A Colorado couple, both pilots with 2,000 hours and instrument ratings, had taken their Malibu to Hutchinson, Kansas, for its annual inspection. They returned home to Steamboat Springs in a rented car, and two weeks later drove back to Hutchinson to retrieve the airplane. The work done had included the removal of free play from the landing gear, which had been cycled on jacks afterward.
The weather briefing for the return flight announced a large low-pressure system moving southward along the Rockies, bringing snow and fog with it. Airmets warned of moderate turbulence and icing, but there was time to beat the storm to the couple’s destination. At 10:10 on the morning of Dec. 22, 2008, having collected the finished paperwork on the annual inspection, the couple departed on an IFR flight plan for Hayden, Colorado, which was still enjoying marginal VFR conditions under a layered overcast.
The flight was uneventful except for its final minutes. The following transcript, compiled from FAA tapes and slightly edited for brevity, begins as the flight is nearing Hayden. INEDE and LUDYE are initial approach fixes; DEN is Denver Center; 37S is a King Air airborne in the vicinity; otherwise, the identities of the speakers should be apparent from the context. Times are Mountain Standard Time.
1148:05
DEN — N46SB, you can expect the VOR/DME-B approach from the southeast side, uh, and you are cleared direct LUDYE.
6SB — 46SB, would rather do the ILS.
DEN — 6SB, OK, I can do that. N6SB cleared direct to INEDE.
6SB — Direct INEDE, Sierra Bravo.
1210:06
DEN — N6SB, you still in the clouds at eleven three?
6SB — We’re in and out.
DEN — 46SB roger, as you get to 11,000, you’re passing just over the airport. Let me know if you get it in sight for the visual – that’ll speed things up a little bit.
6SB — We’re going to go direct INEDE. We’re in and out of the clouds here for, uh, doing a visual.
DEN — 6SB, that’s fine, uh, just if you did get it, that’s all I wanted to know. It would speed things up a little bit, but if you need the approach that’s no problem. … N6SB, I should get you in good radar back before INEDE. Say your DME from INEDE now.
6SB — 6.9 from INEDE.
DEN — N6SB roger … N6SB maintain 11,000 until INEDE, cleared ILS Runway 10 Yankee, Runway 10 approach.
1216:55
6SB — Center, uh, 46SB is having trouble with getting their gear down. Uh, we’re trying to turn back in and do our gear here all at the same time.
DEN — 46SB roger, uh, keep me advised if you need to, uh, go missed and pull off. Just let me know.
6SB — Sierra Bravo.
1218:12
6SB — Sierra Bravo got the gear down.
DEN — N6SB roger, uh, showing three good lights?
6SB — Three good, three green lights, so we’re hoping the gear is down.
DEN — 6SB roger, are you inbound now? Are you established?
6SB — We are now turned inbound.
DEN — 6SB OK, change to advisory frequency approved. Report your, uh, arrival with me and just let me know if anything happens with the gear.
6SB — OK, we’ll report our revi arriv [unintelligible] arrival with you.
1220:27
37S — Center from 37S, sounds like she was trying to call you guys.
DEN — Uh, who’s trying to call me?
37S — 37S, we thought we were hearing the Malibu calling ya.
DEN — Well, if they’re calling on this frequency I should hear ’em. I can talk to them on the ground, if it might not be CTAF — you by chance monitoring both?
37S — No, she was, uh, transmitting when you guys were talking with Execjet.
DEN — 6SB, Denver, are you calling? —
1226:50
DEN — Execjet 984, you didn’t see a Malibu land or taxiing out there at the airport?
EJA — Execjet 984 negative, we’re, we’re listening on Unicom also and haven’t heard ’em.
DEN — Execjet 984, what’s the visibility like out there?
EJA — It, it’s dropping a little bit. I, I’d say, uh, in and out, it’s, it’s 10 miles at the surface but, uh, the ceiling’s dropping on one side of the airport; it’s, uh, three miles, the other side is 10 miles.
