|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Locale Reference||airport : ffo.airport|
|Altitude||agl single value : 0|
|Controlling Facilities||tower : ffo.tower|
tracon : mke.tracon
|Operator||general aviation : instructional|
|Make Model Name||PA-28 Cherokee Arrow IV|
|Operating Under FAR Part||Part 91|
|Flight Phase||descent : approach|
|Route In Use||approach : visual|
|Function||instruction : trainee|
|Qualification||pilot : multi engine|
pilot : instrument
pilot : commercial
|Experience||flight time last 90 days : 2.3|
flight time total : 3100
flight time type : 0
|Function||instruction : instructor|
|Anomaly||non adherence : published procedure|
|Independent Detector||other flight crewa|
other flight crewb
|Resolutory Action||none taken : detected after the fact|
|Problem Areas||ATC Human Performance|
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
The mission was planned and flown from the local aeronautical club for my chkout in the piper arrow iv; my night chkout and instrument chkout. The final event of the evening was a full stop on runway 23L at ffo. After being cleared left closed off of runway 23L; I proceeded to downwind at 1800 ft MSL; at which time the instructor pilot informed me that we would simulate an engine out landing to complete the arrow chkout. I was unsure of which runway the tower wanted us to full stop on; and did not want to turn base until I knew which runway to proceed to. After determining that we were to full stop on runway 23L; we simulated an engine failure. By this time we were slightly extended on downwind. I simultaneously turned base; set up best glide speed and grabbed for the gear handle as I came off the perch. However; since we were extended; I opted to delay configuring the aircraft to extend the glide. The instructor pilot performed the base radio call and called 'gear down.' I told the instructor pilot that I didn't think I'd make the runway; but that I would make the airfield for the simulation. I cleared the engine to ensure power would still be available. The instructor pilot noted that I had not set the propeller to full decrease for the engine out and that I was not in the minimum drag confign. I promptly reset the propeller lever appropriately and noted what seemed to be an improved glide. Shortly thereafter; I added propeller and power in order to land on runway 23L for the full stop. I noted to the instructor pilot the higher pitch attitude due to the zero flap condition and set myself up for a no-flap landing. Upon touchdown; we heard the scraping and I initially thought that the gear had collapsed; but quickly realized we had landed gear up. We had touched down approximately 5 ft right of centerline; wings level in a slightly nose high attitude. The landing was surprisingly non violent and there were no injuries. I shut off the fuel and ignition while the instructor pilot shut off the electrical system. We egressed and waited for a response from the ffo fire department. After the aircraft was jacked up; the gear were dropped and it was towed back to the aeronautical club. Other than the propeller; there was little apparent damage; although the mechanic is still investigating. In my opinion; a root cause was the lack of an aircraft specific habit pattern and the interruption of the generic 'gump' check due to the engine out scenario. My decision to delay confign was correct for the scenario; however; normal procedures can never be neglected for real or simulated emergencys. Neither the instructor pilot nor I recalled hearing the landing gear warning horn on the approach; although it had been working normally earlier in the flight. After touchdown; I specifically listened for the horn and heard it prior to shutting down power. I suspect it may have been working normally; but I can't explain why neither of us heard it. I don't feel my personal factors had a significant impact. I had been somewhat frustrated with domestic chores; a sick pet; etc; but I have always found the focus I achieve while flying to actually be helpful. Keeping these issues in mind; I had performed a personal preflight (ie; I wasn't ill; I was a little fatigued; but had ample sleep. I had eaten and was hydrated; and I had prepared for the chkout). In hindsight; I can't be totally objective and; therefore; can't eliminate personal issues; but I don't think they were a significant factor. I was not relying on the instructor pilot as a safety net and was; in fact; treating the instructor pilot more as a check pilot. Why the instructor pilot didn't catch the gear when I missed it I can't say; although my experience level may have been an issue (high time military pilot). Our crew coordination had been good throughout the flight prior to this event. I was specifically concerned about complacency before the flight; and had made an effort to counter it before and during the flight. I can't be totally unbiased; but I feel my chain can be described as follows: 1) unrecognized task saturation on downwind (confusion over landing runway; extended downwind and glide; correction of improper propeller setting). 2) poor prioritization (failure to accomplish normal 'gump' check due to concentrating on the engine-out scenario). Prevention: awareness of potential task saturation and strict adherence to normal procedures in real or simulated emergencys. Callback conversation with reporter revealed the following information: the reporter advised they were using headsets; but didn't believe either were of the noise canceling variety.
