Sometimes the NTSB gets fixated on the technical parts of an accident and ignore the true cause; this is just such a case. "The operator's decision to allow a flight in an airplane with known, unresolved maintenance discrepancies, and the flight crew's failure to properly configure the airplane in a way that would have allowed the emergency or parking brake systems to stop the airplane during landing." True enough, but that wasn't the cause.
— James Albright
Updated:
2024-06-15
N114TD crash site, NTSB
The bulk of the report is taken up with tomographic analysis (Xrays) of solder joints in the antiskid system control and these do indeed show WHY the brakes failed. The report also notes that the PIC had an SIC-only type rating and that the SIC had no type ratings at all. Again, true enough. What caused the crash then? My speculation follows in the postscript.
1
Accident report
- Date: 27 Sep 2018
- Time: 1346 Local
- Type: Dassault Falcon 50
- Operator: Air America Flight Services
- Registration: N114TD
- Fatalities: 2 of 2 crew, 0 of 2 passengers
- Aircraft Fate: Substantially damaged
- Phase: Landing
- Airport: (Departure) St. Petersburg-Clearwater International Airport, FL (KPIE)
- Airport: (Destination) Greenville Downtown Airport, SC (KGMU)
2
Narrative
The airplane departed from St. Pete-Clearwater International Airport (PIE), Clearwater, Florida, at 1230. According to the cockpit voice recorder (CVR), during the approach to GMU, the flight crew had difficulties understanding the navigation fixes that air traffic control had provided. The CVR also showed that the flight crew did not use any prelanding checklist or discuss that no braking was available with the brake system in the "#1-ON" position (the pilot was the copilot for the previous four flights in the airplane, during which this condition was present). At 1345:34, the CVR recorded the sound of the airplane touching down. At 1345:38, the pilot stated that the brakes were not operating. He and the copilot commented about the lack of brakes several more times before the airplane went over an embankment and came to a stop.
Air traffic controllers at GMU reported that the airplane touched down "normally" at a standard touchdown point on the runway. They saw the airplane's thrust reverser deploy and watched as the airplane continued down the runway without decelerating. An airport security video captured the airplane's touchdown and showed that the thrust reverser and the airbrakes were deployed. The video also showed the airplane as it continued to the end of the runway and went over the embankment.
Source: NTSB Final Report ERA18FA264
3
Analysis
The Pilot
The left seat pilot held an ATP certificate with a type rating for the Falcon 50 with a limitation for second-in-command only. He also held type ratings for Learjet and Westwind business jets. He held a Federal Aviation Administration (FAA) first-class medical certificate issued on August 7, 2018; at that time, he reported 11,650 total hours of flight experience.
Source: NTSB Preliminary Report ERA18FA264
Note: I am using the preliminary report here because some of this information was redacted from the final report.
The Copilot / Owner
The right seat pilot held a private pilot certificate with ratings for airplane single and multiengine land. He did not hold an instrument rating. He held a FAA second-class medical certificate issued on March 27, 2017, and on that date, he reported 5,500 total hours of flight experience.
Source: NTSB Final Report ERA18FA264
[Stephen George] Fox, who was 66 at the time of the crash and lived in Indian Rocks Beach, owned Air America Flight Services and a sister company names as a defendant in the suit, Account Management Group Inc, or AMG.
Fox did not have a pilot-in-command or second-in-command rating for the Falcon 50, according to the report. Fox was certified only for visual flight and didn’t have the rating required to fly an aircraft like the Falcon 50 under instrument flight rules.
Source: Tampa Bay Times
The Aircraft
The Dassault Falcon 50 was a midsize long-range business jet. The three engines were mounted at the rear of the airplane with the left engine identified as No. 1, the center engine identified as No. 2, and the right engine identified as No. 3. A thrust reverser was located on the No. 2 engine. The airplane was equipped with two independent hydraulic systems, which provided hydraulic power to several onboard systems including the airplane's brakes. System 1 provided hydraulic pressure for normal braking (with antiskid), while system 2 provided hydraulic pressure for emergency braking and parking brake. Selection of normal or emergency braking was done via a switch labeled "BRAKE" that was located on the instrument panel. The "#1-ON" position of the switch selected normal braking utilizing system 1, and provided antiskid protection, while the "2-OFF" position selected emergency braking and did not provide antiskid.
Source: NTSB Final Report ERA18FA264
N114TD brake panel, NTSB
The Brakes
According to the operator's director of maintenance, the airplane had been kept in storage in a hangar for about 4 years. In June 2018, a work order was generated to return the airplane to a serviceable status. The work order included a 12-month inspection, a 12-month or 500-hour inspection, a 24-month inspection, and a 36-month inspection. The work order also indicated that 1C, 3C, and 5C checks were to be completed and that a total of 103 discrepancies found during the ongoing inspections needed to be addressed. The work order was about 60% complete at the time of the accident, and there were no maintenance log entries made indicating that the airplane was airworthy and returned to service. The work order did not include removal of the landing gear for overhaul. The last overhaul of the landing gear (main and nose) was completed on July 23, 2002. During the overhaul, the electrical harness for the landing gear position sensors and antiskid transducers was removed and replaced. The overhaul interval was 12 years (plus a grace period of 5 months) or 6,000 landings, whichever came first. As a result, a landing gear overhaul should have been performed no later than December 23, 2014.
A review of the airplane braking system components at the scene of the accident showed that the parking brake handle was in the stowed position and the brake switch was found in the "#1-ON" position. Next to the brake switch was a sticker indicating, "ATA# 32-5 'INOP' DATE: 9/27/18" (ATA code 32-5 involves the antiskid system). Detailed examination of the wheel speed transducers that the antiskid system used showed signs of field splices on the right-side inboard and outboard transducers and no signs of field splices on the left-side inboard and outboard transducers.
