# Accident 20230428002489A: Gulfstream Aerospace Corp GVII-G500, Dulles, VA, April 28, 2023

- Type: FAA accident report (Accident/Incident Data System), as reported
- Date: April 28, 2023, 10:00 local time
- Place: Dulles, VA
- Airport: Washington Dulles Internationa
- Damage: No damage
- Phase of flight: Takeoff: Departure Roll
- Operating rules: General operating rules (Part 91)
- Operator: GDYJ
- Location: 38.9691° N, 77.4594° W: From the FAA
- Nearby events: https://openairdocs.org/map.md?lat=38.9691&lon=-77.4594&mi=10
- Aircraft: N507GD, registered now (https://openairdocs.org/aircraft/N507GD) (OpenAirDocs)
- Registry model: Gulfstream Aerospace GVII-G500 (registry code 3980225, https://openairdocs.org/model/gulfstream-aerospace-gvii-g500) (OpenAirDocs)
- Reported make and model: GULFSTREAM AEROSPACE CORP GVII-G500
- Reported engine: P&W CANADA PW814GA
- People aboard: 4
- Fatal injuries: 0
- Other injuries: 1
- Pilot certificates: Airline transport
- Pilot flight hours: 6,959 total
- NTSB investigation: [NTSB ERA23LA212](https://openairdocs.org/ntsb/ERA23LA212) (OpenAirDocs)
- FAA source: FAA Aviation Safety Information Portal (https://asip.faa.gov/)
- Page: https://openairdocs.org/incident/20230428002489A

## Narrative

As the FAA filed it, in capitals; the FAA replaces private details with ^PRIVACY DATA OMITTED^.

INVESTIGATION. A LARGE CORPORATE TURBOJET BASED AT AND DEPARTING FROM A MAJOR INTERNATIONAL AIRPORT WAS BEING OPERATED ON AN IFR FLIGHT PLAN BY A CREW OF TWO ATP TYPE RATED PILOTS AND A FLIGHT ATTENDANT TRANSPORTING A SINGLE CORPORATE PASSENGER UNDER PROVISIONS OF 14 CFR PART 91. THE AIRPLANE AND CREW WERE PROPERLY CERTIFICATED, QUALIFIED AND CURRENT, WITH NO HISTORY OF NONCOMPLIANCE, ACCIDENTS OR INCIDENTS.

ROOT CAUSE. THE OPERATOR'S PUBLISHED LINE UP PROCEDURES REQUIRE THAT "PRIOR TO ACCEPTING A TAKEOFF OR POSITION AND HOLD CLEARANCE, THE CREW MUST HAVE NOTIFICATION FROM THE FA THAT THE CABIN IS READY FOR TAKEOFF. IF COCKPIT CHECKS CAN BE COMPLETED IN AN UNHURRIED MANNER IN TIME TO PERMIT A CAREFUL AND DELIBERATE SCAN OF THE AREA, THE RUNWAY MAY BE ENTERED WITHOUT STOPPING PROVIDED THE ENTRY IS SLOW."

AFTER INITIAL START AND UPON ENTERING THE GROUND MOVEMENT AREA FROM THE RAMP, THE FA CAME FORWARD, ESTABLISHED COMMUNICATIONS WITH THE HEADSET AND INFORMED THE FLIGHT DECK "CABIN SECURE". BOTH PILOTS HEARD THE "CABIN SECURE" COMMUNICATION AND RESPONDED WITH "THANK YOU".

THIS COMMUNICATION IS A PROCEDURAL SIGNAL UNDERSTOOD BY THE OPERATOR'S FLIGHT CREWMEMBERS TO BE A SIGNAL TO THE PILOTS THAT ALL LOOSE ITEMS ARE SECURED, PASSENGERS SEATED AND BELTED, AND THAT THE FA WILL BE SEATED AND BELTED UPON RETURNING TO THE PASSENGER CABIN.

THE FA WAS NOT SEATED OR BUCKLED IN WHEN THE TAKEOFF BEGAN AND WAS PROPELLED AFT TOWARDS THE LAVATORY DOOR, CAUSING WHAT WAS LATER DIAGNOSED AS A BROKEN ANKLE.