Original NASA ASRS Text
Title: PLT AND INSTRUCTOR PLT ABOARD PA28T LAND GEAR UP FOLLOWING SIMULATED ENG FAILURE MANEUVER.
Narrative: THE MISSION WAS PLANNED AND FLOWN FROM THE LCL AERO CLUB FOR MY CHKOUT IN THE PIPER ARROW IV; MY NIGHT CHKOUT AND INST CHKOUT. THE FINAL EVENT OF THE EVENING WAS A FULL STOP ON RWY 23L AT FFO. AFTER BEING CLRED L CLOSED OFF OF RWY 23L; I PROCEEDED TO DOWNWIND AT 1800 FT MSL; AT WHICH TIME THE INSTRUCTOR PLT INFORMED ME THAT WE WOULD SIMULATE AN ENG OUT LNDG TO COMPLETE THE ARROW CHKOUT. I WAS UNSURE OF WHICH RWY THE TWR WANTED US TO FULL STOP ON; AND DID NOT WANT TO TURN BASE UNTIL I KNEW WHICH RWY TO PROCEED TO. AFTER DETERMINING THAT WE WERE TO FULL STOP ON RWY 23L; WE SIMULATED AN ENG FAILURE. BY THIS TIME WE WERE SLIGHTLY EXTENDED ON DOWNWIND. I SIMULTANEOUSLY TURNED BASE; SET UP BEST GLIDE SPD AND GRABBED FOR THE GEAR HANDLE AS I CAME OFF THE PERCH. HOWEVER; SINCE WE WERE EXTENDED; I OPTED TO DELAY CONFIGURING THE ACFT TO EXTEND THE GLIDE. THE INSTRUCTOR PLT PERFORMED THE BASE RADIO CALL AND CALLED 'GEAR DOWN.' I TOLD THE INSTRUCTOR PLT THAT I DIDN'T THINK I'D MAKE THE RWY; BUT THAT I WOULD MAKE THE AIRFIELD FOR THE SIMULATION. I CLRED THE ENG TO ENSURE PWR WOULD STILL BE AVAILABLE. THE INSTRUCTOR PLT NOTED THAT I HAD NOT SET THE PROP TO FULL DECREASE FOR THE ENG OUT AND THAT I WAS NOT IN THE MINIMUM DRAG CONFIGN. I PROMPTLY RESET THE PROP LEVER APPROPRIATELY AND NOTED WHAT SEEMED TO BE AN IMPROVED GLIDE. SHORTLY THEREAFTER; I ADDED PROP AND PWR IN ORDER TO LAND ON RWY 23L FOR THE FULL STOP. I NOTED TO THE INSTRUCTOR PLT THE HIGHER PITCH ATTITUDE DUE TO THE ZERO FLAP CONDITION AND SET MYSELF UP FOR A NO-FLAP LNDG. UPON TOUCHDOWN; WE HEARD THE SCRAPING AND I INITIALLY THOUGHT THAT THE GEAR HAD COLLAPSED; BUT QUICKLY REALIZED WE HAD LANDED GEAR UP. WE HAD TOUCHED DOWN APPROX 5 FT R OF CTRLINE; WINGS LEVEL IN A SLIGHTLY NOSE HIGH ATTITUDE. THE LNDG WAS SURPRISINGLY NON VIOLENT AND THERE WERE NO INJURIES. I SHUT OFF THE FUEL AND IGNITION WHILE THE INSTRUCTOR PLT SHUT OFF THE ELECTRICAL SYS. WE EGRESSED AND WAITED FOR A RESPONSE FROM THE FFO FIRE DEPT. AFTER THE ACFT WAS JACKED UP; THE GEAR WERE DROPPED AND IT WAS TOWED BACK TO THE AERO CLUB. OTHER THAN THE PROP; THERE WAS LITTLE APPARENT DAMAGE; ALTHOUGH THE MECH IS STILL INVESTIGATING. IN MY OPINION; A