National Transportation Safety Board Aviation Accident Final Report Location: Kapolei, HI Accident Number: Date & Time: 06/29/2015, 1944 HST Registration: N221LM Aircraft: SHORT BROS SD3 60 Aircraft Damage: None Defining Event: Landing gear not configured Injuries: 2 None Flight Conducted Under: Part 91: General Aviation - Other Work Use Analysis The captain/check pilot was conducting a scheduled flight check of the first officer. The pilots reported that the approach was uneventful and that they thought that they had completed the Before Landing checklist, which included extending the landing gear and verifying that it was down before landing. However, the airplane landed with the gear up. The airplane had a tricycle landing gear with a fully retractable nose gear and partially retractable main gear. During the landing roll, about a few hundred feet after touchdown on the main gear and as the airplane's nose was lowered, the forward bottom section of the fuselage contacted the runway surface, which resulted in substantial damage. Once the airplane came to a stop, the pilots safely egressed. The pilots reported that they landed the airplane with the landing gear inadvertently retracted. Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilots failure to extend the landing gear before landing. Contributing to the accident was the pilots failure to complete the Before Landing checklist. Findings Aircraft Personnel issues Gear extension and retract sys - Not used/operated (Cause) Lack of action - Flight crew (Cause) Use of checklist - Flight crew (Factor) Page 1 of 5
Factual Information On June 29, 2015, about 1944 Hawaiian standard time, a Short Bros SD3-60, N221LM, sustained substantial damage following a gear up landing at the Kalaeloa Airport [John Rogers Field] (JRK) Kapolei, Hawaii. The airplane was registered to and operated by Trans Executive Airlines of Hawaii Inc., under the provisions of Title 14 Code of Federal Regulations Part 91. The airline transport pilot and commercial pilot, the only occupants of the airplane, were not injured. Visual meteorological conditions prevailed and instrument flight rules (IFR) flight plan was filed for the flight check flight which originated from Honolulu International Airport, Honolulu, Hawaii at about 1850. The flight was a scheduled flight check for the first officer. The crew reported that prior to landing, they thought they had completed the Before Landing checklist. One of the checklist items was to extend the landing gear and ensure it was down. During the landing roll, about a few hundred feet after touchdown, and as the airplane's nose was lowered, the forward bottom section of the fuselage, made contact with the runway surface. The airplane had a tricycle landing gear that used a fully retractable nose gear and a partially retractable main gear. Once the airplane came to a stop, the crew safely egressed. Examination of the airplane wreckage by a Federal Aviation Administration Inspector revealed that the underside of the fuselage, near the nose wheel, sustained damage. Further assessment of the damage by the National Transportation Safety Board (NTSB), determined that there was structural damage. An operation check of the airplane's landing gear revealed no anomalies. The captain completed his flight review on November 11, 2014 and had logged 20,230 hours of total flight time. 6,011 hours were logged in the accident make and model of airplane. The first officer completed his flight review on May 16, 2015 and had reported that he had 272 hours of total flight time. 29 hours were logged in the accident make and model of airplane. During interviews with the NTSB, investigator-in-charge, the flight crew reported that they flew several approaches and landings at JRK. When the accident occurred, it was during their last approach and landing, which upon completion, they had intended on departing JRK. During this approach and landing, the flight crew stated that they landed with the landing gear inadvertently retracted. According to the flight crew, the warning horn to advise them that the landing gear was not extended, did not activate on final, since they were flying a partial flap approach. According to the airplane's technical information, during a partial flap approach, the airplane's warning horn is designed to activate only when either power lever is pulled back to the flight idle position. The power required to maintain airspeed on the partial flap approach can be more than flight idle position and therefore the landing gear warning horn would not activate. The flight crew reported no major distractions during the approach and said that they were not rushed. During their last traffic pattern at JRK, the captain communicated with the Air Traffic Control Tower (ATCT) on downwind, to receive their clearance back to their originating airport. Page 2 of 5
