Rockwell Gulfstream 695A Jetprop 1000 | Bureau of Aircraft Accidents Archives

The accident pilot had been in a recurrency training program in the accident airplane the week before the accident flight, which was the return flight after completing the week with the instructor. According to the instructor, the pilot wanted to proceed home so they had planned for the accident pilot to depart on that leg of the flight no later than 1830 for a route of flight that remained west of specific terrain due to weather forecasts and that would arrive at the destination airport before dark. The pilot subsequently departed about 30 minutes past the planned departure time and flew a route east of the terrain that had been discussed, which placed the airplane in severe weather conditions after dark. While descending from its cruising altitude, the airplane encountered turbulence and the autopilot disengaged. For the remainder of the flight, multiple transmissions were recorded between air traffic control (ATC) and the pilot regarding course corrections, altitudes, icing conditions, and issues with the airplane’s autopilot. ATC offered vectors from the arrival procedure; however, the accident pilot declined the vectors. After receiving another pilot’s report of airframe icing from ATC, the accident pilot confirmed to ATC that he had accumulated moderate rime ice and agreed when ATC offered a lower altitude. When ATC asked, the pilot confirmed that the airplane remained in icing conditions during the continued descent, and the airplane subsequently leveled at 7,200 ft above mean sea level (msl). ATC instructed the pilot to climb the airplane to the last assigned altitude of 7,400 ft msl; however, the airplane remained at 7,200 ft msl for 29 seconds and began a right turn. During flight at 7,200 ft msl, the airplane’s ground speed slowed from 124 kts to 84 kts. ATC asked the pilot if he was ready to turn back to the left and the pilot responded “turning.” The airplane subsequently began a rapid descent from which the pilot did not recover. It crashed on a hilly and wooded terrain near San Bernardino and was totally destroyed by impact forces. The pilot was killed.

Probable cause:

The pilot’s continued use of the airplane’s autopilot after flight into moderate to severe icing conditions, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall.

Final Report:

Crash of a Rockwell Gulfstream 695A Jetprop 1000 near Cloncurry: 3 killed

Date & Time: Nov 4, 2023 at 1430 LT

Type of aircraft:

Rockwell Gulfstream 695A Jetprop 1000

Operator:

Registration:

VH-HPY

Flight Phase:

Flight

Flight Type:

Fire fighting

Survivors:

Site:

Plain, Valley

Schedule:

Toowoomba - Mount Isa

MSN:

96051

YOM:

1982

Flight number:

Birddog 370

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4900

Captain / Total hours on type:

102.00

Aircraft flight hours:

7566

Circumstances:

On the morning of 4 November 2023, a Gulfstream 695A, registered VH-HPY, was being operated by AGAIR on an instrument flight rules flight from Toowoomba to Mount Isa, Queensland. On board the aircraft were the pilot and 2 camera operators. The purpose of the flight was to conduct line scanning of fire zones located north of Mount Isa. About 1 hour and 50 minutes into the flight, while the aircraft was in cruise at flight level 280, air traffic control (ATC) lost radio contact with the pilot. Over the following 30 minutes, ATC made multiple attempts to re-establish contact, including using alternate frequencies and relaying messages via other aircraft in the vicinity. VH-HPY was observed diverging from track and ATC declared an uncertainty phase for the aircraft. About 20 minutes later, ATC called the pilot’s mobile telephone, and a brief conversation took place. During the conversation, the pilot’s speech was observed as slow and flat. In response, ATC upgraded the aircraft’s status to an alert phase and initiated their hypoxic pilot emergency procedures. About 10 minutes later, the crew of a nearby aircraft was able to establish contact with the pilot, having been requested to do so by ATC. The alert phase was downgraded to an uncertainty phase and, a short time later, ATC re-established direct contact with the pilot. The uncertainty phase was cancelled 1 minute later. The pilot confirmed that their oxygen system was operating normally, and they were issued a clearance to undertake line scanning north of Mount Isa. Over the following 4 minutes, the pilot repeated the clearance from ATC 4 times, seeming uncertain about the status of the clearance. The radio recordings during this period indicate that the pilot’s rate and volume of speech had substantially lowered from earlier communications and was worsening. The pilot’s final radio transmission displayed the slowest speaking rate of all their communications during the flight and contained stuttering and operational mistakes. Air traffic control did not attempt to re-establish contact with the pilot until about 18 minutes later, however no further responses from the pilot were received. A short time later, the aircraft departed controlled flight, initially entering a descending anticlockwise turn with an increasing rate of descent. At about 10,500 ft, the aircraft likely transitioned into an aerodynamic spin, with a subsequent average rate of descent of about 13,500 ft/min. The aircraft collided with terrain 55 km south-east of Cloncurry. The 3 occupants were fatally injured, and the aircraft was destroyed by impact forces and a fuel-fed post-impact fire.

