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NTSB investigation record

ERA16FA188

Completed

Beech D35· N2967B

Date
May 19, 2016
Location
Sevierville, TN
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's failure to properly configure the landing gear and the pilot's inappropriate decision to abort the landing after the propeller had contacted the runway, which resulted in a loss of thrust and a subsequent loss of control of the airplane.

Investigator assessment

Analysis narrative

After takeoff on a personal flight, the private pilot of the complex, high performance airplane flew around the local area for about 30 minutes before returning to the airport to land. According to security camera video, witnesses, and physical evidence, the airplane touched down with the wing flaps down and the landing gear in the up (retracted) position. The propeller struck the ground multiple times as the airplane skidded along the ground on its belly. The pilot increased engine power, and the airplane lifted off. The airplane climbed slowly to a point about 450 feet beyond the departure end of the runway and then pitched up, rolled to the left, and impacted terrain. The pitch up and left roll were consistent with a loss of control due to the pilot exceeding the airplane's critical angle of attack and encountering an aerodynamic stall. Postaccident examination of the landing gear system revealed that the landing gear doors were closed; all three landing gear were in their retracted positions in the gear wells; the emergency gear extension handle was stowed; and the push-pull rods from the gearbox to the "A" frame assemblies at the wheels were retracted. These findings indicated that the pilot had retracted the landing gear after takeoff and failed to extend the landing gear before landing. Examination of the propeller also revealed that it sustained significant impact damage from contacting the runway, which likely affected its aerodynamic performance and resulted in a loss of thrust during the pilot's aborted landing and attempted climb. Although the Federal Aviation Administration (FAA) requires that each pilot acting as pilot-in-command of an airplane must complete a flight review every 24 months to assess that pilot's flying skills, review of the pilot's logbooks revealed that his last flight review had occurred more than 10 years before the accident. Review of the pilot's logbook also indicated that the pilot had received 3.1 hours of flight instruction in the accident airplane about 1 year before the accident, but there was no record of the complex and high-performance endorsements required by the FAA to act as pilot-in-command of the airplane. During the examination of the wreckage, the remains of a Pilot's Operating Handbook and Airplane Flight Manual (POH/AFM) was found behind the pilot's and copilot's seats in the cabin, an area that was out of reach from the pilot's position. The POH/AFM contained a Before Landing Checklist that directed the pilot to extend the landing gear and check that it was down before landing. No checklists were found near the pilot's seat.

