteorological conditions prevailed for the personal cross-country flight, which was being operated in accordance with 14 Code of Federal Regulations (CFR) Part 91, and a flight plan was not filed. The flight departed the Ontario International Airport (ONT), Ontario, California, about 1605, with DVT as its destination. In a report submitted to the Safety Board investigator-in-charge (IIC), the pilot reported that after turning on to base leg he lowered the nose gear and initiated a “landing check.” The pilot stated that the airplane touched down about 1,000 feet down the runway at the “normal rate of descent” and with a slight left crab. The pilot reported, “following initial touchdown and immediately upon placing weight on the nose gear, the nose of the aircraft settled to the ground and the nose gear handle quickly popped out [of] the down position. The aircraft came to a stop left of centerline.” A Federal Aviation Administration (FAA) inspector assigned to the Scottsdale Flight Standards District Office (FSDO), Scottsdale, Arizona , examined the airplane and reported that its forward-mounted rudder had sustained substantial damage. On May 6, 2010, a FAA airworthiness inspector assigned to the Fresno FSDO, Fresno, California, conducted an examination of the accident airplane’s nose landing gear’s extension/retraction system. The inspector reported that it was his assessment during an evaluation of the nose landing gear operation that the gear may not have been “positively” down and locked, as witnessed by the alignment marks or witness marks for the nose landing gear. The inspector further reported that during the examination the system was operated several times, and that each time if the gear handle was not placed “down firmly and hard” the alignment marks were not indicating a “SAFE” condition. The inspector stated, “When placing the gear handle down but not hard it ‘appears’ that the nose gear could be safe and down and locked, but it’s not. Taxiing on the ground that causes any sudden bounce or bump could assist the nose gear to collapse, since it’s not positively down and locked.” The pilot further reported that the down and lock indication consisted of a mechanical alignment of arrows placed down by the right ankle of the pilot. At the conclusion of the gear swings, it was found that the nose gear could be placed in "transition" vice down and locked. He also reported that the indicator arrow misalignment is extremely difficult to perceive. The pilot has since redesigned the nose gear down and locked indicator to be more easily viewed. At 1753, about 13 minutes after the accident, theautomated surface observing system located at DVT reported wind 240 degrees at 18 knots with gusts to 29 knots. Peak wind of 240 degrees at 29 knots was reported at 48 minutes passed the hour, or about 8 minutes after the accident. ## Aircraft - Registration: [N23TR](https://openairdocs.org/deregistered/N23TR-2023-04-01), registration cancelled 2023-04-01, S/N 7 (OpenAirDocs) - Reported make and model: Rogers Rutan Defiant 40 - Registry model: [Rogers Ted RUTAN DEFIANT 40](https://openairdocs.org/model/rogers-ted-rutan-defiant-40) (registry code 05690K4) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 7 - Airframe hours: 788 - Engines: Lycoming IO-360 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, March 4, 2010 - Departed: ONT, Ontario, CA - Destination: DVT, Phoenix, AZ - Airport: DVT, Phoenix Deer Valley, runway 25L, 4,508 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review March 16, 2010; seat: left; flight hours: 3,952 total, 53 in this make and model, 3,885 as pilot in command, 41 in the last 90 days, 25 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 18 knots, gusting 29 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 39 °F - Altimeter: 29.63 inHg - Observed at: DVT ## 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 20100428032549A](https://openairdocs.org/incident/20100428032549A), Apr 28, 2010: Rogers Ted RUTAN DEFIA, Phoenix, AZ, Substantial damage. Nose gear collapsed during landing at Phoenix Deer Valley Airport runway 25L at 281740PDT. POB:1, injuries: none damage; substantial to the rudder, propeller… ## Docket (5 files) The files NTSB released with the investigation on September 28, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75892. 1.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 771 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334499&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Report (item 2, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334485&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - FAA Inspector's Report (item 3, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334486&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Report-Redacted.PDF - Image 1. Nose gear witness marks aligned. (item 4, .PDF, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334488&FileExtension=.PDF&FileName=Image%201.%20Nose%20gear%20witness%20marks%20aligned.-Master.PDF - Image 2. Nose gear witness marks not aligned. (item 5, .PDF, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334491&FileExtension=.PDF&FileName=Image%202.%20Nose%20gear%20witness%20marks%20not%20aligned.-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.