History of Flight Landing-flare/touchdown Landing-landing roll Landing gear not configured (Defining event) Abnormal runway contact Check Pilot Information Certificate: Airline Transport Age: 75, Male Airplane Rating(s): Multi-engine Land Seat Occupied: Left Other Aircraft Rating(s): None Restraint Used: Instrument Rating(s): Airplane Second Pilot Present: Yes Instructor Rating(s): None Toxicology Performed: No Medical Certification: Class 2 With Waivers/Limitations Last Medical Exam: 09/06/2014 Occupational Pilot: Yes Last Flight Review or Equivalent: 11/18/2014 Flight Time: (Estimated) 20230 hours (Total, all aircraft), 6011 hours (Total, this make and model), 17954 hours (Pilot In Command, all aircraft), 129 hours (Last 90 days, all aircraft), 21 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft) Co-Pilot Information Certificate: Commercial Age: 23, Male Airplane Rating(s): Multi-engine Land; Single-engine Land Seat Occupied: Other Aircraft Rating(s): None Restraint Used: Instrument Rating(s): Airplane Second Pilot Present: Yes Instructor Rating(s): None Toxicology Performed: No Medical Certification: Class 2 With Waivers/Limitations Last Medical Exam: 10/17/2014 Occupational Pilot: Yes Last Flight Review or Equivalent: 05/16/2015 Flight Time: Right (Estimated) 272 hours (Total, all aircraft), 29 hours (Total, this make and model), 3 hours (Last 90 days, all aircraft), 3 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft) Page 3 of 5
Aircraft and Owner/Operator Information Aircraft Manufacturer: SHORT BROS Registration: N221LM Model/Series: SD3 60 VARIANT100 Aircraft Category: Airplane Year of Manufacture: Amateur Built: No Airworthiness Certificate: Transport Serial Number: SH3722 Landing Gear Type: Retractable - Tricycle Seats: Date/Type of Last Inspection: 06/17/2015, Continuous Airworthiness Certified Max Gross Wt.: 27100 lbs Time Since Last Inspection: Engines: 2 Turbo Prop Airframe Total Time: 30364.9 Hours Engine Manufacturer: Pratt & Whitney ELT: Installed, not activated Engine Model/Series: PT6-67R Registered Owner: Operator: TRANS EXECUTIVE AIRLINES OF HAWAII INC TRANS EXECUTIVE AIRLINES OF HAWAII Rated Power: Air Carrier Operating Certificate: Operator Does Business As: Operator Designator Code: TXHA On-demand Air Taxi (135) Meteorological Information and Flight Plan Conditions at Accident Site: Visual Conditions Condition of Light: Dusk Observation Facility, Elevation: PHJR, 30 ft msl Observation Time: 1953 HST Distance from Accident Site: 0 Nautical Miles Direction from Accident Site: 0 Lowest Cloud Condition: Scattered / 3500 ft agl Temperature/Dew Point: 26 C / 22 C Lowest Ceiling: None Visibility 10 Miles Wind Speed/Gusts, Direction: 7 knots, 310 Visibility (RVR): Altimeter Setting: 29.97 inches Hg Visibility (RVV): Precipitation and Obscuration: No Obscuration; No Precipitation Departure Point: HONOLULU, HI (HNL) Type of Flight Plan Filed: IFR Destination: HONOLULU, HI (HNL) Type of Clearance: IFR; VFR Departure Time: 1850 HST Type of Airspace: Class D Airport Information Airport: KALAELOA (JOHN RODGERS FIELD) (JRF) Runway Surface Type: Airport Elevation: 30 ft Runway Surface Condition: Dry Runway Used: 22L IFR Approach: None Asphalt Runway Length/Width: 8000 ft / 200 ft VFR Approach/Landing: Touch and Go; Traffic Pattern Page 4 of 5
Wreckage and Impact Information Crew Injuries: 2 None Aircraft Damage: None Passenger Injuries: N/A Aircraft Fire: None Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 2 None Latitude, Longitude: 21.307222, -158.070278 (est) Administrative Information Investigator In Charge (IIC): Albert P Nixon Adopted Date: 02/17/2016 Additional Participating Persons: Edward P Santa-Elena; Federal Aviation Administration; Honolulu, HI Merritte Wilson; Federal Aviation Administration; Honolulu, HI Publish Date: 02/17/2016 Note: The NTSB did not travel to the scene of this accident. Investigation Docket: http://dms.ntsb.gov/pubdms/search/docklist.cfm?mkey=91470 The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. Page 5 of 5