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AIRCRAFT SERIOUS INCIDENT SHORT REPORT

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Overview

This document is an Aircraft Serious Incident Short Report concerning a landing gear malfunction on a Beechcraft King Air 90 (F90) registered as ZS-MHM. The incident occurred on March 8, 2017, during a private flight from Lanseria Aerodrome to Rand Aerodrome. The report details the sequence of events leading to the incident, including the pilot's attempts to troubleshoot the landing gear issue and the subsequent runway excursion following a landing attempt. The investigation aims to promote aviation safety and does not assign blame or liability. It includes factual information about the pilot's qualifications, the aircraft's maintenance history, and the probable cause of the incident, which was attributed to a failure in the landing gear motor and manual extension system.

  • The incident involved a Beechcraft King Air 90 (F90) registered as ZS-MHM.
  • The pilot experienced a landing gear unsafe warning during approach to Rand Aerodrome.
  • Manual extension of the landing gear was attempted but failed to secure the gear in the down position.
  • The aircraft sustained damage to the lower fuselage, landing gear doors, and propellers during the runway excursion.
  • The probable cause was a failure in the landing gear motor and manual extension system.

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Source

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Document details

Type
Other Documents
Year
2018
Pages
12
File size
781 KB
Publisher
caasanwebsitestorage.blob.core.windows.net
How rare is it?
7Beechcraft King Air 90 registered worldwide · 0 active

Common. Rarer than 8% of the aircraft models we track.

Documentation completeness
2/7

Most owners only have the POH. Here's the essential set for the Beechcraft King Air 90.

  • Pilot's Operating Handbook / AFM
  • Checklist
  • Maintenance Manual
  • Parts Catalog (IPC)
  • Systems & Wiring
  • Service Bulletins
  • Type Certificate (TCDS)

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In this document

Synopsis

The pilot, the sole occupant of the Beechcraft King Air 90, experienced a landing gear unsafe warning while approaching Rand Aerodrome. After troubleshooting and attempting to manually extend the landing gear, the pilot chose to land on runway 29. Upon touchdown, the landing gear collapsed, leading to a runway excursion.

History of Flight

The flight originated from Sir Seretse Khama International Airport and was intended to reposition the aircraft to Rand Aerodrome. During the approach, the pilot received a landing gear unsafe warning and attempted to troubleshoot the issue. Despite following the manual extension procedure, the landing gear did not fully extend, leading to a crash landing.

Factual Information

The pilot held a valid commercial pilot’s license with over 2,300 flying hours, including 1,120 on the King Air 90. The aircraft was manufactured in 1980 and had a valid certificate of airworthiness. The last maintenance inspection was conducted on April 22, 2016, at 5,318.6 airframe hours.

Probable Cause

The primary cause of the incident was the inability to lower the landing gear into the down and locked position, resulting in a collapse shortly after touchdown.

Contributing Factors

Factors contributing to the incident included a failure in the landing gear motor and insufficient pressure applied to the manual extension system, which may have caused the landing gear to partially extend but not lock.

Safety notes

  • If the green GEAR DOWN lights do not illuminate, continue pumping until sufficient resistance is felt to ensure that the gear is down and locked, even though this may damage the drive mechanism.

