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|
Attributes | |
ACN | 856513 |
Time | |
Date | 200910 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Gulfstream V / G500 / G550 |
Operating Under FAR Part | Part 91 |
Flight Phase | Initial Climb Takeoff |
Flight Plan | IFR |
Component | |
Aircraft Component | Gear Pins |
Person 1 | |
Function | Captain |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 90 Flight Crew Total 16200 Flight Crew Type 4200 |
Events | |
Anomaly | Deviation - Procedural FAR Deviation - Procedural Published Material / Policy |
Narrative:
At XN29 we took off in a gulfstream G550 with the landing gear pins installed necessitating a return to the airfield to have them removed. This airport is a flight facility with oversight by maintenance personnel. As captain; I accept full responsibility for this flight. In our organization; as in military units and most civilian operations; the maintenance representative/crew chief presents a flyable aircraft to include pulling the pins and chocks. It is the first officer's responsibility to perform the flight readiness inspection to include ensuring that the pins have been removed; the aircraft fueled and the cabin prepared. The captain is the final authority on the operation of the jet and it is his ultimate responsibility to ensure that his aircraft is ready for flight. It would seem that under these condition such an incident would not be possible; but let me detail how we got to the point where I did not complete my duties by performing a tertiary flight readiness inspection. There was a chain of errors not unlike those that result in serious mishaps. I am a military safety officer who was assigned to the director positon in the military as a human factors analyst on a world-wide accident investigation team; so I have a frame of reference for approaching the exogenous factors pertinent to this incident. I have over 16;000 accident-incident free flight hours to include 1105 combat hours. I have never brought an airplane home with damage other than that caused my hostile fire or mechanical failure. Nor had I; until this day; performed and aviation activity that I would characterize as dumb had another pilot done it. I am generally calm when it comes to aviation matters; but this day I was pressed. My day began just after XA00 hours cmt for a XI30 launch on a flight scheduled for terminate at XL30 hours at phoenix. I went to the gym with the intention of eating breakfast upon my return to quarters. When I returned to my gym locker after my workout; I saw that I had a call from my chief pilot. Knowing that I would need to write down mission changes and assignments; I delayed until I reached my home to return his call. It was now XC25 hours. My chief pilot advised me that my destinations had changed for the next two days. I spent the next hour on the phone with hotel canceling and rebooking reservations while trying to not be charged for late cancellations. After what I thought was successfully resetting my reservations. I check the confirmation emails only find that the hotel had the first officer and I in different hotels in washington dc. This necessitate another call. Noting the time as approaching noon; I stepped aside from mission planning to cancel an optical appointment and advise my automobile mechanic that I would be unable to accept a car that had just come out of service and to please hold it until friday. I then turned to canceling and refilling flight plans; checking weather and NOTAMS for my new destinations; sending faxes to the fbos that I would no longer be going to and new faxes to the fbos that I would be going to detail my requirements. I then began researching my new destinations. Our first destination is an airplane design category ii airport that requires a ppr for a design category III airplane. I completed that requirement and turned my attention to our second destination airport. We would be getting in during their quiet hours which required a sideline noise rating no greater than 90 decibels. I called our chief of maintenance to find our what was on our airplane specific noise certificate - 90.8 decibels. I called my chief pilot to let him know that it looked as if we would have a problem with our second destination. I called that airport's noise office to see if any gvs have successfully arrived during their quiet hours - they said that they were unaware of any. For a potential alternate; I did a quick check on an airport nearby our second destination - according to their website; quite hoursdid not begin there until XP00 hours. I let the chief pilot know then continued to work on the second destination. I called the aircraft manufacturers noise representative and the staff of gulfstream flight operations to see if they had any recent experience with that airport. They did not. I then called the manufacturer's chief pilot; and asked him the same question. He told me that while he had not landed after XO00 hours there; he had a technique that might work; which he detailed; then he requested that I let him know how it worked out. Not good enough; we would have to arrive earlier. Then I began to do detailed research for use of our second destination's back-up. It seems we could go there; in the gulfstream noise manual to confirmed that their quiet hours did not begin until XP00 hours on weekdays and it set forth procedure for use there. I spoke with their airport operations representatives because their noise office was closed due to the holiday. They threatened fines and sanctions if I violated their noise restrictions; but beyond that were not too helpful other than confirming that after XP00 hours the noise restrictions dropped to