THE ROOT CAUSE OF THE FA'S INJURY WAS THAT THEY WERE NOT SEATED AND BELTED IN FOR THE TAKEOFF IN A TIMELY MANNER AFTER INFORMING THE COCKPIT CREW THAT THE CABIN WAS SECURE. DIRECTLY CONTRIBUTING TO THE ROOT CAUSE WAS A LOSS OF SITUATIONAL AWARENESS AS TO THE TIMING OF THE TAXI AND ENSUING TAKEOFF DUE TO DISTRACTION.

CATEGORY: SITUATIONAL AWARENESS;

CONTRIBUTING SUBCATEGORY: DISTRACTED.

DISCUSSION AND CORRECTIVE ACTION. DUE TO GUSTY WINDS, THE NORMAL DEPARTURE RUNWAY WAS NOT AVAILABLE FOR TAKEOFF FOR THIS FLIGHT RESULTING IN CLEARANCE TO A MUCH CLOSER RUNWAY WITH SIGNIFICANTLY LESS TAXI TIME. THIS RESULTED IN BEING IN A POSITION SHORT OF THE DEPARTURE RUNWAY SIGNIFICANTLY SOONER THAN IS NORMAL. THE FA DELAYED BEING SEATED AND BELTED AFTER COMMUNICATING WITH THE COCKPIT TO SPEAK FOR SOME AMOUNT OF TIME WITH THE PASSENGER.

THE NORMAL TAXI TO THE STANDARD DEPARTURE RUNWAY, FREQUENTLY USED AT THIS AIRPORT BY THIS CREW, IS ALMOST TWO MILES WHICH TYPICALLY TAKES A MINIMUM OF 6 TO 10 MINUTES OR MORE DEPENDING ON OTHER AIRPORT OPERATIONS. THE TAXI DISTANCE FOR THIS FLIGHT WAS A FEW HUNDRED FEET WITH A SIGNIFICANTLY SHORTER TAXI TIME ON THE ORDER OF A FEW MINUTES.

ALTHOUGH UNKNOWN FOR CERTAIN, IT IS REASONABLE TO ASSERT THAT THE FA, DUE TO EXTENSIVE PAST EXPERIENCE OPERATING AT THIS AIRPORT, DID NOT ANTICIPATE THE MUCH SHORTER TAXI TIME ON THIS FLIGHT RESULTING IN A LOSS OF SITUATIONAL AWARENESS AS TO THE IMPENDING TAKEOFF AND THE NEED TO IMMEDIATELY TAKE THEIR SEAT AND BE BELTED IN AFTER INFORMING THE COCKPIT CREW THAT THE CABIN WAS "SECURE".

THE OPERATOR HAS REVIEWED AND REVISED THEIR PROCEDURES (REF BLOCK #32) AND HAS ESTABLISHED AN ADDITIONAL SAFETY CONTROL, REQUIRED TO BE ACCOMPLISHED BY THE RIGHT SEAT PILOT, TO "LOOK BACK AND SCAN THE CABIN TO ENSURE THAT CABIN OCCUPANTS ARE SEATED" ... "PRIOR TO ACCEPTING A TAKEOFF OR LINE UP AND WAIT CLEARANCE".

COMMENTS. THE OPERATOR MAINTAINS AN SMS PROGRAM AND A POSITIVE SAFETY CULTURE AND HAS TAKEN CORRECTIVE ACTION TO MINIMIZE FUTURE RISK OF RECURRENCE. I AM SATISFIED THAT THE OPERATOR'S CORRECTIVE ACTIONS FULLY ADDRESS THE IDENTIFIED ROOT CAUSES AND HAVE ESTABLISHED CONTINUING COMPLIANCE. NO FURTHER ACTION IS RECOMMENDED.

## The NTSB's investigation of this event (1)

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

- [NTSB ERA23LA212](https://openairdocs.org/ntsb/ERA23LA212), Apr 28, 2023: Gulfstream Aerospace GVII-G500 (N507GD), Dulles, VA, no damage. Probable cause: The initiation of the takeoff while before the flight attendant had returned to her seat, which resulted in a serious injury during takeoff.

From the FAA Accident/Incident Data System. Reports are matched to registry aircraft by N-number and event date, checked against the reported make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. For accidents, the NTSB's own investigation is the fuller record.

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