Aviation safety investigations & reports

Cessna Aircraft Company 404, VH-ANM

Investigation number:
Status: Completed
Investigation completed


The Australian Transport Safety Bureau did not conduct an on scene investigation of this occurrence.

Sequence of events

On 22 July 2004, the pilot of the Cessna Aircraft Company Titan, registered VH-ANM, was conducting a charter flight from Goulburn Island to Darwin with 12 passengers. He tracked the aircraft for landing at Darwin via a position 5 NM on final approach for runway 29.

The pilot reported that he normally completed his pre-landing checks when about 5 NM from Darwin. In this instance, that coincided with the pilot's attempt to fault-analyse a problem with the aircraft instrument landing system. He reported being established on final approach for runway 29 at 4.3 NM from Darwin.

The pilot reported that in order to avoid the expected jet thrust turbulence from a Mirage fighter, which had been cleared for takeoff from runway 29, he amended his approach profile to touch down further along the runway. He reported that consideration and execution of that amended profile coincided with when he normally completed his PUFF1 checks. The pilot was subsequently cleared to land on runway 29, with a requirement to hold short of the crossing runway 36 intersection. Later on final approach, the pilot noted the unusual nature and content of a radio transmission from the pilot of a following C-130 Hercules aircraft. Consideration of that radio call by the pilot coincided with where he normally carried out the last check of his aircraft configuration in preparation for landing.

The pilot reported that, as he realised that he was 'a bit low' during the flare for landing, and that the aircraft's wheels should have contacted the runway, he heard a radio transmission stating `no gear, no gear, no gear'. The pilot advanced the throttles and raised the aircraft's nose, but was unable to prevent the aircraft contacting the runway. Shortly thereafter, the pilot lowered the landing gear, with the initial intent of landing in the remaining available runway. The pilot noted 'that he had three greens2', but after consideration of the requirement to hold short of runway 36, and of the remaining runway length, decided to go around for another landing. The pilot and passengers were not injured.

Damage to the aircraft was confined to the tips of the propellers, the wing flaps, main landing gear tyres, and the left rear automatic direction finder antenna. Superficial damage to the runway surface was identified over a distance of about 11 m, commencing at about 1,000 m upwind from the landing threshold, and displaced about 3 m to the left of the runway centreline. That damage was consistent with a number of propeller tip strikes.

The pilot was appropriately qualified for the operation and complied with company duty requirements. While the pilot reported being medically fit for the flight, he indicated a number of personal and other factors that may have adversely affected his recent sleeping and eating patterns, to the extent that `he didn't feel 100% in himself'.

Royal Australian Air Force, Darwin Air Traffic Control personnel followed published procedures during this occurrence. There was no evidence that any environmental factors were relevant to the circumstances of the occurrence.

The pilot reported that the aircraft landing gear operated normally on the previous landing at Goulburn Island, and on the second landing at Darwin. In addition, the company chief pilot reported that, when tested by company engineers after the occurrence, the landing gear warning horn3 operated normally. The pilot did not recall hearing the warning horn during the occurrence.

It was likely that the pilot's personal and other problems, and the resulting interrupted sleeping and eating patterns diminished the pilot's ability to manage the tasks necessary to prepare the aircraft for landing. That degradation in performance was compounded by the in-flight distractions that coincided with when the pilot would have normally conducted his sequence of pre-landing actions and checks. The result was that the pilot unwittingly omitted to lower the aircraft's landing gear.

1 A personal mnemonic applied by the pilot that checked completion of the actions necessary to confirm that the aircraft was in the landing configuration, including: set propeller pitch, undercarriage down, and flaps full down.
2 Three landing gear position indicator lights are located just left of centre of the aircraft instrument panel. Those lights illuminate when each landing gear is fully extended and locked.
3 The landing gear warning horn can be independently activated by either the throttle position or wing flap position switch. That switch activates the horn if the flaps are lowered past the take-off and approach position, with the landing gear in any position except extended and locked.

General details
Date: 22 July 2004   Investigation status: Completed  
Time: 1530 hours CST    
Location   (show map): Darwin, Aero.    
State: Northern Territory   Occurrence type: Wheels up landing  
Release date: 22 December 2004   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 404  
Aircraft registration VH-ANM  
Serial number 4040010  
Type of operation Charter  
Damage to aircraft Minor  
Departure point South Goulburn Island, NT  
Departure time 1430 hours CST  
Destination Darwin, NT  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 274.0 7560
Last update 13 May 2014