Section/division Occurrence Investigation Form Number: CA 12-12a

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Reference: CA18/2/3/9181
Aircraft
ZS-GJV Date of Accident 03 June 2013 Time of Accident 0650Z
Registration
Beechcraft King Air B200
Type of Aircraft Type of Operation Private
(Aeroplane)
Pilot-in-command Licence Type Airline Transport Age 28 Licence Valid Yes
Pilot-in-command Flying Total Flying
4 130.0 Hours on Type 425.5
Experience Hours
Last point of departure OR Tambo International Airport (FAOR): Gauteng province.

Next point of intended landing Lanseria International Airport (FALA): Gauteng province.
Location of the accident site with reference to easily defined geographical points (GPS readings if
possible)

During landing on runway 06L at FALA International Airport.

Meteorological
Temperature, 12˚C: Dew point, -2˚C: Visibility, 10 kilometres: Clear skies.
Information
Number of people on
1 + 0 No. of people injured 0 No. of people killed 0
board
Synopsis
The pilot being the sole occupant onboard the aircraft departed O R Tambo (FAOR)
international airport on a reposition flight for scheduled maintenance to Lanseria
international (FALA). Take off and climb from FAOR was uneventful however during the
landing sequence, on contact with asphalt runway 06L at FALA the aircraft perfomed a
wheels up landing. The aircraft skid for approximately 300 metres coming to halt in the
middle of the runway. The aircraft was substantially damaged and the pilot got out of the
aircraft uninjured. No fire was reported and the aircraft was later recovered to the hangar
for engineering investigation. The aircraft was placed on hydraulic jacks where after
external power was connected. Numerous gear retraction/extension tests were carried
out including an emergency or manual extension and it responded accordingly. No
abnormalities with the landing gear were noted.
Probable Cause

Wheels up landing due to failure of the pilot to extend the landing gear

IARC Date Release Date

CA 12-12a 25 MAY 2010 Page 1 of 22

 Section/division Occurrence Investigation Form Number: CA 12-12a
Telephone number: 011-545-1000 E-mail address of originator:

AIRCRAFT ACCIDENT REPORT

Name of Owner : RV Consulting Partnership

Name of Operator : Federal Airlines (Pty) Ltd
Manufacturer : Beech Aircraft Cooperation
Model : B200
Nationality : South Africa
Registration Marks : ZS-GJV
Place : Runway 06L at FALA.
Date : 03 June 2013
Time : 0650Z
All times given in this report are 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 (1997) 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 legal liability.

Disclaimer:
This report is given without prejudice to the rights of the CAA, which are reserved.

1. FACTUAL INFORMATION:
1.1 History of Flight:

1.1.1 On Monday morning 03 June 2013 the pilot who held an Airline Transport Pilot
licence (ATPL) reported at O R Tambo (FAOR) international airport at 0600Z with
the intension to reposition the aircraft to Lanseria (FALA) international airport for
scheduled maintenance. Coming to the operators facility at FAOR international, the
pilot perfomed a thorough pre-flight inspection on the aircraft followed by start up
and taxied to runway 21R holding point. Take off was granted and the aircraft took-
off and climb uneventfully. On approach at FALA, the pilot was cleared for a right
hand base leg asphalt runway 06L by the control tower, which he acknowledged.

1.1.2 According to the pilot a normal approach on runway 06L was carried out with the
correct airspeed. After contact with the runway surface he “the pilot” heard an
abnormal noise and noticed the aircraft propellers bending. The aircraft skid on its
belly for approximately 300 metres before coming to a halt in the middle of the
runway. The pilot reported that he immediately unbuckled himself and vacated the
aircraft for fear of fire that may erupt.

CA 12-12a 25 MAY 2010 Page 2 of 22

1.1.3 The airport fire alarm was activated by the air traffic controller (ATC) and the airport
rescue and fire fighting (RFF) team immediately dispatched to the accident site.
Coming to the accident site, one of the fire men quickly disconnected the aircraft
battery as a safety precaution. Seeing that RFF team was on-site, the pilot
considered the site to be safe and immediately got back into the aircraft to confirm
that the fuel condition levers were cut OFF. The pilot immediately through his
mobile telephone contacted his superior and notified him of the occurance. The
aircraft was substantially damaged and the pilot was not injured. No fire was
reported and the aircraft was later towed a safe distance away from the active
runway 06L to allow the operation of the airport.

