Crash During Approach to Landing Gulfstream G-1159A (G-III),(13)

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Postaccident benchtests set to parameters approximating the accident flight profile showed that the —glideslope,“ —500“ foot, —too low terrain,“ —minimums,“ —300“ foot, and —200“ foot GPWS alerts should have activated on the accident flight. However, the CVR did not record the accident GPWS generate any alerts during the flight. The only common failure that could prevent activation of the GPWS glideslope and altitude callouts is a radio altimeter failure. However, a review of Business Jet Services‘ maintenance records and the CVR transcript found no evidence indicating any problems with the radio altimeter. The GPWS unit and the radio altimeter were destroyed during impact; therefore, the Safety Board was unable to determine why the GPWS did not operate as expected. Federal regulations would have required that the accident airplane be equipped with an EGPWS by March 29, 2005. The EGPWS provides pilots with a pictorial view of terrain in addition to aural alerts.
A review of the FAA‘s Program Tracking and Reporting System records indicated that the PMI reviewed company maintenance records, which is a required inspection item, on May 6, 2004, and no discrepancies were noted. However, a Safety Board review of the company‘s maintenance records revealed that some of the maintenance paperwork was inconsistent, incomplete, and/or not documented properly. The Board is concerned that, although the FAA PMI‘s oversight of Business Jet Services was in accordance with standard guidelines, the PMI did not detect the maintenance records deficiencies found during the investigation. As noted previously, the Safety Board addressed this issue by issuing Safety Recommendation A-05-08, which is currently classified —Open–Acceptable Response,“ pending the FAA‘s revisions to Order 8300.10.

Accident Sequence
The examination of CVR and FDR data indicated that the en route portion of the accident flight from DAL to HOU was routine. The first officer started the approach briefing about 0547:50. However, Business Jet Services‘ SOPs state that the flying pilot–in this case, the
20 At 0559:06, the CVR recorded the first officer read back —runway one four“ instead of  —runway four.“
captain–should brief the approach. Further, during the briefing, the first officer did not mention all of the approach checklist items, including the FAF altitude.
About 3 minutes after starting the approach briefing, the CVR recorded the captain asking the first officer to set the navigational approach waypoints in the FMS. The pilots then discussed deleting the HUB VOR waypoint from the list, which the first officer most likely did at that time. The MFD only displays a chronological number for each approach waypoint; therefore, it is possible that the flight crew forgot that the first officer removed the HUB waypoint from the FMS, causing them to mistakenly believe that the last waypoint displayed on the MFD (EISEN) was the airport. Regardless, an FMS serves as a secondary navigational aid on an ILS approach. The pilots should have been relying on the primary navigational aids during the approach.
About 0612, the CVR recorded both pilots stating that they were unable to get the APR mode on their flight directors to activate. About 1 minute later, the first officer told the captain that they were —high on“ the glideslope and then that they were —on“ the glideslope. According to the airplane performance study, the airplane was actually about 700 feet below the glideslope when the first officer made these statements, and the airplane remained well below the glideslope throughout the rest of the approach. Although the first officer entered the ILS frequency in the standby position in both VHF NAV receivers earlier in the approach (about 0559, after the approach clearance), at this point in the approach, neither pilot had selected the ILS frequency. Further, the glideslope indicator would not have been visible on the EADI. Therefore, the first officer could not have been looking at the glideslope indicator when he made the statements about the glideslope.
　
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