What happened
An SA226-TC aircraft, performing an express mail delivery from Hamilton to Ottawa, landed on runway 2/25 at the Ottawa/Macdonald-Cartier airport with its landing gear in the retracted position. The impact of the aircraft on the runway began approximately 4,590 feet from the threshold, with the propellers making first contact. The aircraft skidded to a stop about 6,770 feet down the runway, at which point a fire erupted near the right engine. The two crew members on board successfully evacuated through the main door without injury, and airport firefighters extinguished the flames. The aircraft sustained substantial damage.
During the approach, the pilot had implemented an unplanned simulation of instrument conditions by placing a map against the co-pilot's windscreen to restrict his external view. As the aircraft approached the runway, the co-pilot struggled with the increased workload of the simulated approach, leading the pilot to take control of the aircraft near the threshold. At this stage, the aircraft was traveling at a high speed and was approximately 500 feet above the ground.
The investigation
The investigation examined the crew's performance, the aircraft's mechanical state, and the company's operating procedures. Investigators found that the crew had not followed the company's standard operating procedures (SOPs), which require a challenge-and-response method for all checklists. Specifically, the before-landing checklist, which includes verifying the landing gear is down, was not completed.
Technical inspections of the aircraft revealed that the landing gear selector was in the up position. While the crew did not hear a gear warning horn, investigators discovered that the warning system was non-functional due to a faulty diode. Once the diode was replaced, the system functioned correctly.
Findings
- The crew failed to follow standard operating procedures regarding the before-landing checklist.
- The pilot utilized an unsafe habit of using the activation of landing lights as a proxy for confirming the landing gear was extended.
- The unplanned decision to conduct simulated instrument training increased the workload for both the pilot and the co-pilot, leading to a breakdown in coordination.
- The landing gear warning horn failed to alert the crew to the retracted gear status because of a failed electrical component.
- The co-pilot's limited experience with the aircraft type and the high-speed approach contributed to the difficulty in managing the aircraft's profile.