CHI97MA017

NTSB accident investigation · Gulfstream G-IV · Wheeling, IL · October 30, 1996

Accident · FatalMajor investigationFinal report
Date
October 30, 1996, 13:00 local (19:00 UTC)
Place
Wheeling, IL
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N23ACGulfstream G-IV
Weather
Visual (VMC) · Day
Status
Completed · report March 31, 1998
Report
Approved by Office Director
FAA report
19961030034479A
Case key
10715

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

failure of the pilot-in-command (PIC) to maintain directional control of the airplane during the takeoff roll in a gusty crosswind, his failure to abort the takeoff, and failure of the copilot to adequately monitor and/or take sufficient remedial action to help avoid the occurrence. Factors relating to the accident included the gusty crosswind condition, the drainage ditch, the flight crew's inadequate preflight, the Nose Wheel Steering Control Select Switch in the "Handwheel Only" position, and the lack of standardization of the two companies' operations manuals and Interchage Agreement.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - on ground/waterTakeoff - roll/run
Weather condition - crosswindFactor
Weather condition - gustsFactor
Aircraft preflight - inadequatePilot in commandFactor
Landing gear,steering system - otherFactor
Monitoring - inadequateCopilot/second pilotCause
Directional control - not maintainedPilot in commandCause
Aborted takeoff - not performedPilot in commandCause
Condition(s)/step(s) insufficiently definedCompany/operator managementFactor
On ground/water encounter with terrain/waterTakeoff - roll/run
Terrain condition - ditchFactor

Analysis

The flightcrew of a Gulfstream G-IV began taking off on Runway 34 with a crosswind from 280 deg at 24 kts. About 1,340 feet after the takeoff roll began, the airplane veered left 5.14 deg to a heading of 335 deg. It departed the runway, and tire marks indicated no braking action was applied. One of the pilots said, "Reverse," then one said, "No, no, no, go, go, go, go, go." The airplane traversed a shallow ditch that paralleled the runway, which resulted in separation of both main landing gear, the left and right flaps, and a piece of left aileron control cable from the airplane. The airplane became airborne after it encountered a small berm at the departure end of the runway. Reportedly, the left wing fuel tank exploded. The main wreckage was located about 6,650 ft from the start of the takeoff roll. Examination of the airplane indicated no preexisting anomalies of the engines, flight controls, or aircraft systems. The Nose Wheel Steering Select Control Switch was found in the "Handwheel Only" position, and not in the "Normal" position. The pilot-in-command (PIC) routinely flew with the switch in the "Normal" position. The PIC and copilot (pilot-not-flying) comprised a mix crew in accordance with an Interchange Agreement between two companies which operated G-IV's. The companies' operation manuals and the Interchange Agreement did not address mixed crews, procedural differences, or aircraft difference training.

Factual narrative

History of flight

On October 30, 1996, at 1300 central standard time, a Gulfstream G-IV, N23AC, registered to Alberto Culver USA, Inc., collided with the terrain following a loss of control during a takeoff ground roll on runway 34 (5,137' x 100') at the Palwaukee Municipal Airport, Wheeling, Illinois. The 14 CFR Part 91 corporate flight was departing in visual meteorological conditions with an IFR flight plan on file. The captain, co-pilot, flight attendant, and the sole passenger on board were fatally injured. The airplane was destroyed by impact forces and a post impact fire. The intended destination of the flight was Burbank, California.

The accident flight was operated under the terms of an Interchange Agreement between the Alberto-Culver Corporation and the Aon Corporation. The interchange agreement provided for each company to lease their respective G-IV airplanes to the other company. In regards to the accident flight, the Aon Corporation had requested the use of the Alberto-Culver airplane. Aon furnished one pilot making the flight a mixed crew operation. The pilots of the accident flight were notified of the flight approximately seven days prior to the scheduled departure.

N23AC was scheduled to depart Palwaukee Municipal Airport at 1300 CST on October 30, 1996, for the Burbank-Glendale-Pasadena Airport with a return to Palwaukee the following day. The flight plan was filed by the pilot from Alberto-Culver who occupied the right cockpit seat for departure. Although the aircraft was operated by Alberto-Culver, the pilot from Alberto-Culver listed himself as the co-pilot for the first day of the trip from the Palwaukee Municipal Airport to the Burbank-Glendale-Pasadena Airport. He listed himself as the pilot-in-command on the flight plan for the return flight to Palwaukee Municipal Airport on the following day. The pilot from the Aon occupied the left cockpit seat for the accident flight and was listed on the flight plan as the pilot-in-command. [For the remainder of the report, the pilot from Alberto-Culver will be identified as the pilot not flying (PNF) and the AON pilot as the pilot-in-command (PIC)].

Prior to departure N23AC was parked on the ramp adjacent to hangar #12. A preflight inspection of the airplane was accomplished by an Alberto-Culver aircraft technician. The PNF was also observed performing a preflight inspection of the airplane. The pilots of N23AC received their ATC clearance from clearance delivery at 1242.

