NUIQSUT, AK, USA
N220CS
Piper PA-31T3
The airline transport certificated pilot was landing at a remote village on a scheduled domestic commuter flight with nine passengers. The accident airplane, a twin-engine turboprop certified for single-pilot operations, was equipped with a fuselage-mounted belly cargo pod. Witnesses saw the airplane touch down on the gravel runway with the landing gear retracted. The belly pod lightly scraped the runway for about 40 feet before the airplane transitioned to a climb. The propeller tips did not contact the runway. As the airplane began climbing away from the runway, the landing gear was extended. The airplane climbed to about 100 to 150 feet above the ground, and then began a descending left turn, colliding with tundra-covered terrain. A postcrash fire destroyed the fuselage, right wing, and the right engine. The flaps were found extended to 40 degrees. The balked landing procedure for the airplane states, in part: "power levers to maximum, flaps to 15 degrees, landing gear up, and then retract the flaps." Five passengers seated in the rear of the airplane survived the crash. The survivors did not recall hearing a gear warning horn before ground contact. The airplane was landed gear-up eight months before the accident. The airplane was nearly landed gear-up four months before the accident. Each time, a landing gear warning horn was not heard by the pilot or passengers. A postcrash examination of the airplane and engines did not locate any preimpact mechanical malfunction. The FAA's Fairbanks, Alaska, FSDO conducted an inspection of the operator six months before the accident, and recommended the operator utilize two pilots in the accident airplane. Following the accident, the Fairbanks FSDO required the operator to utilize two pilots for passenger flights in the accident airplane make and model.
HISTORY OF FLIGHT On September 18, 2000, about 1510 Alaska daylight time, a Piper PA-31T3 airplane, N220CS, was destroyed by impact and postimpact fire after colliding with tundra-covered terrain, about 300 yards south of the Nuiqsut Airport, Nuiqsut, Alaska. The airplane was being operated as a visual flight rules (VFR) scheduled domestic commuter flight under Title 14, CFR Part 135, when the accident occurred. The airplane was operated as Flight 181 by Cape Smythe Air Service Inc., Barrow, Alaska. The airline transport certificated pilot and four passengers received fatal injuries; the remaining five passengers received serious injuries. Visual meteorological conditions prevailed, and a VFR flight plan was filed. The flight originated at the Deadhorse Airport, Deadhorse, Alaska, at 1445. Ground witnesses at the Nuiqsut Airport saw the airplane touch down on runway 22 with the landing gear retracted. The airplane was equipped with a fuselage-mounted belly cargo pod. The belly pod lightly scraped the runway for about 40 feet, but the airplane transitioned to a climb. As the airplane began climbing away from the runway, the ground witnesses saw the landing gear extend. The airplane climbed to about 100 to 150 feet above the ground, and then began a descending left turn. The airplane collided with the ground on a 095 degree heading. The ground witnesses did not describe observing any smoke or flames emanating from the airplane before the crash. According to surviving passenger statements and interviews, the accident flight and approach to the Nuiqsut Airport was unremarkable. During the landing phase, the passengers said the airplane scraped the runway. A warning horn was not heard before runway contact. The airplane then pulled upward from a level attitude into a climb that several passengers described as a 30 to 45 degree nose high angle. Several of the passengers felt the airplane "shudder" or "shimmy", roll to the right and left, and then heard a warning horn as the airplane banked to the left. The airplane then descended to the ground in a left-wing-low attitude. The wreckage path extended for about 300 feet, during which the landing gear, belly pod, left wing, and the left engine separated from the airplane. A postcrash fire destroyed the fuselage, right wing, and the right engine. PERSONNEL INFORMATION Pilot Information The pilot held an airline transport pilot certificate with a multiengine land rating, commercial pilot privileges with an airplane single-engine land rating, and private pilot privileges with a single-engine sea rating. The most recent first-class medical certificate was issued to the pilot on August 24, 2000, and contained no limitations. According to the operator, the