Mishap Report
TO COMNAVSAFECEN NORFOLK VA
>
> INFO CNO WASHINGTON DC
> CNO WASHINGTON DC
> COMNAVPERSCOM MILLINGTON TN
> COMNAVPERSCOM MILLINGTON TN
> COMNAVAIRSYSCOM PATUXENT RIVER MD
> COMNAVAIRSYSCOM PATUXENT RIVER MD
> COMNAVREG SW SAN DIEGO CA
> COMNAVREG SW SAN DIEGO CA
> CNET PENSACOLA FL
> ALL NAVY FLYING CLUB ACTIVITIES
> NAVBASE VENTURA CTY PT MUGU CA
> NAVBASE VENTURA CTY PT MUGU CA
>
>
> ATTENTION INVITED TO ADMINISTRATIVE MESSAGE
>
> ROUTINE
>
> R 300133Z JUL 02 ZYB
>
> FM NAVBASE VENTURA CTY PT MUGU CA//N00V//
>
> TO COMNAVSAFECEN NORFOLK VA//10/11/112/112C/115//
>
> INFO CNO WASHINGTON DC//N78/N78WF//
> CNO WASHINGTON DC//N78/N78WF//
> COMNAVPERSCOM MILLINGTON TN//PERS658F/65//
> COMNAVPERSCOM MILLINGTON TN//PERS658F/65//
> COMNAVAIRSYSCOM PATUXENT RIVER MD//JJJ//
> COMNAVAIRSYSCOM PATUXENT RIVER MD//JJJ//
> COMNAVREG SW SAN DIEGO CA//N00/N01/N92//
> COMNAVREG SW SAN DIEGO CA//N00/N01/N92//
> CNET PENSACOLA FL//JJJ//
> ALL NAVY FLYING CLUB ACTIVITIES//00//
> NAVBASE VENTURA CTY PT MUGU CA//N00V//
> NAVBASE VENTURA CTY PT MUGU CA//N00V//
>
> BT
> UNCLAS //N03750//
>
> ***THIS IS A 2 SECTION MESSAGE COLLATED BY DMDS***
>
>
> NARR/THIS IS A GENERAL USE MISHAP REPORT TO BE USED ONLY FOR SAFETY
>
> MSGID/GENADMIN/NAVBASE VENTURA CTY/NOOV//
>
> SUBJ/FINAL NFC MISHAP REPORT (REPORT SYMBOL BUPERS 1710-21)//
>
>
>
>
> REF/A/DOC/BUPERSINST 1710.22 SERIES/-/5JUN01//
>
> AMPN/REF A IS NFC INSTRUCTION//
>
> NARR/THIS IS A GENERAL USE MISHAP REPORT TO BE USED ONLY FOR SAFETY
> PURPOSES PER BUPERSINST 1710.22.//
> POC/WINSETT/LT/CALLSIGN:NBVC AVIATION SAFETY OFFICER/LOC:NOOVV
> /TEL:(805) 986-7520/TEL:DSN: 351-0931//
>
> RMKS/1. NAVBASE VENTURA CTY UIC 69232, PT MUGU NAVY FLYING CLUB.
>
> 2. DATE: 17 JUN 2002, TIME: 1330L DAY ENVIRONMENT.
>
> 3. LOCATION OF MISHAP: MIDFIELD OF RUNWAY 21 AT NAVAL BASE VENTURA
> COUNTY, POINT MUGU, CA.
>
> 4. ACFT TYPE: LOW-WING MONOPLANE SINGLE ENGINE MAKE: BEECH MODEL:
> MENTOR, T-34B, MODEL D45 BUREAU/FAA REGISTRATION NUMBER: 31810
>
> 5. DAMAGE DESCRIPTION AND COST: DAMAGE TO ENGINE, FUSELAGE AND
> PROP, COST: APPROXIMATELY $27,200.
>
> 6. PILOT AT CONTROLS, RETIRED AIR FORCE, GRADE MAJ/04, AGE 75,
> CLUB VICE PRESIDENT AND CHIEF FLIGHT INSTRUCTOR, DEGREE OF INJURY
> NONE.