1.1.4 Post interview with the pilot revealed that after entering the traffic pattern for runway
06L, he completed the descend and before landing checklist “thus extending the
gear” as per the aircraft checklist. According to the pilot the checklist included
verifying the landing gear position by visual observation of the landing gear indicator
lights which according to him indicated three green lights (down and locked
position) on the aircraft sub panel. Below is the gear selector and the landing gear
indicator lights.

Figure 1: View of the gear selector and the position of the gear indicator lights on the aircraft sub
panel.

1.1.5 The aircraft was operated under the provisions of Part 135 of the South African Civil
Aviation Regulations at the time of the occurance. The accident occurred during
́ 2.89
daylight conditions at geographical position determined to be S25˚56́2
E027˚55΄32.07 at an elevation of 4 517 feet above mean sea level (AMSL).

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 1.2 Injuries to Persons:

Injuries Pilot Crew Pass. Other

Fatal - - - -
Serious - - - -
Minor - - - -
None 1 - - -

1.3 Damage to Aircraft:

1.3.1 The aircraft sustained substantial damage during the accident sequence.

Active runway
06L used at
the time of the
occurance.

Figure 2: View of the disabled aircraft after it was removed from the active runway 06L on to the
shoulder.

1.4 Other Damage:

1.4.1 Minor damages or scratches was limited to the airport asphalt runway 06L.

1.5 Personnel Information:

Nationality South African Gender Male Age 28

Airline Transport
Licence Number 0271034134 Licence Type
Pilot
Licence valid Yes Type Endorsed Yes
Ratings Night and Instrument Rating
Medical Expiry Date 31 April 2014
Restrictions Nil
Previous Accidents Nil

CA 12-12a 25 MAY 2010 Page 4 of 22

 *NOTE: Investigation into SA CAA’s pilot file revealed no accidents or incidents
history, enforcement actions, pilot certificate or rating failure, or retest history.

Flying Experience:

Total Hours 4 130.0

Total Past 90 Days 111.6
Total on Type Past 90 Days 22
Total on Type 425.5

1.6 Aircraft Information:

Aircraft description:

A Beechcraft Model B200 Super King Air is a twin-engined turboprop corporate

travel and pressurized cabin produced by the US American manufacturer Beech
Aircraft Corporation, today Hawker Beechcraft Corporation. It is powered by two
Pratt & Whitney Canada PT6A-42 reverse flow, free turbine engines, each rated at
1,050 horse power. It has two, four bladed Hartzell automatic feathering, reversible
pitch metal propellers.

The aircraft is also equipped with a hydraulically retractable tricycle type landing
gear that has twin wheeled main units and steerable nose unit. The gear operated
multi-disc brakes and Beech oleo pneumatic shock absorbers. The main gear
retracts forward and the nose unit retracts rearward.

Figure 3: ZS-GJV aircraft in flight (photo found on internet).

CA 12-12a 25 MAY 2010 Page 5 of 22

 Airframe:

Type Beechcraft King Air B200

Serial Number BB-1167
Manufacturer Beech Aircraft Corporation
Year of Manufacture 1985
Maximum Weight 12 590 lbs
Empty Weight 11 000 lbs
Service Ceiling 35 000 feet
Total Airframe Hours (At time of Accident) 9 782.8
Last MPI (Date & Hours) 21-05-2013 9 730
Hours since Last MPI 52.8
Total Landing Gear Cycles at the time
372 Since overhaul
of the accident
C of A (Issue Date) 05-11-2008
C of A (Expiry Date) 04-11-2013
C of R (Issue Date) (Present owner) 18 -11-2008
Type of fuel used Jet A1
Operating Categories Standard Part 135

*NOTE:The aircraft was maintained by an approved aircraft maintenance

organisation (AMO No 1161) that was in possession of a valid AMO Approval
certificate that had been issued by the regulating authority (SA Civil Aviation
Authority).

Number 1 engine:

Type PT6A-42
Serial Number PCE-93198
Hours since New 874.0
Hours since Overhaul TBO not yet reached

Number 2 engine:

Type PT6A-42
Serial Number PCE-93753
Hours since New 3641.9
Hours since Overhaul TBO not yet reached

Number 1 propeller:

Type HC-E4A-3
Serial Number FY 2664
Hours since New 2760.0
Hours since Overhaul TBO not yet reached

CA 12-12a 25 MAY 2010 Page 6 of 22

 Number 2 propeller:

Type HC-E4A-3
Serial Number FY 1655
Hours since New 2760.0
Hours since Overhaul TBO not yet reached

1.7 Meteorological Information:

1.7.1 Weather information as obtained from the South African Weather Bureau:

The satellite image indicates clear skies, as per attachment below.

