# NTSB WPR11CA142: Piper PA-31P-350, N9237Y, North Bend, OR, February 22, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: February 22, 2011, 13:00 local (21:00 UTC) - Place: North Bend, OR - Coordinates: 42.416942, -124.246948 - Nearby events: https://openairdocs.org/map.md?lat=42.4169&lon=-124.2469&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 June 20, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Portland FSDO - NTSB case key (mKey): 78408 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11CA142 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78408/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78408 - Page: https://openairdocs.org/ntsb/WPR11CA142 ## Probable cause The pilot's failure to lower the landing gear while on approach to landing. Contributing to the accident was the pilot's failure to follow a written checklist during the approach portion of the flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: landing gear actuator](https://openairdocs.org/ntsb-findings/01023233): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Piper PA 31P 350, 1 case](https://openairdocs.org/ntsb-findings/01023233/cases.md?model=7103111), [All aircraft, 54 cases](https://openairdocs.org/ntsb-findings/01023233/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA 31P 350, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7103111), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA 31P 350, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=7103111), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA 31P 350, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7103111), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Landing gear not configured](https://openairdocs.org/ntsb-events/095) (defining event); cases with it: [Piper PA 31P 350, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=7103111), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Piper PA 31P 350, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=7103111), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## Analysis According to the pilot, while in the process of executing a terminal instrument approach to his home airport, he transitioned from instrument meteorological conditions to visual meteorological conditions. He canceled his instrument flight rules clearance, and transitioned from the terminal instrument approach to a visual flight rules approach pattern. During this sequence of events he did not follow a written checklist, and inadvertently forgot to lower the landing gear. During the landing flare, he heard the noise caused by the wing flaps and both propellers contacting the surface of the runway, and he added power and immediately executed a go-around. He then entered a closed pattern, lowered the landing gear and repositioned the flaps, before making an uneventful landing. He said during the approach he heard the gear warning horn sounding, but he thought it was the altitude alerting system. An inspection of both the runway surface scarring and each propeller blade revealed that the tips of all six blades had been grounded down by repeated contact with the asphalt surface. He also said that the airplane did not have any system malfunctions. ## Factual narrative According to the pilot, while in the process of executing a terminal instrument approach to his home airport, he transitioned from instrument meteorological conditions (IMC) to visual meteorological conditions (VMC). He therefore canceled his instrument flight rules (IFR) clearance, and transitioned from the terminal instrument approach to a visual flight rules (VFR) approach pattern. During this sequence of events, the pilot, who was not following a written checklist, inadvertently forgot to lower the landing gear. During the landing flare, the pilot heard the noise caused by the wing flaps and both propellers contacting the surface of the runway, and therefore he added power and immediately executed a go-around. The pilot then entered a closed pattern, lowered the landing gear and repositioned the flaps, before making an uneventful landing. According to the pilot, during his approach he heard the gear warning horn sounding, but he thought it was the altitude alerting system. An inspection of both the runway surface scarring and each propeller blade revealed that the tips of all six blades had been ground down by repeated contact with the asphalt surface. The pilot also said that the airplane did not have any system malfunctions. ## Aircraft - Registration: [N9237Y](https://openairdocs.org/aircraft/N9237Y), registered now, S/N 31P-8414022 (OpenAirDocs) - Reported make and model: PIPER PA-31P-350 - Registry model: [Piper PA 31P 350](https://openairdocs.org/model/piper-pa-31p-350) (registry code 7103111) (OpenAirDocs) - Category: Airplane - Serial number: 31P-8414022 - Engines: Lycoming TIO-540-V2AD 350 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: EAL Leasing, Inc. - Registered owner: EAL Leasing, Inc. - Airworthiness certificate: Standard, Normal - Departed: KUAO, Aurora, OR - Destination: KOTH, North Bend, OR - Flight plan: IFR - Airport: KOTH, Southwest Oregon Regional, runway 31, 4,470 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; commercial, flight engineer; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review June 28, 2010; seat: left; flight hours: 3,850 total, 51 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 10 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: 3,500 ft overcast - Temperature: 45 °F, dew point 34 °F - Altimeter: 30.21 inHg ## 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 20110222002269A](https://openairdocs.org/incident/20110222002269A), Feb 22, 2011: Piper PA 31P 350, North Bend, OR, Substantial damage. During approach into oth, pilot neglected to lower the gear prior to landing. During rotation, the pilot felt and heard scraping and realized his gear was not… ## Docket (2 files) The files NTSB released with the investigation on March 11, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78408. 278 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344192&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation (item 2, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344194&FileExtension=.PDF&FileName=Record%20of%20Conversation-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.