Narrative:

The error chain leading to the gear-up landing is extremely clear, in retrospect. The plan was to fly the newly-purchased aircraft to the aircraft's new home base in florida from the airport in northern illinois, where an annual inspection had just been completed by a repair station. On the morning of the planned departure. Several small minor maintenance discrepancies were still outstanding. The repair station completed the work, and a short test flight was accomplished, during which a few additional discrepancies were noted. Once those were also resolved, the PIC and 2 pilot-rated passenger finally departed, nearly 9 hours later than originally planned, at approximately XA40 CDT. This human factor was the first link in the error chain. The flight to the first fuel stop in tennessee was plagued with turbulence air and slight deviations to avoid convective WX, but was otherwise uneventful. After obtaining fuel, the PIC and passenger proceeded to a nearby restaurant and discussed the prospects of spending the night in a hotel and to continue the journey early the next day. Although everyone had already had a fairly long day, it was agreed that we should make an effort to get home to florida that night, even if it meant flying well into the night. This human factor was the second link in the error chain. Although a non-stop flight to florida from tennessee is possible in this type of aircraft, weight and balance restrs precluded carrying a full fuel load, so another fuel stop was planned in south georgia. It appeared that VFR flight would be possible along the entire route according to all available WX information. Therefore, the PIC departed VFR at approximately X030 CDT. During the climb, it appeared that there was a thin broken layer of clouds, so the PIC instructed the pilot-rated passenger occupying the copilot seat to obtain a pop-up IFR clearance from ATC to the destination airport in south georgia. Upon receiving the IFR clearance, the PIC climbed to 11000 ft MSL, and the flight proceeded uneventfully for the next 2 hours. Nearing the destination airport, fatigue was beginning to set in. In fact, just before beginning the descent, the PIC checked his vital signs using one of the passenger's pulse oxymeter and found that his pulse rate was 86 beats per min and oxygen level was 87%. These are surprisingly high numbers, considering that the PIC is accustomed to high altitude flight and maintains physical fitness through regulation cardiovascular exercise. This human factor was the third link in the error chain. During the initial descent to the destination airport, ATC instructed the flight to report the field in sight and issued IFR cancellation instructions. Although the pilot-rated passenger in the copilot seat spotted the airport beacon when the aircraft was approximately 10 mi away from the airport, the PIC elected to delay cancellation of IFR until he also was able to identify the beacon. The pilot-rated passenger in the copilot seat was somewhat familiar with the field and assured the PIC that there were no terrain or man-made obstructions between the aircraft and the airport, but the