Primary finding
Probable cause
The flight crew's failure to complete the checklist and adhere to airplane placards. Contributing to the accident was a separation of a B-nut on the rudder power hydraulic shut off valve for undetermined reasons.
Investigator assessment
Analysis narrative
The flight crew (FC) was in cruise flight when a master caution light illuminated indicating a loss of the right hydraulic system pressure and hydraulic fluid. The FC used the checklist to trouble shoot the system and attempted to manually extend the main and nose landing gear (NLG) using the alternate extension control lever. Both main gear extended and locked into place; however the NLG did not extend. The airplane was landed with the NLG in the retracted position. Initial inspection of the airplane revealed that a B-nut to the check valve on the rudder power hydraulic shut off valve, was separated from the valve resulting in a total loss of right hydraulic quantity and pressure. Examination of the hydraulic tube, including the B-nut and check valve, did not reveal any abnormalities. Examination of the cockpit revealed the landing gear handle was in the stowed position. A placard on the alternate landing gear extension lever stated, "Pull up forcibly Full Stroke." The airplane was placed on jacks and maintenance personnel successfully extended the nose landing gear. The alternate gear extension control system was also inspected and no defects were noted.
Source record
Factual narrative
HISTORY OF FLIGHT On March 29, 2007, about 1616 eastern daylight time, a McDonnell Douglas DC-9-83 (MD-83), N877GA, registered to Boeing Aircraft Holding Company and operated by Allegiant Air as flight 758, a 14 Code of Federal Regulations (CFR) Part 121 scheduled domestic passenger flight from Portsmouth, New Hampshire to Sanford, Florida, landed with the nose landing gear (NLG) retracted at the Orlando Sanford International Airport (SFB), Sanford, Florida. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane received substantial damage. The airline transport-rated captain, airline transport-rated first officer (FO), 3 flight attendants (FA), and 151 passengers reported no injuries. One passenger received minor injuries and was taken to a local area hospital for observation and released. The flight originated from Portsmouth, New Hampshire, on March 29, 2007, at 1255. The flight crew (FC) stated they were in cruise flight when a master caution light illuminated indicating a loss of the right hydraulic system pressure and hydraulic fluid. The FC used the checklist to trouble shoot the system. When the flight was about 10 miles from SFB the FC attempted to manually extend the main and nose landing gear (NLG) using the alternate extension control lever. Both main gear extended and locked into place; however the NLG did not extend. The FC communicated with the maintenance facilities in SFB and the airline's main base in Las Vegas, Nevada, for assistance in lowering the NLG, which was unsuccessful. The FC flew the airplane near the SFB control tower. The controller informed the FC that the NLG was in the retracted position and they could see fluid streaming from the aircraft. The FC continued to trouble shoot the system, and advised the passengers of the situation. The NLG would not extend after several attempts to lower the landing gear utilizing the alternate landing gear extension procedure. The captain declared an emergency, briefed the passengers, and landed on runway 9 with the NLG in the retracted position. PERSONNEL INFORMATION The captain, age 47, holds an airline transport pilot certificate with ratings for airplane multiengine land. He also holds a commercial pilot certificate with ratings for airplane single-engine land, and airplane instrument, which was issued on September 13, 2006. The captain holds a flight instructor certificate with ratings for airplane single-engine, airplane multiengine, and instrument airplane which was issued on December 19, 1994. The operator hired the captain on September 29, 2005, and he completed initial indoctrination training on October 7, 2005. Initial simulator qualification for the MD-80 was completed on November 22, 2005, and his initial operations check (IOE) was completed on December 11, 2005. He completed ground school for upgrade to captain in the MD-80 on September 6, 2006. Simulator training for the upgrade was completed on September 13, 2006, and his initial IOE/flight review, and line check as a captain was completed on October 30, 2006. His last simulator check before the accident was on March 7, 2007. He is type rated in the DC-9 and Lear jet. The captain has 7,145 total flight hours of