# NTSB WPR19LA144: Piper PA28R, N4992J, Gila Bend, AZ, May 13, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: May 13, 2019, 09:26 local (16:26 UTC) - Place: Gila Bend, AZ - Coordinates: 32.959999, -112.669998 - Nearby events: https://openairdocs.org/map.md?lat=32.9600&lon=-112.6700&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: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Piper Aircraft, Inc., Federal Aviation Administration - NTSB case key (mKey): 99429 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA144 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99429/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99429 - Page: https://openairdocs.org/ntsb/WPR19LA144 ## Probable cause The pilot's failure to configure the landing gear in a timely manner before landing, which resulted in a propeller strike. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-180, 17 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102809), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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-28R-180, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102809), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Landing gear system](https://openairdocs.org/ntsb-findings/01023200): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-findings/01023200/cases.md?model=7102809), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/01023200/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-28R-180, 4 cases](https://openairdocs.org/ntsb-events/095/sequence.md?model=7102809), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28R-180, 7 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102809), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-180, 19 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102809), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, while descending toward his destination airport, he completed a before-landing checklist, but could not recall if he verified that the landing gear down and locked lights were illuminated. The pilot stated that he heard an aural alarm in the final 2 minutes of flight, which he attributed to a stall warning. During landing, the propeller contacted the runway and the airplane veered left and departed the left side of the runway, resulting in in substantial damage to the fuselage and wings. The landing gear selector was found in the down position and the left main landing gear was down and locked at the accident site. The airplane was equipped with a backup gear extender that would extend the landing gear, regardless of selector position, if the engine power was at idle at airspeeds below about 105 mph. The aural gear warning horn was designed to activate under any one of the following conditions: 1) when the landing gear was retracted and power was below about 14 inches manifold pressure, 2) if the backup gear extender has extended the landing gear and the gear selector is in the retracted position, and 3) if the gear selector is in the retracted position while the airplane is on the ground. Postaccident testing could not determine whether the aural warning system was functional at the time of the accident; however, examination and testing of the landing gear extension and retraction revealed no anomalies. Based on the available information, it is likely that the landing gear did not extend in the allotted time prior to touchdown either due to the pilot's delayed deployment or because the conditions for the automatic gear extender to engage were not met. In either case, the accident is consistent with the pilot’s failure to configure the landing gear in a timely manner before landing. ## Factual narrative On May 13, 2019, about 0926 mountain standard time, a Piper PA-28R airplane, N4992J, was substantially damaged when it was involved in an accident near Gila Bend, Arizona. The pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while descending toward the airport for landing, he performed a before landing checklist, but he could not recall whether he verified that the landing gear were extended and locked. During the landing approach, he heard an aural alarm, which he dismissed as a false stall warning. The airplane touched down on the main landing gear. As he lowered the nose, he heard an unusual sound and decided to add power. He later determined the sound was likely the propeller contacting the runway. The airplane turned about 45° to the left and departed the left side of the runway before coming to rest in the dirt. A witness on a nearby taxiway stated that the airplane’s landing gear were not extended when the airplane began the landing flare. The witness attempted to advise the pilot of the landing gear anomaly via radio, but he was unsuccessful. The airplane came to rest about 100 ft off the south side of runway 22 at the runway's midpoint. The runway surface showed striated gouges and two long skid marks indicating the airplane's departure path from the runway. Both the right main landing gear and nose landing gear sustained damage from the impact and the airplane received substantial damage to the fuselage and wings. The airplane's most recent annual inspection was completed on November 7, 2018, at 3,994 total flight hours, and 35 hours before the accident. This maintenance entry did not specify whether a landing gear swing was accomplished; however, in a maintenance entry dated November 10, 