pilot was hired by the company on September 27, 1998, and at that time, his total flight experience was 573 hours, with 72 hours of multiengine. The pilot was assigned to the company base at Barrow. He completed his initial company training, including Cessna 207 ground training, on September 30. He then completed Beech BE-99 ground training on October 2, and Beech BE-99 second-in-command pilot flight training on October 6. The pilot was assigned to Beech BE-99 airplanes, eventually accruing 924 hours in the BE-99 as second-in-command. Company records show that the pilot completed a VFR company check ride in a Cessna 207 on November 13, 1998, and began accruing initial operating experience (IOE) in Cessna 207 airplanes on November 23. He eventually accrued 825 hours in Cessna 207 airplanes. The pilot received two hours of initial ground training on May 8, 1999, on general subjects for Cessna 185 airplanes. He did not receive any flight training in the airplane. Company records show that the pilot was unassigned to all aircraft on February 3, 2000, after undergoing minor surgery, and reassigned to all aircraft on February 29. He was unassigned to Cessna 207 airplanes on March 1, pending completion of a company line check. He was reassigned to Cessna 207 airplanes on March 23, after completion of a line check. According to the company's PA-31-T3 ground/flight training manual, transition training to the airplane requires 16 hours of ground training, 6 hours, or to proficiency, of flight training, a company proficiency flight check, 20 hours of IOE, and then a company line check. Company records indicate that on May 28, 2000, the pilot began receiving flight training in the accident airplane. He received 16 hours of transition ground training in the Piper PA-31-T3 on October 3rd and 4th, 1999. According to the pilots logbook, the pilot first logged flight time in the accident airplane make and model on April 22, 2000, with 1.2 hours of dual instruction while on an extra section mail flight. On May 28, he logged 2.6 hours of dual instruction in the Barrow area, and on June 25, he logged 2.9 hours as pilot-in-command in the Barrow area. From July 10 to July 11, the pilot logged 6.1 hours in the Nome area as dual instruction. On July 12, the pilot logged 1.9 hours as dual instruction during an aircraft check ride as an on-demand pilot. During the check ride, the pilot received an unsatisfactory rating from the director of operations for his conduct of nonprecision approaches. Following retraining, the company removed all instrument approach restrictions on the pilot. The pilot began on-demand charter flights in the accident airplane, logging 1.7 hours as pilot-in-command between Barrow and Atqasuk, Alaska, on July 21, 2000, after passing a company proficiency flight at Barrow. On July 25, the pilot began logging IOE on commuter flights, accompanied by a check airman on most, but not all flights. The pilot continued to conduct single-pilot, on-demand flights before completing his commuter IOE requirements. On August 10, after accruing 51 hours of IOE, the pilot logged his first flight as a commuter captain while flying without a co-pilot, or a company check airman. On September 1, 2000, the pilot accrued 100 hours in the accident airplane, and was authorized to use the autopilot in lieu of a second pilot for IFR operations. He eventually accrued a total of 165 hours in the accident airplane make and model. On the day of the accident, the pilot had completed one flight (Flight 115) from Barrow, to Atqasuk, to Wainwright, Alaska, to Barrow, for a total of 1.25 flight hours. The day before the accident, the pilot accrued 4.15 flight hours. Two days before the accident, the pilot accrued 1.35 hours. All of the pilot's ground and flight training, check rides, and line checks, were conducted by company check airman. A review of the FAA's Program Tracking and Reporting Subsystem (PTRS) data pertaining to the pilot, revealed two en route surveillance flights by FSDO operations inspectors with the pilot in Cessna 207 airplanes. The pilot had two ramp inspections by FSDO maintenance inspectors, one in a Cessna 207, and one in a Beech BE-99. The pilot had one en route surveillance flight by a FSDO avionics inspector in a Cessna 207. During a flight in the accident airplane on August 4, 2000, the pilot reported a landing gear problem in which the nose gear would not extend. The chief pilot was also on board the airplane. At that time, the pilot had logged 61.3 hours in the accident airplane make and model. Company Information The operator