>
> 7. PILOT AT CONTROLS TOTAL TIME: 7649.0, TOTAL TIME IN MODEL:
> 358.0, TOTAL TIME LAST 90/60/30 DAYS (ALL ACFT): 28.3/8.6/5.7, DATE
> OF LAST STANDARDIZATION FLIGHT: 30 JUN 01, FAA CERTIFICATES HELD:
>
>
>
> COMMERCIAL PILOT, CERTIFIED FLIGHT INSTRUCTOR SINGLE AND MULTIENGINE
> LAND INSTRUMENTS, RATINGS: SINGLE AND MULTIENGINE LAND INSTRUMENTS.
>
> 8. OTHER CERTIFIED PILOTS THAT HAD ACCESS TO THE FLIGHT CONTROLS:
> CIVILIAN ACTIVE CLUB MEMBER. CO-PILOT TOTAL TIME, 280.9, TOTAL TIME
> IN MODEL 138.0, TOTAL TIME LAST 90/60/30 DAYS (ALL ACFT)
>
> 7.2/3.9/3.9, DATE OF LAST STANDARDIZATION FLIGHT 13 JUN 01, FAA
> CERTIFICATES HELD: PRIVATE PILOT, RATINGS: SINGLE ENGINE LAND.
>
> 9. IDENTIFICATION OF OTHER CREW MEMBERS OR PASSENGERS: NONE.
>
> 10. TYPE OF FLIGHT: ANNUAL FLIGHT REVIEW CHECKRIDE FOR
> CO-PILOT; FLIGHT CLEARANCE VFR; TAKEOFF TIME 1250L; DESTINATION
> NBVC-PT MUGU; DURATION: ACTUAL FLIGHT TIME WAS 0+40 MINUTES UNTIL
> MISHAP.
>
> 11. PHASE OF OPERATION: TOUCH-AND-GO.
>
> 12. MISHAP NARRATIVE: LOCAL VFR ROUND ROBIN PLANNED FROM CAMARILLO
> AIRPORT TO NBVC PT MUGU, AND BACK. APPROXIMATELY FORTY MINUTES AFTER
> TAKEOFF FROM CAMARILLO AIRPORT, MISHAP AIRCRAFT WAS IN THE PATTERN
> AT NAVY PT MUGU DOING TOUCH-AND-GO LANDINGS. ON THE SIXTH
> TOUCH-AND-GO PASS, PILOT AT CONTROLS RESPONDED TO TOWER WITH A
> "LANDING GEAR DOWN, 3 DOWN AND LOCKED" CALL BUT A GEAR UP LANDING
> WAS MADE AND AIRCRAFT CAME TO A COMPLETE AND ABRUPT STOP MIDFIELD OF
>
>
>
> RWY 21. NO INJURIES WERE SUSTAINED.
>
> 13. FINDINGS.
> A. SUMMARY OF EVIDENCE.
> 1. 31810 WAS AIRWORTHY, LEGAL FOR FLIGHT, VFR CERTIFIED,
> AND HAD NO OUTSTANDING RELEVANT DISCREPANCIES.
> 2. PILOT IN COMMAND (PIC) WAS THE VICE PRESIDENT OF THE
> CLUB, CHIEF FLIGHT INSTRUCTOR, AND CURRENT IN THE T34B AIRCRAFT.
> 3. PIC WAS A RETIRED AIR FORCE MAJOR.
> 4. VFR FLIGHT PLAN WAS ON FILE AT THE CLUB OPERATIONS
> OFFICE AND A WEATHER BRIEF HAD BEEN OBTAINED.
> 5. CO-PILOT WAS A CLUB MEMBER IN GOOD STANDING, CURRENT IN
> T-34B AIRCRAFT, AND A MEMBER OF THE CIVIL AIR PATROL.
> 6. PIC MADE AN UNEVENTFUL VFR DEPARTURE FROM CAMARILLO
> AIRPORT WITH THE INTENT OF DOING SEVERAL TOUCH AND GO LANDINGS AT
> NBVC PT MUGU (APPROXIMATELY 7 MILES AWAY) AND RETURN TO
> CAMARILLO.
> 7. AS PER ABOVE NARRATIVE, MISHAP AIRCRAFT MADE A FULL GEAR
> UP LANDING ON SIXTH TOUCH AND GO PASS WITH PILOT IN COMMAND AT THE
> CONTROLS ON RWY 21 AT NBVC PT MUGU, CA.
