Narrative:

Pilot's failure to lower gear ILS runway 23 btl. How problem arose: checklist (audio 'heads-up' checklist in use) not completed during approach. '3 green, gear in mirror' overlooked. Contributing factors: multiple short early morning IFR flight plans. Reviewing and referring to multiple commercial charts in 24 min IFR flight oeb to arb to pick up passenger involving detroit STAR with unfamiliar procedures and cruxx intersection prior to landing. Loading passenger for short 20 min flight arb to btl. More of same unfamiliar IFR destination procedures for fueling prior to 4 hour IFR to home destination bjc. Additionally, A10 warthog in trail on ILS at btl adding a notch of concern. Excitement of seeing passenger relative after long absence and the rapid single pilot IFR complexity of the unfamiliar area in retrospect were all factors. When things are happening rapidly in single pilot operation, reliance defaults to flying patterns that may be faulty -- in this case, rigidly following checklist and flight procedures. How discovered: btl tower personnel observed and immediately called information, 'gear not extended' short final inside the marker (batol), below decision ht at approximately 100 ft AGL during ILS approach. Corrective action: gear quickly lowered and uneventful landing completed without incident. Future emphasis on checklist techniques and their completion. Consider shortening before landing checklist to 'G' for gear on final. Review gear horn function with maintenance. Explore possibility of having it set to come on at higher torque setting. Human performance considerations, perceptions, judgements, decisions: in this instance, a plan to travel to multiple airports IFR prior to the primary destination open for examination. Travel to the first airport arb and remain overnight the prior night would have eliminated the first destination. The second destination btl was selected for lower priced fuel, and was 'false economy' in retrospect, and could have been eliminated altogether. These are then weighed against the goal of maximum utility of the aircraft. Actions or inactions: clearly the checklist and good procedure is paramount here. Factors affecting the quality of human performance: perhaps when focus is on visiting and travel, flying becomes secondary, when clearly all of the thought and efforts surrounding the activity of flying must always be primary focus, with all other set aside. Heeding the lessons of well motivated, careful training, and placing them into action, developing superior second nature skills is a difficult and unending task.

Google
 

Original NASA ASRS Text

Title: PA31T ACFT ON APCH, RPTR UNFAMILIAR WITH ARPT AND APCH PROCS FAILED TO COMPLETE LNDG CHKLIST AND ALMOST LANDED GEAR UP IF THE TWR CTLR HADN'T WARNED HIM.

Narrative: PLT'S FAILURE TO LOWER GEAR ILS RWY 23 BTL. HOW PROB AROSE: CHKLIST (AUDIO 'HEADS-UP' CHKLIST IN USE) NOT COMPLETED DURING APCH. '3 GREEN, GEAR IN MIRROR' OVERLOOKED. CONTRIBUTING FACTORS: MULTIPLE SHORT EARLY MORNING IFR FLT PLANS. REVIEWING AND REFERRING TO MULTIPLE COMMERCIAL CHARTS IN 24 MIN IFR FLT OEB TO ARB TO PICK UP PAX INVOLVING DETROIT STAR WITH UNFAMILIAR PROCS AND CRUXX INTXN PRIOR TO LNDG. LOADING PAX FOR SHORT 20 MIN FLT ARB TO BTL. MORE OF SAME UNFAMILIAR IFR DEST PROCS FOR FUELING PRIOR TO 4 HR IFR TO HOME DEST BJC. ADDITIONALLY, A10 WARTHOG IN TRAIL ON ILS AT BTL ADDING A NOTCH OF CONCERN. EXCITEMENT OF SEEING PAX RELATIVE AFTER LONG ABSENCE AND THE RAPID SINGLE PLT IFR COMPLEXITY OF THE UNFAMILIAR AREA IN RETROSPECT WERE ALL FACTORS. WHEN THINGS ARE HAPPENING RAPIDLY IN SINGLE PLT OP, RELIANCE DEFAULTS TO FLYING PATTERNS THAT MAY BE FAULTY -- IN THIS CASE, RIGIDLY FOLLOWING CHKLIST AND FLT PROCS. HOW DISCOVERED: BTL TWR PERSONNEL OBSERVED AND IMMEDIATELY CALLED INFO, 'GEAR NOT EXTENDED' SHORT FINAL INSIDE THE MARKER (BATOL), BELOW DECISION HT AT APPROX 100 FT AGL DURING ILS APCH. CORRECTIVE ACTION: GEAR QUICKLY LOWERED AND UNEVENTFUL LNDG COMPLETED WITHOUT INCIDENT. FUTURE EMPHASIS ON CHKLIST TECHNIQUES AND THEIR COMPLETION. CONSIDER SHORTENING BEFORE LNDG CHKLIST TO 'G' FOR GEAR ON FINAL. REVIEW GEAR HORN FUNCTION WITH MAINT. EXPLORE POSSIBILITY OF HAVING IT SET TO COME ON AT HIGHER TORQUE SETTING. HUMAN PERFORMANCE CONSIDERATIONS, PERCEPTIONS, JUDGEMENTS, DECISIONS: IN THIS INSTANCE, A PLAN TO TRAVEL TO MULTIPLE ARPTS IFR PRIOR TO THE PRIMARY DEST OPEN FOR EXAMINATION. TRAVEL TO THE FIRST ARPT ARB AND REMAIN OVERNIGHT THE PRIOR NIGHT WOULD HAVE ELIMINATED THE FIRST DEST. THE SECOND DEST BTL WAS SELECTED FOR LOWER PRICED FUEL, AND WAS 'FALSE ECONOMY' IN RETROSPECT, AND COULD HAVE BEEN ELIMINATED ALTOGETHER. THESE ARE THEN WEIGHED AGAINST THE GOAL OF MAX UTILITY OF THE ACFT. ACTIONS OR INACTIONS: CLRLY THE CHKLIST AND GOOD PROC IS PARAMOUNT HERE. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE: PERHAPS WHEN FOCUS IS ON VISITING AND TRAVEL, FLYING BECOMES SECONDARY, WHEN CLRLY ALL OF THE THOUGHT AND EFFORTS SURROUNDING THE ACTIVITY OF FLYING MUST ALWAYS BE PRIMARY FOCUS, WITH ALL OTHER SET ASIDE. HEEDING THE LESSONS OF WELL MOTIVATED, CAREFUL TRAINING, AND PLACING THEM INTO ACTION, DEVELOPING SUPERIOR SECOND NATURE SKILLS IS A DIFFICULT AND UNENDING TASK.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.