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CEN11FA193 · Gulfstream Aerospace Corp. GV-SP

14 Feb 2011 · Appleton, WI, United States

Gulfstream Aerospace Corp. GV-SP · Accident: system/component malfunction/failure (non-power) on approach

From Appleton International Airport (ATW) to Appleton International Airport (ATW)

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Event

NTSB case
CEN11FA193
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Gulfstream Aerospace Corp. GV-SP

Aircraft type
Gulfstream GV-SP
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N535GA
Onboard fatalities
Unknown
Route
From Appleton International Airport (ATW), Appleton, WITo Appleton International Airport (ATW), Appleton, WI
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach · IFR final approach
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
System/component malfunction/failure (non-power)
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Personnel issues › Action/decision

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

While the airplane was inside the final approach fix, an amber left side hydraulic quantity low crew alerting system (CAS) message illuminated. The pilot flying (PF) noticed the hydraulic fluid quantity decreasing. Subsequently, an amber left hydraulic system fail CAS message appeared. The pilot not flying (PNF) pulled out the checklist to accomplish the left hydraulic system failure procedures and then suggested a go-around because the landing runway was about 500 feet shorter than the recommended minimum runway length indicated in the checklist. The PF decided to land due to the hydraulic quantity indications, prior autopilot problems, and the airplane's landing configuration. The PNF turned on the auxiliary pump about 500 feet above ground level, and both the PF and PNF thought the auxiliary hydraulic system could support normal spoilers, brakes, and nosewheel steering. The PF selected right thrust reverser aft and began pressing the brakes, but he felt no braking action. He reached for the emergency brakes; however, he did not immediately apply them to slow the airplane because he decided that there was not enough distance remaining to stop the airplane on the runway. Therefore, he attempted to go around with insufficient runway remaining by advancing the throttles to the maximum continuous thrust setting. The PNF did not see the airspeed increase and believed that not enough runway remained to get airborne, so he pulled the throttles back to avoid a runway overrun. The airplane exited the runway and sustained substantial damage. A review of the cockpit voice recorder transcript indicated that, before the emergency, the flight crew did not maintain a disciplined cockpit environment that focused on operationally relevant discussion but instead repeatedly made reference to and discussed objects on the ground and other operationally irrelevant topics. The lack of a sterile cockpit did not promote crew coordination and communication and adherence to procedures, which would have helped mitigate this emergency.

A postaccident examination of the airplane revealed that the nose landing gear swivel assembly, which had passed an acceptance test procedure before its installation on the airplane, was seized and bound and had a fracture on its inboard connecting tube, which was the site of the hydraulic fluid leak. The swivel assembly had galling wear scars on the outside diameter of the spool and the inside diameter of the housing; both the spool and housing were made from similar aluminum alloys that have a propensity to gall and adhere to each other when rubbed together. The connecting tube fracture was consistent with a single bending and torsional overload event associated with high opening forces or seizure in the center swivel due to galling wear. The center housing/spool seizure was consistent with a misalignment of the swivel, which led to the binding together of the similar aluminum alloys of the spool and housing. Further examination showed that the nose landing gear hydraulic system did not have a volumetric hydraulic fuse designed to minimize the loss of hydraulic fluid in the event of a line break downstream of such a device.

Probable cause

The pilot flying's (PF) decision to land on a shorter-than-recommended runway with a known left hydraulic system failure rather than go around as suggested by the pilot-not-flying, his failure to immediately apply emergency brakes following the detection of the lack of normal brakes, and his attempt to go around late in the landing roll with insufficient runway remaining. Contributing to the accident was the nose landing gear swivel assembly failure, the lack of a hydraulic fuse before this critical failure point, and the design of the swivel using two similar alloys with a propensity to adhere to each other when rubbed together. Also contributing to the accident was the lack of a disciplined cockpit environment.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record CEN11FA193
Event ID
20110216X44712
Case number
CEN11FA193
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 63641aa83f19a3d2e5149836c7be7a119b6d85ecaaac2bf85550409ccf8cb636; retrieved 2026-09-15T15:49:20.126Z.