just 86 decibels. I had questioned that because crash fire rescue equipment 36 state III limits at 98.6 decibels. I was under pressure all day to professionally complete all required tasks in a timely manner. I was once again on the phone with that airport's operations as I reached the airplane; this time to confirm that the holiday didn't mean that quiet hours began at XO00 hours. As I took my seat in the left front of the jet there was 19 minutes remaining until my new moved-up departure time. The first officer had put a flight plan in the FMS to the wrong destination and had cancelled the correct flight plan. I re-filed; put the correct flight plan in the FMS and performed the cockpit preflight checks. The minutes were ticking by. I completed the cockpit checks; headed to the back to make sure the cabin was set-up; then proceeded to the main entrance door to do my tertiary walk-around. It was at that time my passenger arrive. I was out of time. As I brought his bags onto the jet through the forward door; I checked to see that the nose chocks were pulled again I didn't see a gear pin; but I have to admit that looking for one wasn't a priority because I counted on two others to have already pulled them. Had I not been in a hurry; I might have recalled that this first officer had once before done an inadequate preflight which resulted in costly repairs. Subsequently; I would have taken the time to perform that final check. I would have been hard to force myself to do so; however with my boss in a hurry and sitting on board. I closed the main cabin door. The first officer had already started the number two engine under the outside supervision of the maintenance technician as I took my seat to buckle in and started number one. I performed the after starting engines checks; the first officer called for taxi; I signaled the maintenance tech that we were ready for taxi and he cleared us onto the taxiway. Ten minutes later we were back with landing gear that would not retract. Being unsure of the nature of the gear problem at this point; we were towed from the runway. The maintenance technician pulled the gear pins; inspected the aircraft and pronounced it airworthy. I had already refiled and we were once again on our way. The entire exercise cost us considerable embarrassment; but less than 45 minutes from takeoff to takeoff. I should not have allowed myself to be rushed. I have learned from this incident and it will not happen again. In an effort to ensure that every aspect of my flight was perfect; I omitted a basic aviation fundamental - ensuring that the aircraft was ready for flight. While this was an insignificant incident where the only thing damaged was reputation; it is an example of the classic error chain that had preceded more significant mishaps. In future I will take the time to perform all of my responsibility - even if it is to do a triple check. If I don't; the next time I might not be so lucky.
Original NASA ASRS Text
Title: A Corporate GV Captain describes in detail how preflight duties consumed time and energy to the extent that he relied on his First Officer to complete his duties without question. In the end; the aircraft took off with the gear pins installed requiring a return to land.
Narrative: At XN29 we took off in a Gulfstream G550 with the landing gear pins installed necessitating a return to the airfield to have them removed. This airport is a flight facility with oversight by maintenance personnel. As Captain; I accept full responsibility for this flight. In our organization; as in military units and most civilian operations; the Maintenance representative/crew chief presents a flyable aircraft to include pulling the pins and chocks. It is the First Officer's responsibility to perform the flight readiness inspection to include ensuring that the pins have been removed; the aircraft fueled and the cabin prepared. The Captain is the final authority on the operation of the jet and it is his ultimate responsibility to ensure that his aircraft is ready for flight. It would seem that under these condition such an incident would not be possible; but let me detail how we got to the point where I did not complete my duties by performing a tertiary flight readiness inspection. There was a chain of errors not unlike those that result in serious mishaps. I am a Military Safety Officer who was assigned to the Director positon in the military as a human factors analyst on a world-wide accident investigation team; so I have a frame of reference for approaching the exogenous factors pertinent to this incident. I have over 16;000 accident-incident free flight hours to include 1105 combat hours. I have never brought an airplane home with damage other than that caused my hostile fire or mechanical failure. Nor had I; until this day; performed and aviation activity that I would characterize as dumb had another pilot done it. I am generally calm when it comes to aviation matters; but this day I was pressed. My day began just after XA00 hours CMT for a XI30 launch on a flight scheduled for terminate at XL30 hours at Phoenix. I went to the gym with the intention of eating breakfast upon my return to quarters. When I returned to my gym locker after my workout; I saw that I had a call from my Chief Pilot. Knowing that I would need to write down mission changes and assignments; I delayed until I reached my home to return his call. It was now XC25 hours. My Chief Pilot advised me that my destinations had changed for the next two days. I spent the next hour on the phone with hotel canceling and rebooking reservations while trying to not be charged for late cancellations. After what I thought was successfully resetting my reservations. I