WPR15LA264

NTSB accident investigation · Douglas A4N · Phoenix, AZ · September 17, 2015

Accident · Minor injuriesLimited investigationFinal report
Date
September 17, 2015, 12:41 local (19:41 UTC)
Place
Phoenix, AZ
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
CFGZTDouglas A4N
Defining event
Landing: Landing gear not configured
Weather
Visual (VMC) · Day
Status
Completed · report June 1, 2016
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
92015

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 before landing. Contributing to the accident were the pilot’s distraction during the downwind leg and his difficulty seeing the landing gear indicators due to the sun angle and shadows.

Findings · 6

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.

Action: forgotten action/omissionPersonnel issues › Action/decision · PilotAll aircraft: 440 casesProbable cause
Landing gear system: gear extension and retract sysAircraft › Aircraft systems · Not used/operatedAll aircraft: 416 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotAll aircraft: 1,391 casesProbable cause
Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · PilotAll aircraft: 330 casesProbable cause
Workload managementPersonnel issues › Task performance · PilotAll aircraft: 14 casesProbable cause
Light conditionEnvironmental issues › Conditions/weather/phenomena · Effect on personnelAll aircraft: 15 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 commercial pilot was conducting a test flight. The pilot reported that, toward the end of the flight, he was scheduled to test the emergency generator. When the generator was deployed, the fuel gauge indicated below "0" remaining fuel, and all of the warning/advisory lights illuminated for a few seconds. The pilot subsequently chose to return to the airport to land. The pilot reported that, while on the downwind leg, as he was configuring the airplane for a planned drag-chute landing, he became distracted by something in the cockpit that disrupted his checklist flow, but he could not explain what distracted him. As he turned the airplane onto the base leg, he checked the flap and spoiler positions and the landing gear wheel indicators. He noted that he saw three "jittering wheels" but that the gear indicators were difficult to see due to the sun angle and shadows. The pilot then landed the airplane and deployed the drag chute. The airplane slowed very rapidly and came to a rest on the drop tank, which ruptured, and a fire ensued. The pilot egressed from the airplane and noticed that the landing gear were not down. A postaccident examination of the landing gear system revealed no anomalies that would have precluded normal operation. It is likely that the pilot's distraction during the downwind leg and his difficulty seeing the landing gear indicators led to his failure to extend the landing gear before landing.

Factual narrative

On September 17, 2015 about 1241 mountain standard time, a Douglas A-4N, Canadian registration C-FGZT, landed gear up at the Phoenix-Mesa Gateway Airport (IWA), Phoenix, Arizona. The commercial pilot (sole occupant) sustained minor injuries and the airplane sustained substantial damage to the left wing. The airplane was registered to Discovery Air Defence Services, Montreal, Canada and operated by Top Aces, Mesa, Arizona under the provisions of 14 Code of Federal Regulations Part 91 as a test flight. Visual meteorological conditions prevailed, and a visual flight rules flight plan was filed at the time of the accident. The flight departed IWA at 1015. The pilot reported that towards the end of a 2.6 hour test flight, he conducted three touch and go landings. During the third touch and go he noted that the landing gear handle was "stiff" when lowering the landing gear. The airplane landed uneventfully and took off again. As part of the test plan, the pilot requested to depart the traffic pattern to test an emergency generator. When the generator was deployed everything appeared normal with the exception of the fuel gauge indicating below "0" remaining fuel. Suddenly all of the warning/advisory lights illuminated for 2-3 seconds before extinguishing. Concerned about the fuel gauge indication the pilot proceeded back to the airport to land. The pilot put the electrical system back on the main generator and the fuel gauge returned to an indication he expected. As the pilot approached the airport he prepared for a planned drag chute landing. He entered the downwind; as he started to configure the airplane for landing he remembered becoming distracted by something in the cockpit, but couldn't explain what. As the airplane turned base, he noted that the flaps were in the full down position and the spoilers were armed. He recalls glancing at the landing gear wheel indicators and saw three "jittering wheels," but they were difficult to view due to the sun angle, shadows, and gauge placement. The airplane landed uneventfully and the drag chute was deployed; the airplane slowed very rapidly and came to a rest as it started on fire. The pilot egressed from the airplane safely and noticed that the landing gear was not down. During a postaccident examination of the landing gear system by a Federal Aviation Administration inspector the airplane was lifted up and the landing gear was extended. The airplane was placed back onto the ground and wheeled into the hangar where it was put onto jacks. The inspector visually inspected the landing gear system and was unable to find any physical anomalies. The landing gear system was cycled various times with no anomalies noted.

Aircraft

Registration
CFGZT
Reported as
Douglas A4N
Category
Airplane
Serial number
14542
Airframe hours
3,339
Engine
Pratt & Whitney J52-P408, 11,200 lbs thrust, turbo jet
Damage
Substantial damage
Fire
On-Ground
Flight
Flight test · Part 91
Operator
Top Aces
Registered owner
Discovery Air Defence Services
Airworthiness certificate
Special, Experimental (Special)
Last inspection
AAIP · August 10, 2015 · 10 hours before
Departed
IWA · Phoenix, AZ
Destination
IWA · Phoenix, AZ
Flight plan
VFR/IFR
Airport
IWA · Phoenix-Mesa Gateway Airport, runway 12L, 9,300 × 150 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Minor
Certificates
Flight instructor, Commercial, Foreign, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 11, 2014
Seat
Single
Restraint
4-point
Flight hours
12,150 total · 3,002 in this make and model · 7,520 as pilot in command · 48 in the last 90 days · 32 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 5 knots
Visibility
45 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 52 °F
Altimeter
29.93 inHg
Observed at
IWA

Docket · 3

The files NTSB released with the investigation on April 13, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.3 MB in all.