PIC nonetheless elected to maintain a safe published altitude and fly a wide visual pattern to runway 8. The PIC selected the landing gear handle to the down position, while turning to join a wide left downwind to runway 8, and proceeded to reduce power to fly a relatively slow traffic pattern. Simultaneously, the PIC was making gentle banked turns to try to spot the runway while on downwind leg. These tasks diverted the PIC's attention from confirming that the 3 green landing gear down-and-locked lights had illuminated. Also, the PIC did not notice that the 5-AMP landing gear control circuit breaker had popped. Unfortunately, this popped circuit breaker prevented the landing gear from extending normally. Additionally, this circuit breaker also prevented any of the gear unsafe warnings from functioning. In normal circumstances, these warnings consist of a red gear unsafe light as well as a gear unsafe warning horn actuated by either throttle being positioned to a low power setting. Therefore, the gear was still retracted, and none of these warnings occurred. This mechanical factor was the fourth link in the error chain. Upon turningfinal, the PIC visually idented the VASI, corrected for the right crosswind, and stabilized the approach to runway 8. This was the first night landing at a small, uncontrolled field without ILS guidance for the PIC, who is accustomed to landing on category ii and category III ILS runways at major airports. The PIC even noted out loud that this was the first time in yrs that he was landing at night on a runway without centerline lighting. As a result, the PIC was fully occupied with flying a stabilized visual approach with only VASI guidance, and again failed to notice that the '3 green' indication was missing. This human factor was the fifth link in the error chain. The PIC did an admirable job maintaining a stabilized approach and touched down on the runway centerline in the touchdown zone. If only the landing gear had been extended, it would have been a really nice landing. In addition to the specifically mentioned links in the error change, it is also worthwhile to mention the PIC's aeronautical experience. The PIC is a highly experienced pilot with nearly 10000 hours of experience, most of which is flying xport category turboprops and turbojets under far part 121. However, the gear-up landing event occurred in an aircraft, which the PIC had relatively little recent experience flying. This, coupled with the unfamiliarity with the destination airport and the myriad other human factors mentioned above, set the stage for the PIC to fail to notice the malfunction in the landing gear system. Furthermore, the fact that the PIC had pulled the landing gear lever on various high-performance piston, turboprop, and jet aircraft thousands of times before without a malfunction contributed to his mindset that 'when the gear handle is down, the gear is down.' in summary, the PIC was extremely fatigued, flying an unfamiliar aircraft in an unfamiliar environment and experienced a landing gear malfunction. All of these factors combined to the result of an inadvertent gear-up landing. Suggestions to enhance safety: treat every flight like a scheduled commercial flight by insuring proper rest before acting as PIC.

