Contributor - Safety

David Jack Kenny

<h1>Preliminary Reports</h1>
<h2>Gear Collapse Preceded Fatal Runway Excursion</h2>
<h3>Gates Learjet 35A, Feb. 10, 2025, Scottsdale, Arizona</h3>
<p>An apparent collapse of the left main landing gear led the jet to depart the left side of the runway just after touchdown, sliding across the intervening safety area and a taxiway before striking the windsock and colliding with a parked Gulfstream 200. The Learjet pilot was killed; the first officer, one of the two passengers, and a person inside the Gulfstream suffered serious injuries, and the second passenger incurred minor injuries. Operated under Part 91 by Chromed in Hollywood, the Learjet was substantially damaged.</p>
<p>Security camera footage and images from several personal cell phones showed that the left main gear was not down and locked during the approach, but trailing well aft of its normal position.</p>
<p>N81VN was en route to Scottsdale from Florida, with a refueling stop in Austin, Texas. At 2,800 feet agl, the jet turned onto the final approach path to Runway 21. Security footage and witness videos showed the left landing gear trailing aft from its normal position. Upon touchdown, the aircraft veered left, exited the runway, and struck the G200. The Learjet engines continued to run until emergency responders arrived and shut them down.​</p>
<p>Investigators found the left main landing gear on Taxiway Bravo, with the aft trunnion pin missing from its casting. Investigators noted excessive grease in the wheel well. In June 2024, the report indicated that the same flight crew had a previous hard landing incident, requiring a hard landing inspection. Another mechanic who serviced the landing gear in December noted excessive grease usage.</p>
<p>In an interview with the NTSB, the technician who performed the hard landing inspection said he removed both main landing gear to facilitate the pertinent eddy-current inspections that were required. He told the NTSB that he followed the maintenance manual for all of the work he performed.</p>
<p>According to the NTSB report, the procedure to reinstall the gear must be followed explicitly. “If the [retaining] bolt is secured before engaging the pin in the trunnion casing then the grease hole could be aft of the bushing, allowing grease to escape outside the pin, into the wing bay behind spar #7,” the NTSB said. “With the adjacent access panel removed, using a mirror, the pin can visibly be seen not making contact with the aft trunnion fitting when it is not fully pushed into the trunnion casing.”</p>
<p>Notably, the NTSB is aware of at least three other previous events where a Learjet landing gear had disconnected from the airframe because the retaining bolt was not engaged through the aft trunnion pin.</p>
<p>The accident occurred under clear weather conditions, with visibility of 10 miles reported. Within minutes, the Scottsdale Fire Department arrived on the scene, and the first officer was extracted from the cockpit and transported to the hospital.​</p>
<h2>Brazil Excursion Involved Wet Runway Conditions</h2>
<h3>Cessna 525 Citation CJ1, Jan. 9, 2025, Ubatuba, Brazil</h3>
<p>The private jet, registered in Brazil as PR-GFS, was landing at Ubatuba’s Gastão Madeira State Aerodrome (SDUB) and overran Runway 9’s boundary, colliding with a fence, bursting into flames, and coming to a final stop on a beach as shown in videos posted to social media by bystanders. The pilot in command died in the accident. Three of the four passengers on board suffered serious injuries and one suffered minor injuries; one person on the ground received serious injuries and another suffered minor injuries, according to a preliminary report by Brazil’s Aeronautical Accidents Investigation and Prevention Center (CENIPA) published on January 15.</p>
<p>“The aircraft took off from Mineiros Aerodrome (SWME), Mineiros, GO [Goiás], bound for Gastão Madeira State Aerodrome (SDUB), Ubatuba, SP [São Paulo], at approximately 11:20 a.m. (UTC) in order to carry out a private flight, with one crew member and four passengers on board,” the report states. “During landing, the aircraft exceeded the longitudinal limit of the runway and collided with the fence that limited the airport site, coming to a final stop outside the aerodrome area.”</p>
<p>Textron Aviation gave a takeoff distance for the CJ1+ at 3,260 feet and landing distance of 2,590 feet in its 2005 announcement on receiving FAA type certification for the aircraft. The runway at SDUB is 3,084 feet long (940 meters), according to AIP data. On the date of the accident, the first 1,247 feet (380 meters) of Runway 9 was closed, leaving only about 1,837 feet of non-displaced runway available for landing.</p>
<p>Textron Aviation’s landing distance number appears to include a pilot and three passengers; it would also imply standard temperature and pressure and dry surface conditions. Videos of the accident indicate Ubataba’s runway was wet when PR-GFS made its landing. The investigation by CENIPA is ongoing.</p>
<h1>Final Reports</h1>
<h2>External Load Accident Attributed to 'Rotorcraft-pilot Coupling'</h2>
<h3>Airbus Helicopters AS350B3, Nov. 16, 2020, Sognesand, Rogaland County, Norway</h3>