> 8. THREE EYEWITNESSES SAW THE MISHAP AIRCRAFT ON FINAL
>
>
>
> APPROACH WITH THE GEAR FULLY UP. ONE OF THE THREE WITNESSES, A TOWER
> CONTROLLER, SAW THE AIRCRAFT MAKE THE GEAR UP LANDING. THE TOWER
> CONTROLLER DID NOT SEE THE SITUATION IN TIME TO WARN THE PILOTS
> BEFORE TOUCHDOWN.
> 9. PILOT-IN-COMMAND AND CO-PILOT BOTH SAID THAT THE LANDING
> GEAR WAS VISUALLY CHECKED TO BE DOWN AND LOCKED AND HYPOTHESIZED
> THAT A MECHANICAL MALFUNCTION LED TO A COLLAPSE OF THE GEAR UPON
> TOUCHDOWN. FULL STATEMENTS WERE OBTAINED FROM BOTH PILOTS.
> 10. AUDIOTAPES OF THE PILOT'S TRANSMISSIONS TO TOWER WERE
> REVIEWED. IT WAS VERIFIED THAT PILOT-AT-CONTROLS IN THE
> AIRCRAFT DID ACKNOWLEDGE TOWER'S REQUEST TO VERIFY LANDING GEAR WAS
> "DOWN AND LOCKED" AND REPORTED BACK "810, 3 DOWN AND LOCKED" PRIOR
> TO LANDING GEAR UP.
> 11. SEVERAL EXTERIOR AND INTERIOR PHOTOGRAPHS WERE TAKEN OF
> THE AIRCRAFT IMMEDIATELY FOLLOWING THE MISHAP TO DOCUMENT DAMAGE.
> THE LANDING GEAR POSITION INDICATORS WERE CROSSHATCHED BECAUSE
> ELECTRICAL POWER HAD ALREADY BEEN REMOVED, AND THE GEAR HANDLE WAS
> UP (THE PILOT IN COMMAND SAID HE CYCLED IT AND LEFT IT IN THE UP
> POSITION AFTER COMING TO A STOP ON THE RUNWAY). THE FUSELAGE AND
> ENGINE EXHAUST TUBES DISPLAYED MINOR DAMAGE FROM CONTACTING THE
>
>
>
> RUNWAY. THE INNER EDGES OF THE FLAPS HAD MORE SEVERE DAMAGE FROM
> CONTACTING THE RUNWAY AND ABSORBING MOST OF INITIAL IMPACT ENERGY.
> THE FIRST THIRD OF EACH PROP BLADE WAS CURLED FORWARD WITH EVIDENCE
> OF REPEATED STRIKES WITH RUNWAY. THE TWO MAIN LANDING GEAR DOORS
> WERE FULLY CLOSED, AND WITHOUT EVIDENT DAMAGE.
> 12. THE AIRCRAFT WAS PUT ON JACKSTANDS WITH THE LANDING GEAR
> REMAINING IN THE UP POSITION AS IT WAS AT TOUCHDOWN. WITH THE GEAR
> HANDLE REMAINING IN THE UP POSITION, ELECTRICAL POWER WAS APPLIED.
> THE LANDING GEAR INDICATORS DISPLAYED THE GEAR POSITION AS UP. THIS
> WAS THE CORRECT AND LAST KNOWN POSITION OF THE GEAR PRIOR TO
> IMPACTING RUNWAY. THE LANDING GEAR WAS LOWERED AND RAISED SEVERAL
> TIMES. IT WORKED PROPERLY AND INDICATORS DISPLAYED CORRECT POSITION
> OF THE LANDING GEAR.
> 13. THERE WAS NO DAMAGE TO LANDING GEAR, LANDING GEAR
> DOORS, OR ASSEMBLIES. THE LANDING GEAR, GEAR HANDLE, AND INDICATORS
> WORKED PROPERLY AND SHOWED ALL NORMAL INDICATIONS. THE LANDING GEAR
> WARNING HORN WAS TESTED AND WORKED PROPERLY.
