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Attributes | |
ACN | 589526 |
Time | |
Date | 200307 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : charter |
Make Model Name | Falcon 50 |
Operating Under FAR Part | Part 135 |
Navigation In Use | other |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : charter |
Function | flight crew : captain instruction : instructor oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 164 flight time total : 26200 flight time type : 2850 |
ASRS Report | 589526 |
Person 2 | |
Affiliation | company : charter |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : brake indications other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other other other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airport Aircraft Maintenance Human Performance |
Primary Problem | Aircraft |
Narrative:
On jul/thurs/03, at approximately XA30 hours, I was acting as the captain, in the position of PIC, on a dassault falcon 50. The aircraft was being operated on an IFR flight plan, under 14 crash fire rescue equipment part 91 rules. Day VMC conditions prevailed at the time of the incident (dusk). No other aircraft were involved. During this flight I was acting in the capacity of a training pilot, providing in-flight instruction to another company pilot, who was acting as the sic. The sic was operating the controls of the aircraft up until reaching the final approach fix at ZZZ. At FAF, I became primary manipulator of the controls but requested that the sic remain on the controls with me. I told the sic that I had control of the aircraft, but to 'stay on the controls with me' so that he could feel the inputs I made, on the aircraft controls, during the final approach and landing sequence. The aircraft originated out of ZZZ1 after being picked up from, an approved dassault maintenance facility located there. The aircraft was delivered to maintenance facility, a few weeks earlier, so that maintenance could be performed on the aircraft, including troubleshooting the aircraft's antiskid braking system. (Regarding an intermittent problem with the aircraft's anti-skid system.) when the proper landing weight was ensured to be achieved upon arrival at ZZZ, an arrival into ZZZ was requested and ATC approved the arrival, followed by the ILS runway 24 approach. Both the arrival and approach were uneventful and all normal and required procedures and checklist were followed. Upon touchdown at ZZZ, the braking system failed. I had no brake pressure and saw that the aircraft's braking system annunciator panel lights were flickering indicating an abnormality. I initiated the emergency procedures for the brake system failure. Although I initiated the emergency procedures, I was unable to stop the aircraft before the end of the runway. Fearing that eminent danger existed for my crew and passenger (company employees), I executed an evasive maneuver at the end of the runway to prevent the aircraft from either tumbling or rolling down the hillside after exiting. As such the aircraft came to a complete stop shortly after exiting the end and just prior to starting down the hillside. The aircraft suffered damage to the nose gear and undercarriage area, but no injuries were reported. This NASA report was not originally filed within 10 days of the date incident, because I was originally informed it was an accident. I was also instructed that a NASA report could not be filed on an 'accident or criminal act' by both the FAA and the information stated in the NASA reporting system information sheet that accompanies the form filed. On jul/fri/03, I was advised by FAA principal operations inspector, the FAA investigator in charge of the investigation of this incident, that this would now be categorized as an incident and not an accident. As such I immediately filed this report. Callback conversation with reporter revealed the following information: the reporter stated the FAA first categorized this event as an accident and later changed it to an incident. The reporter said this airplane had a maintenance history of brake anti-skid failures and had just come from a manufacturer's authority/authorized repair station for a positive fix. The reporter stated the brake manufacturer representative was contacted and agreed to help correct the problem, which turned out to be a grip and tube subassembly of the brake assembly. The reporter said the brake technical representative determined the problem was a swedge breaking on the grip and tube subassembly and supplied us with test brakes that failed on testing. The reporter stated 19 brakes were tested until a modified brake set was installed and tested satisfactory. The reporter said the modified brake assemblies can only be used on this airplane with an authority/authorized engineering deviation and special maintenance manual procedures are to be used for these brake assemblies.
Original NASA ASRS Text
Title: A FALCON 50 ON TOUCHDOWN, THE BRAKING SYS FAILED AND AN EVASIVE MANEUVER WAS EXECUTED STOPPING AND PREVENTING THE ACFT FROM ROLLING DOWN A HILLSIDE.
