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ASN Wikibase Occurrence # 122530
Last updated: 14 October 2021
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Date:17-MAY-2011
Time:06:45
Type:Silhouette image of generic B190 model; specific model in this crash may look slightly different
Beechcraft 1900D
Owner/operator:Great lakes Aviation
Registration: N218YV
MSN: UE-218
Fatalities:Fatalities: 0 / Occupants: 11
Aircraft damage: Minor
Category:Incident
Location:Denver International Airport, CO (DEN/KDEN) -   United States of America
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:Pueblo, CO (PUB)
Destination airport:Denver, CO (DEN)
Investigating agency: NTSB
Narrative:
While on approach to landing, the first officer (the pilot flying) called for the landing gear to be extended. The captain placed the gear handle in the down position and waited for the three landing gear down-and-locked annunciator lights to illuminate. Although the “NOSE” and “RH” annunciators illuminated fully, only the “L” side of the “LH” annunciator for the left main landing gear (LMLG) appeared to be illuminated (each annunciator has two light bulbs). During the landing roll, the airplane began to wobble, and the LMLG collapsed.

An examination of the airplane revealed that the nose landing gear (NLG) actuator end cap, which was found on the runway, failed due to fatigue from multiple origins that propagated from the inside diameter toward the exterior of the cap. The end cap failure, which likely occurred once the NLG reached its down and locked position, allowed most of the hydraulic fluid to be blown out of the NLG actuator, resulting in a decrease in hydraulic system pressure before the LMLG could reach the full down-and-locked position (the LMLG is the last in the system to receive a pressure pulse). No premishap mechanical deficiencies were noted with the LMLG system that would have precluded it from operating normally if sufficient hydraulic pressure had been available. However, because the loss of hydraulic pressure also disabled the manual landing gear extension system, the Quick Reference Handbook (QRH) procedure for the flight crew to manually extend the gear would have been ineffective in securing the LMLG.

The investigation identified safety issues related to the failure mode and inspection procedure for the NLG actuator end cap. Metallurgical examination of the NLG end cap revealed that the fractured NLG end cap’s grain was not in the optimum longitudinal direction. (Grain direction in the metal’s microstructure affects its tensile properties and resistance to fatigue stresses.) The NLG end cap was manufactured before the specifications were revised to indicate a longitudinal grain direction for the part. Also, evidence indicates that the fatigue crack was likely present when the end cap was overhauled in 2008 and during a routine inspection of the airplane in 2010; however, the dye penetrant inspection performed during the overhaul did not detect the crack, which would not have been detectable during the visual inspection of the airplane (because the crack had not propagated to the outside of the end cap). As a result of this investigation, the airplane’s maintenance manual was changed to recommend ultrasonic inspections and overhauls for the NLG end cap at specified cycles.

Another safety issue was identified regarding the illuminated appearance of the LH annunciator in the cockpit. According to the system design, when the LMLG is not down and locked, the indication circuit is not complete, and the LH annunciator lights will not be illuminated in the cockpit. However, examination of the incident airplane revealed that an incorrect lamp module, which did not have a light dam, was installed in the center position. As a result, light from the illuminated "R" (in the adjacent annunciator) was able to bleed over and give the appearance that the "L" was also illuminated, providing the flight crew with an erroneous indication that the LMLG was down and locked.

The investigation examined other factors that influenced the flight crew’s belief that the LMLG was safe and the captain’s decision to continue the approach. The captain noted that, after he placed the gear handle down, the landing gear in-transit light stayed on and that the gear motor continued to run for about 16 seconds before the gear-motor relay circuit breaker popped, but he stated that he was confident that the illuminated “L” indicated that the LMLG was down and locked. The captain also noted that the gear unsafe warning horn sounded just before touchdown, but he stated that he was not concerned about the horn and elected not to go-around and run the QRH checklists because he had confirmed several times that the gear annuncia
Probable Cause: The fatigue failure of the nose landing gear (NLG) end cap, which resulted in insufficient hydraulic pressure to secure the left main landing gear into the down and locked position. Contributing to the fatigue failure was the NLG end cap’s non-optimum grain direction and the inadequate inspection procedure performed during overhaul.

Sources:

NTSB

Accident investigation:
cover
  
Investigating agency: NTSB
Status: Investigation completed
Duration: 10 months
Download report: Final report
Location


Images:

Photo of N218YV courtesy AirHistory.net


Las Vegas - McCarran International (KLAS / LAS)
30 March 2011; (c) Danny Grew

Revision history:

Date/timeContributorUpdates
19-May-2011 14:45 harro Added
05-Apr-2012 12:46 ryan Updated [Source, Narrative]
21-Dec-2016 19:25 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
27-Nov-2017 18:09 ASN Update Bot Updated [Operator, Departure airport, Destination airport, Source, Narrative]

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