Figure 4: Satallite image at time of the accident.

• Dry-bulb temperature: 12.0 0C.

• Dew-point temperature: -2.0 0C.

• Wind direction and speed: 0000 00KT.

• Weather phenomenon: NSW.

• Cloud amount and height: No significant cloud reported.

CA 12-12a 25 MAY 2010 Page 7 of 22

1.8 Aids to Navigation:

1.8.1 The aircraft was fitted with the following navigational aids.

• Magnetic compass.

• Panel-mounted Garmin GPS.

• Mode S transponder.

• ADF (Automatic Direction Finder).

• DME (Distance Measuring Equipment).

• VOR (Variable Omni Range) finder.

• Instrument landing system (ILS).

• Collins Weather radar.

1.9 Communications:

1.9.1 The aircraft was equipped with standard communication equipment as required by
the Regulator. There were no recorded defects to communication equipment prior
to the flight.

1.10 Aerodrome Information:

Lanseria International Airport (FALA) is Situated 22

Aerodrome Location Nautical Miles (NM) North West of OR Tambo
international.
Aerodrome Co-ordinates S25˚56΄22.89 E027˚55́32.07
Aerodrome Elevation 4 517 feet AMSL
Runway Designations 06L 24R
Runway Dimensions 2 918 x 30 2 918 x 30
Runway Used 06L
Runway Surface Asphalt
Approach Facilities Variable Omni Range (VOR), Non Direction Beacon
(NDB), Instruments Landing System (ILS) and Runway
lighting.

CA 12-12a 25 MAY 2010 Page 8 of 22

 Figure 5: FALA international airport lay out as per aeronautical information publication.

1.11 Flight Recorders:

1.11.1 The aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice
recorder (CVR) nor was it required by regulation to be fitted to this aircraft type.

CA 12-12a 25 MAY 2010 Page 9 of 22

1.12 Wreckage and Impact Information:

1.12.1 On contact with runway 06L during the landing sequence the aircraft performed a
wheels up landing and skid for approximately 300 metres before coming to a halt.
Damage was sustained to the underbelly, the engines, the propellers, the landing
light, the landing gear doors, the pitot-tubes, and the control surfaces. After
removing the engine cowlings, it was evident that significant movement of the
engines had occurred as a result of the propellers striking the ground. This has
taken a form of twisting action and caused both the starter/generators, which are
mounted at the top of the accessory gearbox at the rear of each engine to contact
the underside of their respective upper nacelle panels. See the picture below.

Figure 6: Closer view of the disabled aircraft from the front.

1.13 Medical and Pathological Information:

1.13.1 The pilot sustained no injuries.

1.14 Fire:

1.14.1 There was no pre or post impact fire.

1.15 Survival Aspects:

1.15.1 The accident was considered to be survivable. The cockpit cabin area remained
intact and the pilot was wearing the aircraft equipped safety harness.

CA 12-12a 25 MAY 2010 Page 10 of 22

1.16 Tests and Research:

1.16.1 At the accident site the aircraft was found to have been sitting on its belly and
disabled with the cabin door opened. The investigating team got into the cockpit area
and discovered that the landing gear selector was in a down position as it can be seen
on the picture below.

The position
of the gear
selector

Figure 7: The position of the landing gear selector as found at the accident site.

1.16.2 A fork lift and a crane were brought to the accident site with the intention to lift up
and recorver the aircraft. The aircraft was secured with a cable from the crane and
a fork lift was used to stabilise the aircraft tail. As the aircraft was lifted the left main
undercarriage pushed the doors to open position and fell free. The nose gear
hanged loose due to a severed drag brace. The right main gear was still trapped
inside the wheel well and the doors were closed. The investigators in charge got into
the cockpit and by means of an emergency gear extension hand pump that is
located between the pilot right foot and the pedestal pumped the undercarriage out.

Emergency gear pump.

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1.16.3 During the process, the right hand side gear doors opened and the right gear
extended. The process went so slow and ultimately a cluck sound was heard,
indicating that the main gear was in a down and locked position. This allowed a
visual inspection of the gear and wheel wells, which revealed that the hydraulic
lines had remained intact. Both gear doors were intact except damage caused by
abrasion with the runway surface. The nose gear was placed in the down position
and an attempt to secure it by ratchet straps was made but did not work. See the
picture below.