check the confirmation emails only find that the hotel had the First Officer and I in different hotels in Washington DC. This necessitate another call. Noting the time as approaching noon; I stepped aside from mission planning to cancel an optical appointment and advise my automobile mechanic that I would be unable to accept a car that had just come out of service and to please hold it until Friday. I then turned to canceling and refilling flight plans; checking weather and NOTAMS for my new destinations; sending faxes to the FBOs that I would no longer be going to and new faxes to the FBOs that I would be going to detail my requirements. I then began researching my new destinations. Our first destination is an Airplane Design Category II airport that requires a PPR for a Design Category III airplane. I completed that requirement and turned my attention to our second destination airport. We would be getting in during their quiet hours which required a sideline noise rating no greater than 90 decibels. I called our Chief of Maintenance to find our what was on our airplane specific noise certificate - 90.8 decibels. I called my Chief Pilot to let him know that it looked as if we would have a problem with our second destination. I called that airport's noise office to see if any GVs have successfully arrived during their quiet hours - they said that they were unaware of any. For a potential alternate; I did a quick check on an airport nearby our second destination - according to their website; quite hoursdid not begin there until XP00 hours. I let the Chief Pilot know then continued to work on the second destination. I called the aircraft manufacturers noise representative and the staff of Gulfstream Flight Operations to see if they had any recent experience with that airport. They did not. I then called the manufacturer's Chief Pilot; and asked him the same question. He told me that while he had not landed after XO00 hours there; he had a technique that might work; which he detailed; then he requested that I let him know how it worked out. Not good enough; we would have to arrive earlier. Then I began to do detailed research for use of our second destination's back-up. It seems we could go there; in the Gulfstream Noise Manual to confirmed that their quiet hours did not begin until XP00 hours on weekdays and it set forth procedure for use there. I spoke with their Airport Operations Representatives because their noise office was closed due to the holiday. They threatened fines and sanctions if I violated their noise restrictions; but beyond that were not too helpful other than confirming that after XP00 hours the noise restrictions dropped to just 86 decibels. I had questioned that because CFR 36 state III limits at 98.6 decibels. I was under pressure all day to professionally complete all required tasks in a timely manner. I was once again on the phone with that airport's Operations as I reached the airplane; this time to confirm that the holiday didn't mean that quiet hours began at XO00 hours. As I took my seat in the left front of the jet there was 19 minutes remaining until my new moved-up departure time. The First Officer had put a flight plan in the FMS to the wrong destination and had cancelled the correct flight plan. I re-filed; put the correct flight plan in the FMS and performed the cockpit preflight checks. The minutes were ticking by. I completed the cockpit checks; headed to the back to make sure the cabin was set-up; then proceeded to the main entrance door to do my tertiary walk-around. It was at that time my passenger arrive. I was out of time. As I brought his bags onto the jet through the forward door; I checked to see that the nose chocks were pulled again I didn't see a gear pin; but I have to admit that looking for one wasn't a priority because I counted on two others to have already pulled them. Had I not been in a hurry; I might have recalled that this First Officer had once before done an inadequate preflight which resulted in costly repairs. Subsequently; I would have taken the time to perform that final check. I would have been hard to force myself to do so; however with my boss in a hurry and sitting on board. I closed the main cabin door. The First Officer had already started the number two engine under the outside supervision of the maintenance technician as I took my seat to buckle in and started number one. I performed the after starting engines checks; the First Officer called for taxi; I signaled the Maintenance tech that we were ready for taxi and he cleared us onto the taxiway. Ten minutes later we were back with landing gear that would not retract. Being unsure of the nature of the gear problem at this point; we were towed from the runway. The Maintenance technician pulled the gear pins; inspected the aircraft and pronounced it airworthy. I had already refiled and we were once again on our way. The entire exercise cost us considerable embarrassment; but less than 45 minutes from takeoff to takeoff. I should not have allowed myself to be rushed. I have learned from this incident and it will not happen again. In an effort to ensure that every aspect of my flight was perfect; I omitted a basic aviation fundamental - ensuring that the aircraft was ready for flight. While this was an insignificant incident where the only thing damaged was reputation; it is an example of the classic error chain that had preceded more significant mishaps. In future I will take the time to perform all of my responsibility - even if it is to do a triple check. If I don't; the next time I might not be so lucky.
Data retrieved from NASA's ASRS site as of April 2012 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.