is a Federal Aviation Regulations (FAR) Part 135 Air Carrier, and holds commuter and on-demand operations specifications. Company facilities are located at Barrow, Alaska, Nome, Alaska, Kotzebue, Alaska, and Deadhorse, Alaska. The president, chief pilot, and the director of maintenance reside in Barrow. The director of operations, and the chief maintenance inspector/manager of stations, reside in Nome. A review of the company's operations manual revealed that the president, director of maintenance, director of operations, chief pilot, and the manager of stations, are designated as having the authority of exercising operational control over company aircraft, and/or flight crews. The company's operations specification, issued by the FAA, indicate that flights shall only be initiated, diverted, or terminated under the authority of the director of operations, who may delegate his authority, but retains responsibility. On June 17, 1999, the company requested and received approval from the FAA for a change in the chief pilot position. On August 18, 2000, the FAA withdrew the check airman approval for the company's chief pilot because of his numerous accidents during the previous year. AIRCRAFT INFORMATION The airplane is a nonpressurized, twin-engine turboprop equipped with Pratt & Whitney PT6A-11 engines that produce 500 horsepower each. The maximum takeoff and landing weight is 9,000 pounds. The maximum zero fuel weight is 7,600 pounds. The airplane is not required to have a cockpit voice recorder, a flight data recorder, nor a ground proximity warning system. The airplane is equipped for instrument flight into known icing conditions, and may be operated by a single pilot. The airplane was maintained on an approved aircraft inspection program (AAIP). The AAIP is divided into phase inspections, each consisting of four event cycles, each 150 hours apart. Examination of the maintenance records revealed that an event number four inspection was accomplished on September 15, 2000, 7.7 hours before the accident. The airplane had accumulated a total time in service of 10,156.7 hours. The left engine had accrued a total time of 11,666.40 hours, 6,017.2 hours since overhaul. The right engine had accrued a total time of 10,622.90 hours, 4,444.1 hours since overhaul. Both propellers had accrued 364.1 hours. The accident airplane pilot had a nose gear extension problem with the accident airplane on August 4, 2000. The maintenance log notes that the pilot cycled the gear several times, pulled the nose gear bottle (emergency blow-down system), and reset the circuit breaker, even though it had not popped. The nose gear extended after recycling the gear. The corrective action noted in the maintenance log was removal of mud from the nose gear up-lock, cleaning and lubricating of the nose gear, and a replacement of the emergency actuator. The pilot again wrote up a nose gear problem in the accident airplane on August 8, 2000, by noting the gear-down light was intermittent, and the red in-transit light was inoperative. Maintenance personnel cleaned the nose gear down switch and adjusted the nose gear actuator. The accident airplane is equipped with two landing gear warning horn switches that are installed in the control pedestal, each controlled by an engine power lever. The airplane service manual states, in part: "Each switch activates the warning horn when either or both power levers are reduced below 150 foot-pound of engine torque." If the landing gear has not been extended, when either or both power levers are reduced below 150 ft. pounds of engine torque, the landing gear warning horn should sound. The airplane's service manual specifies a ground adjustment procedure, a gear horn operational check procedure, and a flight test. During a flight from the accident scene to Barrow in a company Piper PA-31-T2 (Cheyenne II) airplane, the landing gear warning horn system was demonstrated to the NTSB IIC by the director of operations. This was performed by reducing each engine throttle until the warning horn sounded. On this flight, the warning horn for the left engine throttle did not sound until the engine torque was reduced to zero. The gear warning horn for the right engine throttle activated at 175 pounds of torque. On October 2, 2000, the NTSB IIC received a telephone call from an individual who had previously flown as a passenger in the accident airplane. The pilot of the previous flight was not the accident airplane pilot. The passenger reported that during an approach to landing at Deadhorse on May 6, 2000, the airplane descended