What happened
On September 2, 2011, at 20:35 UTC, a Piper PA-3-220T, registration PT-XVV, was performing a transit flight from Ituverava to Fazenda Mosquito (SDOR) in Orlândia, São Paulo. The flight lasted approximately 15 minutes. During the approach to runway 34, the pilot failed to extend the landing gear, resulting in a gear-up landing.
The aircraft's propeller blades made initial contact with the asphalt 95 meters from the runway threshold. Following the propeller strike, the aircraft's belly dragged along the runway for an additional 217 meters before coming to a complete stop. The impact caused substantial damage to the propeller blades, struts, flaps, and the fuselage belly, along with minor damage to the windshield during recovery.
The investigation
CENIPA investigators established that the pilot was experiencing significant physiological discomfort during the flight. The pilot reported that the lack of adequate sanitary facilities at the departure airport prevented him from addressing his needs before takeoff. To reach the destination airport more quickly, the pilot increased the aircraft's speed and performed a non-standard right-hand traffic pattern.
The investigation examined the pilot's use of cockpit procedures and found that the pilot did not use the aircraft's checklist, nor did he have a habit of using it. While the aircraft's landing gear warning horn was functional, the pilot reported confusing the sound with the stall warning horn, likely due to the high-stress situation and physiological distraction.
Findings
- The pilot's physiological distress acted as the primary driver for the sequence of events, impairing his reasoning and judgment.
- The pilot failed to extend the landing gear due to an oversight caused by his physical discomfort.
- The pilot's decision-making was compromised by the pressure to reach the destination quickly.
- A lack of adherence to standard operating procedures, specifically the failure to use the aircraft checklist, prevented the pilot from verifying the gear position during the pre-landing checks.
- The pilot's decision to proceed with the flight despite feeling unwell contributed to the error.