# NTSB CEN09LA415: Cessna 441, N988AE, Albuquerque, NM, July 3, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 3, 2009, 05:40 local (11:40 UTC) - Place: Albuquerque, NM - Coordinates: 35.040279, -106.609169 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0403&lon=-106.6092&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report October 19, 2009 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 74214 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA415 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74214/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74214 - Page: https://openairdocs.org/ntsb/CEN09LA415 ## Probable cause A malfunction of the landing gear selector switch and a loose fitting on the emergency extension system which rendered the landing gear system inoperable. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: landing gear selector](https://openairdocs.org/ntsb-findings/01023234): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna 441, 1 case](https://openairdocs.org/ntsb-findings/01023234/cases.md?model=2076020), [All aircraft, 54 cases](https://openairdocs.org/ntsb-findings/01023234/cases.md) - [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Inoperative (probable cause); cases with it: [Cessna 441, 1 case](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=2076020), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna 441, 3 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2076020), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-flare/touchdown: Landing gear not configured](https://openairdocs.org/ntsb-events/095); cases with it: [Cessna 441, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=2076020), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) ## Analysis While on final approach to the intended destination airport, the landing gear was selected and the landing gear circuit breaker popped. After initial troubleshooting of the system, the pilot initiated the "Landing Gear Will Not Extend Normally" checklist. The pilot activated the nitrogen blowdown bottle, but the landing gear did not extend. The pilot elected to land gear up utilizing a longer runway at an alternate airport. During the flare, the pilot shut off both engines, and the airplane settled on to the runway. An examination of the landing gear system found that a fitting had separated on the blowdown bottle system resulting in a failure of the emergency extension system. In addition, the airplane's operator discovered a faulty landing gear selector switch. ## Factual narrative On July 3, 2009, approximately 0540 mountain daylight time, a Cessna 441, N988AE, owned and operated by Air Evac Services Incorporated, was substantially damaged following an intentional gear-up landing at Albuquerque International Sunport (KABQ), Albuquerque, New Mexico. The repositioning flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 with an instrument flight plan. Night visual meteorological conditions prevailed. The airline transport pilot and two crew members were not injured. The flight departed the Double Eagle II Airport (KAEG), Albuquerque, New Mexico, at 0320. According to a statement provided by the pilot, the flight was dispatched to pick up a trauma patient in Socorro, New Mexico. While en route, thunderstorms developed along the intended route of flight, so the pilot decided to return to KAEG. While on final approach to KAEG, the gear down position was selected and the landing gear circuit breaker popped. After one minute, the pilot reset the circuit breaker and again the circuit breaker popped. After putting the landing gear handle up, the circuit breaker would remain reset until the landing gear handle was selected down. The pilot initiated the "Landing Gear Will Not Extend Normally" checklist. After activating the nitrogen blowdown bottle, the crew heard the nitrogen flow but the landing gear did not extend. The pilot attempted to maneuver the airplane in an attempt to lower the landing gear. Despite troubleshooting the malfunction, the gear was confirmed in the retracted position by another pilot utilizing night vision goggles during a low approach at KAEG. The pilot elected to land gear up utilizing runway 03 at KABQ. During the landing flare, the pilot shut off both engines, and the airplane settled on to the runway. The airplane slid to the right side of the runway and came to a stop. An inspection of the airplane revealed substantial damage to the fuselage. After recovering the airplane, an examination of the airplane was conducted under the supervision of a Federal Aviation Administration inspector. A fitting was found loose on the nitrogen bottle distribution system resulting in a failure of the emergency extension system. A review of maintenance records indicated that maintenance was performed in the are of the loose fitting in July 2008. A gear extension and retraction tested was performed and no anomalies were detected. However, addition testing on the landing gear selector switch, performed by the operator at a later time, replicated the popped circuit breaker condition, when the landing gear down position was selected. ## Aircraft - Registration: [N988AE](https://openairdocs.org/deregistered/N988AE-2018-06-04), registration cancelled 2018-06-04, S/N 441-0175 (OpenAirDocs) - Reported make and model: CESSNA 441 - Registry model: [Cessna 441](https://openairdocs.org/model/cessna-441) (registry code 2076020) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 441-0175 - Airframe hours: 15299 - Engines: AIRESEARCH TPE331 SERIES 904 horsepower turbo prop; AIRESEARCH TPE331 SERIES 904 horsepower turbo prop - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Air Evac Services Inc, doing business as Phi Air Medical - Registered owner: Air Evac Services Inc - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, April 14, 2009, 74 hours before - Departed: KAEG, Albuquerque, NM - Destination: KABQ, Albuquerque, NM - Flight plan: IFR - Airport: KABQ, Albuquerque International, runway 03, 10,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; flight instructor, airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review April 23, 2009; seat: left; flight hours: 5,500 total, 1,400 in this make and model, 3,400 as pilot in command, 21 in the last 90 days, 17 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft broken - Temperature: 64 °F, dew point 61 °F - Altimeter: 30.23 inHg - Observed at: KABQ ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20090703010499A](https://openairdocs.org/incident/20090703010499A), Jul 3, 2009: Cessna 441, Albuquerque, NM, Substantial damage. (-23) On July 3, 2009 at 0540 MDT,N988AE, a Cessna 441, made a gear up landing at alburquerque international Sunport 9ABQ). The air ambulance flight had… ## Docket (4 files) The files NTSB released with the investigation on August 25, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74214. 4.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 731 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316690&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement: Pilot's statement (item 2, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317244&FileExtension=.PDF&FileName=Witness%20Statement%3A%20Pilot%27s%20statement-Master.PDF - Photo: Accident overview (item 3, .PDF, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317246&FileExtension=.PDF&FileName=Photo%3A%20Accident%20overview-Master.PDF - Photo: Damage to fuselage (item 4, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317247&FileExtension=.PDF&FileName=Photo%3A%20Damage%20to%20fuselage-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.