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Old 30th Aug 2010, 22:28   #1 (permalink)
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Serious Gulfstream incident in Kerry Ireland.

I have read this incident report today. Only just published by the Irish Aviation Authority.

I must say as an airline pilot myself I can see how the holes in the Swiss cheese line up, although saying that there was also a serious loss of situational awareness with the crew esp. the F.O.

The crew briefed for any emergencies after T/O but never followed through on the plan and flew around IMC below the MSA without radar control from the controlling ATC.

I was baffled reading the report, and I hope never to be in a similar situation.

Have a read! Makes interesting reading and teaching!!!


Air Accident Investigation UnitFull List of Reports
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Old 31st Aug 2010, 03:25   #2 (permalink)
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Pumps, thanks for that amazing "story." Any way I can get the names of the crew so I can keep an eye out for them - and run the other direction?

I have lost count of the number of cracked outer panes that I've had. I'm sure its similar on other types of jets - no big deal. Don't need to divert, land, or reduce cabin diff. Just turn off the window heat. Gulfstream has since re-designed the window and its not supposed to happen as frequently. Anybody who has as much Gulfstream time as the captain allegedly does should know this - its the same window in the 3, 4, and 5...

Crew is lucky they lived through this cause I don't think skill had anything to do with it.
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Old 31st Aug 2010, 05:50   #3 (permalink)
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The sole passenger that alighted was lucky to have done so without the aid of a body bag. The report is illuminating, and begs the following question about the corporate world's aviation business: Why do rich businessmen have such pilots on their flight decks?

You have to have a lot of money floating about to run a Gulfstream. Yet as rich as these captains of industry are, they either don't seem to care or they just don't know how unsafe operators in the corporate world, along with their pilots, can be.

Here is a summary of the incident:

"The Investigation has concerns regarding the oversight of the operation of this aircraft by the Operator, in particular the standard, training and proficiency of the crew.

This is evidenced by the confusion in the cockpit during the occurrence, the apparent lack of familiarity with navigational equipment, the loss of situational awareness on the part of the crew, failure to comply with DGCA of India Civil Aviation Requirements, poor crew resource management and an inappropriate series of engine starts and run-ups to a high power setting conducted on an engine which was known by the crew to be damaged"...

not to mention the following four points:

1. The crew made a number of rushed and inappropriate decisions during the flight, thus displaying poor crew resource management.

2. The First Officer’s lack of recent flying hours is likely to have contributed to his loss of navigational and situational awareness.

3. A "false localiser" signal was received due to Approach mode being armed while the aircraft was outside the specific localiser coverage sector.

4. The Captain commenced a descent without having a valid ILS signal and without cross-checking other available navigation aids.

Good work from the controller....
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Old 31st Aug 2010, 09:25   #4 (permalink)
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Most worrying is the Captain's attempts to blame everyone but himself; even knowingly falsifying in order to do so!
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Old 31st Aug 2010, 11:42   #5 (permalink)
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"Most worrying is the Captain's attempts to blame everyone but himself;........"

I spent a few years, in the country where the aircraft is registered. Not once did I hear from crew members these words, "I screwed up", "I made a mistake" or "I am sorry" for eg.

Last edited by weido_salt; 31st Aug 2010 at 11:56.
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Old 31st Aug 2010, 11:50   #6 (permalink)

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Weirdo, the report said the captain returned to his home in the USA and did not return to India.
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Old 31st Aug 2010, 11:51   #7 (permalink)
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they either don't seem to care or they just don't know how unsafe operators in the corporate world, along with their pilots, can be.
Big White Bird

Please don't tar all corporate operators with the same brush, we all know there are plenty of John Wayne airlines and airline pilots out there as well.