> 14. REVIEW OF MAINTENANCE RECORDS FOUND THAT NO RECENT
> MAINTENANCE OR OUTSTANDING MAINTENANCE REQUIREMENTS RELATING TO THE
> LANDING GEAR EXISTED PRIOR TO THE MISHAP. A STATEMENT FROM THE
>
> NARR/THIS IS A GENERAL USE MISHAP REPORT TO BE USED ONLY FOR SAFETY
>
> MSGID/GENADMIN/NAVBASE VENTURA CTY/NOOV//
>
> SUBJ/FINAL NFC MISHAP REPORT (REPORT SYMBOL BUPERS 1710-21)//
>
>
>
> FLYING CLUB MAINTENANCE OFFICER WAS TAKEN AND HE WAS PRESENT DURING
> ALL MECHANICAL EXAMINATION OF THE AIRCRAFT.
> 15. THE MISHAP DAY WAS VFR WITH UNLIMITED VISIBILITY.
> WINDS AT THE TIME OF THE MISHAP WERE 250/10 . ENVIRONMENT WAS NOT A
> FACTOR IN THE MISHAP. ?
> A. ANALYSIS.
> 1. THE AIRCRAFT WAS EXAMINED BY NBVC AUTHORITIES,
> THE PT MUGU NAVY FLYING CLUB SAFETY OFFICER AND MAINTENANCE OFFICER.
> NO EVIDENCE OF FAILURE OF THE LANDING GEAR WAS FOUND. HAD THE GEAR
> COLLAPSED ON TOUCHDOWN AS THE AIRCREW HYPOTHESIZED, THERE WOULD
> HAVE BEEN DAMAGE TO THE INNER LANDING GEAR DOORS. THERE WAS NONE.
> EYEWITNESS STATEMENTS OF A GEAR UP APPROACH AND TOUCHDOWN FURTHER
> CONFIRM THAT THE GEAR WAS NOT DOWN DURING APPROACH OR UPON RUNWAY
> CONTACT. ALTHOUGH BOTH PILOTS SAID THE GEAR WAS DOWN AND LOCKED
> DURING THE APPROACH (PILOT AT CONTROLS VERBALLY REPORTED THAT TO
> TOWER), THERE IS NO EVIDENCE TO SUPPORT THAT CLAIM. NO FURTHER
> INVESTIGATION IS WARRANTED OR REQUIRED.
> B. CONCLUSION.
> 1. THE PRIMARY CAUSE OF THE MISHAP IS PILOT ERROR.
> THE MISHAP PILOT FAILED TO LOWER THE LANDING GEAR PRIOR TO LANDING.
>
>
>
> A CONTRIBUTING CAUSAL FACTOR IS LACK OF AIRCREW COORDINATION.
> NEITHER PILOT VISUALLY VERIFIED THAT THE GEAR WAS DOWN DURING
> LANDING CHECKLISTS OR WHEN QUERIED BY TOWER CONTROLLER.
>
> 14. RECOMMENDATIONS: BRIEF MISHAP TO PT MUGU FLYING CLUB MEMBERS
> AND EMPHASIZE ABSOLUTE NEED TO FOLLOW CHECKLISTS AND VISUALLY VERIFY
> EVERY ACTION ON CHECKLISTS. RECOMMEND AN AIRCREW COORDINATION BRIEF
> BE GIVEN AS WELL TO RE-EMPHASIZE THE CREW CONCEPT AND HOW IT APPLIES
> TO AVIATION SAFETY.
>
> 15. OTHER DAMAGE OR INJURY: NONE
>
> 16. ADDITIONAL INFORMATION:
> A. AIRCRAFT ON NBVC PT MUGU RAMP BEHIND TOWER (BLDG PM355).
> B. NTSB AND FAA NOTIFIED: 18 JUN 2002.
>
> 17. POC: DAVID WINSETT, LT/O3, PT MUGU NAVY FLYING CLUB SAFETY
> ADVISOR, COMM: 805-989-0931, DSN: 351-0931. ALT POC TIM TROTMAN,
> 1LT, 02, COMM: 805-986-7520.//
>
> BT
> #0265
> CDR Ken Taylor
> Operations Officer
> Naval Base Ventura County
> (O)805-989-0336
> (C)805-207-7207
> (F)805-989-7906
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