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National Transportation Safety Board NTSB ID: CEN09FA094 Aircraft Registration Number: N511MJ

FACTUAL REPORT Occurrence Date: 12/15/2008 Most Critical Injury: None

AVIATION Occurrence Type: Incident Investigated By: NTSB

Location/Time
Nearest City/Place State Zip Code Local Time Time Zone
Chicago IL 60018 2239 CST

Airport Proximity: On Airport/Airstrip Distance From Landing Facility:

Aircraft Information Summary


Aircraft Manufacturer Model/Series Type of Aircraft

BOMBARDIER CL-600-2C10 Airplane

Revenue Sightseeing Flight: No Air Medical Transport Flight: No


Narrative
Brief narrative statement of facts, conditions and circumstances pertinent to the accident/incident:
HISTORY OF FLIGHT

On December 15, 2008, at 2239 central standard time (all times cst), a Bombardier CL-600-2C10
(CRJ-700), N511MJ, operated by Mesa Airlines, Inc, dba Air Shuttle Flight 7164, sustained minor
damage during a landing gear emergency at Chicago O'Hare International Airport (ORD). The Title 14
Code of Federal Regulations Part 121 passenger flight had departed ORD about 2130 en route to South
Bend Regional Airport (SBN), South Bend, Indiana. During the landing approach to SBN, the landing
gear "Gear Disagree" warning message appeared. The flight crew performed the appropriate emergency
checklists without success. The flight returned to ORD where an emergency landing was conducted on
runway 28 (13,000 feet by 150 feet, asphalt). The airplane landed on a fully extended nose and
right main landing gear, but the left main landing gear was not extended. The airplane skidded to
a stop with the left wing supported by the wing flaps and the outboard leading edge slats. The 2
pilots, 2 flight attendants, and 28 passengers were not injured, and they departed the airplane
through the main cabin door. Night visual meteorological conditions prevailed at the time of the
incident. An instrument flight rules (IFR) flight plan was filed.

The pilot reported that he was able to keep the left wing up for only a few seconds before it
contacted the runway. He maintained runway centerline during the landing and brought the airplane
to a complete stop on the runway. The pilot reported that the flight attendants evacuated the
passengers, and the emergency responders were on the scene immediately to secure the airplane and
evacuate the passengers.

PERSONNEL INFORMATION

The pilot was an airline transport pilot with single-engine, multi-engine, and instrument airplane
ratings. He was a certified flight instructor in single-engine and multi-engine airplanes, and an
airplane instrument instructor. He held a first-class medical certificate that was issued on June
23, 2008. He reported a total of 3,100 flight hours with 570 hours in the Bombardier CL-600-2C10.

The co-pilot was a commercial pilot with single-engine, multi-engine, and instrument airplane
ratings. He was a certified flight instructor in single-engine and multi-engine airplanes, and an
airplane instrument instructor. He reported a total of 1,450 flight hours with 210 hours in the
Bombardier CL-600-2C10.

AIRCRAFT INFORMATION

The airplane was a Bombardier CL-600-2C10, serial number 10104, equipped with two General Electric
CF34 engines. The left engine was a CF34-8C1 and the right was a CF34-8C5B. The airplane seated 64
and had a maximum gross weight of 75,250 pounds. The last continuous airworthiness inspection was
conducted on December 13, 2008. The airplane had a total time of 14,596 hours.

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National Transportation Safety Board NTSB ID: CEN09FA094

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

Narrative (Continued)

METEOROLOGICAL CONDITION

At 2253, the surface weather observation at ORD was: Wind 360 at 10 knots, visibility 10 miles, few
clouds at 2,100 feet, sky broken at 20,000 feet, temperature -12 degrees Celsius (C), dew point -17
degrees C, altimeter 30.59 inches of Mercury.

FLIGHT RECORDERS

The cockpit voice recorder (CVR) was sent to the National Transportation Safety Board’s (NTSB)
Vehicle Recorder Division Audio Laboratory for download. The CVR recorded 30 minutes of cockpit
voice communications. A summary of key events recorded on the CVR follows:

At 22:08:58 - Start of recording.

At 22:09:18 - Captain declared an emergency.

At 22:09:42 - Captain took the flight controls.

At 22:13:37 - Captain briefed flight attendants. Aircrew discussed evacuation door and safest
location for passengers during landing.

At 22:16:25 - Lead flight attendant briefed passengers on emergency. Crew continued with emergency
checklist and secured loose equipment in the cockpit.

At 22:18:27 - First officer reviewed entire checklist for familiarity.

At 22:20:16 - Captain directed first officer to double-check the completed checklist items.

At 22:20:59 - Discussion of landing technique

At 22:22:24, Discussion of completed manual extension procedure

At 22:23:57 - First officer reviewed emergency items to be accomplished after landing.

At 22:25:54 - Captain briefed flight attendants on unlocking the cockpit door, depressurization,
the brace command, and evacuation signal.

At 22:28:24 - Crew reviewed emergency checklist items for approach and landing.

