1999-10 · NASA ASRS report 453353
AN INSTRUCTOR AND FLT REVIEW PLT LANDED A MOONEY M20 WITH THE GEAR UP AT ESN.
2 PLTS WERE ON BOARD THE INCIDENT FLT. THERE WERE NO OTHER ACFT INVOLVED OR EVEN IN THE VICINITY. I WAS ACTING AS FLT INSTRUCTOR (I AM A CFI-IA). I WAS CONDUCTING A FLT REVIEW WITH THE OTHER PLT WHO IS AN INST RATED PVT PLT AND WHO HAS MANY HUNDRED OF HRS IN THE M20. IT WAS NIGHTTIME; THE WX WAS CLR AND THERE WAS BRIGHT MOONLIGHT. IN PREPARATION FOR A LNDG ON RWY 22 AT ESN; I HAD OBSERVED THE PF PERFORM THE PRELNDG CHK AND I CONFIRMED THEN THAT THE LNDG GEAR WAS DOWN. WHEN THE FLT WAS ON SHORT FINAL FOR RWY 22 I AGAIN CONFIRMED THAT THE LNDG GEAR WAS DOWN. AT ABOUT 1/2 MI FROM THE APCH END OF THE RWY; I SAID 'YOU CAN MAKE A TOUCH-AND-GO OR A FULL STOP.' THE PF EXECUTED A GAR. IMMEDIATELY AFTER THE PF ESTABLISHED A CLB ATTITUDE WITH FULL PWR; I RETARDED THE THROTTLE TO SIMULATE A LOSS OF PWR ON TKOF/GAR. AT THAT MOMENT THE ACFT WAS AT ABOUT 75 FT AGL AND 85 KIAS. THE PF IMMEDIATELY LOWERED THE NOSE TO MAINTAIN FLYING SPD AND THEN ESTABLISHED A SPD APPROPRIATE FOR LNDG (ABOUT 70-75 KIAS). HE MAINTAINED EXCELLENT LATERAL CTL AND AIRSPD CTL WITH THE THROTTLE AT IDLE. I BELIEVE I SPLIT MY TIME BTWN OBSERVING THE AIRSPD INDICATOR AND THE ACFT'S ATTITUDE; AND JUDGING IF THERE WAS SUFFICIENT REMAINING RWY TO LAND. ALTHOUGH I OBSERVED THE PF LOWER THE FLAPS TO FULL; I FAILED TO CHK THAT THE LNDG GEAR WAS STILL EXTENDED. THE PROP AND THEN PARTS OF THE UNDERSIDE OF THE ACFT STRUCK THE RWY; THE ENG STOPPED; AND THE ACFT SLID TO A STOP DIRECTLY ON THE CTRLINE OF THE RWY ABOUT 1000 FT FROM THE END OF RWY 22. THE 2 PLTS SHUT OFF THE FUEL; ENG; IGNITION AND ELECTRICAL SYS AND SWITCHES AND EXITED THE ACFT WITHIN LESS THAN 30 SECONDS. AFTER A FEW MOMENTS WE OBSERVED THAT THERE WAS NO SIGN OR SMELL OF FUEL; AND WE SAW THAT THE WINGS HAD NEVER TOUCHED THE GND (WE HAD 1 FLASHLIGHT AT THIS POINT). A FEW MINS LATER WE RETURNED TO THE ACFT TO CONFIRM THAT THE ACFT WAS PROPERLY SHUT DOWN AND TO RETRIEVE ADDITIONAL FLASHLIGHTS AND A HAND-HELD TRANSCEIVER. ASAP WE CONTACTED THE POLICE/FIRE AUTHS (VIA 911) AND THE ARPT MGR; NOTIFYING THEM OF THE INCIDENT AND STATING THAT RWY 22 WAS BLOCKED. WE MONITORED THE ESN UNICOM FREQ TO NOTIFY ANY ACFT THAT RWY 22 WAS CLOSED (NONE APCHED OR DEPARTED) UNTIL THE ARPT AUTHS ARRIVED AND OUR ACFT WAS REMOVED. I BELIEVE THAT ALMOST EVERY ACCIDENT/INCIDENT IS THE RESULT OF A