The Crosscheck: A Puzzle With Missing Pieces  

Trying to understand what caused an accident is a bit like solving a jigsaw puzzle. You keep collecting pieces and putting them in their proper places until a picture emerges. A few missing pieces can mar the final result. 

After a Dassault Falcon 900EX overran the end of the runway during a takeoff attempt at at Montgomery-Gibbs Executive Airport (MYF) in San Diego, the NTSB found most of the pieces of the puzzle, but some were missing. Did those missing pieces represent an opportunity to address an important safety issue? Maybe. It’s hard to say.

The Dassault Falcon 900EX EASy, registered N823RC, attempted a takeoff from runway 28R at MYF on Feb. 13, 2021. The captain tried to rotate at 110 kts indicated airspeed (KIAS) even though the appropriate rotation speed (Vr) for the jet’s takeoff weight was 133 KIAS. He couldn’t get the nose to rise, and initiated an abort at 123 kt. He overran the end of the 4,598 ft runway going 75 kts and struck a berm at 59 kts. All three of the landing gear sheared off and the jet slid to a halt 545 ft. beyond the departure end of the runway. The wings and fuselage were damaged and the fuel tanks ruptured. 

The reason the pilot couldn’t rotate the nose became apparent when the weight and balance was reconstructed by investigators. The required trim setting was -7.5, but the crew had set -5.5. The reason the jet couldn’t achieve the proper rotate speed was that the required takeoff distance was 5,215 ft.—617 ft. more than was available. 

Neither of the two pilots could tell the FAA inspectors who responded to the scene what the V speeds were for takeoff. There was no takeoff/landing data (TOLD) card on the airplane and the crew did not access the aircraft communications addressing and reporting system (ACARS) for performance data. If they had, the flight management system (FMS) would have warned them with an amber “FIELD LIMITED” message, and it would not have computed takeoff speeds.

The copilot could have learned how to use the FMS when he attended the Flight Safety type rating course, but he said he wasn’t proficient at using the system. He passed his second-in-command type rating ride on the second attempt. The captain could have learned how to use the FMS, but he dropped out of the Flight Safety course before completing it. One obvious reason he couldn’t complete the course was that he had no pilot certificate.

The captain’s pilot certificates were all revoked by the FAA two years before the accident because he falsified logbook entries and records for pilot proficiency checks, competency checks and training events multiple times.

Most of the puzzle pieces then came together. An unqualified, untrained, and decertified captain and an inexperienced and poorly trained copilot tried to make a maximum weight takeoff from a field that was too short. In addition, they had only flown the jet twice and yet they were destined for Hilo, Hawaii, 2,500 very watery miles away. The pilots clearly made egregious errors.

The Missing Pieces
Here’s where the missing pieces of the puzzle become apparent. By what stretch of regulatory oversight, owner due diligence, and common sense were these two fellows in the cockpit of this very expensive, high-performance, long-range executive jet? Even if the pilots were properly rated, current and qualified, what training and experience did they have in conducting oceanic flights? Was the airplane properly equipped for overwater flight? Why did the crew not reposition the airplane to San Diego International Airport (SAN), only six miles away, refuel, and then take off from that airport’s 9,401-ft.-long runway? Was the price of jet fuel a factor?

The role of the owner in this accident was not examined. When the copilot filled out the NTSB’s standard questionnaire, Form 6120, he scratched through the entry for the owner’s name and wrote in Aerospike Iron LLC. Investigators did not interview the owner. They did not determine if the two people in the cabin on the accident flight were the owner and a flight attendant, although it seems likely. 

The cockpit voice recording was summarized, not transcribed, and there was one statement on the summary that might have been revealing. “The crew engaged in miscellaneous conversation during taxi, including a discussion regarding general working conditions.” Did the crew have doubts about the owner’s judgment? We didn’t find out.

Is owner indifference to the operation of Part 91 business jets a safety issue that needs to be pursued, or is this case just a one-off? Are a lot of bizjet owners too busy or too casual about their own safety to vet their pilots and ensure that their flight operation is safe and legal? A couple of previous accidents indicate the answer may be yes.

A Dassault Falcon 50 crashed after landing at Greenville Downtown Airport (GMU), South Carolina, on Sept. 27, 2018. The two unqualified pilots died and the two passengers were severely injured. The owner was one of the pilots. A Gulfstream GIV crashed on takeoff at Laurence G. Hanscom Field (BED) in Bedford, Massachusetts on May 31, 2014, killing seven people, including the airplane owner. The owner was apparently unaware that his pilots were routinely skipping their preflight inspections and pre-takeoff checklists. 

The Falcon crew and owner were lucky. They only struck a berm, and the cabin remained intact. The GIV crew and passengers were not so lucky. They hit a ravine and the airplane broke up and caught fire.

If the events in multiple accidents begin to look like a trend, the NTSB can expand the scope of similar investigations to understand what’s happening. Owner lack of care, awareness, and involvement in Part 91 bizjet operations might be one of those trends.