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Original NASA ASRS Text

Title: GA PLT HAS GEAR UP LNDG AT BHC.

Narrative: THE ERROR CHAIN LEADING TO THE GEAR-UP LNDG IS EXTREMELY CLR, IN RETROSPECT. THE PLAN WAS TO FLY THE NEWLY-PURCHASED ACFT TO THE ACFT'S NEW HOME BASE IN FLORIDA FROM THE ARPT IN NORTHERN ILLINOIS, WHERE AN ANNUAL INSPECTION HAD JUST BEEN COMPLETED BY A REPAIR STATION. ON THE MORNING OF THE PLANNED DEP. SEVERAL SMALL MINOR MAINT DISCREPANCIES WERE STILL OUTSTANDING. THE REPAIR STATION COMPLETED THE WORK, AND A SHORT TEST FLT WAS ACCOMPLISHED, DURING WHICH A FEW ADDITIONAL DISCREPANCIES WERE NOTED. ONCE THOSE WERE ALSO RESOLVED, THE PIC AND 2 PLT-RATED PAX FINALLY DEPARTED, NEARLY 9 HRS LATER THAN ORIGINALLY PLANNED, AT APPROX XA40 CDT. THIS HUMAN FACTOR WAS THE FIRST LINK IN THE ERROR CHAIN. THE FLT TO THE FIRST FUEL STOP IN TENNESSEE WAS PLAGUED WITH TURB AIR AND SLIGHT DEVS TO AVOID CONVECTIVE WX, BUT WAS OTHERWISE UNEVENTFUL. AFTER OBTAINING FUEL, THE PIC AND PAX PROCEEDED TO A NEARBY RESTAURANT AND DISCUSSED THE PROSPECTS OF SPENDING THE NIGHT IN A HOTEL AND TO CONTINUE THE JOURNEY EARLY THE NEXT DAY. ALTHOUGH EVERYONE HAD ALREADY HAD A FAIRLY LONG DAY, IT WAS AGREED THAT WE SHOULD MAKE AN EFFORT TO GET HOME TO FLORIDA THAT NIGHT, EVEN IF IT MEANT FLYING WELL INTO THE NIGHT. THIS HUMAN FACTOR WAS THE SECOND LINK IN THE ERROR CHAIN. ALTHOUGH A NON-STOP FLT TO FLORIDA FROM TENNESSEE IS POSSIBLE IN THIS TYPE OF ACFT, WT AND BAL RESTRS PRECLUDED CARRYING A FULL FUEL LOAD, SO ANOTHER FUEL STOP WAS PLANNED IN S GEORGIA. IT APPEARED THAT VFR FLT WOULD BE POSSIBLE ALONG THE ENTIRE RTE ACCORDING TO ALL AVAILABLE WX INFO. THEREFORE, THE PIC DEPARTED VFR AT APPROX X030 CDT. DURING THE CLB, IT APPEARED THAT THERE WAS A THIN BROKEN LAYER OF CLOUDS, SO THE PIC INSTRUCTED THE PLT-RATED PAX OCCUPYING THE COPLT SEAT TO OBTAIN A POP-UP IFR CLRNC FROM ATC TO THE DEST ARPT IN S GEORGIA. UPON RECEIVING THE IFR CLRNC, THE PIC CLBED TO 11000 FT MSL, AND THE FLT PROCEEDED UNEVENTFULLY FOR THE NEXT 2 HRS. NEARING THE DEST ARPT, FATIGUE WAS BEGINNING TO SET IN. IN FACT, JUST BEFORE BEGINNING THE DSCNT, THE PIC CHKED HIS VITAL SIGNS USING ONE OF THE PAX'S PULSE OXYMETER AND FOUND THAT HIS PULSE RATE WAS 86 BEATS PER MIN AND OXYGEN LEVEL WAS 87%. THESE ARE SURPRISINGLY HIGH NUMBERS, CONSIDERING THAT THE PIC IS ACCUSTOMED TO HIGH ALT FLT AND MAINTAINS PHYSICAL FITNESS THROUGH REG CARDIOVASCULAR EXERCISE. THIS HUMAN FACTOR WAS THE THIRD LINK IN THE ERROR CHAIN. DURING THE INITIAL DSCNT TO THE DEST ARPT, ATC INSTRUCTED THE FLT TO RPT THE FIELD IN SIGHT AND ISSUED IFR CANCELLATION INSTRUCTIONS. ALTHOUGH THE PLT-RATED PAX IN THE COPLT SEAT SPOTTED THE ARPT BEACON WHEN THE ACFT WAS APPROX 10 MI AWAY FROM THE ARPT, THE PIC ELECTED TO DELAY CANCELLATION OF IFR UNTIL HE ALSO WAS ABLE TO IDENT THE BEACON. THE PLT-RATED PAX IN THE COPLT SEAT WAS SOMEWHAT FAMILIAR WITH THE FIELD AND ASSURED THE PIC THAT THERE WERE NO TERRAIN OR MAN-MADE OBSTRUCTIONS BTWN THE ACFT AND THE ARPT, BUT THE PIC NONETHELESS