<p>Control inputs intended to counter unexpected vertical oscillations inadvertently amplified them instead, leading to the helicopter’s collision with trees during the delivery of a load of concrete to the site of a powerline pylon. The solo pilot escaped without injury. The Norwegian Safety Investigation Authority concluded that “rotorcraft--pilot coupling”—a term that includes both pilot-assisted and pilot--induced oscillations—was triggered by compensation for a sudden change in altitude caused by a gust of wind, contact between the bucket and the pylon foundation, or both. The helicopter’s light fuel load relative to the weight of the concrete, the pilot’s use of minimal control friction, and the design of the servos in the 2002-model aircraft all likely contributed to the oscillations.</p>
<p>The accident occurred on the 14th of a series of short flights between a loading zone and the construction site, hauling concrete in a manually operated bucket suspended on a 15-meter (49-foot) steel cable. The pilot approached from the west and established a hover over the pylon form in variable winds, likely including a light quartering right tailwind. Strong vertical oscillations developed shortly after workmen opened the bucket’s hatch, and the pilot immediately released the cable; he did not feel any contact between the bucket and the concrete form, but the workers reported that it was in contact with the form and was in fact left standing on it afterwards. The pilot lowered the nose to fly away from the people on the ground and raised collective, but “the helicopter did not respond as expected.” The main rotor rpm appeared to decrease throughout its descent into the trees.</p>
<p>Beginning with the 2006 model year, AS350 helicopters were delivered with a new design of main servos that reduced sensitivity to rotorcraft-pilot coupling. Service bulletins published in 2010 and 2018 recommended retrofitting the new-model servos and banjo screws with flow restrictors, respectively, but these modifications were optional and had not been made to the accident helicopter.</p>
<h2>Insufficient Airspeed Thwarted Go-around</h2>
<h3>Daher TBM 700, April 7, 2023, Ashland, Oregon</h3>
<p>Failure to maintain at least the required 80 knots airspeed on final approach left the airplane with insufficient rudder authority to counter left yaw resulting from increased torque during an attempted go-around, leading it to touch down left of centerline and then depart the runway. The pilot and the instructor conducting his flight review were able to secure the aircraft and exit through the passenger door after it “traveled through bushes and scrub trees…coming to rest at the edge of a creek” with the pilot’s door obstructed by branches. However, “a small fire engulfed much of the airplane.”</p>
<p>The flight review began with an IFR round trip between the Medford and Klamath Regional airports. On the return to Medford, the instructor requested a diversion to Ashland, where the pilot successfully dealt with a simulated gear malfunction and flew a stabilized approach to Runway 30. As they crossed the threshold, the instructor called for a go-around. The pilot increased torque to 70% and leveled the airplane, but its airspeed did not increase and right rudder did not correct an immediate left yaw. Impact occurred 3 to 5 seconds after the power increase.</p>
<p>Neither the pilot nor the instructor recalled feeling “any indication of impending loss of control” or hearing a stall warning, but the audio track of the airplane’s L3 lightweight data recorder captured three audible callouts of “Stall, stall” after it descended below 500 feet. Stall warnings were also recorded before the successful landing at Klamath Regional. The airspeed on both approaches dropped below 70 knots. The instructor’s estimated 9,347 hours of experience included 5.3 in type.</p>
<h2>Snagged Bucket Disrupted Emergency Landing</h2>
<h3>Bell 205A-1, July 19, 2023, Haig Lake, Alberta, Canada</h3>
<p>The pilot’s attempt to touch down in a patch of muskeg after a complete engine failure was thwarted when the firefighting helicopter’s dip bucket caught on trees. Though the pilot immediately released the line, the snag caused the helicopter to pitch downwards and strike the ground in a nose-low, left-banked attitude. The pilot extricated himself from the wreckage but later died of his injuries.</p>
<p>Shortly after takeoff from the Haig Lake firebase with a dip bucket on a 150-foot longline, the pilot levelled off at 1,400 feet and contacted dispatch for more information about the fire. The helicopter descended 300 feet while the pilot read back the dispatcher’s transmission; he then radioed that he was returning to base “due to an unspecified issue.” The helicopter continued to descend during a 180-degree right turn, then lost all engine power. The pilot entered an autorotation but did not immediately release the bucket.</p>
<p>The power loss was traced to a complete failure of the brazed joint between the air diffuser casing assembly and the No. 2 bearing support cone. Neither component showed evidence of previous disassembly or repair, and the failure was attributed to an undetermined manufacturing defect. The engine’s time in service was not reported.</p>
<p><em>—Amy Wilder contributed to this report</em></p>


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