What happened
On August 11, 2021, a Cessna 310G, registration PR-VRR, was performing a local instructional flight at the Votuporanga Aerodrome (SDVG) in São Paulo, Brazil. The flight was intended to assist a pilot under supervision in re-adapting to multi-engine aircraft operations. The crew consisted of an instructor and a pilot under supervision.
During the first traffic pattern for runway 23, the aircraft made contact with the runway with the landing gear in the retracted position. Following the initial touchdown, the aircraft slid approximately 325 meters on the underside of the fuselage before coming to a stop on its right side. The impact caused light damage to the propellers, engines, and the lower portion of the fuselage, but both occupants remained uninjured.
The investigation
CENIPA's investigation focused on the cockpit procedures and the crew's experience levels. The instructor held valid multi-engine and flight instructor ratings, though recent flight logs showed a high frequency of operating fixed-gear aircraft compared to retractable-gear models. The pilot under supervision was in the process of revalidating multi-engine ratings and had not flown in such an aircraft since late 2016.
The investigation examined the aircraft's landing gear warning system, which included a green light for gear down, an amber light for gear in transit (which could be obscured by the control yoke position), and an audible alarm triggered when power was reduced below a certain threshold. Investigators found that the propellers struck the ground with low rotation, as the pilot had reduced power significantly during the transition to the flare, which prevented the crew from noticing the incorrect configuration.
Crucially, the investigation found that the crew did not utilize the aircraft's checklists during the approach. The training philosophy at the flight school required the student to perform the checklist reading while flying, and the instructor's oversight was found to be inadequate in ensuring all critical steps were completed.
Findings
- The crew failed to perform the "before landing" and "final approach" checklists.
- The failure to execute checklists led to the oversight of the landing gear position.
- The instructor did not adequately monitor the pilot under supervision, failing to ensure the proper execution of operational procedures.
- The crew's reliance on memory rather than standardized checklists increased the susceptibility to error.
- The landing gear warning system was not effectively utilized or noticed during the final stages of the approach.