ROOT CAUSE WAS THE LACK OF AN ACFT SPECIFIC HABIT PATTERN AND THE INTERRUPTION OF THE GENERIC 'GUMP' CHK DUE TO THE ENG OUT SCENARIO. MY DECISION TO DELAY CONFIGN WAS CORRECT FOR THE SCENARIO; HOWEVER; NORMAL PROCS CAN NEVER BE NEGLECTED FOR REAL OR SIMULATED EMERS. NEITHER THE INSTRUCTOR PLT NOR I RECALLED HEARING THE LNDG GEAR WARNING HORN ON THE APCH; ALTHOUGH IT HAD BEEN WORKING NORMALLY EARLIER IN THE FLT. AFTER TOUCHDOWN; I SPECIFICALLY LISTENED FOR THE HORN AND HEARD IT PRIOR TO SHUTTING DOWN PWR. I SUSPECT IT MAY HAVE BEEN WORKING NORMALLY; BUT I CAN'T EXPLAIN WHY NEITHER OF US HEARD IT. I DON'T FEEL MY PERSONAL FACTORS HAD A SIGNIFICANT IMPACT. I HAD BEEN SOMEWHAT FRUSTRATED WITH DOMESTIC CHORES; A SICK PET; ETC; BUT I HAVE ALWAYS FOUND THE FOCUS I ACHIEVE WHILE FLYING TO ACTUALLY BE HELPFUL. KEEPING THESE ISSUES IN MIND; I HAD PERFORMED A PERSONAL PREFLT (IE; I WASN'T ILL; I WAS A LITTLE FATIGUED; BUT HAD AMPLE SLEEP. I HAD EATEN AND WAS HYDRATED; AND I HAD PREPARED FOR THE CHKOUT). IN HINDSIGHT; I CAN'T BE TOTALLY OBJECTIVE AND; THEREFORE; CAN'T ELIMINATE PERSONAL ISSUES; BUT I DON'T THINK THEY WERE A SIGNIFICANT FACTOR. I WAS NOT RELYING ON THE INSTRUCTOR PLT AS A SAFETY NET AND WAS; IN FACT; TREATING THE INSTRUCTOR PLT MORE AS A CHK PLT. WHY THE INSTRUCTOR PLT DIDN'T CATCH THE GEAR WHEN I MISSED IT I CAN'T SAY; ALTHOUGH MY EXPERIENCE LEVEL MAY HAVE BEEN AN ISSUE (HIGH TIME MIL PLT). OUR CREW COORD HAD BEEN GOOD THROUGHOUT THE FLT PRIOR TO THIS EVENT. I WAS SPECIFICALLY CONCERNED ABOUT COMPLACENCY BEFORE THE FLT; AND HAD MADE AN EFFORT TO COUNTER IT BEFORE AND DURING THE FLT. I CAN'T BE TOTALLY UNBIASED; BUT I FEEL MY CHAIN CAN BE DESCRIBED AS FOLLOWS: 1) UNRECOGNIZED TASK SATURATION ON DOWNWIND (CONFUSION OVER LNDG RWY; EXTENDED DOWNWIND AND GLIDE; CORRECTION OF IMPROPER PROP SETTING). 2) POOR PRIORITIZATION (FAILURE TO ACCOMPLISH NORMAL 'GUMP' CHK DUE TO CONCENTRATING ON THE ENG-OUT SCENARIO). PREVENTION: AWARENESS OF POTENTIAL TASK SATURATION AND STRICT ADHERENCE TO NORMAL PROCS IN REAL OR SIMULATED EMERS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR ADVISED THEY WERE USING HEADSETS; BUT DIDN'T BELIEVE EITHER WERE OF THE NOISE CANCELING VARIETY.
Data retrieved from NASA's ASRS site as of January 2009 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.