What happened
On the evening of October 26, 2013, a privately owned Beechcraft A36, registration JA4159, was conducting a cross-country flight from Kikai Airport to Matsuyama Airport. The flight, operated under visual flight rules, was nearing its destination as night fell. During the approach to Matsuyama, the pilot encountered difficulties due to a lack of cockpit illumination, as the aircraft's instrument lights were non-functional.
As the aircraft approached the runway, the pilot attempted to manage the landing despite being unable to clearly read the airspeed indicator without the use of a portable waterproof light. During the final stages of the landing, the aircraft touched down with a heavy impact on the nose gear. The force of the impact was sufficient to break the nose-gear fork and cause the tire to tear away, resulting in significant damage to the airframe, including the propeller blades and engine components. The pilot escaped the incident without injury.
The investigation
The Japan Transport Safety Board (JTSB) conducted an investigation that examined the aircraft's flight history, GPS records, and air traffic control communications. Investigators reviewed the pilot's pre-flight procedures and the mechanical state of the aircraft's electrical systems. The investigation specifically looked into why the instrument lights failed to illuminate and why the pilot did not execute a go-around despite the visibility and instrumentation challenges. Physical examination of the wreckage revealed damage to the nose-gear structure, engine cylinders, and propeller blades.
Findings
- The pilot did not perform a complete operational check of the aircraft's lights during the pre-flight inspection, leaving the crew unprepared for the transition to night flight.
- The instrument lights were inoperable because the dimmers had been turned to the off position, and the pilot was unaware of their location on the right subpanel.
- The pilot's ability to monitor airspeed during the flare was severely compromised because the cockpit instruments were not illuminated.
- The landing light was not activated, which likely hindered the pilot's ability to accurately judge the aircraft's height above the runway surface in the dark.
- The aircraft touched down heavily on the nose gear because the pilot failed to sufficiently raise the nose (pitch-up attitude) before touchdown.
- The pilot's familiarity with Matsuyama Airport may have led to overconfidence, resulting in the decision to proceed with the landing rather than diverting to another airport or performing a go-around.