At 22:28:25 - Lead flight attendant briefed passengers in detail.

At 22:28:54 – Aircraft cleared for the instrument approach.

At 22:33:34 - First officer notified company operations of emergency.

At 22:35:55 - Cleared to land and told equipment was standing by.

At 22:38:26 - Captain disconnected the autopilot.

At 22:38:35 - Flight attendant gave brace command.

At 22:39:07 - Sound similar to aircraft touchdown.

At 22:39:57 - Captain gave command to evacuate.

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National Transportation Safety Board NTSB ID: CEN09FA094

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

Narrative (Continued)

At 22:40:02 - End of recording.

The flight data recorder (FDR) was sent to the NTSB Vehicle Recorder Division for download. The
data indicated that after takeoff, the weight-on-wheels (WOW) parameters for the left, right, and
nose landing gear all transitioned from “ground” to “air”. Approximately 22 minutes later, while
the aircraft was in a descent, the gear down and locked parameters for the right and nose gear
transitioned to down and locked, but the left parameter did not. The Gear Disagree and master
warning parameters also activated at this time. The data indicated that the gear cycled and 3
minutes later, the right and nose gear parameters again showed “down and locked” while the left
gear parameter did not. There was an associated master warning and Gear Disagree indication. The
down and locked states and the Gear Disagree indication stayed active for the next 38 minutes until
landing. Upon touchdown, the WOW right and nose parameters transitioned from “air” to “ground”, but
the left gear parameter did not change state. After the aircraft came to rest, the roll angle on
the FDR measured –9 degrees to the left.

WRECKAGE AND IMPACT INFORMATION

An on-site inspection of the airplane was conducted at a hangar facility at ORD. The inspection
revealed that the left main landing gear door had gouge marks on the door, and the corresponding
area of the belly fairing was fractured. The left landing gear door to belly fairing interface
examination revealed that the screws used to secure the weather seal retainer on the belly fairing
matched the gouge marks found on the left main landing gear door.

The fractured belly fairing was speed taped into its original contoured position. With the airplane
on jacks, the landing gear were raised into the stowed position. The left main landing gear door
was found to be intruding over the belly fairing. When the landing gear was selected down, the left
landing gear door forward edge penetrated the belly fairing fracture (held in place by the speed
tape) and the left landing gear momentarily hesitated before breaking through the speed tape and
extending to its down and locked position. The left landing gear door was examined and no new gouge
marks were noted. The screws holding the belly fairing seal passed over the same gouge marks when
the gear door penetrated the fractured belly fairing.

The examination of the left belly fairing weather seal at the fracture area revealed black marks
parallel to the seal that were consistent with heavy rubbing with the gear door. The weather seal
contained an embedded metal strip in the seal for rigidity.

The clearance between the left landing gear door and the belly fairing was measured while the
landing gear was in the stowed position. It was noted that the manufacturer’s Aircraft Maintenance
Manual (AMM) task 32-12-01-220-801-A01 did not specify any rigging criteria for zone “E”, which was
the zone that corresponded to the fractured belly fairing.

TESTS AND RESEARCH

The left main landing gear retraction actuator and the Proximity Sensor Electronic Unit (PSEU) were
removed from the airplane and sent to their respective manufacturers for testing. The functional
tests revealed that both components operated within specifications when functionally bench tested.

ADDITIONAL INFORMATION

A review of the airplane’s maintenance records indicated that the left main landing gear door had
been replaced in September 2007 because the original door was lost in flight. The maintenance
records indicated that the door was replaced at the manufacturer’s heavy maintenance facility. The
manufacturer reviewed all maintenance records of the incident door and interviewed maintenance
personnel involved in the replacement of the door. The maintenance review revealed that the door

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National Transportation Safety Board NTSB ID: CEN09FA094

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

Narrative (Continued)

was rigged and checked with the use of the aircraft hydraulic pumps instead of the external
hydraulic power unit as required by AMM Task 32-12-01-220-801 (Config A01).

On December 23, 2008, the aircraft manufacturer issued Service Letter CRJ700/900-SL-32-039, “Body
Fairing Seal Inspection Common to MLG Inboard Door” to provide operators with guidelines for
inspecting the body fairing seal common to the main landing gear inboard doors at the next
convenient maintenance opportunity (i.e., 72 hour or 100 flight hours). On January 28, 2009, the
Federal Aviation Administration (FAA) issued a Special Airworthiness Information Bulletin (SAIB)
No. NM-09-06. The SAIB stated that the FAA “strongly recommends that the affected operators comply
with Bombardier Service Letter CRJ700/900-SL-32-039 at the earliest opportunity.”
Updated on Oct 5 2009 3:40PM

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NTSB ID: CEN09FA094


National Transportation Safety Board

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

Landing Facility/Approach Information


Airport Name Airport ID: Airport Elevation Runway Used Runway Length Runway Width
Chicago O'Hare International ORD 672 Ft. MSL 28 13000 150

