WPR14CA391

NTSB accident investigation · Piper PA 31T - II · Oakland, CA · September 24, 2014

Accident · No injuriesData collectionFinal report
Date
September 23, 2014, 20:10 local (Sep 24, 2014, 03:10 UTC)
Place
Oakland, CA
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N774MFPiper PA 31T - II
Defining event
Landing: Landing gear not configured
Weather
Visual (VMC) · Night
Status
Completed · report December 15, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20140923021219A
Case key
90159

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 pilot's failure to extend the landing gear which resulted in a gear-up landing. Contributing to the accident was the pilot's failure to use the checklist and reported stress.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Mental/emotional state: stressPersonnel issues › Psychological · PilotPiper PA-31T: 1 caseAll aircraft: 14 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotPiper PA-31T: 1 caseAll aircraft: 336 casesProbable cause
Landing gear system: gear extension and retract sysAircraft › Aircraft systems · Not used/operatedPiper PA-31T: 1 caseAll aircraft: 416 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · PilotPiper PA-31T: 1 caseAll aircraft: 440 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot stated that while on an instrument landing system (ILS) approach for the medical life-flight, he was struggling to keep the airplane on the localizer and glide path. As the airplane descended through 800 to 900 feet above the ground, he broke out of the cloud layer but had difficulty locating the runway in the dark night conditions. During the landing flare he reduced the throttle and as the airplane touched down on the runway surface, he realized the landing gear were retracted; he did not hear any horns. The pilot recalled that when he selected the landing gear, he may have put the handle in neutral rather than keeping his hand on the lever and waiting for the three green lights to illuminate confirming the extended position. He did not follow his normal checklists because of the demands of the ILS approach. He also cited a few stressors in his life that may have contributed to a distraction including a change of airplanes and few ILS approaches performed in the recent six months. The pilot further added that there were no pre impact mechanical malfunctions or failures that would have precluded normal operation. The airplane incurred substantial damage to the lower fuselage and engine mounts.

Factual narrative

The pilot stated that while on an instrument landing system (ILS) approach for the medical life-flight, he was struggling to keep the airplane on the localizer and glide path. As the airplane descended through 800 to 900 feet above the ground, he broke out of the cloud layer but had difficulty locating the runway in the dark night conditions. During the landing flare he reduced the throttle and as the airplane touched down on the runway surface, he realized the landing gear were retracted; he did not hear any horns. The pilot recalled that when he selected the landing gear, he may have put the handle in neutral rather than keeping his hand on the lever and waiting for the three green lights to illuminate confirming the extended position. He did not follow his normal checklists because of the demands of the ILS approach. He also cited a few stressors in his life that may have contributed to a distraction including a change of airplanes and few ILS approaches performed in the recent six months. The pilot further added that there were no pre impact mechanical malfunctions or failures that would have precluded normal operation. The airplane incurred substantial damage to the lower fuselage and engine mounts.

Aircraft

Registration
N774MF
Reported as
Piper PA 31T - II
Category
Airplane
Serial number
31T-7920035
Built
1979
Engines
P&W Canada PT6A-60A, 1,127 horsepower, turbo propP&W Canada PT6A-60A, 1,127 horsepower, turbo prop
Damage
Substantial damage
Flight
Part 135
Operator
American Medflight Inc
Registered owner
American Medflight Inc
Airworthiness certificate
Standard, Normal
Departed
KRNO · Reno, NV
Destination
OAK · Oakland, CA
Flight plan
IFR
Airport
OAK · Metropolitan Oakland Intl, runway 28R, 5,458 × 150 ft, asphalt
Equipment
Onboard weather, Electronic primary flight display, Auto-pilot

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Flight hours
17,718 total · 239 in this make and model · 9,614 as pilot in command

Weather

Conditions
Visual (VMC) · Night
Lowest ceiling
1,000 ft broken

Docket · 1

The files NTSB released with the investigation on December 5, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.9 MB in all.

FAA reports on this event · 1

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