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Old 31st Aug 2010, 13:44   #8 (permalink)
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The whole operation sounds like an accident about to happen, which of course it nearly did.
How many times have I heard crews blame the FMS when things go wrong. The plane was flying them rather than the other way round. I fail to understand why anybody would want to program an FMS in this situation. I have never been so lucky as to fly a GIV but perhaps somebody could tell me..... Do you have to program everything via the FMS? Can't one simply tune up an NDB and an ILS frequency on an old fashioned control head? As for situational awareness there cannot be a better demonstration as to why ADF's should be fitted to aircraft. (Apparantly the most modern aircraft do no have them fitted anymore)
Equally worrying was the engine. Something metal about an inch in diameter had been ingested at some time and the crew knew about it! My guess would be a torch but I am sure bobody would own up to that.
As far as the Captain not returning to India is concerned, not surprising really, the Indian Authorities are pretty hard to deal with when things are going well, he will just have to put a large red ring around the sub continent and make sure he does not go back there.
But the bigger question is why is it so easy for foreign registered aircraft to operate within Europe? The CAA or any other European aviation authority does not have the authority to intervene in the organisation (or lack of it). As EASA land becomes more costly to comply with more aircraft are going on M, N, VP, VT registers. It will be interesting to see how the statistics hold up in a year or two's time regarding serious incidents on aircraft of differing registration.
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Old 31st Aug 2010, 14:38   #9 (permalink)
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A thoroughly interesting and ultimately disturbing read.
The crew showed a clear lack of understanding in pretty well all the aspects of the non-normal situation they were faced with.
I would think that all of us as professional aviators if we are honest with ourselves would admit to a slight cringe or even wince whilst going through that report.
I found myself moving between emotions of frustration and incredulouty...
How did they get it SO wrong? The crew did their level best to line the cheese up with milimetric precision!
In any moderately stressful situation we revert to how we have been trained, I think serious questions need to be asked as to the standard of training both these individuals have received in the past few years....a cracked windscreen followed by high vibration indications is no excuse for an almost CFIT.
Certainly our comments here are from the comfort of our front room/hotac etc etc, but given an identical set of circumstances, surely the old adage of Aviate, Communicate, Navigate holds true...there seems to have been precious little of any of that in this instance.
The commander had 12500hrs! where were his management skills? whats wrong with getting above MSA, flying round in circles for a bit with the F/O flying (I'm sure once properly trimmed the G4 A/P is perfectly capable of flying an LNAV track)whilst the commander uses his superior management and command skills to manage and formulate a safe and expeditious course of action.
A damning indictment of the training/checking organization where these fellows attended.
I'm still utterly stunned at how poorly this was handled.
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Old 31st Aug 2010, 14:44   #10 (permalink)
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It should be easy for foreign registered aircraft to operate in Europe, just as it should be easy for European aircraft to operate in the rest of the world, that's what aircraft are for and any restrictions that are put in place for that would put our jobs at risk. Its not the reg that causes the problem is it.
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Old 31st Aug 2010, 17:01   #11 (permalink)
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So you think If I set up business with a G reg aircraft in Teterborough USA the FAA are going to be happy about it?
Too many owners/operators use flags of convenience because it is the easier option, and the main reason for "easier" is that the country that keeps an eye on them is a long way away.
How many professionals here really believe that the scenario in Kerry would have happened to a UK AOC company? Why one rule for the privates and another for the commercials? Would you like your family to go on holiday with an operation and crew like that. No! That is why the commercial world has compulsory standards and the private world does not. Do not get me wrong, I am sure there are loads of very professional private operations about that stick to FTL's and crew training and have inhouse CRM training. But there are many who have no FTL schemes, hire (and do not pay if this forum is to be believed) contract pilots from where ever they can get them. I would bet that this crew never had a CRM session together. If they did they must have been asleap during it.
I believe EASA is proposing a licencing system for private operations. Are you private operators afraid of this?
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Old 31st Aug 2010, 18:02   #12 (permalink)
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I have operated out of Teterboro on several different registrations, both private and public transport. As you say "If I set up business with a G reg aircraft in Teterborough" no it would not be acceptable, let alone make anyone happy. But, it is perfectly acceptable to operate out of Teterboro on a private flight no matter what the registration. Being as the aircraft in question was VT reg it implies that it was on a private flight form India, is the VT reg a flag of convenience? There are many reasons why private jets are put on various registrations, the ease of finding crew and being able to validate a ICAO licence is one of them, another is ceratainly a more user friendly system. If you are so opposed to the ability of owners to choose their registration authority, get on to the authorities and voice your concerns to them, I am sure they will recognise imediately that your knowledge and experience far outweighs theirs and they will change their way of do things forthwith. Until such time as you have achieved this you might allow others, who have as much right as anybody else to avail themselves of available legislation, to get on with what they are doing without being maligned by such rhetoric. The M, VPs, & N are run by competant authorities, not by incompetant and uncaring idiots.
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Old 31st Aug 2010, 19:00   #13 (permalink)
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I appear to have hit a decate point for you.
I am sure M, N, VP authorities are very reputable, it is SOME operators who hide behind them I am refering to
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Old 31st Aug 2010, 19:41   #14 (permalink)
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I'm not sure I know what you mean by "decate" if it was a typo and supposed to be delicate then, no not at all. I am just a pilot, never been an operator and probably never will be so if you have something to say then get it off your chest, it will make you feel better I'm sure. If not the whats with all the inuendo's. I guess you are an AOC chap, if you are thats great, I have also been in that environment and I loved it, JAROps actually. But, as for flying jets, its not the only game in town. You didnt mention why you equate the VT reg with a flag of convenience though.
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Old 31st Aug 2010, 20:20   #15 (permalink)
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just as it should be easy for European aircraft to operate in the rest of the world
Judging by the amount of "MIKE" registered aircraft in the Middle East, I would say that its extremely easy to operate European aircraft in the rest of the world.