Probable cause:

Contributing factors
- The pilot's ability to safely operate the aircraft was almost certainly significantly degraded by the onset of altitude hypoxia.
- While in cruise at flight level 280, both power levers were probably reduced without an appropriate descent rate being initiated, resulting in a progressive reduction of airspeed.
- The aircraft entered a descending anticlockwise turn with an increasing rate of descent. At about 10,500 ft, control input(s) were almost certainly made, probably an attempt to recover, that transitioned the aircraft from a high-speed descent to a spin condition that was likely unrecoverable and which continued until the impact with terrain.
- The pilot had a normalized practice of operating VH-HPY with a cabin altitude that required the use of supplemental oxygen. These flights were conducted without access to a suitable oxygen supply, significantly increasing the risk of altitude hypoxia induced incapacitation.
- The aircraft's pressurization system probably did not attain the required cabin altitude when operating at flight level 280 during the accident flight. The pilot probably knowingly continued the flight with a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply.
- The AGAIR aircraft VH-HPY pressurization system could not reliably attain the required cabin altitude during flight due to a known, long-term, unresolved intermittent defect. AGAIR management personnel were aware of the defect and, through a combination of inaction, encouragement and, in some instances direct involvement, permitted the aircraft to continue operations at an excessive cabin altitude. (Safety issue)
- AGAIR management exercised ineffective operational control over the line scanning activities. As a result, the ongoing intermittent pressurization defect was not formally recorded, the issues with the aircraft were not communicated to the AGAIR safety manager, and the hazardous practice of operating the aircraft at a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply, was allowed to continue. (Safety issue)
- The AGAIR head of flying operations did not communicate critical safety information about the known intermittent pressurization defect on VH-HPY when they were phoned by air traffic control about concerns that the pilot may be impacted by hypoxia.
- After being told by the pilot that operations were normal, controllers likely reduced their vigilance about hypoxia and did not re-identify the possibility of hypoxia during the subsequent progressive deterioration of the pilot’s speech.
Other factors that increased risk:
- AGAIR Gulfstream 690 and 695 aircraft were operated with known defects without being recorded on the aircraft’s maintenance releases, likely as a routine practice. For VH-HPY, the absence of documented historical information limited the ability to assess the operational impact of the pressurization defect and the effectiveness of maintenance rectification activities. (Safety issue)
- The Airservices Australia hypoxic pilot emergency checklist did not contain guidance on ceasing the emergency response. This increased the risk that a controller may inappropriately downgrade the emergency response during a developing hypoxic scenario. (Safety issue)
Other finding:
- A 2019 Civil Aviation Safety Authority surveillance event of AGAIR triggered by concerns reported by an AGAIR pilot, including delayed rectification of airworthiness issues, did not include a crosscheck of maintenance releases against the aircraft logbooks, which limited the surveillance team’s ability to determine whether any non-reporting and improper deferral of defects had been taking place at that time.

Final Report:

HB-GHK

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Crash of a Rockwell Gulfstream 695A Jetprop 1000 in Puerto López: 8 killed

Date & Time: Feb 19, 2001

Type of aircraft:

Rockwell Gulfstream 695A Jetprop 1000

Operator:

Registration:

EJC-114

Flight Phase:

Landing (descent or approach)

Flight Type:

Military

Survivors:

Site:

Airport (less than 10 km from airport)

MSN:

695-96083

YOM:

1985

Location:

Puerto López

Crash of a Rockwell Gulfstream 695A Jetprop 1000 in Boca Raton: 3 killed

Date & Time: Jan 21, 1998 at 1534 LT

Type of aircraft:

