Fools Rush In …

The NTSB has released its final report on a February 2021 accident in which a 2008-vintage, Dassault Falcon 900EX EASy, registration N823RC, was substantially damaged during a runway excursion event secondary to an aborted takeoff from San Diego, California’s Montgomery-Gibbs Executive Airport (MYF). Neither the two pilots, the single flight attendant, nor the two passengers aboard the Part 91 personal flight sustained injuries.

Excepting the factory-fitted Honeywell/Dassault EASy avionics suite with which the Falcon 900EX EASy is equipped, the model is identical to Dassault’s Falcon 900EX.

The crew of the ill-fated Falcon reported the accident flight—which was bound for Hawaii’s Ellison Onizuke Kona International (KOA)—was only their third trip in the aircraft.

N823RC departed MYF Runway 28R at approximately 11:50 PST on 13 February 2021. The Pilot In Command (PIC) was the Pilot Flying (PF), and the Second In Command (SIC) was the Pilot Monitoring (PM). Both crewmembers reported no anomalies had been observed during preflight inspection of the aircraft, and all pre-takeoff checks, engine start, taxi, and engine run-ups had proved normal. The first officer reported a maximum performance takeoff had been planned.

The MYF Automatic Terminal Information Service (ATIS) was obtained at 11:15:21. Prior to departure, the crew discussed the aircraft’s fuel-load—citing a total of 19,500-pounds, an estimated trip burn of 11,500-pounds, and reserves of between six-and-seven-thousand-pounds.

At 11:36:58 the crew performed the after-start/before-taxi checklist, which included a brief discussion of takeoff trim settings to include expression of the opinion “We’re pretty far aft.” Takeoff airspeeds were briefed, to include the comment “Green, 112.” The crew reviewed the flight’s departure plan and briefed the procedures by which they would operate in the event of a rejected takeoff. The crew specified no abort would be attempted after the aircraft had accelerated beyond eighty-Knots-Indicated-AirSpeed (KIAS).

The crew contacted the MYF VFR control tower at 11:42:16 and requested a momentary takeoff delay for a short field takeoff.

The takeoff roll was initiated at 11:46:13. The crew noted the Airspeed Indicator (AI) coming alive and cross-checked their flight instruments at eighty-KIAS—at which time the SIC stated the flight was committed to takeoff. The V1 and rotate calls were made in rapid-succession at 11:46:52.

Seven-seconds later, the PIC stated “I can’t take-off.”

The SIC called for “thrust reversers,” to which the PIC repeatedly and alternately exclaimed “I can’t!” and “We can’t!”

Sounds consistent with the aircraft departing the paved runway surface were subsequently captured by the jet’s Cockpit Voice Recorder (CVR), as were the sounds of numerous master caution aural alerts. Immediately prior to the recording’s terminus, the PIC was heard to state, “Kill it.”

The aircraft overran the departure end of MYF Runway 28 by approximately 315-feet, struck a berm—which sheared off all three of its landing-gear assemblies—slid an additional 230-feet sans-landing-gear, and came to rest atop a gravel overrun pad.

The accident aircraft’s wings and fuselage sustained substantial damage. Notwithstanding multiple ruptured fuel tanks and considerable fuel-leakage, no post-accident fire ensued.

The accident aircraft’s PIC stated he was employed directly by the Falcon’s owner, for whom he’d previously flown a different aircraft. The pilot alleged he held multiple type ratings in numerous jet aircraft. Responding FAA safety inspectors contended the pilot, when asked to present his airman certificate, initially failed to produce such. In time, however, the individual produced a pilot certificate listing no type rating for the Falcon 900EX. A review of airmen records revealed the FAA, on 13 February 2019, had issued an emergency revocation of the entirety of the pilot certificates then held by the accident aircraft’s PIC.

While employed as a check pilot for a Part 135 operator, subject individual had, on 15 separate occasions, violated 14 CFR §61.59(a)(2) by falsifying logbook entries and certificate-holder records pertaining to training events and pilot proficiency checks.

The accident aircraft’s PIC stated he’d calculated aircraft performance and filed the MYF-KOA flight plan by dint of his tablet and Aircraft Performance Group (APG) performance data software. Asked by NTSB investigators to produce the tablet, the pilot stated it had been destroyed. Queried about weight-and-balance and performance data germane to the accident flight, the PIC set forth he could recall details of neither.

The PIC had enrolled in an October 2020 DA-900EX EASy initial training event at Flight Safety International. Though he sporadically attended the didactic/classroom aspect of the training, the pilot was not issued a DA-900EX EASy type rating insomuch as he never met the curriculum’s ground or flight-simulator training requirements.