The PNF called for and received taxi clearance at 1254. N23AC was instructed to taxi on Mike but hold short of runway 34. The flightcrew acknowledged the hold short instructions and began to taxi. At 1257 the local controller who was also working the ground control position cleared N23AC to back taxi and expedite down the active runway to the departure pad. N23AC taxied southeast on runway 16-34 and at 1258 the local controller asked them if they would be ready at the end. N23AC replied they would be ready at the end of the runway. At 1259, the local controller said, "Two Three Alpha Charlie, three four, expedite departure, turn left heading two niner zero, cleared for takeoff."

At 1259, the PNF replied, "Cleared for takeoff, heading two nine zero, we'll hurry it out." The pilots applied power and began the takeoff roll on runway 34. Passing the intersection of 12L-30R, tire tracks indicated the airplane began to diverge to the left of runway heading. As the airplane continued to diverge from the centerline of the runway the nose gear tire tracks ended; however, the main gear tire tracks continued into the grass bordering the runway.

The airplane remained off the runway and continued across the grass and across taxiways, Yankee, Mike, and November. Landing gear, flight control surfaces, and other airplane components separated once N23AC left the runway. The airplane slid on its belly roughly parallel with the runway and momentarily got airborne when it launched off a small berm near the departure end of runway 34. Once airborne the airplane flew over Hintz Road, contacted the embankment along Wolf Road, and skipped over Wolf Road. It slid across a field and stream gully and came to rest on the edge of an apartment complex parking lot where the airplane was consumed by fire. Both pilots, the flight attendant, and passenger perished as a result of the accident and subsequent fire.

Witness statements

The Alberto-Culver aircraft technician who performed a pre-flight inspection of the airplane reported that he was positioned on the ramp forward of the airplane during engine start and initial taxi. He stated he observed the control check and the engine start and everything appeared normal. There were no unusual sounds, smoke, or other abnormal indications associated with the airplane. The brakes, gear, control surfaces, and engines all appeared to operate normally.

While N23AC was taxiing for takeoff, a Falcon 900 landed on runway 34. The pilots from the Falcon 900 reported that after they stopped on the runway, they back taxied before turning off at runway 30. The pilots observed the G-IV and reported that everything on the G-IV looked normal. They reported the thrust reversers were stowed, the tires looked normal, and the taxi path was straight. There was no white or black smoke coming from the engines.

A co-pilot of a Falcon 10 was standing on an aircraft ramp on the west side of runway 34. He reported that the G-IV's engine noise was normal during takeoff. He reported that the spool up was normal and that he heard no reduction in engine noise.

An Aon aircraft technician had assisted the Aon executive in boarding the aircraft. He reported that he observed N23AC back taxi to the end of runway 34, turn around, and without holding short, start its takeoff roll. He reported the engine spool-up and acceleration were normal and that the auto-throttles were engaged. He saw the aircraft go off the runway and continue paralleling runway 34 until it was out of his field of view, shedding aircraft parts in the process. The aircraft was on its belly with the nose off the ground, and the engines were running at full power. He did not hear a power reduction.

An aircraft line serviceman observed the main landing gears separate from the aircraft as it continued on its path across the ground. He reported, "...I came out [and] the left main was gone and [the] left wing was dragging on the ground. Two or three seconds later the right main came off. (But all this time the nose wheel never hit the ground.)"

The air traffic controller who had been working local and ground control for 10 to 15 minutes prior to the accident viewed parts of the accident sequence from his position in the tower cab. He reported seeing N23AC begin its takeoff roll, but did not see it departing the runway since he was observing another aircraft at the time. He next saw N23AC as it was sliding on its belly in the grass. He reported that it seemed to decelerate and then accelerate at full power.

A second air traffic controller who was in the tower reported seeing N23AC become airborne and exploding near the north boundary of the field. He saw a fireball encompass the aircraft. He did not recall if the aircraft had been yawing.

An airport employee witnessed the accident from the departure end of runway 34. He had been inspecting the approach lighting system for runway 16 from outside the airport fence, and he was looking down the runway when the aircraft started its takeoff roll. He witnessed the airplane depart the runway, shedding aircraft parts as it passed taxiways Mike and November. He reported that after the aircraft passed taxiway November, the aircraft was turned 2/3 to the right until it hit the berm near the departure end of runway 34. He reported the airplane became airborne and it started yawing back to the left. The back end of the airplane exploded

Aircraft

Registration
N23AC
Reported as
Gulfstream G-IV
Category
Airplane
Serial number
1047
Airframe hours
2,938
Engine
Rolls-Royce MARK 611-8, 13,850 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Registered owner
Alberto Culver USA, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 19, 1997 · 67 hours before
Departed
PWK
Destination
BUR · Burbank, CA
Flight plan
IFR
Airport
PWK · Palwaukee Municipal, runway 34, 5,137 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
17,086 total · 496 in this make and model · 16,812 as pilot in command · 54 in the last 90 days · 21 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 24 knots, gusting 35
Visibility
10 statute miles
Lowest ceiling
2,500 ft broken
Temperature
108 °F
Altimeter
29.00 inHg
Observed at
PWK

Docket · 74

The files NTSB released with the investigation on December 8, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 38.3 MB in all.