DEFINITE CHAIN OF EVENTS. WHILE MOST EVENTS OCCUR IN A SEQUENTIAL ORDER; SOME RUN PARALLEL. PROPER ACTION AT ANY ONE OF THE KEY LINKS WILL ALMOST ALWAYS BREAK THE CHAIN AND THE ACCIDENT/INCIDENT WILL NOT OCCUR. ALTHOUGH THE CHAIN OF EVENTS IN THE ABOVE INCIDENT APPEARS TO BE RELATIVELY SHORT; BOTH IN TIME AND IN SEQUENCE; IT STILL REQUIRED SEVERAL DISTINCT LAPSES ON MY PART BEFORE I WOUND UP AT THE WRONG END OF THAT CHAIN. PROPER ACTION BY ME ANYWHERE OR ANYTIME ALONG THE CHAIN WOULD HAVE KEPT ME AND MY STUDENT OFF THE ASPHALT THAT EVENING. HOW THE PROB AROSE: I USED BAD JUDGEMENT BY SIMULATING AN ENG-OUT EMER AT NIGHT. IT WAS ALSO POOR JUDGEMENT TO SIMULATE AN EMER FOLLOWING THE PF'S GAR. IT WAS OBVIOUS THAT HE WAS UNCERTAIN ABOUT SOMETHING; AND MY ADDING A SIMULATED EMER MUST HAVE CONTRIBUTED TO HIS UNCERTAINTY. THE FINAL; AND MOST INEXCUSABLE; LINK IN THIS CHAIN WAS MY FAILURE TO CHK THAT THE LNDG GEAR WAS DOWN. CONTRIBUTING FACTORS: HUMAN PERFORMANCE CONSIDERATIONS: CONTRIBUTING FACTORS AFFECTING THE QUALITY OF PERCEPTIONS; JUDGEMENTS AND DECISIONS: IN RETROSPECT; MY PERCEPTIONS; JUDGEMENTS AND DECISIONS WERE INFLUENCED BY THE FOLLOWING CONTRIBUTING FACTORS; BUT THEY DO NOT IN ANY WAY EXCUSE MY ACTIONS OR INACTIONS: 1) THE PF IS ONE OF THE BETTER; SAFEST PLTS I FLY WITH. I WOULD NOT SIMULATE AN ENG FAILURE ON TKOF; AT NIGHT OR DURING THE DAY; WITH MOST OF THE PLTS I FLY WITH. I DID SO IN THIS CASE BECAUSE I BELIEVED THE PF WOULD BE ABLE TO HANDLE THE TRANSITION FROM A FULL PWR CLB TO A PWR OFF GLIDE AND LNDG. 2) I WAS NOT TERRIBLY CONCERNED THAT IT WAS NIGHT BECAUSE THE VISIBILITY WAS SUPERB AND THERE WAS A VERY BRIGHT (ALMOST FULL) MOON. 3) I WASUNDER THE FALSE IMPRESSION/PERCEPTION THAT THE LNDG GEAR WAS DOWN. I HAD CHKED THAT THE LNDG GEAR WAS DOWN JUST A FEW MOMENTS BEFORE THE GAR. I DID NOT SEE THE PF RAISE THE LNDG GEAR; BUT I DID SEE HIM LOWER THE FLAPS. MOREOVER; SINCE I HAD REDUCED THE THROTTLE IMMEDIATELY AFTER THE PF HAD ESTABLISHED A CLB; I DID NOT ANTICIPATE THAT HE WOULD HAVE RAISED THE GEAR. THIS WAS THE KEY; THOUGH FALSE; IMPRESSION/PERCEPTION; THAT MAY HAVE CAUSED ME NOT TO RECHK THAT THE LNDG GEAR WAS DOWN. ALL OF THESE THOUGHTS AND INACTIONS WERE INCORRECT. THE LNDG GEAR POS WAS; OF COURSE; DISPLAYED ON THE ANNUNCIATOR PANEL AT ALL TIMES THROUGHOUT THIS INCIDENT.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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