MIA00IA128

NTSB incident investigation · Dassault DA-20 · Opa Locka, FL · April 4, 2000

Incident · No injuriesIncident investigationFinal report
Date
April 4, 2000, 17:24 local (21:24 UTC)
Place
Opa Locka, FL
Injuries
2 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N175GADassault DA-20
Weather
Visual (VMC) · Day
Status
Completed · report April 6, 2001
Report
Approved by Office Director
Case key
48886

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

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Probable cause

The failure of the PIC to execute the complete procedure for emergency extension of the landing gear and the subsequent landing with the left main landing gear not locked fully down, resulting in an excursion off the runway and collision with a runway stanchion. A factor in the incident was the fatigue failure of the left MLG door hydraulic emergency slide valve bolts due to non-compliance with a 1984 factory service bulletin that recommended replacement with larger bolts.

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.

Airframe/component/system failure/malfunctionApproach
Hydraulic system,actuator - leakFactor
Maintenance,service bulletin/letter - not complied withCompany maintenance personnelFactor
Insufficient standards/requirements,manufacturerManufacturerFactor
Wheels up landingLanding
Checklist - discontinuedPilot in commandCause
Landing gear,main gear - unlocked
On ground/water collision with objectLanding - roll
Directional control - not possiblePilot in command
Object - pole

Analysis

According to the PIC, when the landing gear selector was positioned to the gear down position in preparation for landing, the landing gear did not extend and cockpit indications confirmed not down. A go around was executed and 'Procedure A' of the 'Emergency Gear Extension' checklist was executed. The result was a down and locked indication of the nose gear and the right main gear, no indication of the left gear being down, both hydraulic system quantities started decreasing, and control pressures felt in the yoke/stick indicated that the flight controls were losing their boost. The PIC elected to declare an emergency with the tower and execute a 2 gear down/1 gear up landing instead of completing the 'Procedure B' and 'Procedure C' portions of the checklist. The aircraft swerved off the left edge of the runway and sustained minor left under-wing skin scraping and a puncture to the left wing droop. Examination of the left wheel well revealed the malfunction causing the double hydraulic system leakage was the failure of two bolts attaching the hydraulic emergency slide valve to the left gear door actuating cylinder. Dassault Falcon Jet Service Bulletin FJF 32-160 dated April 26, 1984, recommends replacement of the 4-mm bolts with 5-mm bolts, to be accomplished, 'when the components are returned for major overhaul or repair, or upon request'. The incident aircraft had not undergone accomplishment of Service Bulletin FJF 32-160.

Factual narrative

On April 4, 2000, about 1724 eastern daylight time, a Dassault Falcon DA-20, N175GA, registered to Grand Aire Express, Inc., operating as a Title 14 CFR Part 91 positioning flight, experienced a failure of the left main landing gear to extend for landing and an excursion off the runway edge during landing rollout at Opa Locka, Florida. Visual meteorological conditions prevailed and an IFR flight plan was filed. The airplane sustained minor damage and the ATP-rated pilot and commercially-rated copilot were not injured. The flight left Louisville, Kentucky, about 2 hours 30 minutes before the accident.

According to the pilot, during the approach to Opa Locka's runway 27R, when the landing gear handle was selected down by the copilot, none of the three landing gears extended. The pilot commanded gear handle up and back down a second time, but again, to no avail. At that point, the pilot executed a go- around, and on his downwind leg, he commanded the reading and execution of, "Procedure A" of the checklist for, "Landing Gear Extension Failure". At the completion of the "Procedure A", the right main and nose gear indicated extended; however, the left main gear indicated not extended, and the pilot lost hydraulic boost to the flight controls while simultaneously observing both hydraulic quantity indications decreasing. The pilot declared an emergency and stated he would be landing as soon as possible.

Reference to the "Operating Handbook, Abnormal and Emergency" that was on board N175GA and used by the crew during the failure of the landing gear to extend revealed that there is a "Procedure B" and a "Procedure C" to be executed, in sequence as necessary, to insure extension of all three landing gear prior to landing.

The aircraft sustained superficial under-wing skin scraping of the left wing. A puncture in the left wing leading edge droop resulted from collision with a runway stanchion, but no structural member was damaged. Speed tape was applied to the wing droop perforation by a company mechanic, a ferry permit was issued by the FAA, and the airplane was flown to the airline's headquarters in Louisville. According to the airline's Director of Maintenance, the failed component was the attaching hardware for the hydraulic emergency slide valve, P/N A2-23769, mounted to the left main landing gear door-actuating cylinder. The emergency slide valve's function is to allow continued hydraulic operation of the landing gear door with the operable hydraulic system in the event of a single hydraulic system failure. The emergency slide valve is common to both of the aircraft's hydraulic systems; therefore, a leak caused by failure of the mounting hardware results in a double hydraulic system failure.

On April 26, 1984, the product support division of Dassault Falcon Jet promulgated Service Bulletin FJF 32-160 recommending that the attachment hardware for the emergency slide valve to be increased in size, (4-mm bolt diameter to 5-mm). The compliance wording states, "when the component is returned for major overhaul or repair, or upon request." Maintenance records revealed that the incident aircraft had not had the SB complied with. A copy of SB FJF 32-160 is included as an attachment to this report.

The left MLG door actuator, PN A23729-0, SN 095, was examined for failure analysis at a repair station/subsidiary of Dassault Falcon Jet Corporation with NTSB oversight. The attached data plate revealed a pre-modification part number and measurement of the emergency slide valve attachment bolt diameters confirmed that SB FJF 32-160 had not been complied with. Both bolt shanks revealed minor cadmium plating decay and stress corrosion. Both bolt shanks revealed fatigue failure and total fracture at the location where the first thread, (closest to the bolt head) was machined. The repair station engineering report is an attachment to this report.

The FAA Data Section of Aviation Flight Standards, AFS-620, researched their database for Falcon 20 landing gear door actuator service difficulty reports from 1974 to the present and found no other cases of hydraulic failures due to emergency slide valve attachment hardware failure.

Aircraft

Registration
N175GA
Reported as
Dassault DA-20
Category
Airplane
Serial number
45
Airframe hours
16,552
Engine
GE CF-700-202, 4,500 lbs thrust, turbo jet
Damage
Minor damage
Flight
Positioning · Part 91
Registered owner
Grand Aire Express, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · February 27, 2000 · 72 hours before
Departed
SDF · Louisville, KY
Destination
OPF · Opa Locka, FL
Flight plan
IFR
Airport
OPF · Opa Locka, runway 27R, 8,002 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
6,000 total · 3,000 in this make and model · 4,500 as pilot in command · 150 in the last 90 days · 35 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 68 °F
Altimeter
29.00 inHg
Observed at
OPF, 1 nm away