Full document text

CA 12-40 13 February 2018 Page 1 of 12 Section/division Accident and Incident Investigations Division Form Number: CA 12-40 AIRCRAFT SERIOUS INCIDENT SHORT REPORT CA18/3/2/1162: ZS-MHM, Landing gear related malfunction resulting in a runway excursion Date and time : 8 March 2017, 1730Z Occurrence type : Serious Incident Aircraft registration : ZS-MHM Aircraft manufacturer and model : Beechcraft King Air 90 (F90) Last point of departure : Lanseria Aerodrome (FALA) Next point of intended landing : Rand Aerodrome (FAGM) Location of incident site with reference to easily defined geographical points (GPS readings if possible) At FAGM to the left of runway 29 on the grass (26°14’ 32.87” South 028°08’ 54.55” East) Meteorological information : METAR FAOR 081730Z VRB03KT CAVOK 22/09 Q1021 NOSIG= Type of operation : Private (Part 91) Persons on board : 1 + 0 Injuries : None Damage to aircraft : Lower fuselage, landing gear doors, flaps, both propellers, lower engine nacelles. All times given in this report is Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the Investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (2011) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish blame or liability. Disclaimer: This report is produced without prejudice to the rights of the CAA, which are reserved. CA 12-40 13 February 2018 Page 2 of 12 1. SYNOPSIS 1.1 The pilot being the sole occupant on board the aircraft departed FALA with the intention of repositioning the aircraft to FAGM. On approach to runway 11 at FAGM, the pilot observed a landing gear unsafe warning. 1.2 The pilot carried out troubleshooting and attempted to manually extend the landing gear. After the troubleshooting process the pilot elected to use runway 29 for landing. On touch down the landing gear collapsed causing the aircraft to lose directional control and exit the runway to the left. 2. HISTORY OF FLIGHT 2.1 On Wednesday, 8 March 2017, the pilot accompanied by two passengers departed Sir Seretse Khama International Airport (FBSK) in Botswana on a non-schedule international flight to Lanseria Airport (FALA) in Johannesburg. On arrival at FALA the three occupants disembarked from the aircraft and cleared customs. On completion of this procedure, the pilot being the sole occupant on board repositioned the aircraft to Rand Aerodrome (FAGM) where it was hangered. 2.2 The pilot was cleared by air traffic control (ATC) at FAGM to land Runway 11. On final approach the pilot observed that he had a landing gear unsafe warning and requested to perform a go around. The warning to the pilot was the landing gear switch light that illuminated, this light cannot be cancelled. The aircraft was also equipped with an intermittent warning horn. He then requested ATC to observe if the landing gear was down as he performed a low level fly past the tower. 2.3 ATC reported that the landing gear does not appear to be down as the nose gear was only partially extended and the main landing gears were not visible. The pilot then advised ATC that he will be routing to the general flying area to try and rectify the problem. He indicated that he cycled the gear several times but failed to obtain three green lights in the cockpit. He then engaged the auto pilot and followed the landing gear manual extension procedure as stipulated in the pilot’s operating handbook (POH), Section 3 as listed below: 1. Airspeed - ESTABLISH 125 KNOTS 2. Landing Gear Relay Circuit Breaker (pilot’s right subpanel) - PULL 3. Landing Gear Switch Handle - DOWN CA 12-40 13 February 2018 Page 3 of 12 4. Emergency Engage Handle - LIFT AND TURN CLOCKWISE TO THE STOP TO ENGAGE 5. Extension lever - PUMP up and down until 3 green GEAR DOWN lights are illuminated WARNING If for any reason the green GEAR DOWN lights do not illuminate (i.e., in case of electrical system failure), continue pumping until sufficient resistance is felt to ensure that the gear is down and locked, even though this procedure may damage the drive mechanism. 2.4 After being airborne for approximately 40 minutes he was still not able to obtain three green lights. He then opted to return to FAGM and requested another fly past and asked ATC if they can observe the position of the landing gear. 2.5 The pilot was advised that the landing gear appears to be down. At this stage it was dark already and it was difficult for people in the tower to make an accurate observation of the landing gear position. The pilot again informed them that he did not have three green lights in the cockpit. 2.6 He then opted to execute a full stop landing and he requested runway 29 as it was the longer of the two runways. The aerodrome rescue and fire-fighting (ARFF) personnel were placed on standby. The pilot stated that on short final approach he opted to shut down both engines and feathered both propellers and glided the aircraft in. 2.7 At 1729Z the aircraft touched down, the pilot stated that following a gentle touchdown the landing gear appeared to hold but as soon as the nose wheel touched the landing gear collapsed. He was unable to maintain directional control and the aircraft veered off the runway to the left. ARFF vehicles followed the aircraft and rendered assistance once it came to halt. 2.8 The aircraft sustain damage to lower fuselage, landing gear doors, flaps and propellers. Two runway lights were severed when the aircraft veered off the runway surface. The pilot was not injured. CA 12-40 13 February 2018 Page 4 of 12 3. FACTUAL INFORMATION 3.1 The pilot held a valid commercial pilot’s licence (CPL) which was initially issued on the 29th September 2009 and expiring on the 28th September 2019. The pilot had the necessary rating to operate the aircraft.

