Photo: G550 N535GA Aerial view of accident site, from NTSB Accident Docket

Eddie Sez:

Poor pilot decision making is not a conscious choice, of course. Pilots don't set out to make poor decisions but there are some pilots who are poor decision makers and are predisposed to making poor decisions. In mishap report after mishap report you can almost predict the pilot in question is going to screw things up. When you pair two such pilots together, even a minor problem can become something much more severe. This is just such a mishap.

This mishap should not have occurred, it could have been handled by any two G550 pilots straight out of school willing to approach their jobs with a little more professionalism.

One of the problems with pilots who have little oversight is they start to rationalize all of their actions and soon their subconscious agrees with everything they do. They will lose that "voice in their head" that checks everything they do. See: Normal Procedures & Techniques / Decision Making.

What follows are quotes from the sources listed below, as well as my comments in blue.


Accident Report


Narrative

Figure: N535GA Route of Flight, from flightware.com

[NTSB Factual Report, pg. 1]

Photo: G550 N535GA Landing incident runway (Gulfstream submission), from NTSB Accident Docket


Analysis

It appears the leak was in the nose wheel steering system which would cause the left system fluid to be depleted and the auxiliary system to be depleted once the auxiliary pump was activated. (That would happen once the switch was turned on or if the AUTO position once any wheel brake pedal exceeded 10° deflection.)

Once the first indication of hydraulic system failure had occurred, the prudent decision would be to go around and carefully consider the ramifications. It is likely the pilots would have then realized a longer runway was necessary and the likelihood of losing brakes would require the emergency brakes.

Even after all these improper decisions, once the thrust reversers were deployed a safe stop could have been achieved using the emergency brakes. The "go" and then the "no go" indecisions sealed the aircraft's fate.


Probable Cause

[NTSB Factual Report, pg. 1j] The National Transportation Safety Board determines that the probable cause of this accident was the captain's decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots' poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots' performance; and (3) the failure of the Federal Aviation Administration (FAA) to require crew resource management (CRM) training and standard operating procedures (SOPs) for 14 CFR Part 135 operators.


See Also:


References

Gulfstream G550 Quick Reference Handbook, GAC-AC-G550-OPS-0003, Revision 27, 24 July 2008

NTSB Factual Report Aviation, CEN11FA193, N535GA, 02/14/2011, Appleton, WI.