The accident flight’s SIC stated he, too, was employed directly by the Falcon 900EX EASy’s owner, who’d retained his services in 2019—primarily for purpose of flying a helicopter and serving in a security specialist capacity. When the accident aircraft was purchased, the helicopter pilot/security specialist was offered an SIC position aboard such. At the time of the accident, the SIC reported only 568 total hours of flight time—of which 380 had been logged in helicopters.

According to Flight Safety International, the SIC had enrolled in an August 2020 DA-900EX EASy initial training event, which he completed and, on his second check-ride attempt, received a type rating with pilot-in-command limitations. At the time of the accident, the SIC had logged only 16-hours in the Falcon 900EX EASy.

In an interview with NTSB investigators, the SIC stated he’d confirmed the accuracy of the FMS inputs made by the PIC, but later conceded he possessed little understanding of the equipment.

With the airplane configured at slats/flaps 20-degrees (SF2) and an available takeoff distance of 4,598-feet, the maximum takeoff weight (MTOW) at which the Falcon could have legally departed MYF Runway 20R was 45,064-pounds. According to both its crew and Digital Flight Data Recorder (DFDR) the accident aircraft, at the time of departure, was laden with 20,500-pounds of fuel. Ergo, based on known aircraft loading, Falcon 900EX EASy’s actual takeoff weight was 48,039-pounds. The balance field length requirement for such a weight would—under atmospheric conditions observed at the time of the accident—have been 5,173-feet.

Per the accident aircraft’s Aircraft Flight Manual (AFM), the forward Center of Gravity (CG) limit for takeoff in the SF2 configuration is 15-percent. The calculated CG for the accident flight, based on the cabin occupants’ seating locations, was 15.2-percent.

Furthermore, the accident aircraft’s AFM specifies a -7.5-degree horizontal-stabilizer pitch-trim position for heavy-gross-weight takeoffs with forward CGs. In the event the aircraft’s horizontal-stabilizer trim was outside the green band (-4.5-degrees to -7.5-degrees), the crew would observe a “NO TAKEOFF” configuration alert. The accident aircraft’s DFDR indicated the jet’s horizontal-stabilizer trim had been set to -5.73-degrees with SF2 selected. Such was confirmed by physical examination of the aircraft’s wreckage.

According to Dassault, an amber “FIELD LIMITED” message would have illuminated on the Take-Off & Landing Data (TOLD) page of the accident aircraft’s FMS had the jet’s Maximum Take-Off Weight (MTOW) been exceeded. Under such conditions, the FMS would not compute takeoff speeds. Therefore, no takeoff card would have been displayed for the crew—thereby precluding acknowledgment of TOLD performance calculations and summarily preventing the appearance of flight-correct airspeed bugs (V1 and Vr) on the airspeed tapes of the aircraft’s left and right-side cockpit Primary Flight Displays (PFDs).

Data derived of the accident aircraft’s DFDR indicated the PIC attempted takeoff at a rotation speed (Vr) of 110-KIAS. In actuality, Vr should have been 133-KIAS at the accident aircraft’s MTOW.

DFDR data further indicated the accident aircraft’s crew had aborted the takeoff at an airspeed of 123-KIAS, and the maximum airspeed attained during the ground-roll was 127-KIAS. The accident aircraft’s thrust-reversers were not deployed until the jet had slowed to 102-KIAS and traveled some 3,770-feet down the 4,598-foot departure runway.

The Falcon exited the departure end of the MYF Runway 28R at 75-KIAS and impacted the berm at 59-KIAS. The aircraft’s CVR, DFDR, and Maintenance Data Recorder (MDR) showed its engines, flight controls, and brakes had been functioning normally at the time of the accident.

The Crew Operational Documentation for Dassault EASy aircraft directs the pilot to set the trim indicator in the green band for takeoff and includes the following two notes:

• NOTE: Appropriate position within this green band depends on location of airplane CG: Nose Up (NU) if airplane is balanced towards forward limits of CG envelope (i.e., if fuel tanks are fully loaded), Nose Down (ND) if airplane balanced aft.
• NOTE: During take-off with heavy gross weight and forward CG, and if aircraft has not been trimmed toward nose-up limit of green take-off range, rotation may require full aft control yoke and a delay may be noticed between reaching full aft control and actual rotation.

According to the FAA’s Aircraft Weight and Balance Handbook (FAA-H-8083-1-A), Chapter Ten: Weight and Balance: Loading in a nose-heavy condition causes problems in controlling and raising the nose, especially during takeoff and landing.

The National Transportation Safety Board determined the probable cause(s) of the accident to be the flight-crew’s operation of the airplane outside of the manufacturer’s specified weight and balance limitations, and improper setting of the aircraft’s horizontal stabilizer trim setting—which resulted in the airplane’s inability to rotate during the attempted takeoff. The PIC’s lack of proper certification and the crew’s collective lack of flight experience in the Falcon 900EX EASy was determined to have contributed directly to the accident.

FMI: www.ntsb.gov