# NTSB WPR15LA264: Douglas A4N, Phoenix, AZ, September 17, 2015 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 17, 2015, 12:41 local (19:41 UTC) - Place: Phoenix, AZ - Coordinates: 33.304721, -111.653335 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.3047&lon=-111.6533&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: Minor injuries - Injuries: 1 minor - Status: Completed, report June 1, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 92015 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA264 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92015/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92015 - Page: https://openairdocs.org/ntsb/WPR15LA264 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/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: [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/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: [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Pilot (probable cause); cases with it: [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md) - [Workload management](https://openairdocs.org/ntsb-findings/02064000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/02064000/cases.md) - [Light condition](https://openairdocs.org/ntsb-findings/03036000): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/03036000/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: [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: DOUGLAS A4N - Category: Airplane - Serial number: 14542 - Airframe hours: 3339 - Engines: Pratt & Whitney J52-P408 11200 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. - Pilot; age 63; injuries: minor; 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 files) The files NTSB released with the investigation on April 13, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92015. 1.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438826&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - FAA Inspector (item 2, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438827&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - On Scene Photos - Courtesy of Airport Operations (item 3, .PDF, 2 photos, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438828&FileExtension=.PDF&FileName=On%20Scene%20Photos%20-%20Courtesy%20of%20Airport%20Operations-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.