3 fatalities

2012-07-13: Gulfstream GIV (N823GA) — Universal Jet Aviation — Le Castellet, France

Le Castellet, FranceLanding (descent or approach)

On July 13, 2012, a Gulfstream GIV (registration N823GA) operated by Universal Jet Aviation was involved in an aviation accident near Le Castellet, France during landing or approach. 3 people were killed. Investigators recorded the probable cause as: 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… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781194729Data APIEditorial standards

A flight from Nice to Le Castellet ended in a runway excursion and fire. The crew forgot to arm the ground spoilers, and the investigation cited checklist non-compliance and other factors.

Flight Details

A crew consisting of a captain (pilot monitoring) and a co-pilot (pilot flying), along with a cabin aid, operated a flight from Athens to Istanbul Sabiha Gokcen, then on to Nice with three passengers. After dropping them off, they departed Nice at 12:56 for a short flight to Le Castellet aerodrome to park the aircraft due to lack of parking at Nice. The flight was conducted under US regulation 14 CFR Part 135. Cruise at FL160 lasted about 5 minutes.

Approach and Landing

Cleared for a visual approach to runway 13, the crew disengaged the autopilot and auto-throttle. The landing gear was down and flaps were in the landing position. The GND SPOILER UNARM message appeared on the EICAS with a single chime, indicating the ground spoilers were not armed. The crew did not arm them. At a height of 25 ft, a SINK RATE warning triggered. The pilot flying corrected, and the main landing gear touched down 15 meters beyond the touchdown zone, 365 meters from the threshold, slightly left of the centerline. The ground spoilers did not automatically deploy. The crew braked and selected thrust reversers, which did not fully deploy. Hydraulic brake pressure increased slightly, but deceleration was slow.

Runway Excursion

Four seconds after touchdown, a MASTER WARNING activated, followed by another five seconds later. The nose landing gear touched down 785 meters beyond the threshold but then lost contact as the pitch attitude increased. The aircraft crossed the centerline to the right; the crew corrected with left rudder input. A strong nose-down input caused the nose gear to contact again at 1,050 meters. The crew manually deployed speed brakes. Maximum thrust reverser was reached one second later, at 655 meters from the runway end. The aircraft began curving left; the crew applied right rudder to the stop and right brake but did not correct the trajectory. The aircraft skidded to the right and ran off the runway to the left 385 meters from the end at about 95 knots ground speed. It struck a runway edge light, the PAPI for runway 31, a metal fence, and trees, catching fire instantly.

Post-Impact Fire

An aerodrome firefighter responded quickly but could not bring the fire under control. The occupants were unable to evacuate the aircraft.

Investigation Findings

The investigation determined that the accident resulted from a combination of factors: the ground spoilers were not armed during approach; a lack of complete before-landing checklist performance; procedural and ergonomic issues with monitoring ground spoiler extension; a possible left tiller input or nose gear steering failure causing left orientation beyond rudder pedal authority; lack of crew training for uncommanded nose wheel steering; inadequate introduction of that procedure by Gulfstream and the FAA; failures in documentation updates; and FAA monitoring deficiencies.

Probable cause

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.