Docket And Docket Items - National Transportation Safety Board: http://dms.ntsb.gov/pubdms
National Transportation Safety Board - Aviation Accident Data Summary: http://app.ntsb.gov/pdf
NTSB Identification: DCA11MA076
14 CFR Part 91: General Aviation
Accident occurred Saturday, April 02, 2011 in Roswell, NM
Probable Cause Approval Date: 09/24/2013
Aircraft: GULFSTREAM GVI, registration: N652GD
Injuries: 4 Fatal.
NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-12-02.
On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center Airport, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
an aerodynamic stall and subsequent uncommanded roll during a one engine-inoperative takeoff flight test, which were the result of (1) Gulfstream’s failure to properly develop and validate takeoff speeds for the flight tests and recognize and correct the takeoff safety speed (V2) error during previous G650 flight tests, (2) the G650 flight test team’s persistent and increasingly aggressive attempts to achieve V2 speeds that were erroneously low, and (3) Gulfstream’s inadequate investigation of previous G650 uncommanded roll events, which indicated that the company’s estimated stall angle of attack while the airplane was in ground effect was too high. Contributing to the accident was Gulfstream’s failure to effectively manage the G650 flight test program by pursuing an aggressive program schedule without ensuring that the roles and responsibilities of team members had been appropriately defined and implemented, engineering processes had received sufficient technical planning and oversight, potential hazards had been fully identified, and appropriate risk controls had been implemented and were functioning as intended.
The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-12-02.
The crash, which occurred April 2, 2011, in Roswell, N.M., during a takeoff run simulating late-stage engine failure, resulted in the deaths of all four Gulfstream employees on board: experimental test pilots Kent Crenshaw and Vivan Ragusa and technical specialists David McCollum and Reece Ollenburg.
“Two prior close calls should have prompted a yellow flag, but instead of slowing down to analyze what had happened, the program continued full speed ahead,” NTSB chairwoman Deborah Hersman said in her opening comments.
“In this investigation, we saw an aggressive flight test schedule and pressure to get the aircraft certified,” she said. “Assumptions and errors were made, but they were neither reviewed nor evaluated when review data was collected.”
In a submission to the agency dated May 21 of this year and placed on the NTSB public docket in June, Gulfstream said the company “accepts full responsibility for the accident.”
“Developmental flight test is inherently risky, but risks can and should be appropriately mitigated,” the Gulfstream report stated.
Among the factors Gulfstream listed as likely leading to the crash were an overestimation of the angle at which the aircraft could safely lift off and a takeoff speed schedule that was not properly developed or verified, resulting in an unachievable test point for the accident run.
“Gulfstream’s internal analysis, review and approval processes did not identify those two errors prior to field performance flight testing,” the report stated, adding that “two prior wing drop events in the G650 field performance program and other flight test anomalies arising from these improper speed schedules were not widely reviewed or properly understood.”
Although the NTSB’s final written report is still a few weeks away, most insiders have suggested from the beginning that the crash had more to do with the process than the airplane itself.
“It doesn’t matter who you are — Gulfstream, Bombardier, Airbus,” said a former test pilot familiar with business aviation. “When you are developing a new product, the pressure to get it certified in a timely manner is huge.”
That Gulfstream cited a breakdown in its internal analysis, review and approval processes indicated the crash was most likely a result of human error rather than any structural issues with the aircraft, he said.
It’s also important to remember that tests such as the ones the Gulfstream crew was performing the day of the fatal crash are part of the risks associated with the development of a new airplane, Chris Dancy, spokesman for the Aircraft Owners and Pilots Association, said at the time.
“In order to achieve FAA certification, flight-test crews have to determine the safe operating parameters of the aircraft,” Dancy said. “They have to be able to answer questions like, ‘What happens if you lose an engine during takeoff?’
“With every new aircraft, the performance envelope has to be defined, and qualified flight-test crews then fly to the edge of that envelope.”
Hersman said at the close of the hearing that Gulfstream recognized that many changes needed to be made and has begun to implement them.
The company has taken several steps to improve safety since the accident, including the appointment of an aviation safety official who reports directly to the firm’s president and enhanced communication throughout the company, Gulfstream spokeswoman Heidi Fedak said.
Gulfstream released the following statement at the conclusion of Wednesday’s hearing:
“We appreciate the National Transportation Safety Board’s commitment to thoroughly examining this accident and determining its cause. Gulfstream has and will continue to support the families of the flight crew of Aircraft 6002. Their well-being remains a top consideration of everyone at Gulfstream.
“Safety is Gulfstream’s first priority. Since this accident, we have redoubled our efforts to strengthen the safety culture in flight test and throughout the rest of the company. We are committed to continuous safety improvement.”
The NTSB also released a list of 19 findings, a statement of probable cause and 10 recommendations — two of which were directed at Gulfstream.
