# NTSB WPR14CA391: Piper PA 31T - II, N774MF, Oakland, CA, September 24, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 23, 2014, 20:10 local (Sep 24, 2014, 03:10 UTC) - Place: Oakland, CA - Coordinates: 37.721389, -122.221107 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.7214&lon=-122.2211&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Landing gear not configured](https://openairdocs.org/ntsb-events/095) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report December 15, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 90159 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14CA391 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90159/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90159 - Page: https://openairdocs.org/ntsb/WPR14CA391 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Mental/emotional state: stress](https://openairdocs.org/ntsb-findings/02022510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-31T, 1 case](https://openairdocs.org/ntsb-findings/02022510/cases.md?model=7103124), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/02022510/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-31T, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7103124), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/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: [Piper PA-31T, 1 case](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=7103124), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-31T, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=7103124), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Landing gear not configured](https://openairdocs.org/ntsb-events/095) (defining event); cases with it: [Piper PA-31T, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=7103124), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) ## 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](https://openairdocs.org/deregistered/N774MF-2024-05-01), registration cancelled 2024-05-01, S/N 31T-7920035, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA 31T - II - Registry model: [Piper PA-31T](https://openairdocs.org/model/piper-pa-31t) (registry code 7103124) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 31T-7920035 - Year built: 1979 - Engines: P&W CANADA PT6A-60A 1127 horsepower turbo prop; P&W CANADA PT6A-60A 1127 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: none; 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 ## 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 20140923021219A](https://openairdocs.org/incident/20140923021219A), Sep 23, 2014: Piper PA-31T, Oakland, CA, Substantial damage. On 09/23/2014, aircraft N774MF was being piloted by, airman [privacy data omitted]. The aircraft was being used for an air ambulance operation with one… ## Docket (1 files) The files NTSB released with the investigation on December 5, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90159. 1.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419717&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.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.