Runway Surface Type: Asphalt; Concrete

Runway Surface Condition: Dry

Approach/Arrival Flown: ILS

VFR Approach/Landing: Full Stop

Aircraft Information
Aircraft Manufacturer Model/Series Serial Number
BOMBARDIER CL-600-2C10 10104

Airworthiness Certificate(s): Normal

Landing Gear Type: Tricycle


Amateur Built Acft? No Number of Seats: 64 Certified Max Gross Wt. 75250 LBS Number of Engines: 2
Engine Type: Engine Manufacturer: Model/Series: Rated Power:
Turbo Fan General Electric CF34-8C1 13790 LBS
- Aircraft Inspection Information
Type of Last Inspection Date of Last Inspection Time Since Last Inspection Airframe Total Time

Continuous Airworthiness 12/2008 Hours 14596 Hours

- Emergency Locator Transmitter (ELT) Information

ELT Installed?/Type Yes / Unknown ELT Operated? No ELT Aided in Locating Accident Site? No

Owner/Operator Information
Registered Aircraft Owner Street Address

First Union National Bank Trustee City State Zip Code


Charlotte NC 28288
Street Address
Operator of Aircraft 410 North 44th Street, Suite 700
City State Zip Code
Mesa Airlines, Inc
Phoenix AZ 85008
Operator Does Business As: Operator Designator Code: MESA
- Type of U.S. Certificate(s) Held:
Air Carrier Operating Certificate(s): Flag Carrier/Domestic

Operating Certificate: Operator Certificate:

Regulation Flight Conducted Under: Part 121: Air Carrier

Type of Flight Operation Conducted: Scheduled; Domestic; Passenger Only

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National Transportation Safety Board NTSB ID: CEN09FA094

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

First Pilot Information


Name City State Date of Birth Age

On File On File On File On File 27

Sex: M Seat Occupied: Left Occupational Pilot? Yes Certificate Number: On File

Certificate(s): Airline Transport; Flight Instructor

Airplane Rating(s): Multi-engine Land; Single-engine Land


Rotorcraft/Glider/LTA: None

Instrument Rating(s): Airplane

Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane

Current Biennial Flight Review? 09/2008

Medical Cert.: Class 1 Medical Cert. Status: With Waivers/Limitations Date of Last Medical Exam: 06/2008

This Make Airplane Airplane Instrument Lighter


All A/C
- Flight Time Matrix and Model Single Engine Mult-Engine
Night
Actual Simulated
Rotorcraft Glider
Than Air

Total Time 3100 570 1200 1900


Pilot In Command(PIC) 1750 500 1150 600
Instructor 1000 900 100
Instruction Received

Last 90 Days 150 150 150 50 15


Last 30 Days 40 40 40 20 4
Last 24 Hours 5 5 5 3 2
Seatbelt Used? Yes Shoulder Harness Used? Yes Toxicology Performed? No Second Pilot? Yes

Flight Plan/Itinerary
Type of Flight Plan Filed: IFR
Departure Point State Airport Identifier Departure Time Time Zone

Chicago IL ORD 2100 CST

Destination State Airport Identifier


Same as Accident/Incident Location ORD

Type of Clearance: IFR

Type of Airspace:

Weather Information
Source of Wx Information:

Automated Report

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National Transportation Safety Board NTSB ID: CEN09FA094

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

Weather Information
WOF ID Observation Time Time Zone WOF Elevation WOF Distance From Accident Site Direction From Accident Site

ORD 2253 CST 672 Ft. MSL 0 NM 0 Deg. Mag.


Sky/Lowest Cloud Condition: Few 2100 Ft. AGL Condition of Light: Night

Lowest Ceiling: Broken 20000 Ft. AGL Visibility: 10 SM Altimeter: 30.59 "Hg

Temperature: -12 ° C Dew Point: -17 ° C Weather Conditions at Accident Site: Visual Conditions

Wind Direction: 360 Wind Speed: 10 Wind Gusts:

Visibility (RVR): Ft. Visibility (RVV) SM

Precip and/or Obscuration:

Accident Information
Aircraft Damage: Minor Aircraft Fire: None Aircraft Explosion None

- Injury Summary Matrix Fatal Serious Minor None TOTAL

First Pilot 1 1
Second Pilot 1 1
Student Pilot

Flight Instructor

Check Pilot

Flight Engineer

Cabin Attendants 2 2
Other Crew

Passengers 28 28
- TOTAL ABOARD - 32 32
Other Ground

- GRAND TOTAL - 32 32

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NTSB ID: CEN09FA094


National Transportation Safety Board

FACTUAL REPORT Occurrence Date: 12/15/2008

AVIATION Occurrence Type: Incident

Administrative Information
Investigator-In-Charge (IIC)
James P. Silliman

Additional Persons Participating in This Accident/Incident Investigation:

Christine Soucy
FAA
Washington, DC

Les Geisler
Mesa Airlines, Inc
Chicago, IL

Jimmy Avgoustis
Bombardier
Montreal, Quebec,

Gerasimos Kouverianos
Goodrich
Toronto, Ontario,

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