What happened
A Transport Canada Beechcraft King Air A100, registration not provided, was conducting a visual flight rules training flight from Ottawa/McDonald-Cartier International Airport to Ottawa/Gatineau Airport. The flight was intended to provide recurrent training for a co-pilot. During the circuit for runway 27, the crew simulated an engine failure by reducing power on the left engine while climbing through 500 feet.
Following a touch-and-go, the crew performed a second approach, this time simulating a single-engine, flapless landing. During this maneuver, the landing gear warning horn sounded but was immediately silenced by the crew. The pilots failed to perform the Before Landing checklist and did not lower the landing gear. Upon touchdown, the aft fuselage and both propellers struck the runway surface. The captain successfully executed a go-around, declared an emergency, and returned to Ottawa/McDonald-Cartier International Airport. There were no injuries, though the aircraft suffered substantial damage.
The investigation
The TSB examined the aircraft's landing gear warning system and the crew's adherence to standard operating procedures (SOPs). Investigators found that the landing gear warning light in the handle was not bright enough to be easily noticed in daylight. Furthermore, the Pilot's Operating Manual (POM) lacked a clear description of how the warning horn behaves when power levers are retarded sequentially.
The investigation also reviewed the pilot-in-command's workload. While the pilot had worked significant overtime and had previously expressed concerns regarding fatigue, his schedule complied with regulatory flight duty time and rest period requirements. The analysis of his 72-hour sleep and work history did not indicate acute fatigue, though chronic fatigue remained inconclusive.
Findings
- The crew failed to complete the Before Landing checklist and did not extend the landing gear.
- The landing gear warning horn was silenced, which effectively removed the primary audible defense against a gear-up configuration.
- The King Air SOPs did not require a redundant check of the landing gear status during single-engine approach and landing exercises.
- The landing gear warning light was likely illuminated, but its visibility in daylight was insufficient to reliably alert the crew.
- The functionality of the warning system during sequential power lever retardation was not clearly documented in the aircraft's manual.
Safety action
- Transport Canada's Aircraft Services Directorate (ASD) issued a Pilot Information File to clarify the functionality of the King Air landing gear warning system.
- The ASD is revising its Single-Engine Approach and Landing checklist to ensure its exclusive use during all single-engine landing scenarios.
- The ASD is amending its King Air SOPs to include a redundant challenge/response verification of the landing gear position prior to landing.