ELECTED TO MAINTAIN A SAFE PUBLISHED ALT AND FLY A WIDE VISUAL PATTERN TO RWY 8. THE PIC SELECTED THE LNDG GEAR HANDLE TO THE DOWN POS, WHILE TURNING TO JOIN A WIDE L DOWNWIND TO RWY 8, AND PROCEEDED TO REDUCE PWR TO FLY A RELATIVELY SLOW TFC PATTERN. SIMULTANEOUSLY, THE PIC WAS MAKING GENTLE BANKED TURNS TO TRY TO SPOT THE RWY WHILE ON DOWNWIND LEG. THESE TASKS DIVERTED THE PIC'S ATTN FROM CONFIRMING THAT THE 3 GREEN LNDG GEAR DOWN-AND-LOCKED LIGHTS HAD ILLUMINATED. ALSO, THE PIC DID NOT NOTICE THAT THE 5-AMP LNDG GEAR CTL CIRCUIT BREAKER HAD POPPED. UNFORTUNATELY, THIS POPPED CIRCUIT BREAKER PREVENTED THE LNDG GEAR FROM EXTENDING NORMALLY. ADDITIONALLY, THIS CIRCUIT BREAKER ALSO PREVENTED ANY OF THE GEAR UNSAFE WARNINGS FROM FUNCTIONING. IN NORMAL CIRCUMSTANCES, THESE WARNINGS CONSIST OF A RED GEAR UNSAFE LIGHT AS WELL AS A GEAR UNSAFE WARNING HORN ACTUATED BY EITHER THROTTLE BEING POSITIONED TO A LOW PWR SETTING. THEREFORE, THE GEAR WAS STILL RETRACTED, AND NONE OF THESE WARNINGS OCCURRED. THIS MECHANICAL FACTOR WAS THE FOURTH LINK IN THE ERROR CHAIN. UPON TURNINGFINAL, THE PIC VISUALLY IDENTED THE VASI, CORRECTED FOR THE R XWIND, AND STABILIZED THE APCH TO RWY 8. THIS WAS THE FIRST NIGHT LNDG AT A SMALL, UNCTLED FIELD WITHOUT ILS GUIDANCE FOR THE PIC, WHO IS ACCUSTOMED TO LNDG ON CATEGORY II AND CATEGORY III ILS RWYS AT MAJOR ARPTS. THE PIC EVEN NOTED OUT LOUD THAT THIS WAS THE FIRST TIME IN YRS THAT HE WAS LNDG AT NIGHT ON A RWY WITHOUT CTRLINE LIGHTING. AS A RESULT, THE PIC WAS FULLY OCCUPIED WITH FLYING A STABILIZED VISUAL APCH WITH ONLY VASI GUIDANCE, AND AGAIN FAILED TO NOTICE THAT THE '3 GREEN' INDICATION WAS MISSING. THIS HUMAN FACTOR WAS THE FIFTH LINK IN THE ERROR CHAIN. THE PIC DID AN ADMIRABLE JOB MAINTAINING A STABILIZED APCH AND TOUCHED DOWN ON THE RWY CTRLINE IN THE TOUCHDOWN ZONE. IF ONLY THE LNDG GEAR HAD BEEN EXTENDED, IT WOULD HAVE BEEN A REALLY NICE LNDG. IN ADDITION TO THE SPECIFICALLY MENTIONED LINKS IN THE ERROR CHANGE, IT IS ALSO WORTHWHILE TO MENTION THE PIC'S AERONAUTICAL EXPERIENCE. THE PIC IS A HIGHLY EXPERIENCED PLT WITH NEARLY 10000 HRS OF EXPERIENCE, MOST OF WHICH IS FLYING XPORT CATEGORY TURBOPROPS AND TURBOJETS UNDER FAR PART 121. HOWEVER, THE GEAR-UP LNDG EVENT OCCURRED IN AN ACFT, WHICH THE PIC HAD RELATIVELY LITTLE RECENT EXPERIENCE FLYING. THIS, COUPLED WITH THE UNFAMILIARITY WITH THE DEST ARPT AND THE MYRIAD OTHER HUMAN FACTORS MENTIONED ABOVE, SET THE STAGE FOR THE PIC TO FAIL TO NOTICE THE MALFUNCTION IN THE LNDG GEAR SYS. FURTHERMORE, THE FACT THAT THE PIC HAD PULLED THE LNDG GEAR LEVER ON VARIOUS HIGH-PERFORMANCE PISTON, TURBOPROP, AND JET ACFT THOUSANDS OF TIMES BEFORE WITHOUT A MALFUNCTION CONTRIBUTED TO HIS MINDSET THAT 'WHEN THE GEAR HANDLE IS DOWN, THE GEAR IS DOWN.' IN SUMMARY, THE PIC WAS EXTREMELY FATIGUED, FLYING AN UNFAMILIAR ACFT IN AN UNFAMILIAR ENVIRONMENT AND EXPERIENCED A LNDG GEAR MALFUNCTION. ALL OF THESE FACTORS COMBINED TO THE RESULT OF AN INADVERTENT GEAR-UP LNDG. SUGGESTIONS TO ENHANCE SAFETY: TREAT EVERY FLT LIKE A SCHEDULED COMMERCIAL FLT BY INSURING PROPER REST BEFORE ACTING AS PIC.

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.