which 2,996 hours are in the MD-80, and 105 hours as pilot-in-command. He holds a first-class medical certificate issued on May 22, 2007, without limitations or waivers. Review of the captain's training records revealed all pertinent aviation records pertaining to 14 CFR Part 121 airman competency and proficiency checks had been recorded as conducted. The first officer (FO), age 37, holds an airline transport pilot certificate with ratings for airplane multiengine land. He also holds a commercial pilot certificate with ratings for airplane single engine land, and airplane instrument which was issued on January 29, 2005. In addition, the FO holds a flight instructor certificate with ratings for airplane single-engine, airplane multiengine, and airplane instrument which was issued on March 21, 1999. The operator hired the FO on September 28, 2006. He completed initial indoctrination training and ground school for the MD-80 on October 26, 2006. Simulator training for qualification in the MD-80 was completed on November 7, 2006. He completed his initial IOE/ flight review on November 20, 2006 and was qualified as a FO on the MD-80. No additional simulator training or line checks were preformed before the accident. The FO is type rated in the Boeing 737, ATR-42 and ATR-72. The FO has 5,300 total flight hours of which 300 hours are in the MD-80. The FO holds a first-class medical certificate issued on March 14, 2007, without limitations or waivers. Review of the FO training records revealed all pertinent aviation records pertaining to 14 CFR Part 121 airman competency and proficiency checks had been recorded as conducted. A review of records provided by the operator revealed that the No.1 FA was hired on October 1, 2005. The FA completed initial flight attendant training on October 6, 2005, and her last recurrent training on the MD-80 was on October 18, 2006. The No.2 FA was hired on October 26, 2006. The FA completed initial flight attendant training on October 31, 2006. The No.3 FA was hired on October 1, 2005. The FA completed initial flight attendant training on October 10, 2005, and his last recurrent training on the MD-80 was on September 21, 2006. AIRCRAFT INFORMATION The DC-9-83 (MD-83), serial number 53467 is a twin-engine, medium range, single isle commercial jet airplane with a tricycle landing gear. McDonald Douglas manufactured the airplane in 1994. The airplane has a seating capacity of 3 flight crew, 4 flight attendants, and 150 passengers. The airplane has two rear fuselage-mounted Pratt and Whitney JT8D-219, 21,700 pounds of thrust turbo fan engines, small, highly efficient wings, and a T-tail. The airplane is in a continuous airworthiness program and the last A check was completed on March 20, 2007. The total airframe time at the time of the A check was 22, 138.8 hours. The left engine had 26309.3 total flight hours at the time of the accident, and had flown 70.8 hours since the last A check. The last engine shop visit was on December 6, 2005. The right engine had 20, 982 total flight hours at the time of the accident, and had flown 70.8 hours since the last A check. The last engine shop visit was on November 30, 2005. The last gear retraction test before the accident and emergency gear extension test was completed on April 26, 2004. METEOROLOGICAL INFORMATION The 1628 SFB surface weather observation was: wind 070 degrees at 16 knots gusting to 21 knots, visibility 10 miles, few clouds at 4,500 feet, temperature 27 degrees Celsius, dew point temperature 13 degrees Celsius, and altimeter 30.14 inches of mercury. FLIGHT RECORDERS The Fairchild Model A-100 cockpit voice recorder (CVR) was forwarded to the National Transportation Safety Board Vehicle Recorder Division for analysis. The CVR did not sustain any heat or structural damage and audio information was successfully extracted. The recording consisted of three channels of audio information containing captain and copilot hot microphones, interphone audio, and one channel containing cockpit area microphone audio. The accident events were captured on the recording, the audio offered no additional information that had not been obtained through other sources during the investigation. A CVR group was not formed and a transcript was not prepared. The Honeywell model 980-47, 64-word solid-state flight data recorder (SSFDR) was forwarded to the Safety Board for analysis. The recorder was in good condition and data was successfully extracted. The data indicates that approximately 51.1 minutes after take off, the right hydraulic low status transitioned from "Not Low" to "Low," and 3 minutes 21 seconds later, the left hydraulic low status also transitioned from