2017, for the airplane's previous annual inspection, the landing gear retraction and emergency extension were verified. According to the pilot's operating handbook, the airplane was equipped with retractable tricycle landing gear, hydraulically actuated by an electrically powered reversible pump. The pump was controlled by a selector switch on the instrument panel and the landing gear could be retracted and extended in about 7 seconds. The airplane was also equipped with a pressure-sensing device that lowered the gear regardless of the gear selector position. A gear extension was designed to occur, regardless of selector position, at airspeeds below approximately 105 mph. Further, the airplane was equipped with a gear warning horn that was triggered under any one of the following conditions: 1) when the throttle was in the idle position and manifold pressure was below 14 inches, 2) if the backup gear extender has extended the landing gear and the landing gear selector is in the retracted position, and 3) when the gear selector switch is in the retracted position while on the ground. A landing gear position indicator on the instrument panel displayedthree green lights to indicate that the gear was down and locked. A yellow light was used to show the landing gear in a transit position. Examination of the landing gear system revealed that the gear selector switch was in the down/extended position. The nose landing gear fell without intervention from the motor or manual manipulation into the extended position multiple times and could be locked into place with slight pressure applied to the over-center hook. The right main landing gear displayed multiple fractures from the impact that were consistent with overload separation; however, the landing gear could be manipulated once it was manually extended beyond the gear door by hand. The right main landing gear could not lock due to impact damage. The left main landing gear moved freely by hand into the down and locked position. Electrical power was applied to the airplane to test the functionality of the landing gear system. The aural warning horn did not annunciate, but the landing gear motor functioned normally and the gear extended and retracted successfully. Manipulation of the nose landing gear down lock switch caused the landing gear motor to start and stop accordingly. ## Aircraft - Registration: [N4992J](https://openairdocs.org/aircraft/N4992J), registered now, S/N 28R-30748, built 1968 (OpenAirDocs) - Reported make and model: Piper PA28R (180) - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30748 - Year built: 1968 - Airframe hours: 3994.2 - Engines: Lycoming Engines IO-360-B1E 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 7, 2018, 35 hours before - Departed: AVQ, Marana, AZ - Destination: E63, Gila Bend, AZ - Flight plan: VFR - Airport: E63, Gila Bend Muni, runway 22, 5,200 × 75 ft, asphalt - Equipment: Electronic multifunction display, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Handheld GPS, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 80; injuries: minor; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed, without waivers/limitations; last flight review July 2, 2018; seat: left; restraint: 4-point; flight hours: 2,790 total, 2,393.6 in this make and model, 2,663 as pilot in command, 21.6 in the last 90 days, 8 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 48 °F - Altimeter: 29.95 inHg - Observed at: 5 nm away ## 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 20190513004599A](https://openairdocs.org/incident/20190513004599A), May 13, 2019: Piper PA-28R-180, Gila Bend, AZ, Substantial damage. Gila Bend Municipal Airport (E63): N4992J (PA-28R) was involved in an accident due to the gear not being fully down and locked prior to landing. Just prior to… ## Docket (8 files) The files NTSB released with the investigation on March 7, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99429. 5.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 830 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9428494&FileExtension=pdf&FileName=6120%20Form_Redacted-Rel.pdf - Record of conversations (item 2, PDF, 3 pages, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9430569&FileExtension=pdf&FileName=Record%20of%20Conversations-Rel.pdf - Excerpt from aircraft logbooks (item 3, PDF, 2 pages, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9428906&FileExtension=pdf&FileName=aircraft%20logs_Redacted-Rel.pdf - Excerpt from pilot's operating handbook (item 4, PDF, 2 pages, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9428534&FileExtension=pdf&FileName=Excerpt%20from%20POH-Rel.pdf - Federal aviation administration landing gear examination report (item 5, PDF, 2 pages, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9430303&FileExtension=pdf&FileName=FAA%20landing%20gear%20exam_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 6, PDF, 1 page, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9430343&FileExtension=pdf&FileName=Party%20form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 2 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9430411&FileExtension=pdf&FileName=N4992J%20Aircraft%20Release_Redacted-Rel.pdf - Accident photographs (item 8, PDF, 3 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9429451&FileExtension=pdf&FileName=Accident%20Photographs-Rel.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.