to within 15 feet of the ground, and the pilot suddenly added engine power and pulled the airplane into a climb. The passenger said the pilot had failed to lower the landing gear. The passenger reportedly did not hear any warning horns during the approach. When questioned about the event, the pilot told the passenger that he was "not paying any attention to what I'm doing." The accident airplane was landed with the landing gear retracted on January 25, 2000, at Savoonga, Alaska. The gear-up event was reviewed by the FAA as an incident. (The pilot of the Savoonga airplane was not the pilot who is the subject of this report). In the text of the FAA's incident report, the Savoonga pilot reported that during a go-around, he retracted the landing gear. On the next landing approach, the pilot failed to lower the gear. He did not hear or was not aware of a gear unsafe horn until on the ground. The airplane required replacement of the engine propellers, inspection of the engines, and repair of the belly cargo pod. According to the airplane's operating handbook, the landing gear is hydraulically operated. Each engine is equipped with a hydraulic pump. Selection of gear up or down is accomplished by the movement of the landing gear handle. When the desired position of the gear is obtained, the landing gear handle is automatically forced back to a neutral position by hydraulic pressure. Gear retraction or extension will normally occur in about 6 seconds. When the gear handle returns to neutral, it relieves all pressure in the hydraulic system. The gear is held in position by mechanical locks. The return of the handle to neutral is an indication that the components have reached full extension or retraction. However, the landing gear position lights should be used as primary indications. The airplane is equipped with landing gear position indicator lights installed on the instrument panel, to the right of the landing gear handle. There is one red, and three green indicator lights. The red light indicates the gear is in transit between the up-locked, and down-locked positions. The green lights indicate when each gear is down and locked. When the gear is up and locked, there is no indication light. The nose gear doors, and the outboard main landing gear doors, operate by mechanical linkage to each gear assembly, and remain open when the gear is extended. The inboard main gear doors are hydraulically operated, opening during gear extension, and closing when the gear is fully extended. The airplane is equipped with an emergency hydraulic hand pump that is used to provide hydraulic system pressure in the event of a failure of the engine-driven hydraulic pumps. The airplane also has a pneumatic extension system (3,000 psi nitrogen bottles) installed on each of the three landing gear (nose, left main, and right main). It is utilized if the hand pump fails to extend and lock all three gear. Once an emergency pneumatic extension system is utilized, the landing gear is hydraulically locked in the down position, and requires resetting by maintenance personnel. The airplane is equipped with a small mirror, mounted on the inboard side of the left engine nacelle. This mirror allows the pilot to observe the position of the nose gear. A company checklist for the accident airplane states, in part: BEFORE LANDING, Landing Gear - Down and Locked. The airplane's operating handbook contains several checklists. The BEFORE LANDING checklist states, in part: Gear (below 156 KIAS) - DOWN. Gear lights - 3 Green. Nose gear position - Check in mirror. The BALKED LANDING checklist states, in part: Power levers - As required to obtain maximum power. Airspeed - 113 KIAS. Flaps - Approach, 15 degrees. Gear - Up. Climb power - 455 SHP. Flaps - Full up. Airspeed - 123 KIAS. According to the airplane's operating handbook, with the cargo pod installed, the balked landing performance chart indicated that at maximum gross weight, gear down, and flaps at 40 degrees, at sea level, the airplane should be capable of about an 800 feet per minute climb. The airplane is equipped with a stall warning horn. The warning is activated by a sensing vane on the leading edge of the right
The pilot's failure to extend the landing gear, his improper aborted landing procedure, and inadvertent stall/mush. Factors in the accident were an improper adjustment of the landing gear warning horn system by company maintenance personnel, and the failure of the pilot to utilize the prelanding checklist.
Source: NTSB Aviation Accident Database
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