Fork lift Site view of

on-site the engineers
as they were
trying to
secure the
nose gear

Figure 8: Veiw of the aircraft after it was lifted off the ground with the main gear in a down and locked
position.

1.16.4 The aircraft was by means of a rope secured to the arms of a fork lift and was
successfully towed to the hangar for engineering investigation. The aircraft was
placed on hydraulic jacks and a damaged nose gear drag brace was replaced. The
aircraft wheel well was checked for cleanliness and foreign objects and was found
to be clean and free of mud and debris. The squat switches and valves were also
checked for cleanliness and all was found to be clean because they both have a
tendency of causing false safe gear light indications or interrupting the extension
cycle before the landing gear is completely in a down and locked position.

1.16.5 The aircraft battery, which had been disconnected immediately after the accident,
was reconnected and the Battery Master switch was turned ON. The external power
source was connected to the aircraft external power socket and the aircraft was
energised.

CA 12-12a 25 MAY 2010 Page 12 of 22

1.16.6 Numerous gear retraction/extension tests were carried out by a lisenced
maitenanace engineer “including an emergency extension” as per the manufacturer
instructions and all worked accordingly. After every extension there was evidence of
three greens “landing gear down and locked indication lights on the pilot inboard
sub-panel. Inspection on the main gear also revealed evidence of the mechanical
locking system “squat switches” being in a locked position. It was noted that the
system was fully functional and working in accordance with the manufacturers
specification. At no time during the retraction and extension process did the landing
gear malfunction. Below is the aircraft picture shot during the investigation in the
hanger.

Figure 9: View of the aircraft picture shot during the investigation.

1.16.7 The as found position of the gear selector following the accident thus became
difficult to explain but the condition “intact” of the gear doors showed that the
landing gear was at no time extended. This suggest that the before landing
checklist was not performed at all, and that the pilot did not confirm the gear was
down and locked. In addition it is possible that the gear warning horn sounded
during the approach, indicating that the landing gear was not extended, but it was
ignored. Unaware that the gear was not down, the pilot performed a wheels up
landing.

CA 12-12a 25 MAY 2010 Page 13 of 22

 *NOTE: During the investigation in the hangar, the gear selector was moved to UP
“retracted” position with full flaps and the aircraft gear horn sounded. The gear horn
couldn’t stop until the circuit breaker “CB” was pulled. During flight, a warning horn
and red lights in the landing gear handle warn the crew of improper landing gear
position relative to flap and/or power lever position. They also activate when the
gear handle is up while on the ground.

1.17 Organizational and Management Information:

1.17.1 This was a private repositioning flight.

1.17.2 The flight was conducted under the provisions of Part 135 of the Civil Aviation
Regulations of 1997 as amended. The operator was in possession of a valid air
operating certificate (AOC) number N9333D at the time of the occurance.

1.17.3 The aircraft was maintained by an approved aircraft maintenance organisation

(AMO no 1161) that was in possession of a valid AMO Approval certificate that had
been issued by the regulating authority (SA Civil Aviation Authority).

1.18 Additional Information:

1.18.1 Description and operation of a Beechcraft King Air B200 hydraulic landing gear
system.

A landing gear control handle on the pilots inboard sub-panel actuates the retract
and extend circuitry of the landing gear. A solenoid operated downlock latch
prevents the switch from being actuated while the airplane is on the ground. Should
it become necessary, the latch can be overridden by depressing the red downlock
release switch.

To prevent accident retraction of the landing gear, a safety switch mounted on each
main gear cuts power to the control circuit whenever the shock struts are
compressed. When the landing gear control handle is moved to the ON position,
the power pack down solenoid is actuated, routing fluid to the extend potion of the
system. As the actuator piston moves to extend the landing gear, the fluid in the
actuators exits through the normal retraction port of the actuators and is carried
back to the power pack to allow the return fluid to flow into the primary reservoir.
When the actuator pistons are positioned to fully extend the landing gear, an
internal mechanical lock in the nose gear actuator will lock the actuator piston to
hold the nose gear in the down position: the main gears are held by a mechanical
locking system.
CA 12-12a 25 MAY 2010 Page 14 of 22
 In this position, the internal locking mechanism in the nose gear actuator will
actuate downlock switch to interrupt current to the pump motor. The motor will
continue to run until all three landing gears are down and locked.

