Cases › DCA11MA076 › The analyst
GULFSTREAM GVIGULFSTREAM AEROSPACE CORPORATION
What the docket says, assembled. No language model is involved, so nothing on this page can be invented — every line traces to a recorder, a report page or the Board's own record.
31
timed facts
8
precedents
104
passages to ask
Ask the docket
passages, not paraphrasesTry
Every answer is a passage of the docket with the page it came from, or the words “not in the docket”. Nothing is summarised or reasoned for you — read the source.
One timeline
31 timed factsthe recorder events from the FDR report, with the transcript's warnings, callouts, the words nearest each event and the final seconds — on one clock, as printed in each report- 09:23:43.5CVR TWRp.10“Gulftest three one ah one eighty approved wind one seven zero at seven runway two one right seventy correction ah right ninety left two seventy approved cleared for takeoff.”read in context ↗
- 09:23:55.5CVR RDO-2calloutp.10“cleared for takeoff on two one with the teardrop Gulftest three one.”read in context ↗
- 09:23:59.8CVR HOT-3calloutp.10“okay this time we're gonna be doin' a the (card) seven ah Alpha which is the max takeoff power to ah idle on the right engine.”read in context ↗
- 09:24:04.0CVR HOT-1warningp.10“engine out, engine out?”read in context ↗
- 09:24:18.3CVR HOT-?calloutp.11“* * * hundred * * one twenty eight, one thirty six rotate will be one trims are the same.”read in context ↗
- 09:24:35.1CVR HOT-2calloutp.11“so rotate's one twenty eight's the call.”read in context ↗
- 09:25:21.7CVR HOT-1calloutp.13“okay you're gonna you're gonna get that at one one hundred * * this here and then give me a little bit of a lead on the rotate.”read in context ↗
- 09:26:19.5CVR HOT-2calloutp.15“stand by rotate, ah.”read in context ↗
- 09:27:50.9CVR HOT-1calloutp.17“gear down landing checklist.”read in context ↗
- 09:28:44.2CVR TWRcalloutp.18“Gulftest three one wind one niner zero at seven runway three cleared to land.”read in context ↗
- 09:28:49.6CVR RDO-2calloutp.18“cleared to land runway three Gulftest three one.”read in context ↗
- 09:29:05.9CVR HOT-2calloutp.19“(ground) flaps spoilers we're cleared to land.”read in context ↗
- 09:29:09.3CVR HOT-1calloutp.19“cleared to land.”read in context ↗
- 09:29:21.2CVR HOTcalloutp.19“minimums [electronic voice].”read in context ↗
- 09:30:55.9CVR HOT-1warningp.22“I think it's a target and then ah because if you have a real engine failure the guys aren't gonna be lookin' at nine degrees they're gonna be looking at trying to get V-2 they're not payin' any attention to that. so, what I think.”read in context ↗
- 09:31:04.3CVR RDO-2calloutp.22“and tower Gulftest three one like to do a one eighty at the end and takeoff on two one teardrop return.”read in context ↗
- 09:31:11.0CVR TWRcalloutp.23“* three one one eighty approved runway two one right ninety left two seventy approved cleared for takeoff wind one seven zero at niner.”read in context ↗
- 09:31:19.6CVR RDO-2calloutp.23“* approved cleared for takeoff runway two one Gulftest thirty one.”read in context ↗
- 09:32:26.7CVR HOT-3calloutp.25“yeah I think this is probably the last takeoff then.”read in context ↗
- 09:33:00.9CVR HOT-2calloutp.26“okay cleared for takeoff.”read in context ↗
- 09:33:11.4CVR HOT-2calloutp.26“seven * two chop at a hundred. one twenty seven rotate one thirty five speed.”read in context ↗
- 09:33:45.7CVR HOT-2calloutp.27“standby, rotate.”read in context ↗
- 09:33:53.6CVR HOTwarningp.27“bank angle, bank angle [electronic voice].”read in context ↗
- 09:33:54.3CVR HOT-1final secondsp.27“power power power.”read in context ↗
- 09:33:55.2CVR HOT-2final secondsp.27“power power power's up.”read in context ↗
- 09:33:56.6CVR HOT-1final secondsp.27“power power power.”read in context ↗
- 09:33:57.4CVR HOT-2final secondsp.28“no no no no. *.”read in context ↗
- 09:33:58.5CVR HOTfinal secondsp.28“bank angle, bank angle [electronic voice].”read in context ↗
- 09:34:00.0CVR HOT-1final secondsp.28“ah sorry guys.”read in context ↗
