DCA11MA076

NTSB accident investigation · Gulfstream GVI · Roswell, NM · April 2, 2011

Accident · FatalClass 1 · MajorFinal report
Date
April 2, 2011, 09:34 local (15:34 UTC)
Place
Roswell, NM
Injuries
4 fatal
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N652GDGulfstream GVI
Defining event
Takeoff: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report September 24, 2013
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
FAA AVP-100
Safety recommendations
Yes
FAA report
20110402006199A
Case key
78738

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

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: an aerodynamic stall and subsequent uncommanded roll during a one engine-inoperative takeoff flight test, which were the result of (1) Gulfstream’s failure to properly develop and validate takeoff speeds for the flight tests and recognize and correct the takeoff safety speed (V2) error during previous G650 flight tests, (2) the G650 flight test team’s persistent and increasingly aggressive attempts to achieve V2 speeds that were erroneously low, and (3) Gulfstream’s inadequate investigation of previous G650 uncommanded roll events, which indicated that the company’s estimated stall angle of attack while the airplane was in ground effect was too high. Contributing to the accident was Gulfstream’s failure to effectively manage the G650 flight test program by pursuing an aggressive program schedule without ensuring that the roles and responsibilities of team members had been appropriately defined and implemented, engineering processes had received sufficient technical planning and oversight, potential hazards had been fully identified, and appropriate risk controls had been implemented and were functioning as intended.

Findings · 13

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Related operating infoGulfstream Aerospace GVI: 1 caseAll aircraft: 1,681 casesProbable cause
Aircraft capability: engine out capabilityAircraft › Aircraft oper/perf/capability · Related operating infoGulfstream Aerospace GVI: 1 caseAll aircraft: 8 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Related operating infoGulfstream Aerospace GVI: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Flight crewGulfstream Aerospace GVI: 1 caseAll aircraft: 1,391 casesProbable cause
Scheduling: task scheduling/workloadOrganizational issues › Management · ManufacturerGulfstream Aerospace GVI: 1 caseAll aircraft: 4 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · ManufacturerGulfstream Aerospace GVI: 1 caseAll aircraft: 61 casesProbable cause
Design: policy/procedure developmentOrganizational issues › Development · ManufacturerGulfstream Aerospace GVI: 1 caseAll aircraft: 17 casesProbable cause
Communication systemEnvironmental issues › Operating environment · Not specifiedGulfstream Aerospace GVI: 1 caseAll aircraft: 5 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-12-02. On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center Airport, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-12-02.On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center Airport, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N652GD
Reported as
Gulfstream GVI (G650)
Category
Airplane
Serial number
6002
Airframe hours
434
Engines
Rolls-Royce Deutschland BR700-725A1, 16,100 lbs thrust, turbo fanRolls-Royce Deutschland BR700-725A1, 16,100 lbs thrust, turbo fan
Damage
Substantial damage
Fire
On-Ground
Flight
Flight test · Part 91
Operator
Gulfstream Aerospace Corporation
Registered owner
Gulfstream Aerospace Corporation
Airworthiness certificate
Special, Experimental (Special)
Departed
ROW · Roswell, NM
Destination
ROW · Roswell, NM
Airport
ROW · Roswell Intl Air Center Airpor, runway 21, 13,001 × 150 ft, concrete
Equipment
Data recorder

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Fatal
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
5-point
Flight hours
11,237 total · 263 in this make and model
Role
Co-pilot
Age
51
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Restraint
5-point
Flight hours
3,940 total · 140 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 25 °F
Altimeter
30.01 inHg
Observed at
KROW

