What happened
On 9 January 2015, a pilot in-command-under-supervision (ICUS), and a supervising pilot, operated a Piper PA-31-350 aircraft, registered VH-TXK, on a charter flight from Palm Island to Townsville, Queensland, with seven passengers on board. At about 1630 Eastern Standard Time (EST), air traffic control (ATC) cleared the aircraft to conduct a visual approach via a left base, to runway 07 at Townsville Airport.
When about 4 NM from the runway, the pilot ICUS performed the pre-landing checks, but omitted to extend the landing gear. The supervising pilot confirmed the mixture, fuel pumps and landing lights had been set correctly, and assumed the rest of the checks had been similarly completed. As the aircraft turned from base to final for runway 07, the supervising pilot alerted the pilot ICUS that the aircraft was too high, which the pilot ICUS immediately corrected by selecting full flap and a lower nose attitude. As the aircraft was then slightly higher and faster than for a normal approach, the pilot ICUS reduced the throttle to idle slighter earlier than normal. As he flared the aircraft to land, he anticipated the landing gear touching down on the runway, but as it did not occur when he expected, he commenced a go-around. At the same time, the supervising pilot expected the landing gear to touch down and called ‘go around’. Neither of the pilots heard an aural gear warning horn sound.
As the pilot ICUS commenced the go-around, a VHF antenna fitted to the underside of the aircraft fuselage contacted the runway and both pilots heard a scraping sound. The pilots broadcast ‘going around’ and did not receive a response. After a second call to ATC also did not elicit a response, the supervising pilot selected the second VHF radio (COMM2) and was then able to communicate with ATC. When at about 50 ft above ground level (AGL), the pilot ICUS observed the landing gear lever in the UP position, and was then unsure whether he had omitted to select the landing gear DOWN during the pre-landing checks, or whether a technical fault had occurred.
The supervising pilot assumed that there was a technical fault with the landing gear and prepared to perform a manual gear extension. The pilot ICUS established the aircraft in a slow cruise configuration at about 1,400 ft (AGL), extended flap and, when the aircraft was below the maximum gear extension speed, selected the landing gear lever to the extended position. The landing gear extended and locked and three green lights indicated a safe extension. The pilot ICUS confirmed visually that the nose landing gear was extended. The pilots discussed the option of conducting a fly-by to verify the landing gear had extended fully, but elected to return for a landing. The aircraft subsequently landed on runway 07 without further incident.
The VHF antenna was found on the runway, having broken off from the underside of the aircraft after striking the runway (Figures 1 and 2). Two aerodynamic fins also sustained minor scrapes from the runway. The pilots and passengers were uninjured in the occurrence and a subsequent engineering inspection found that the landing gear warning horn was serviceable.
Figure 1: Broken antenna
Source: Aircraft operator
Figure 2: Photo of new antenna fitted to VH-TXK
Source: Aircraft operator
Pilot comments
The pilots provided the following comments:
- The pre-landing and finals checks were conducted from memory, rather than a written checklist. With a pilot ICUS and supervising pilot, the pilot may have vocalised the checks as they were being performed, but on this flight the pilot ICUS could not recall vocalising the checks and the supervising pilot did not recall hearing them. The company did not have standard procedures for ICUS flights.
- Neither pilot completed checks when on final to confirm the landing gear indicated three green lights. The supervising pilot reported that when landing on runway 07 late in the afternoon, the position of the sun often made the cockpit display, including the landing gear indication, appear to be illuminated.
- The stall warning would normally sound during the landing phase in that aircraft. Neither pilot recalled hearing the aural stall warning or landing gear warning horn. As the aircraft was on a slightly higher and faster approach than normal, the pilot ICUS reduced the throttle to idle earlier than for a normal landing. This should have activated the landing gear warning, unless the throttle levers were not retarded to a position fully against the idle stops.
- The pilot ICUS had used written checklists when operating other aircraft, but had been trained to perform checks from memory for the PA-31.
Aircraft operator comments
The pilot ICUS held the appropriate endorsements for the aircraft and had 47.7 hours experience on the aircraft type. His total flying time was 319.5 hours. The aircraft insurer required a pilot to hold a minimum of 600 hours total time to operate the aircraft as pilot in command, hence the pilot was operating under supervision.
As they do not normally conduct two-pilot operations, they did not have a training program in place for such operations.
Department of Defence investigation
The Department of Defence conducted an internal investigation into the incident and reported that, during normal operations, the Tower controller was required to scan an aircraft during critical stages of flight. This included monitoring that the aircraft was on the appropriate track, level and positioned for the correct runway. They were also required to scan for any abnormalities with the aircraft. It was normal process for all Townsville air traffic controllers to visually scan the undercarriage status of all aircraft on final approach.
The Tower controller could not recall specifically observing the position of the aircraft’s landing gear when scanning the aircraft on final approach, but the position of the sun at the time of the incident may have affected the Tower controller’s ability to observe the aircraft’s landing gear.
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Aircraft operator
As a result of this occurrence, the aircraft operator has advised the ATSB that pilots will henceforth require a minimum of 600 hours total aeronautical experience prior to operating that aircraft type. Company pilots will receive additional experience and training prior to operating as supervising pilots.
Department of Defence
As a result of this occurrence, the Department of Defence has advised the ATSB that they are taking the following safety actions:
- A safety awareness poster was created and displayed in prominent locations for Townsville based controllers to view, describing an ‘effective scan’.
- Townsville controllers were briefed on the importance of proper scan technique during the critical stages of an aircraft’s flight. Particular mention was made of the importance of checking the status of the landing gear when an aircraft is cleared to land.
Safety message
This incident is a reminder for pilots and operators of the limitations of human performance and highlights the need to follow procedures and complete checklists diligently.
Aviation Short Investigations Bulletin - Issue 40
Purpose of safety investigationsThe objective of a safety investigation is to enhance transport safety. This is done through:
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. TerminologyAn explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing informationReleased in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2015 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly. |