- 09:34:02.4CVR HOTfinal secondsp.28“[sound similar to triple chime alarm].”read in context ↗
- 09:34:04.7CVR HOT-?final secondsp.28“* * *. End of Transcript 09:34:10.3 [end of recording]”read in context ↗
Cockpit Voice Recorder 12 - Factual Report of Group Chairman · 31 of 222 lines shown
How the Board coded the sequence
- Prior to flight: Preflight or dispatch event→
- Takeoff: Simulated/training event→
- Takeoff: Aerodynamic stall/spin→
- Post-impact: Fire/smoke (post-impact)
Precedents
8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded- GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLCBedford, MA
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Development › Selection/certification/testing
- ●Organizational issues › Support/oversight/monitoring › Oversight
- +1 more shared findings
Fire/smoke (post-impact)Preflight or dispatch event - TEXTRON AVIATION INC 208B · BERING AIR INCNome, AK
- ●Aircraft › Aircraft oper/perf/capability › Aircraft capability
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Support/oversight/monitoring › Oversight
- +1 more shared findings
Aerodynamic stall/spin - Learjet LR60 · Global Exec AvaitionColumbia, SC
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Development › Design
- ●Organizational issues › Development › Selection/certification/testing
- +2 more shared findings
Fire/smoke (post-impact) - AERO COMMANDER 500 B · Central Air Southwest Inc.Chicago, IL
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Personnel issues › Task performance › Use of equip/info
Aerodynamic stall/spin - BRITTEN-NORMAN BN-2A · MCPHILLIPS FLYING SERVICE INCBeaver Island, MI
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Personnel issues › Task performance › Use of equip/info
Aerodynamic stall/spin - Convair 440 · Ferreteria E Implementos San FranciscoMonclova, OH
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Personnel issues › Task performance › Use of equip/info
- DEHAVILLAND DHC-3 · REDISKE FAMILY LIMITED PARTNERSHIPSoldotna, AK
- ●Aircraft › Aircraft oper/perf/capability › Aircraft capability
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Support/oversight/monitoring › Oversight
Aerodynamic stall/spinPreflight or dispatch event - LEARJET 35A · Trans-Pacific JetsTeterboro, NJ
- ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
- ●Organizational issues › Support/oversight/monitoring › Oversight
Aerodynamic stall/spin
What the record says
a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable causeFindings the Board cited in those cases
- 8 of 8Aircraft › Aircraft oper/perf/capability › Performance/control parameterscited here too
- 6 of 8Personnel issues › Task performance › Use of equip/infocited here too
- 5 of 8Organizational issues › Support/oversight/monitoring › Oversightcited here too
- 3 of 8Organizational issues › Management › Policy/procedure
- 3 of 8Personnel issues › Action/decision › Action
- 2 of 8Organizational issues › Development › Selection/certification/testingcited here too
- 2 of 8Aircraft › Aircraft oper/perf/capability › Aircraft capabilitycited here too
- 2 of 8Personnel issues › Task performance › Planning/preparation
Occurrences it coded
- 5 of 8Aerodynamic stall/spin
- 5 of 8Collision with terr/obj (non-CFIT)
- 3 of 8Loss of control in flight
- 2 of 8Fire/smoke (post-impact)
- 2 of 8Preflight or dispatch event
- 2 of 8Runway excursion
Set against the Board’s own findings for this case
Cited here, and common in the precedents
- Aircraft oper/perf/capability › Aircraft capability
- Aircraft oper/perf/capability › Performance/control parameters
- Development › Selection/certification/testing
- Support/oversight/monitoring › Oversight
- Task performance › Use of equip/info
Cited here, not seen in the precedents
- Management › Scheduling
Common in the precedents, not cited here
- Management › Policy/procedure
- Action/decision › Action
- Task performance › Planning/preparation
A teaching device, not a verdict: what the record would have looked at, next to what the Board found.