A caution HYD FLUID LOW annunciator located in the CAUTION/ADVISORY panel

will illuminate in the event the hydraulic fluid level in the landing gear power pack
becomes critically low. When low fluid level is indicated, the landing gear should not
be extended or retracted using the hydraulic power pack: however, the landing
gear can be extended using the alternate extension emergency hand pump.
A sensing unit mounted on the motor end of the power pack provides the
necessary switching circuitry to illuminate the low fluid light. The optically operating
sensing has an integrated self test circuit. The intergral self test circuit in energised
by a switch on the instrument panel and fuctionally tests the sensing units internal
circuitry.

Manual landing gear extension is provided through a manually powered hydraulic

system. A hand pump, placarded LANDING GEAR ALTERNATE EXTENSION, is
located on the floor between the pilots seat and the pedestal. The pump is used
when alternate extension of the gear is required. To extend the gear with this
system, pull the landing gear control circuit breaker on the pilots inboard sub-panel
and place the landing gear control handle in the DN position. Remove the pump
handle from the securing clip and pump the handle up and down to extend the gear.

As the handle is pumped, hydraulic fluid is drawn from the hand pump suction port
of the power pack and pumped through the power pack hand pump pressure port to
the actuators. The pressure exerted on the secondary extend port of the actuators
shifts the shuttle valves, allowing the fluid to enter the extend side of the actuator
cylinders. As the actuator pistons move to extend the landing gear, the fluid in the
actuator exits through the normal retract port of the actuators and is carried back to
the power pack through the normal retract plumbing.

The fluid routed to the power pack hand pump pressure port from the hand pump
unseats the internal dump valve of the pump to allow the return fluid to flow into the
primary reservoir. As many as 80 full strokes may be required to fully extend the
landing gear. Continue to pump the handle up and down until the green GEAR
DOWN indicator lights on the pilots inboard sub-panel illuminates. Make sure that
the pump handle is in the fully down position prior to placing the pump handle in the
securing clip. When the pump handle is stowed, an internal relief valve is actuated
to relieve the hydraulic pressure in the pump.
CA 12-12a 25 MAY 2010 Page 15 of 22
1.19 Useful or Effective Investigation Techniques:

1.19.1 None

2. ANALYSIS:
2.1 The available information revealed that fine weather conditions prevailed in the area
at the time of the occurance. Therefore it was concluded that weather was not a
contributory factor to the accident. According to available records the pilot was the
holder of an Airline Transport pilot licence and had the aircraft type endorsed in his
license. The pilot́s medical was valid and he was fit to commence with flying
activities at the time of the occurance. According to available maintenance records,
the aircraft was properly maintained. The Mandatory Periodic Inspection (MPI) was
conducted as per the regulations.

2.2 The aircraft technical log book did not reflect any defect or malfunction that could
have contributed or have caused the accident. The aircraft took off from FAOR
bound for FALA on a reposioning flight for maintenance with the pilot being the sole
occupant on board. All was normal during the entire flight and during the landing
sequence on contact with runway 06L, the aircraft perfomed a wheels up landing.
The aircraft skid for approximately 300 metres coming to rest in the middle of
runway. Following the wheels up landing, a licensed aircraft maintenance engineer
and the investigators examined the landing gear system. The aircraft was lifted on
hydraulic jacks and the landing gear was hydraulically/manually extended. The
landing gear worked accordingly with the three green down and locked indication
lights illuminated.

2.3 The landing gear doors also showed evidence that the gear was at no time
extended prior the occurance. In conclusion, however the landing gear selector
was found to be in DOWN “extended” position at the accident site, it is possible that
it was tempered with, with the intension to mislead the investigation.

3. CONCLUSION:

3.1 Findings:

3.1.1 The pilot had a valid license and was properly rated to the aircraft type.

3.1.2 The pilot had a valid medical certificate which expires on the 31 March 2014.

CA 12-12a 25 MAY 2010 Page 16 of 22

3.1.3 According to available records the aircraft was properly maintained. The Mandatory
Periodic Inspection was conducted as per regulations.

3.1.4 The aircraft performed a wheels up landing.

3.1.5 The landing gear retraction test was commenced and no abnormalities with the
landing gear system was noted.

3.1.6 Fine weather conditions prevailed at the time of the occurance.

3.2 Probable Cause/s:

3.2.1 Wheels up landing due to failure of the pilot to extend the landing gear.

4. SAFETY RECOMMENDATIONS:
4.1 None.

5. APPENDICES:
5.1 Beechcraft King Air B200 schematic landing gear schematic.

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