Computed tomography performed on the antiskid system components revealed a broken solder joint on the left-side inboard transducer and a bent pin connection on the right-side inboard transducer. Functional tests of the antiskid wheel speed transducers revealed a failure in the operation of the leftside inboard wheel speed transducer; the other three transducers passed their respective functional tests. Visual inspection of the wiring for the right-side wheel speed transducers found that the wiring to the right outboard transducer was reversed.
According to the pilot who conducted four flights in the airplane before the accident flight, upon application of the brakes with the brake switch in the "#1-ON" position, braking was normal at low speeds (estimated to be 15-20 knots) but at faster speeds, no braking was available. Braking was restored when the brake switch was placed in the "#2-OFF" position. This pilot stated that he reported the brake system failure to the company's director of maintenance after the first two flights (in late August and early September 2018) and indicated his belief that the source of the problem was the antiskid system. This pilot also stated that the last two flights occurred 7 and 8 days before the accident flight and that the accident pilot was the copilot for all four flights.
Source: NTSB Final Report ERA18FA264
Maintenance
This office [The NTSB] then asked how Steve Fox [the owner] was able to take the aircraft if he [Timothy Fox, the DOM] was performing inspections or maintenance on it. Mr. Timothy Fox replied, "he just does and doesn't tell me about it.""
This office [The NTSB] informed Mr. Timothy Fox of a statement provided to the FAA from a pilot about a recurring maintenance issue with N114TD on 4 previous flights before the accident flight. The pilot reported a maintenance issue involving the brakes and stated that he informed Steve Fox that when the anti-skid was "ON", the brakes would not work until the anti-skid breaker was manually popped; then the brakes would be activated but the anti-skid would not be functional. This office [The NTSB] asked Timothy fox if Steve Fox replayed this maintenance issue to him and he said "yes", but also stated that Steve Fox told him the "brakes are fine". Timothy Fox stated that he did not perform any troubleshooting or maintenance on the brake system of N114TD.
Source: NTSB Interview with the Director of Maintenance, ERA18FA264
None of the available maintenance records indicated the brake system issue or showed maintenance actions that were performed to resolve the issue.
According to the abnormal procedures section of the airplane's flight manual, a failure of the (normal) brake system or an inoperative antiskid system in-part required the flight crew to move the brake switch to the "#2 / OFF" position. The manual also stated that if both normal and emergency braking was inoperative, that the thrust reverser and parking brake could be used to bring the airplane to a stop.
Source: NTSB Final Report ERA18FA264
Air America Flight Services, a Part 135 charter company based at St Petersburg-Clearwater International Airport in Florida, operated the aircraft, N114TD. Company management insisted it was not a revenue flight but invoices presented by the passengers, and the assessment of investigators, proved otherwise.
As the investigation expanded, the NTSB learned that the anti-skid system discrepancies were known prior to the accident by multiple people associated with the company, including its owner, Steve Fox, who served as the copilot on the Greenville charter.
In separate interviews weeks and months later, the company’s director of operations (DO), Joe Vigil, as well as chief pilot Charles Presley and director of maintenance (DM) Tim Fox (Steve's son), would all insist they did not know the flight was being conducted. They claimed to have no knowledge that the aircraft, or indeed the company, was involved in FAR Part 135 charter operations. John Caswell, whose name they learned after the crash, was a complete mystery. “Nobody knew who this man was,” asserted Vigil. Tim Fox and Vigil, both of whom were at work when the aircraft departed, declared they did not even know N114TD had taken off until hours after the fact. Vigil said he found out the airplane was gone only when the company’s FAA principal operations inspector called to tell him it had crashed.
Source: AIN
4
Cause
The National Transportation Safety Board determines the probable cause(s) of this accident to be: The operator's decision to allow a flight in an airplane with known, unresolved maintenance discrepancies, and the flight crew's failure to properly configure the airplane in a way that would have allowed the emergency or parking brake systems to stop the airplane during landing.
Source: NTSB Final Report ERA18FA264
5
Postscript
What caused the crash? Failed solder joints are the reason the brakes didn't work during the landing, but that wasn't the cause. The PIC didn't have the necessary training and ratings to handle the airplane, but that wasn't the cause. The SIC was unqualified to be in either of the pilot seats, but that wasn't the cause.
In my opinion, the cause of the crash was that the lack of FAA oversight on an owner/operator who was determined to make revenue from an airplane he didn't have qualified pilots to fly. With today's technology, it should be a simple matter to crosscheck pilot qualifications against filed flight plans and flight records.
For professional pilots there is another problem. If somebody hires you to fill a seat, you assume the pilot in the other seat is qualified, the aircraft is airworthy, and the operation is sound. There are, of course, warning signs that something might be amiss. I know there are owner-pilots out there that meet all the requirements. But I think an owner-pilot bears considerable scrutiny. The NTSB did an incomplete investigation here and we don't know much about the pilot listed as the PIC for this accident. He may very well have assumed the owner-pilot was fully qualified and the aircraft was airworthy. That assumption killed him.
More about this topic: De Facto Owner Authority Gradient.
References
(Source material)
Aviation Accident Investigation Final Report, National Transportation Safety Board (NTSB) ERA18FA264, Dassault Falcon 50, N114TD, September 27, 2018
"Illegal Charter and the Falcon 50 Crash," AIN, Colleen Mondor, October 7, 2021
"Injured Tampa passengers sue estates of pilot, co-pilot who died in jet crash," Tampa Bay Times, Tony Marrero, Dec 10, 2018