Fatal G-IV Runway Excursion Accident in France – Lessons
The French accident investigation agency, the Bureau d’Enquêtes et d’Analyses (BEA), has issued their report (warning 12Mb) on the 13 July 2012 accident to Gulfstream G-IV business jet N823GA. The US registered aircraft was operated by Universal Jet Aviation (UJT) under 14 CFR Part 135. It suffered a runway excursion while landing during a short ferry flight from Nice, France to Le Castellet Airport. All three occupants were killed.
The BEA comment (emphasis added):
Between Nice airport and Le Castellet aerodrome which was not familiar to the crew, the flight was short. The cruise, which lasted only five minutes, left the crew little time to prepare for their arrival. The flight was the last of the day and it was made without any passengers, with the co-pilot in the right seat as PF. This context may have been conducive to lax pre-flight planning and management of the flight by the crew with a heavy workload during the cruise and the approach. Despite having been warned the day before of the need to park the aeroplane at Le Castellet, the copilot learnt the characteristics of the aerodrome during the flight. Few checklists and briefings were heard throughout the flight. During the flight, the crew referred to the proximity of the terrain, the need to reduce speed and anticipate the configuration, and the short runway length. The crew nevertheless understated the impact of a short flight on the preparation of the arrival.
The BEA say that:
During a visual approach to land on runway 13 at Le Castellet aerodrome, the crew omitted to arm the ground spoilers. During touchdown, the latter did not deploy. The crew applied a nose-down input which resulted, for a short period of less than one second, in unusually heavy loading of the nose gear. The aeroplane exited the runway to the left, hit some trees and caught fire.
The Investigator’s Conclusions
The BEA concluded:
The runway excursion was the result of an orientation to the left of the nose gear and the inability of the crew to recover from a situation for which it had not been trained. The investigation revealed inadequate pre-flight preparation, checklists that were not carried out fully and in an appropriate manner. A possible link between the high load on the nose gear and its orientation to the left was not demonstrated.
In particular they explain:
Forgetting to arm the ground spoilers delayed the deployment of the thrust reversers despite their selection. Several MASTER WARNING alarms were triggered and the deceleration was low. The crew then responded by applying a strong nose-down input in order to make sure that the aeroplane stayed in contact with the ground, resulting in unusually high load for a brief moment on the nose gear. After that, the nose gear wheels deviated to the left as a result of a left input on the tiller or a failure in the steering system. It was not possible to establish a formal link between the high load on the nose gear and this possible failure. The crew was then unable to avoid the runway excursion at high speed and the collision with trees.
The aerodrome fire-fighter, alone at the time of the intervention, was unable to bring the fire under control after the impact. Although located outside of the runway safety area on either side of the runway centre line, as provided for by the regulations, the presence of rocks and trees near the runway contributed to the consequences of the accident.
The BEA concluded the accident was caused by the combination of the following factors:
The ground spoilers were not armed during the approach
A lack of a complete check of the items with the ‘‘before landing’’ checklist, and more generally the UJT crews’ failure to systematically perform the checklists as a challenge and response to ensure the safety of the flight
Procedures and ergonomics of the aeroplane that were not conducive to monitoring the extension of the ground spoilers during the landing
A possible left input on the tiller or a failure of the nose gear steering system having caused its orientation to the left to values greater than those that can be commanded using the rudder pedals, without generating any warning
A lack of crew training in the ‘‘Uncommanded Nose Wheel Steering’’ procedure, provided to face uncommanded orientations of the nose gear
An introduction of this new procedure that was not subject to a clear assessment by Gulfstream or the FAA
Failures in updating the documentation of the manufacturer and the operator
Monitoring by the FAA that failed to detect both the absence of any updates of this documentation and the operating procedure for carrying out checklists by the operator.
The BEA observe on the use of checklists:
During the flight, the ‘‘before landing’’ checklist, which was not fully verbalized or carried out in ‘‘challenge and response’’ mode, i.e. without any check or confirmation by the other pilot, did not provide the crew with a check step. As a result, they did not detect the failure to arm the ground spoilers during the approach.
The analysis of the accident flight [and] the video recordings of flights by UJT pilots and interviews, shows that carrying out the checklists in ‘‘challenge and response’’ mode was not systematic within the operator’s personnel. This had not been identified as a problem during in-flight audits by the FAA.
Using a checklist as a list of actions to carry out does not provide a step for cross-checking items and makes the flight more susceptible to errors and omissions.
Approvals and SMS
The BEA also note that:
UJT had not sent any application for an operating permit for non-scheduled air services for the flights on 13 and 15 July 2012 made or planned to be made in French airspace.
The operator did have a Safety Management System and a confidential reporting system, even though neither were required by US regulations. The BEA however concluded that at the time of the accident neither has:
…a sufficient degree of maturity to enable effective feedback in terms of improving safety: feedback to the crews did not contain information on flight safety as such, and the feedback system was not yet used by crews.
The report contains a number of safety recommendations regarding:
The nose gear steering system of the G-IV, to inhibit inputs at high speed
Review of the effectiveness of uncommanded nose gear steering system recovery procedure
Requiring training on that recovery procedure
The procedures for arming of the ground spoilers and their certification requirements (26.699)
Requiring appropriate use of checklists
Enhancing rescue and fire-fighting service (RFFS) provision at Le Castellet aerodrome.
Other Accident Case Studies
We have previously written an article about a G-IV take-off accident in the US: Gulfstream G-IV Take Off Accident & Human Factors. That accident also featured poor use of checklists and resulted in a runway excursion and a catastrophic fire.
In 2013 an AgustaWestland A109E collided with a building in central London while en route to collect a client in poor visibility: Fatal Helicopter / Crane Collision – London Jan 2013. The following year an AgustaWestland AW139 crashed making a departure from the client’s stately home in poor visibility at night: Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons.
We have also looked at an accident to an ad hoc chartered CASA C212: Catastrophe in the Congo – The Company That Lost its Board of Directors
In other organisations it has been apparent after accidents that the documented SMS was not an effective, living system but in practice was just ‘shelfware’ (as we discussed recently in the cases of Metro-North and a Mid Air Collision between a Typhoon & target Learjet 35).
UPDATE 24 October 2016: Execuflight Hawker 700 N237WR Akron Accident: Casual Compliance A disturbing accident after an unstabilised approach that begs serious questions of the operator’s procedures and culture.
UPDATE 6 January 2020: Runway Excursion Exposes Safety Management Issues
Although this accident happened on a positioning flight, after delivering their client, it again highlights the importance of understanding the true capabilities of any operator you plan to charter from and seeking specialist aviation advice.
Aerossurance is pleased to sponsor the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 9-10 November 2015.