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Safety Recommendation Details

Safety Recommendation A-80-057
Details
Synopsis: AS PART OF A RECENTLY COMPLETED SPECIAL INVESTIGATION, THE SAFETY BOARD REVIEWED ITS FILES FOR EVERY INADVERTENT LANDING GEAR RETRACTION ACCIDENT BETWEEN 1975 AND 1978. THESE ACCIDENTS TYPICALLY HAPPENED BECAUSE THE PILOT WAS ATTEMPTING TO PUT THE FLAPS CONTROL "UP" AFTER LANDING, AND MOVED THE LANDING GEAR CONTROL INSTEAD. THIS INADVERTENT MOVEMENT OF THE LANDING GEAR CONTROL WAS OFTEN ATTRIBUTED TO THE PILOT'S BEING UNDER STRESS OR DISTRACTED, AND BEING MORE ACCUSTOMED TO FLYING AIRCRAFT IN WHICH THESE TWO CONTROLS WERE IN EXACTLY OPPOSITE LOCATIONS. TWO POPULAR LIGHT AIRCRAFT, THE BEECH BONANZA AND BARON, WERE INVOLVED IN THE MAJORITY OF THESE ACCIDENTS. THE BONANZA CONSTITUTED ONLY ABOUT 30 PERCENT OF THE ACTIVE LIGHT SINGLE ENGINE AIRCRAFT FLEET WITH RETRACTABLE LANDING GEAR, BUT WAS INVOLVED IN 16 OF THE 24 ACCIDENTS SUFFERED BY THIS CATEGORY OF AIRCRAFT. SIMILARLY, THE BARON CONSTITUTED ONLY 16 PERCENT OF THE LIGHT TWIN FLEET, YET SUFFERED 21 OF THE 39 SUCH ACCIDENTS OCCURRING TO THESE AIRCRAFT.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT, AFTER A SPECIFIED DATE, PREVIOUSLY MANUFACTURED BEECHCRAFT BARON AND BONANZA AIRCRAFT WHICH DO NOT CONFORM TO THE LANDING GEAR AND FLAP CONTROL ARRANGEMENTS OUTLINED IN 14 CFR 23.777 BE EQUIPPED WITH AN ADEQUATE GUARD OR LATCH MECHANISM TO PREVENT INADVERTENT ACTUATION OF THE LANDING GEAR CONTROLS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Aviation
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: 80629
Accident Reports:
Report #: SR-80-01
Accident Date: 7/16/1980
Issue Date: 7/16/1980
Date Closed: 7/18/1983
Addressee(s) and Addressee Status: FAA (Closed - Reconsidered)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/18/1983
Response: The installation of the alternate switch guard which is offered by the beechcraft service instruction no. 1215 would accomplish the intent of this safety recommendation if the compliance were other than at the owner's option. Human engineering considerations, like all engineering criteria, are not arbitrary but are essential for the safety and integrity of the aviation system. The accident data developed in the board's special investigation on this subject (ntsb-sr-80-1) adequately support the critically of establishing adequate human engineering design objectivesby aircraft manufactures. However, in light of the faa's argument that modification of all previouslymanufactured beechcraft baron and bonanza airplanes would present an unrea-sonable burden on owners and that the switch guard offered by beechcraft service instruction no. 1215 offers a reasonable solution to the problem, the board will place safety recommendation a-80-57 in a closed--re- considered action status.

From: FAA
To: NTSB
Date: 12/1/1982
Response: FAA LETTER: THE FAA DOES NOT CONCUR WITH THIS SAFETY RECOMMENDATION AS IT REQUIRES MANDATORY ACTION THAT MODIFIES ALL PREVIOUSLY MANUFACTURED BEECH BONANZA AND BARON MODELS WHICH DO NOT CONFORM TO 14 CFR 23.777 WITH AN ADEQUATE GUARD OR LATCH MECHANISM ON THE LANDING GEAR CONTROLS. THE INSTALLATION OF THE ALTERNATE SWITCH GUARD WHICH IS OFFERED BY BEECH SERVICE INFORMATION (NO. 1215) WILL ACCOMPLISH THE INTENT OF THE RECOMMENDATION BY OFFERING A SWITCH GUARD TO OPERATORS WHO HAVE PROBLEMS WITH THE SWITCH LOCATION ON THEIR PANEL. THE SWITCH GUARD IS A REASONABLE SOLUTION TO THE PROBLEM IN LIEU OF THE MAJOR EXPENSE OF A SWITCH RELOCATION MODIFICATION.

From: NTSB
To: FAA
Date: 8/31/1982
Response: In our followup letter of december 10, 1980, we informed the faa that a-80-56 through -58 were being maintained in an open--acceptable action status pending the faa's resolution of these recommendations. We would now appreciate receiving an updated status report.

From: NTSB
To: FAA
Date: 12/10/1980
Response: The safety board is pleased to note that the faa will make an in-depth examination of these design-design-induced, inadvertent landing gear retraction accidents to determine a satisfactory solution of the problem. At this time, we would like to comment that the landing gear control on current beechcraft models has a center detent, which evidently is not as effective as it should be, especially on the baron models. The faa should examine the mechanical latch on the landing gear control of the piper pa-23. The arrangement seems to be effective since this aircraft has an inadvertent gear retraction incidence that is one-tenth that of the baron. Also, we do not believe that merely alerting aircraft owners and potential purchasers to the significantly high incidence of inadvertent gear retraction in the beech bonanza and baron, or to the existence of a non- standard control arrangement in any other aircraft, will satisfy the intentof our recommendations. In effect, the public has already been alerted by virtue of the board's report on this subject. We believe the faa of the board's report on this subject. We believe the faa should address Data Source: NTSB Recommendations to FAA and FAA Responses more directly the intent of our recommendations in order to alleviate problems.

From: FAA
To: NTSB
Date: 10/14/1980
Response: FEDERAL AVIATION ADMINISTRATION LTR: WE AGREE THAT, WHERE APPROPRIATE, COCKPIT CONTROL CONFIGURATIONS SHOULD BE STANDARDIZED. HOWEVER, THESE RECOMMENDATIONS INTRODUCE A NUMBER OF QUESTIONS AND WILL REQUIRE FURTHER STUDY BEFORE A SOUND CONCLUSION CAN BE REACHED. FOR EXAMPLE, THE LANDING GEAR OPERATING SWITCHES IN CURRENT PRODUCTION ON BONANZAS AND BARONS HAVE CENTER LOCK DETENTS WHICH REQUIRE TWO SEPARATE MOTIONS TO ACTUATE THE SWITCH IN EITHER DIRECTION. THIS IS IN EFFECT A LATCH. WE ARE CONCERNED THAT MORE COM PLEX LATCHING ARRANGEMENTS COULD INTERFERE WITH EMERGENCY PROCEDURES AND PERHAPS CREATE A MORE SERIOUS ACCIDENT POTEN TIAL THAN NOW EXISTS. WE INTEND TO EXAMINE THIS ENTIRE SUB JECT IN DEPTH TO DETERMINE WHAT ALTERNATIVES ARE AVAILABLE TO DEAL WITH THESE LESS SERIOUS (NON-FATAL OR MINOR INJURY) ACCIDENTS. AS A PART OF OUR EFFORT, WE MAY CONSIDER THE USE OF PROCEDURES WHICH WILL HELP ALERT AIRCRAFT OWNERS, AND POTENTIAL PURCHASERS OF ACCIDENT STATISTICS WHICH ARE HIGHER THAN NORMAL FOR SPECIFIC AIRCRAFT MODELS.