The G650 — which is manufactured at Gulfstream headquarters in Savannah — received its certification from the Federal Aviation Administration in September, and the company is preparing to deliver it to customers by the end of this year, Fedak said.
“We can’t change what happened” the day the jet crashed in New Mexico, Hersman said.
“But we owe it to the four flight test professionals who lost their lives to make sure we learn from it.”
NTSB’S STATEMENT ON PROBABLE CAUSE
The National Transportation Safety Board determines that the cause of this accident was an aerodynamic stall and subsequent uncommanded roll during a one engine-inoperative takeoff flight test, which were the result of (1) Gulfstream’s failure to properly develop and validate takeoff speeds for the flight tests and recognize and correct the takeoff safety speed (V2) error during previous G650 flight tests, (2) the G650 flight test team’s persistent and increasingly aggressive attempts to achieve V2 speeds that were erroneously low, and (3) Gulfstream’s inadequate investigation of previous G650 uncommanded roll events, which indicated that the company’s estimated stall angle of attack while the airplane was in ground effect was too high.
Contributing to the accident was Gulfstream’s failure to effectively manage the G650 flight test program by pursuing an aggressive program schedule without ensuring that the roles and responsibilities of team members had been appropriately defined and implemented, engineering processes had received sufficient technical planning and oversight, potential hazards had been fully identified, and appropriate risk controls had been implemented and were functioning as intended.
RECOMMENDATIONS FOR GULFSTREAM
• Commission an audit by qualified independent safety experts, before the start of the next major certification flight test program, to evaluate the company’s flight test safety management system, with special attention given to the areas of weakness identified in this report, and address all areas of concern identified by the audit.
• Provide information about the lessons learned from the implementation of its flight test safety management system to interested manufacturers, flight test industry groups, and other appropriate parties.
GULFSTREAM G650’S ILL-FATED FLIGHT
Here’s the transcript of the final moments of the Gulfstream G650 test flight that crashed April 2, 2011:
09:33:17.00 — Take-off roll starts
09:33:45.70 — Co-pilot: “Rotate”
09:33:49.00 — Pitch angle increased to 9?
09:33:50.05 — Pitch angle at 11.2? (stall)
09:33:50.06 — Right wheel lifts off
09:33:50.10 — Left wheel lifts off
09:33:52.30 — Stick shaker/right wing scrape
09:33:53.06 — Bank angle warning sounds
09:33:54.30 — Pilot: “Power power power”
09:33:55.20 — Co-pilot: “Power, power, power’s up”
09:33:56.60 — Pilot: “Power, power, power”
09:33:58.05 — Bank angle warning sounds
09:34:00.00 — Pilot: “Ah sorry guys”
09:34:02.40 — Triple chime warning alarm sounds
09:34:10.03 — End of recording
Source: NTSB/Gulfstream
ABOUT THE CRASH
The two flight-test pilots and two flight-test engineers on board survived the initial impact but were almost immediately overcome by smoke and fire and were not able to exit the aircraft.
The crew had been performing its ninth flight of the day, a heavy take-off weight field test with the right engine idle — a test used to determine the lift-off and climb-out speeds needed to develop procedures for pilots in the event of engine failure late in a take-off run.
Post-crash analyses revealed the stall angle for the aircraft to be lower than originally anticipated.
http://savannahnow.com
NTSB Identification: DCA11MA076
14 CFR Part 91: General Aviation
Accident occurred Saturday, April 02, 2011 in Roswell, NM
Aircraft: GULFSTREAM GVI, registration: N652GD
Injuries: 4 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
On April 2, 2011, about 0934 mountain daylight time, a Gulfstream GVI (G650) airplane, N652GD, was substantially damaged after impact with terrain during takeoff at Roswell International Air Center Airport (ROW), Roswell, New Mexico. Visual meteorological conditions prevailed and a company flight plan was filed for the 14 Code of Federal Regulations Part 91 flight. The two flight crewmembers and the two technical crewmembers were fatally injured. The flight had originated from ROW about 0700 for a local area flight.
The airplane was operating under a Federal Aviation Administration (FAA) Experimental Certificate of Airworthiness and was performing a take off with a simulated engine failure to determine take-off distance requirements at minimum flap setting.
Wingtip scrape marks beginning on the runway approximately 5,300 feet from the end of the runway lead toward the final resting spot about 3,800 feet from the first marks on the runway. Witnesses close to the scene saw the airplane sliding on the ground with sparks and smoke coming from the bottom of the wing, and described the airplane being fully involved in fire while still moving across the ground. The airplane struck several obstructions and came to rest upright about 200 feet from the base of the airport control tower. Several airport rescue and fire fighting (ARFF) units responded quickly and fought the fire.
No comments:
Post a Comment