I would also hazard a guess that some of the aircraft are operating charters on the "grey" market............

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Old 31st Aug 2010, 20:46   #16 (permalink)
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There's plenty of all types of reg in the ME.
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Old 31st Aug 2010, 22:24   #17 (permalink)
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What is the registration of the G4 from the Irish incident?
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Old 31st Aug 2010, 23:18   #18 (permalink)
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Dont tar all operators with a bad brush, I've had the discussion on here many times about alledged AOC safety. AOC's dont make the safety case PILOTS do. Doesn't matter how many ops manuals you have in ops or onboard, a brain fart is a brain fart.

Only recently theres been guidance to inhouse TRE's to ensure LPC's are to take a minimum of 60 minutes, I've witnessed too many once around the tower LPC's and minimum training due to commercial pressure's to have as much faith in AOC safety as you do.

My flightsafety bill could be converted to a lot of jet fuel or indeed a nice bonus.

My FO has just come back from Holiday to the airport we operate from in a 30 year old 737 operated by a loco, piloted by a cadet FO probably the first night landing (a/c was late due to a technical problem) all season, they landed that deep and bounced so badly that my FO reckoned they had to get stopped in 900 metres - some very heavy braking ensued to the point my FO adopted the brace position.....

My point......

You can have as many AOC's with as much oversight as you like, on any given day pilots can screw up just as badly as each other. AOC operators love to think they're safer - the fact is they're as safe on any given day as anybody else. Crew training in corporate AOC companies is not always as good as it could be and people react innappropiately in times of high stress and always will do
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Old 31st Aug 2010, 23:28   #19 (permalink)
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Am I the only one that read the following:

1. the Captain lied about the level of engine vibration

2. the Captain lied about closing the #1 throttle to reduce the vibration

3. the Captain failed to secure the CVR

4. the Captain (at a date later then the interview) added the additional info they they were effectively flying solo etc etc etc

5. the company never authorised the engine runs that just happened to delete the relevant CVR.

and thought about the turbo prop some years back at Wick I think who it is believed almost landed gear up, and then went into the hold for a while and just happened to land and secure the CVR at a time after all the relevant conversations were deleted.


Sounds like an average day at some training organisations I have come across - "Good JaaaaaB!!! You Guys Are Great!!! Top 98%!!!!!


Still trying to decide if the investigation comment regarding the FO's training records and the FMS / systems comments were pointing the finger at the training organisation or questioning what the Captain was claiming.

I believe based on my reading of the report that yes - the FO lost situational awareness and this is evidenced by the fact that they did not take control during the unsafe descent. However, the only available evidence does not back up the Captain's claims in regard to FO performance.

Finally the fact that the timing of the door opening / closing is very significant when combined with the fact that the Captain has clearly has a very close look the the blades of the engine.

In sumary I see a Captain telling lies about things they did not need to so what are they not telling?????
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Old 31st Aug 2010, 23:39   #20 (permalink)
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I have never been so lucky as to fly a GIV but perhaps somebody could tell me..... Do you have to program everything via the FMS? Can't one simply tune up an NDB and an ILS frequency on an old fashioned control head?
I don't think anyone answered that specific question - I can't speak for the G-4 but in a lot of the bigger newer stuff all the nav radio selections can only be done via a "navrad page" on the FMC/S. The NDB freqs are entered numerically longhand, the ILS is entered by either typing in the LOC freq and QDM numerically or by selecting an arrival airport, and then runway and procedure on a "departures arrivals" page e.g. " ILS 26" . So in short (phew) in many types now there is no "old fashioned control head" - isn't progress wonderful?
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