Pilot Debrief

ISRAEL AIRCRAFT INDUSTRIES GULFSTREAM 200 near Newburgh, NY — 2011-05-27

Final reportERA11IA316
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Date
2011-05-27
Location
Newburgh, NY, USA
Airport
SWF
Aircraft
ISRAEL AIRCRAFT INDUSTRIES GULFSTREAM 200
Registration
N749QS
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The flight crew did not ensure that the landing gear selector handle was in the full down (extend) position. Contributing to the incident was inadequate checklist information.

Contributing factors

Contributing to the incident was inadequate checklist information.

NTSB narrative

Prior to the incident flight, the flight crew performed an uneventful repositioning flight and did not experience any problems with the airplane's landing gear system. During the incident flight, the flight crew was performing a visual approach to the destination airport. The second-in-command (SIC) initiated a landing gear extension, and the landing gear extended but did not lock. The flight crew entered a holding pattern to perform the Landing Gear Down Lock Indication Failure checklist. Before the SIC reached the steps to cycle the landing gear, the flight crew was distracted by a hydraulic overheat condition and diverted to the Hydraulic System Overheat checklist to address that condition. When the SIC returned to the Landing Gear Down Lock Indication Failure checklist, he could not cycle the landing gear per the checklist instructions, because the hydraulic pressure was low. He then began the Emergency Landing Gear Extension checklist. The emergency extension resulted in all three landing gear remaining extended, but only the nosegear locked, and no further pertinent information remained in the checklist. The flight crew then performed an emergency landing at an airport with a longer runway. During the landing, the right main landing gear collapsed, and the airplane came to rest on the runway. During postaccident examination of the airplane, the landing gear selector handle was found 1/8- to 1/4-inch from the full down position. Subsequent ground testing revealed that when the landing gear selector handle was positioned full up, followed by full down, the landing gear cycled successfully, indicating that, if the flight crew had placed the handle in the full down position, the landing gear would likely have operated normally. When the landing gear selector handle was positioned where it was found, the landing gear extended, but did not lock. A hydraulic bypass also occurred, with a resulting increase in hydraulic fluid temperature and decrease in hydraulic fluid pressure. The hydraulic bypass was most likely the reason that the landing gear did not lock when the emergency gear extension procedure (blow down) was followed during the incident flight. Although, the rigging of the landing gear selector valve arm was found to be 2 degrees beyond specifications, the fact that the landing gear was successfully cycled numerous times with this discrepancy indicates that it was not a contributing factor to this incident. After the incident, the airplane manufacturer revised several checklists by replacing the terms "normal" and "low" with actual numerical values. Additionally, the Landing Gear Down Lock Indication Failure and Emergency Landing Gear Extension checklists were revised to include more guidance on ensuring that the landing gear handle was positioned full down. Lastly, the Emergency Landing Gear Extension checklist was expanded to include a situation where the blow-down procedure failed to extend and lock all three landing gear.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Flightcrew could have cycled the landing gear selector handle earlier.

NTSB coding

  • Landing gear collapse · Landing

Evidence available

  • CVR
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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