Rockwell Gulfstream 695A Jetprop 1000

Operator:

Airplanes of Boca

Registration:

N269M

Flight Phase:

Takeoff (climb)

Flight Type:

Private

Survivors:

Site:

Plain, Valley

Schedule:

Boca Raton - Lawrenceville

MSN:

695-96098

YOM:

1985

Location:

Boca Raton

Florida

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1606

Captain / Total hours on type:

843.00

Aircraft flight hours:

3274

Circumstances:

The pilot had received a weather briefing and was aware of the weather conditions west and north of the airport. The pilot was issued the flight clearance as filed, and was assigned an initial altitude of 2000 feet. Approximately five minutes into the flight, the air traffic controller questioned the pilot concerning the assigned heading. The controller stated that the pilot 'sounded extremely strained' and replied, 'N269M is in trouble.' Radar altitude data showed a rapid loss of altitude for N269M; the last radar altitude data showed the flight at 2800 feet. The airplane collided with the ground in a nose low attitude. Weather radar data from the Miami Weather Surveillance Radar-1988, Doppler (WSR-88D) showed a large, intense convective cell just west of Boca Raton between 1530:15 and 1535:57. Moderate to very heavy rain showers were associated with the convective activity. A review of the radar data showed that N269M was 3.5 to 4.0 miles north of the core of the large convective cell.

Probable cause:

The pilot flew into known convective meteorological conditions and lost control of the airplane. Factors were low clouds, and moderate to heavy rain.

Crash of a Rockwell Gulfstream 695A Jetprop 1000 in Llanos del Yarí: 7 killed

Date & Time: Mar 21, 1990

Type of aircraft:

Rockwell Gulfstream 695A Jetprop 1000

Operator:

Aerocauca Colombia - Aerovias del Cauca

Registration:

HK-3278

Flight Phase:

Flight

Flight Type:

Test

Survivors:

Site:

Mountains

MSN:

695-96073

YOM:

1984

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The twin engine aircraft was carrying five mechanics and two pilots and was completing a post maintenance test flight. In unknown circumstances, it struck the slope of a mountain near Llanos del Yarí. All seven occupants were killed.

Crash of a Rockwell Gulfstream 695A Jetprop 1000 near San Rafael: 3 killed

Date & Time: Jun 13, 1988

Type of aircraft:

Rockwell Gulfstream 695A Jetprop 1000

Operator:

Registration:

HK-3390

Flight Phase:

Flight

Flight Type:

Illegal (smuggling)

Survivors:

Site:

Desert

MSN:

695-96047

YOM:

1982

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The twin engine aircraft departed Bogotá-Guaymaral Airport on an illegal flight to the US via Mexico, carrying one passenger and two pilots. In unknown circumstances, the aircraft crashed in a desert area located near the village of San Rafael, Coahuila. The aircraft was destroyed and all three occupants were killed. On board was found a load of 780 kilos of cocaine. At the time of the accident, the registration on the aircraft was XC-NCL while its real registration was HK-3390.

Crash of a Rockwell Gulfstream 695A Jetprop 1000 in Checotah: 2 killed

Date & Time: Oct 9, 1984 at 1140 LT

Type of aircraft:

Rockwell Gulfstream 695A Jetprop 1000

Operator:

Registration:

N81502

Flight Phase:

Flight

Flight Type:

Test

Survivors:

Site:

Plain, Valley

Schedule:

Bethany - Bethany

MSN:

695-96000

YOM:

1981

Location:

Checotah

Oklahoma

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11098

Captain / Total hours on type:

447.00

Aircraft flight hours:

778

Circumstances:

The pilot allowed the aircraft to stall at an altitude which was too low to effect recovery before ground impact occurred. He was in the process of performing VMC test and maximum performance single engine climbs during the test flight. Witness description of the aircrafts movements at the beginning of the accident sequence suggests that the VMC test were in progress immediately before the accident occurred. Both occupants were killed.

Probable cause:

Occurrence #1: loss of control - in flight
Phase of operation: maneuvering
Findings
1. (c) airspeed - not maintained - pilot in command
2. (c) stall/spin - inadvertent - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled

Final Report:

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