Supplement CItem 1 · .PDF · 440 KBSupplement DItem 2 · .PDF · 466 KBSupplement EItem 3 · .PDF · 438 KBSupplement K (1)Item 4 · .PDF · 410 KBSupplement K (2)Item 5 · .PDF · 463 KBSupplement K (3)Item 6 · .PDF · 449 KBSupplement K (4)Item 7 · .PDF · 451 KBSupplement NItem 8 · .PDF · 178 KBSupplement QItem 9 · .PDF · 248 KBSupplement SItem 10 · .PDF · 47 KBOperations 2 - Factual Report of Group ChairmanItem 11 · .PDF · 5.8 MBWitness - Factual Report of Group ChairmanItem 12 · .PDF · 10.9 MBStructures - Factual Report of Group ChairmanItem 13 · .PDF · 2.1 MBPowerplants - Factual Report of Group ChairmanItem 14 · .PDF · 1.2 MBPowerplants - Photos 1 & 2Item 15 · .PDF · 47 KBPowerplants - Photos 3 & 4Item 16 · .PDF · 45 KBPowerplants - Photos 5 & 6Item 17 · .PDF · 47 KBPowerplants - Photos 7 & 8Item 18 · .PDF · 40 KBPowerplants - Photos 9 & 10Item 19 · .PDF · 45 KBPowerplants - Photos 11 & 12Item 20 · .PDF · 43 KBPowerplants - Photos 13 & 14Item 21 · .PDF · 48 KBPowerplants - Photos 15 & 16Item 22 · .PDF · 45 KBPowerplants - Photos 17 & 18Item 23 · .PDF · 47 KBPowerplants - Photos 19 & 20Item 24 · .PDF · 42 KBPowerplants - Photos 21 & 22Item 25 · .PDF · 42 KBPowerplants - Photo 23Item 26 · .PDF · 48 KBSystems - Factual Report of Group ChairmanItem 27 · .PDF · 553 KBCockpit Voice Recorder - Factual Report of Group ChairmanItem 28 · .PDF · 993 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 29 · .PDF · 544 KBWeather Reports and RecordsItem 30 · .PDF · 192 KBFAA ATC Report and Transcript of Radio CommunicationsItem 31 · .PDF · 1.1 MBWheeling Police Department ReportItem 32 · .PDF · 3.6 MBAirport Specialist's Factual Report of InvestigationItem 33 · .PDF · 536 KBTakeoff Performance CalculationsItem 34 · .PDF · 549 KBMaintenance RecordsItem 35 · .PDF · 214 KBAirport Crash/Fire/Rescue InformationItem 36 · .PDF · 312 KBGPWS ReportItem 37 · .PDF · 85 KBHoneywell Components ReportItem 38 · .PDF · 123 KBRudder Actuator InformationItem 39 · .PDF · 1.4 MBWarning Messages, Lights, and Tones InformationItem 40 · .PDF · 228 KBStatement of Party Representatives to NTSB InvestigationItem 41 · .PDF · 596 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 42 · .PDF · 520 KBToxicological ReportItem 43 · .PDF · 263 KBPhoto 1. View of Tire Marks Departing Runway 34.Item 44 · .PDF · 34 KBPhoto 2. View of Tire Marks Departing Runway and Entering Drainage Ditch.Item 45 · .PDF · 48 KBPhoto 3. View of Drainage Ditch and Main Landing Gear Tracks.Item 46 · .PDF · 37 KBPhoto 4. Piece of Right Flap.Item 47 · .PDF · 40 KBPhoto 5. Piece of Aileron Control Cable.Item 48 · .PDF · 116 KBPhoto 6. View of Scrape Marks at Mike Taxiway.Item 49 · .PDF · 39 KBPhoto 7. View of Scrape Marks Across Mike Taxiway.Item 50 · .PDF · 35 KBPhoto 8. Right Main Landing Gear.Item 51 · .PDF · 89 KBPhoto 9. View of Scrape Marks on 335 Degree Heading.Item 52 · .PDF · 49 KBPhoto 10. Left Main Landing Gear.Item 53 · .PDF · 93 KBPhoto 11. View of Scrape and Skids Going Toward Berm.Item 54 · .PDF · 50 KBPhoto 12. Anti-Cavitation Valve.Item 55 · .PDF · 102 KBPhoto 13. View of Accident Scene From Wolf Road.Item 56 · .PDF · 91 KBPhoto 14. View of Buffalo Creek and the Main Wreckage.Item 57 · .PDF · 98 KBPhoto 15. View of Left and Right Engines. Right Engine is in the Creek.Item 58 · .PDF · 161 KBPhoto 16. View of Vertical and Horizontal Stabilizers. Note Rudder Actuator in Foreground.Item 59 · .PDF · 144 KBPhoto 17. Rudder Actuator.Item 60 · .PDF · 156 KB
All 74 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.