Pilot Debrief

ISRAEL AIRCRAFT INDUSTRIES GULFSTREAM 200 near Savannah, GA — 2014-01-14

Final reportERA14LA098
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Date
2014-01-14
Location
Savannah, GA, USA
Airport
KSAV
Aircraft
ISRAEL AIRCRAFT INDUSTRIES GULFSTREAM 200
Registration
N720QS
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

Maintenance personnel’s failure to properly secure the auxiliary power unit service door before returning the airplane to service, which resulted in substantial damage to the rudder.

NTSB narrative

The airplane had undergone maintenance for an unresolved landing gear position indication issue. The flight crew reported that, during the third postmaintenance operational check flight (OCF), the airplane experienced a "thud" and momentary shudder as it climbed through 16,000 ft at 280 knots. The flight crew observed no other anomalies and did not experience any abnormal handling characteristics with the airplane during the remainder of the flight. Upon landing, the flight crew observed that the auxiliary power unit (APU) service door was open and bent but that it remained attached at its aft hinge point. The door's lower latches were partially engaged, and a detailed examination revealed no anomalies with the latch assembly. The lower portion of the rudder was substantially damaged due to contact with the service door. Review of maintenance work orders revealed that maintenance had been performed in the APU compartment before another OCF that had been conducted several days before the accident flight and that it was subsequently inspected in accordance with the maintenance provider's procedures. Maintenance personnel should have noted that the APU service door was not properly secured during the inspection. The flight crew's preflight inspection did not include inspecting the APU service door because it was only accessible with the aid of a ladder. .

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Inspection of APU service door security before the flight could have prevented the incident.

NTSB coding

Evidence available

  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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