Narrative: ON JUL/THURS/03, AT APPROX XA30 HRS, I WAS ACTING AS THE CAPT, IN THE POS OF PIC, ON A DASSAULT FALCON 50. THE ACFT WAS BEING OPERATED ON AN IFR FLT PLAN, UNDER 14 CFR PART 91 RULES. DAY VMC CONDITIONS PREVAILED AT THE TIME OF THE INCIDENT (DUSK). NO OTHER ACFT WERE INVOLVED. DURING THIS FLT I WAS ACTING IN THE CAPACITY OF A TRAINING PLT, PROVIDING INFLT INSTRUCTION TO ANOTHER COMPANY PLT, WHO WAS ACTING AS THE SIC. THE SIC WAS OPERATING THE CTLS OF THE ACFT UP UNTIL REACHING THE FINAL APCH FIX AT ZZZ. AT FAF, I BECAME PRIMARY MANIPULATOR OF THE CTLS BUT REQUESTED THAT THE SIC REMAIN ON THE CTLS WITH ME. I TOLD THE SIC THAT I HAD CTL OF THE ACFT, BUT TO 'STAY ON THE CTLS WITH ME' SO THAT HE COULD FEEL THE INPUTS I MADE, ON THE ACFT CTLS, DURING THE FINAL APCH AND LNDG SEQUENCE. THE ACFT ORIGINATED OUT OF ZZZ1 AFTER BEING PICKED UP FROM, AN APPROVED DASSAULT MAINT FACILITY LOCATED THERE. THE ACFT WAS DELIVERED TO MAINT FACILITY, A FEW WEEKS EARLIER, SO THAT MAINT COULD BE PERFORMED ON THE ACFT, INCLUDING TROUBLESHOOTING THE ACFT'S ANTISKID BRAKING SYS. (REGARDING AN INTERMITTENT PROB WITH THE ACFT'S ANTI-SKID SYS.) WHEN THE PROPER LNDG WT WAS ENSURED TO BE ACHIEVED UPON ARR AT ZZZ, AN ARR INTO ZZZ WAS REQUESTED AND ATC APPROVED THE ARR, FOLLOWED BY THE ILS RWY 24 APCH. BOTH THE ARR AND APCH WERE UNEVENTFUL AND ALL NORMAL AND REQUIRED PROCS AND CHKLIST WERE FOLLOWED. UPON TOUCHDOWN AT ZZZ, THE BRAKING SYS FAILED. I HAD NO BRAKE PRESSURE AND SAW THAT THE ACFT'S BRAKING SYS ANNUNCIATOR PANEL LIGHTS WERE FLICKERING INDICATING AN ABNORMALITY. I INITIATED THE EMER PROCS FOR THE BRAKE SYS FAILURE. ALTHOUGH I INITIATED THE EMER PROCS, I WAS UNABLE TO STOP THE ACFT BEFORE THE END OF THE RWY. FEARING THAT EMINENT DANGER EXISTED FOR MY CREW AND PAX (COMPANY EMPLOYEES), I EXECUTED AN EVASIVE MANEUVER AT THE END OF THE RWY TO PREVENT THE ACFT FROM EITHER TUMBLING OR ROLLING DOWN THE HILLSIDE AFTER EXITING. AS SUCH THE ACFT CAME TO A COMPLETE STOP SHORTLY AFTER EXITING THE END AND JUST PRIOR TO STARTING DOWN THE HILLSIDE. THE ACFT SUFFERED DAMAGE TO THE NOSE GEAR AND UNDERCARRIAGE AREA, BUT NO INJURIES WERE RPTED. THIS NASA RPT WAS NOT ORIGINALLY FILED WITHIN 10 DAYS OF THE DATE INCIDENT, BECAUSE I WAS ORIGINALLY INFORMED IT WAS AN ACCIDENT. I WAS ALSO INSTRUCTED THAT A NASA RPT COULD NOT BE FILED ON AN 'ACCIDENT OR CRIMINAL ACT' BY BOTH THE FAA AND THE INFO STATED IN THE NASA RPTING SYS INFO SHEET THAT ACCOMPANIES THE FORM FILED. ON JUL/FRI/03, I WAS ADVISED BY FAA PRINCIPAL OPS INSPECTOR, THE FAA INVESTIGATOR IN CHARGE OF THE INVESTIGATION OF THIS INCIDENT, THAT THIS WOULD NOW BE CATEGORIZED AS AN INCIDENT AND NOT AN ACCIDENT. AS SUCH I IMMEDIATELY FILED THIS RPT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE FAA FIRST CATEGORIZED THIS EVENT AS AN ACCIDENT AND LATER CHANGED IT TO AN INCIDENT. THE RPTR SAID THIS AIRPLANE HAD A MAINT HISTORY OF BRAKE ANTI-SKID FAILURES AND HAD JUST COME FROM A MANUFACTURER'S AUTH REPAIR STATION FOR A POSITIVE FIX. THE RPTR STATED THE BRAKE MANUFACTURER REPRESENTATIVE WAS CONTACTED AND AGREED TO HELP CORRECT THE PROB, WHICH TURNED OUT TO BE A GRIP AND TUBE SUBASSEMBLY OF THE BRAKE ASSEMBLY. THE RPTR SAID THE BRAKE TECHNICAL REPRESENTATIVE DETERMINED THE PROB WAS A SWEDGE BREAKING ON THE GRIP AND TUBE SUBASSEMBLY AND SUPPLIED US WITH TEST BRAKES THAT FAILED ON TESTING. THE RPTR STATED 19 BRAKES WERE TESTED UNTIL A MODIFIED BRAKE SET WAS INSTALLED AND TESTED SATISFACTORY. THE RPTR SAID THE MODIFIED BRAKE ASSEMBLIES CAN ONLY BE USED ON THIS AIRPLANE WITH AN AUTH ENGINEERING DEV AND SPECIAL MAINT MANUAL PROCS ARE TO BE USED FOR THESE BRAKE ASSEMBLIES.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.