In the Board’s words — the closest cases
- ERA14MA2712014-06-01 · GULFSTREAM AEROSPACE G IV · Arizin Ventures, LLC
The flight crewmembers' failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew's habitual noncompliance with checklists, Gulfstream Aerospace Corporation's failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and th…
- ANC25MA0182025-02-06 · TEXTRON AVIATION INC 208B · BERING AIR INC
The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s inadequate airspeed management due to workload and degraded situation awareness and his improper inputs leading up to and during the aerodynamic stall, which increased the airplane’s angle of attack. Also causal was operation of the airplane above maximum gross weight, which reduced the airplane’s stall margin. Contributing to the accident were the operator’s inadequate safety management, which allowed the r…
- DCA08MA0982008-09-20 · Learjet LR60 · Global Exec Avaition
The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of criti…
- CEN15FA0482014-11-18 · AERO COMMANDER 500 B · Central Air Southwest Inc.
The pilot's failure to maintain airspeed while attempting to return to the airport after a reported engine problem, which resulted in an aerodynamic stall/spin.
- CEN22FA0312021-11-13 · BRITTEN-NORMAN BN-2A · MCPHILLIPS FLYING SERVICE INC
The pilot's exceedance of the airplane's critical angle of attack during final approach, which resulted in an aerodynamic stall and loss of control at an altitude too low to recover.
What it recommended after them
- A-15-030TO THE FEDERAL AVIATION ADMINISTRATION: Identify nonfrangible structures outside of a runway safety area during annual 14 Code of Federal Regulations Part 139 inspections and place increased emphasis on replacing nonfrangible fittings of an… · ERA14MA271Open Acceptable Alternate Response
- A-15-031TO THE FEDERAL AVIATION ADMINISTRATION: After Gulfstream Aerospace Corporation develops a modification of the G-IV gust lock/throttle lever interlock, require that the gust lock system on all existing G-IV airplanes be retrofitted to comply… · ERA14MA271Closed - Acceptable Action
- A-15-032TO THE FEDERAL AVIATION ADMINISTRATION: Develop and issue guidance on the appropriate use and limitations of the review of engineering drawings in a design review performed as a means of showing compliance with certification regulations. · ERA14MA271Open - Acceptable Response
- A-15-033TO THE INTERNATIONAL BUSINESS AVIATION COUNCIL: Amend International Standard for Business Aircraft Operations auditing standards to include verifying that operators are complying with best practices for checklist execution, including the us… · ERA14MA271Closed - Acceptable Action
- A-15-034TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing d… · ERA14MA271Closed - Acceptable Action
- A-26-064TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 135 and 91K operators, except single-pilot and single-pilot-in-command operators, to incorporate upset prevention and recovery training, whether in a si… · ANC25MA018Open - Await Response
- A-26-065TO THE FEDERAL AVIATION ADMINISTRATION: Develop explicit surveillance criteria for 14 Code of Federal Regulations Part 135 and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents,… · ANC25MA018Open - Await Response
- A-09-055TO THE FEDERAL AVIATION ADMINISTRATION: Require Learjet to change the design of the Learjet 60 thrust lever system in future-manufactured airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverse… · DCA08MA098Closed - Unacceptable Action
This is the pattern in the NTSB’s own record across similar accidents — which findings it cited, what it coded, what it recommended. It is drawn from the record, not written about this case, and it never assigns blame: investigations exist to prevent the next accident (ICAO Annex 13).