Docket · 87

The files NTSB released with the investigation on March 5, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 128 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 466 KBAccident Report Photographs (With 2 Embedded Photographs)Item 2 · .PDF · 2 photos · 213 KBOperations Group ReportItem 3 · .PDF · 1.3 MBOperations Group Attachment 1 - Flight Crew Company FileItem 4 · .PDF · 3.1 MBOperations Group Attachment 2 - Aircraft 6002 Flight Log (September 10, 2010 - April 1, 2011)Item 5 · .PDF · 776 KBOperations Group Attachment 3 - Gulfstream Standard Practice Manual, Rev F (October 1998)Item 6 · .PDF · 2.9 MBOperations Group Attachement 4 - Excerpt of Safety Review Board Meeting Minutes (October 2010)Item 7 · .PDF · 1.8 MBGulfstream Flight Operations Standard Operating Procedures (November 2009)Item 8 · .PDF · 1.5 MBGulfstream Problem Reporting Process Description DocumentItem 9 · .PDF · 714 KBGulfstream Problem Reporting Quick Reference GuideItem 10 · .PDF · 2.5 MBExcerpts of Gulfstream Presentations of Roswell I and Flight 132Item 11 · .PDF · 447 KBGulfstream Flight Test Standard Practice Manual (November 2011)Item 12 · .PDF · 9.9 MBWritten Witness Statements by Accident WitnessesItem 13 · .PDF · 1.4 MBErrata for Interviews of Gulfstream Personnel (June 2011)Item 14 · .PDF · 494 KBInterviews of Gulfstream Personnel (June 2011)Item 15 · .PDF · 3.7 MBErrata for Interviews of Gulfstream Personnel (October 2011)Item 16 · .PDF · 9.9 MBInterviews of Gulfstream Personnel (October 2011) -Item 17 · .PDF · 8.8 MBErrata for Interview of Gulfstream Personnel (November 2011)Item 18 · .PDF · 38 KBInterview of Gulfstream Personnel (November 2011)Item 19 · .PDF · 999 KBInterviews with FAA Atlanta ACO PersonnelItem 20 · .PDF · 248 KBInterview with Former Gulfstream PersonnelItem 21 · .PDF · 123 KBMeteorology 5 - Factual Report of Group ChairmanItem 22 · .PDF · 2.9 MBMeteorology 5 - Attachment 1Item 23 · .PDF · 670 KBSurvival Factors 6 - Factual Report of Group Chairman [See also Errata to the Factual Report of Group Chairman, dated May 11, 2012]Item 24 · .PDF · 601 KBSurvival Factors 6 - Errata to the Factual Report of Group ChairmanItem 25 · .PDF · 1 photo · 183 KBSurvival Factors 6 - Attachment 1: PhotographsItem 26 · .PDF · 25 photos · 1.3 MBSurvival Factors 6 - Attachment 2: Gulfstream G650 Personnel Door Operation InterviewsItem 27 · .PDF · 185 KBSurvival Factors 6 - Attachment 3: Injury ChartItem 28 · .PDF · 48 KBSurvival Factors 6 - Attachment 4: Airport Personnel, Emergency Response and Witness InterviewsItem 29 · .PDF · 93 KBSurvival Factors 6 - Attachment 5: ROW Airport DiagramItem 30 · .PDF · 445 KBSurvival Factors 6 - Attachment 6: RFD ARFF Training RecordsItem 31 · .PDF · 147 KBSurvival Factors 6 - Attachment 7: G650 Crash Crew Information BookletItem 32 · .PDF · 2.1 MBSurvival Factors 6 - Attachment 8: Pecos Valley Regional Communication Center Dispatch ReportItem 33 · .PDF · 1.8 MBSurvival Factors 6 - Attachment 9: RFD Incident ReportItem 34 · .PDF · 1.1 MBSurvival Factors 6 - Attachment 10: ARFF Response RouteItem 35 · .PDF · 677 KBSurvival Factors 6 - Attachment 11: FAA Letter of Correction for 2010 ROW InspectionItem 36 · .PDF · 373 KBSurvival Factors 6 - Attachment 12: ROW Triennial Drill InformationItem 37 · .PDF · 87 KBSurvival Factors 6 - Attachment 13: ROW After-Accident Debrief InformationItem 38 · .PDF · 64 KBSurvival Factors 6 - Attachment 14: On-site Accident Photographs with TimestampsItem 39 · .PDF · 11 photos · 770 KBAirworthiness Specialist's Report of Investigation (With 73 Embedded Photos)Item 40 · .PDF · 73 photos · 35.7 MBAirworthiness Specialist Report - Attachment 1Item 41 · .PDF · 1.1 MBData Recorder - Factual Report of Group ChairmanItem 42 · .PDF · 3.8 MBData Recorder - Attachment 1 - Tabular Data - Flight 153 - (CSV Format)Item 43 · .CSV · 632 KBData Recorder - Attachment 2 - FDR Tabular Data - Flight 153 - (CSV Format)Item 44 · .CSV · 11 KBData Recorder - Attachment 3 - Tabular Data - Flight 132 - (CSV Format)Item 45 · .CSV · 132 KBData Recorder - Attachment 4 - Tabular Data - Flight 088 - (CSV Format)Item 46 · .CSV · 134 KBData Recorder - Factual Report of Group Chairman Addendum 1Item 47 · .PDF · 42 KBData Recorders Factual Report Addendum 1 - Attachment 1 - Tabular Data - (CSV Format)Item 48 · .CSV · 966 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 49 · .PDF · 1.4 MBAircraft Performance 13 - Group Chairman's Aircraft Performance StudyItem 50 · .PDF · 2.8 MBAircraft Performance 13 - Errata 1 to Aircraft Performance StudyItem 51 · .PDF · 24 KBAircraft Performance 13 - Aircraft Performance Study Addendum #1Item 52 · .PDF · 1.7 MBAircraft Performance 13 - Errata 1 to Addendum 1Item 53 · .PDF · 17 KBHuman Performance 14 - Factual Report of Group ChairmanItem 54 · .PDF · 260 KBHuman Performance 14 - Errata to the Human Performance Group Chairman's Factual ReportItem 55 · .PDF · 20 KBHuman Performance 14 - Attachment 1, Interviews with On-Board Crew Next of KinItem 56 · .PDF · 97 KBHuman Performance 14 - Attachment 2, Toxicological Test Results for the PICItem 57 · .PDF · 104 KBHuman Performance 14 - Attachment 3, Toxicological Test Results for the SICItem 58 · .PDF · 92 KBHuman Performance 14 - Attachment 4, Toxicological Test Results for the Lead FTEItem 59 · .PDF · 92 KBHuman Performance 14 - Attachment 5, Toxicological Test Results for the Second FTEItem 60 · .PDF · 93 KB
All 87 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.