DEN — Execjet 984 roger, now you, uh, good visibility to the north, uh, west out there for coming in to 28?
EJA — Execjet 984, that’s probably the, uh, the least visibility. It looks like, uh, at the most three miles.
1229:15
37S — And Center, from King Air 37S, when you were talking with Execjet, we’re pretty sure we heard her making some sort of exclamation.
DEN — 37S roger, but you could not make out what it was?
37S — No, we couldn’t; it was just too broken. … In case you weren’t briefed, sir, uh, she was troubleshooting a gear item that last contact going into Hayden, and she indicated that she was flying around VFR.
As outbound traffic held at Hayden for the missing Malibu and the Denver controller tried to find it, Execjet 803, approaching Hayden, began to pick up an ELT signal, as did Delta 1955, which pinpointed it as coming from three miles west of the VOR. A search-and-rescue team was immediately mobilized, and, despite reduced visibilities and occasionally heavy snowfall, they located the wreckage at 1645, a little north of the localizer and about 10½ miles west of the airport at an elevation of 6,563 feet. The two pilots were dead. The storm soon arrived in full force, and only a week later were accident investigators able to examine the wreckage.
The wife, who was in the right seat and was the radio speaker, reported the gear problem while the Malibu was in the course-reversal portion of the procedure turn. Radar showed the airplane overshooting the localizer and correcting back. Its groundspeed was 85 knots, and its altitude was 9,650 feet. At this point, the gear problem, which had required slowing to below 90 knots, had been dealt with and the gear was apparently down and locked.
So far, so good — or so it seemed. But at this point things quickly fell apart. The airplane began to turn left, away from the localizer. It descended to 9,200 feet while accelerating to 152 knots, then climbed to 10,200 feet and slowed to 76 knots. By the time it had turned almost 180 degrees and was flying away from the airport, it was back at 8,900 feet with a groundspeed of 120 knots. The last two radar fixes are perplexing; the airplane was at 8,700 feet with a groundspeed of 20 knots, and then, 24 seconds later at 1220:11, it was at 8,400 feet with a groundspeed of 38 knots. The speeds are implausible, but at any rate the Malibu was clearly out of control.
Inspection of the airframe and engine revealed no indication of a mechanical failure, and the NTSB concluded that this was a matter of spatial disorientation. But how could two experienced, instrument-rated pilots making a routine ILS approach lose control of an airplane with which both were very familiar?
Some sort of mechanical or instrumentation malfunction cannot be ruled out, but the rapidity with which the loss of control followed the gear problem strongly suggests a linkage between the two. This seems to have been one of those freakish situations in which pilots simply lose track of what an airplane is doing.
This husband-and-wife team, like most nonprofessional pairings of pilots, might not have enforced a professional level of cockpit discipline, with preflight briefings and a clearly stated division of authority and responsibilities. When the gear malfunctioned, the fact that they did not immediately declare a missed approach, climb to a holding pattern over the VOR and then deal with the gear suggests that they felt that with two pilots aboard, they could fly the approach and lower the gear at the same time.
It is likely, though, that in the heat of the moment, rather than have one pilot focus on the flying and the other on the gear-lowering procedure (which is not very complicated), they might both have turned their attention to the gear. They succeeded in getting three greens, but that the unexpected complication left the wife rattled is suggested by her difficulty in articulating the word arrival — she began to say revival — and by the Execjet pilot’s report of her making an unintelligible exclamation. That the husband, who was in the left seat and was probably the pilot flying, became disoriented is suggested by the airplane’s final erratic maneuvers. The well-ordered instrument-approach process — outbound course, procedure turn, glideslope, landing — had been fatally interrupted by the balky gear.
The human pilot is usually the weakest link in the chain of safety. Two weak links don’t make the chain any stronger, unless each focuses on a separate and clearly articulated task; and the task with the highest priority, least tolerant of distraction, is always the flying of the airplane.
This article is based on the NTSB’s report of the accident and is intended to bring the issues raised to our readers’ attention. It’s not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.