Source record

Factual narrative

GKT is owned by Sevier County and is located 2 miles southeast of Sevierville, Tennessee. It is classified by the FAA as a publicly-owned, uncontrolled, public airport. The airport elevation was 1,014 ft above mean sea level. Runway 10 was asphalt, in good condition, and measured 5,506-ft-long by 75-ft-wide with a 0.1% gradient. Complex Airplane Endorsement According to 14 CFR 61.31(e), no person may act as pilot-in-command of a complex airplane (an airplane with a retractable landing gear, flaps, and a controllable pitch propeller) unless that person has received and logged ground and flight training from an authorized instructor in a complex airplane, or in a flight simulator or flight training device that is representative of a complex airplane, and has been found proficient in the operation and systems of the airplane; and received a one-time endorsement in the pilot's logbook from an authorized instructor who certifies the person is proficient to operate a complex airplane. High-Performance Endorsement According to 14 CFR 61.31(f), no person may act as pilot-in-command of a high-performance airplane (an airplane with an engine of more than 200 horsepower), unless the person has received and logged ground and flight training from an authorized instructor in a high-performance airplane, or in a flight simulator or flight training device that is representative of a high-performance airplane, and has been found proficient in the operation and systems of the airplane; and received a one-time endorsement in the pilot's logbook from an authorized instructor who certifies the person is proficient to operate a high-performance airplane. Flight Review According to 14 CFR 61.56(a), no person may act as pilot-in-command of an aircraft unless, in the last 24 months, that person has accomplished a flight review given in an aircraft for which that pilot is rated by an authorized instructor. Preventing Landing Gear Mishaps According to the FAA Pamphlet "On Landings Part III" (FAA-P-8740-50), landing gear mishaps can be prevented by establishing a set routine and sticking with it. The pamphlet provides the following suggestions: - Have the landing gear down and checked before you are on downwind, or in any event, by the time you are abeam the runway numbers. - Always use your before-landing checklist and gas-undercarriage-mixture-prop (GUMP) check. - When lowering the landing gear, always check the landing gear indicator for down and locked position and make it a habit to physically touch the gear indicators and say out loud "gear down," or "down and locked," or "three in the green." - Use your checklist on every landing. Put the landing gear down at a standardized point every time, and always recheck for three green on short final. Before Landing Checklist During examination of the wreckage, a fire-damaged, closed Beechcraft Bonanza D35 Pilot's Operating Handbook and Airplane Flight Manual (POH/AFM) was found behind the pilot's and copilot's seats in the cabin, an area that was out of reach from the pilot's seat. The POH/AFM contained a Before Landing Checklist that included the following step: "Landing Gear – DOWN and CHECK. (Maximum extension speed 110kts/127mph)". No checklists were discovered near the pilot's seat. At 1135, the reported weather at GKT included wind 080° at 6 knots, visibility 10 miles, few clouds at 2,700 ft, an overcast ceiling at 3,500 ft, temperature 18°C, dew point 11°C, and an altimeter setting of 30.09 inches of mercury. The Knox County Regional Forensic Center, Knoxville, Tennessee, performed an autopsy on the pilot and determined that the cause of death was massive blunt trauma to the chest. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing. The results were negative for carbon monoxide. The drugs carvedilol, used to treat hypertension, glipizide, used to treat type 2 diabetes, losartan, used to treat of hypertension, and salicylate, used to treat mild pain, were detected. None of these drugs are generally considered to be impairing. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with an airplane single-engine land rating. His most recent FAA third-class medical certificate was issued on March 24, 2015. According to pilot records, the pilot had accrued about 210 total hours of flight experience, 157 hours of which were as pilot-in-command. He had received 3.1 hours of flight instruction in the accident airplane in April 2015, but no record of a complex or high-performance endorsement was found. His most recent flight review endorsement was dated November 25, 2005. The airplane was a complex, high-performance, low-wing, single-engine airplane of conventional metal construction. It was equipped with retractable tricycle-type landing gear and wing flaps, and it was powered by a 205-horsepower, air-cooled, 6-cylinder, horizontally-opposed, Continental E-185-11 engine driving a Hartzell 2-bladed, variable-pitch, constant-speed propeller. According to FAA and airplane maintenance records, the airplane was manufactured in 1953. The airplane's most recent annual inspection was completed on November 1, 2015. At the time of the inspection, the airplane had accrued about 6,029.8 total hours of operation. Landing Gear System When retracted, the airplane's landing gear was fully enclosed by the landing gear doors. The landing gear system was electrically operated. Power for retraction was transmitted through push-pull rods from arms on the gearbox to the "A" frame assemblies at each wheel. Landing gear limit switches were located above the gearbox and were actuated by the main wheel retraction arms. Automatic locking was provided in the down position when the gear was extended. The landing gear was operated by a using the landing gear position switch, which could be identified by sight or touch as a small wheel on a flat surface switch, located on the right inboard lower portion of the instrument panel. A landing gear warning chime was activated by two switches connected in series; one above the gearbox, which was activated by an angle on the landing gear actuator spider, and the other on the throttle control at the carburetor end. The landing gear warning chime would annunciate when the throttle was reduced, and the landing gear was not fully extended. Landing gear position lights were installed to indicate the position of the landing gear. When the red landing gear position light was illuminated, the landing gear was fully retracted. When the green landing gear position light was illuminated, the landing gear was fully extended. When neither light was illuminated, the landing gear was in an intermediate position. Position of the landing gear could also be visually confirmed by use of a mechanical landing gear position indicator which was just above the floor, in front of and between the pilot's and copilot's seats. An emergency landing gear extension hand crank was provided for the manual extension of the landing gear in case of a malfunction. The hand crank was located between the front seats. It was operated by placing the landing gear circuit breaker in the "OFF" position, then placing the landing gear position switch in the down position, removing the safety strap, moving the handle down into the cranking position, and turning the handle clockwise. Examination of runway 10 revealed propeller strike marks on the runway pavement in three different areas on the runway. The first set of propeller strikes began about 1,535 ft from the runway threshold and continued for about 51 ft. The second set of propeller strikes began about 1,714 ft from the runway threshold and continued for about 41 ft. The third set of propeller strikes began about 1,798 ft from the runway threshold and continued for about 45 ft. Examination of the propeller strike marks

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