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3.2 The pilot had accumulated a total of 2 312.4 flying hours of which 1 120.0 were on the aircraft type at the time of the incident. 3.3 The pilot held a valid aviation medical certificate which expires on the 31st August 2019. 3.4 The aircraft was manufactured in 1980 and was in possession of a valid certificate of airworthiness. 3.5 The last maintenance inspection (phase 3 and 4) that was carried out on the aircraft prior to the incident was certified on 22 April 2016 at 5 318.6 airframe hours. Since the inspection a further 183.6 hours were flown with the aircraft. 3.6 Sunset on the day for Johannesburg was 1533Z. The aircraft landed at 1729Z, therefore, night conditions prevailed at the time of landing. 3.7 The normal landing gear extension system is controlled by moving the landing gear lever into the down detent. Once the lever is down, an electric motor drives the landing gear actuators to the extended position. Once each gear is extended and locked, a green light illuminates in the cockpit. If the gear is in transit or unsafe a red light will illuminate. This process had failed when the pilot was on final approach for landing runway 11. 3.8 The manual extension system was a chain driven system that required the pilot to pump the gear down until the three green landing gear lights illuminated. This process manually actuates the landing gear actuators by bypassing the electric motor. If any of the green lights do not illuminate and the pilot was required to land, the pilot was required to pump the lever at regular intervals until maximum resistance was felt. The manual does not state what the definition of maximum resistance was. 3.9 The pilot had complied with the manual extension procedure as listed in the pilot’s operating handbook (POH), Section 3. CA 12-40 13 February 2018 Page 5 of 12 3.10 The commutator end bearing was found to have collapsed in the landing gear motor, which resulted in excessive current flow and the subsequent deactivation of the circuit breaker underneath the floor structure. 3.11 The travel/operation of the manual landing gear extension crank mechanism was restricted by a loose cover plate underneath the floor structure. 3.12 The prevailing weather conditions at the time had no bearing on the incident. 4. PROBABLE CAUSE 4.1 The landing gear could not be lowered into the down and locked position via the normal or emergency system, which caused the gear to collapse shortly after touch down, and a runway excursion followed. 5. CONTRIBUTING FACTORS 5.1 The landing gear motor experienced an internal bearing failure (see Annexure A: purple arrow) which caused it to overheat and the circuit breaker to deactivate. The circuit breaker in-turn was not located on the normal circuit breaker panel in the cockpit but underneath the floor panel. This was out of sight and out of reach of the pilot. 5.2 A further factor that may have contributed to the collapse was the insufficient pressure applied to the manual extension system which may have caused the gears to partially extend but not locked in the down position. This was due to a missing screw on a securing plate next to the manual extension hand crank mechanism. This plate, due to the motion of the hand crank, shifted causing the hand crank mechanism to be partially jammed. This might have been interpreted by the pilot as the required pressure to manually extend the landing gear. 6. REFERENCES USED ON THE REPORT Beechcraft King Air 90 Flight Manual Beechcraft King Air 90 Illustrated Parts Catalogue CA 12-40 13 February 2018 Page 6 of 12 Figure 1: The aircraft as it came to rest to the left of runway 29 Figure 2: The position of the landing gear with the gear doors open (photograph taken during the recovery) CA 12-40 13 February 2018 Page 7 of 12 Figure 3: The manual extension lever that was used by the pilot to physically pump the gear down Figure 4: The King Air 90 landing gear schematic (F90 IPC) The manual gear extension lever CA 12-40 13 February 2018 Page 8 of 12 Figure 5: The purple arrow shows the bearing that failed on the gear motor CA 12-40 13 February 2018 Page 9 of 12 Figure 6: The red arrow shows the missing screw; the white arrow shows the chaffing caused by the hand crank on the loose plate Figure 7: A different angle of the hand crank mechanism and the markings on the loose plate CA 12-40 13 February 2018 Page 10 of 12 Figure 8: The location of the deactivated circuit breaker which was underneath the floor panel Figure 9: The floor panel removed Circuit breaker in the deactivated position Circuit breaker CA 12-40 13 February 2018 Page 11 of 12 7. SAFETY RECOMMENDATION None 8. ORGANISATION None 9. TYPE OF SAFETY ACTION None 10. SAFETY MESSAGE None 11. APPENDIX Annexure A (Avionic Engineer’s report on the landing gear motor teardown inspection) CA 12-40 13 February 2018 Page 12 of 12 APPENDIX A