NTSB Factual Report

HISTORY OF FLIGHT

On October 30, 1996, at 1300 central standard time, a Gulfstream G-IV, N23AC, registered to Alberto Culver USA, Inc., collided with the terrain following a loss of control during a takeoff ground roll on runway 34 (5,137' x 100') at the Palwaukee Municipal Airport, Wheeling, Illinois. The 14 CFR Part 91 corporate flight was departing in visual meteorological conditions with an IFR flight plan on file. The captain, co-pilot, flight attendant, and the sole passenger on board were fatally injured. The airplane was destroyed by impact forces and a post impact fire. The intended destination of the flight was Burbank, California.

The accident flight was operated under the terms of an Interchange Agreement between the Alberto-Culver Corporation and the Aon Corporation. The interchange agreement provided for each company to lease their respective G-IV airplanes to the other company. In regards to the accident flight, the Aon Corporation had requested the use of the Alberto-Culver airplane. Aon furnished one pilot making the flight a mixed crew operation. The pilots of the accident flight were notified of the flight approximately seven days prior to the scheduled departure.

N23AC was scheduled to depart Palwaukee Municipal Airport at 1300 CST on October 30, 1996, for the Burbank-Glendale-Pasadena Airport with a return to Palwaukee the following day. The flight plan was filed by the pilot from Alberto-Culver who occupied the right cockpit seat for departure. Although the aircraft was operated by Alberto-Culver, the pilot from Alberto-Culver listed himself as the co-pilot for the first day of the trip from the Palwaukee Municipal Airport to the Burbank-Glendale-Pasadena Airport. He listed himself as the pilot-in-command on the flight plan for the return flight to Palwaukee Municipal Airport on the following day. The pilot from the Aon occupied the left cockpit seat for the accident flight and was listed on the flight plan as the pilot-in-command. [For the remainder of the report, the pilot from Alberto-Culver will be identified as the pilot not flying (PNF) and the AON pilot as the pilot-in-command (PIC)].

Prior to departure N23AC was parked on the ramp adjacent to hangar #12. A preflight inspection of the airplane was accomplished by an Alberto-Culver aircraft technician. The PNF was also observed performing a preflight inspection of the airplane. The pilots of N23AC received their ATC clearance from clearance delivery at 1242.

The PNF called for and received taxi clearance at 1254. N23AC was instructed to taxi on Mike but hold short of runway 34. The flightcrew acknowledged the hold short instructions and began to taxi. At 1257 the local controller who was also working the ground control position cleared N23AC to back taxi and expedite down the active runway to the departure pad. N23AC taxied southeast on runway 16-34 and at 1258 the local controller asked them if they would be ready at the end. N23AC replied they would be ready at the end of the runway. At 1259, the local controller said, "Two Three Alpha Charlie, three four, expedite departure, turn left heading two niner zero, cleared for takeoff."

At 1259, the PNF replied, "Cleared for takeoff, heading two nine zero, we'll hurry it out." The pilots applied power and began the takeoff roll on runway 34. Passing the intersection of 12L-30R, tire tracks indicated the airplane began to diverge to the left of runway heading. As the airplane continued to diverge from the centerline of the runway the nose gear tire tracks ended; however, the main gear tire tracks continued into the grass bordering the runway.

The airplane remained off the runway and continued across the grass and across taxiways, Yankee, Mike, and November. Landing gear, flight control surfaces, and other airplane components separated once N23AC left the runway. The airplane slid on its belly roughly parallel with the runway and momentarily got airborne when it launched off a small berm near the departure end of runway 34. Once airborne the airplane flew over Hintz Road, contacted the embankment along Wolf Road, and skipped over Wolf Road. It slid across a field and stream gully and came to rest on the edge of an apartment complex parking lot where the airplane was consumed by fire. Both pilots, the flight attendant, and passenger perished as a result of the accident and subsequent fire.

WITNESS STATEMENTS

The Alberto-Culver aircraft technician who performed a pre-flight inspection of the airplane reported that he was positioned on the ramp forward of the airplane during engine start and initial taxi. He stated he observed the control check and the engine start and everything appeared normal. There were no unusual sounds, smoke, or other abnormal indications associated with the airplane. The brakes, gear, control surfaces, and engines all appeared to operate normally.

While N23AC was taxiing for takeoff, a Falcon 900 landed on runway 34. The pilots from the Falcon 900 reported that after they stopped on the runway, they back taxied before turning off at runway 30. The pilots observed the G-IV and reported that everything on the G-IV looked normal. They reported the thrust reversers were stowed, the tires looked normal, and the taxi path was straight. There was no white or black smoke coming from the engines.

A co-pilot of a Falcon 10 was standing on an aircraft ramp on the west side of runway 34. He reported that the G-IV's engine noise was normal during takeoff. He reported that the spool up was normal and that he heard no reduction in engine noise.

An Aon aircraft technician had assisted the Aon executive in boarding the aircraft. He reported that he observed N23AC back taxi to the end of runway 34, turn around, and without holding short, start its takeoff roll. He reported the engine spool-up and acceleration were normal and that the auto-throttles were engaged. He saw the aircraft go off the runway and continue paralleling runway 34 until it was out of his field of view, shedding aircraft parts in the process. The aircraft was on its belly with the nose off the ground, and the engines were running at full power. He did not hear a power reduction.

An aircraft line serviceman observed the main landing gears separate from the aircraft as it continued on its path across the ground. He reported, "...I came out [and] the left main was gone and [the] left wing was dragging on the ground. Two or three seconds later the right main came off. (But all this time the nose wheel never hit the ground.)"

The air traffic controller who had been working local and ground control for 10 to 15 minutes prior to the accident viewed parts of the accident sequence from his position in the tower cab. He reported seeing N23AC begin its takeoff roll, but did not see it departing the runway since he was observing another aircraft at the time. He next saw N23AC as it was sliding on its belly in the grass. He reported that it seemed to decelerate and then accelerate at full power.

A second air traffic controller who was in the tower reported seeing N23AC become airborne and exploding near the north boundary of the field. He saw a fireball encompass the aircraft. He did not recall if the aircraft had been yawing.

An airport employee witnessed the accident from the departure end of runway 34. He had been inspecting the approach lighting system for runway 16 from outside the airport fence, and he was looking down the runway when the aircraft started its takeoff roll. He witnessed the airplane depart the runway, shedding aircraft parts as it passed taxiways Mike and November. He reported that after the aircraft passed taxiway November, the aircraft was turned 2/3 to the right until it hit the berm near the departure end of runway 34. He reported the airplane became airborne and it started yawing back to the left. The back end of the airplane exploded before it departed the airport boundary. He reported that it made it over Hintz Road and the mid-section impacted the curb area of Wolf Road.

A witness reported seeing the airplane on fire. He reported that, "...it appeared the fire was coming from the wing tanks and from the left engine. The angle of ascent was still at a 45 degree attitude and the plane appeared to be a[t] full throttle. At that point the plane exploded [I] think the left engine blew or the fuel tanks and the entire airplane was engulfed in flame[s]."

A witness who observed N23AC from the Airport Administration Office reported seeing a "...white mist-vapor..." trailing the wing. He additionally reported, "The aircraft was in a nose high attitude and appeared to gain about 20 ft of altitude over Hintz Road. At the very next instant a huge explosion erupted... . Black smoke engulfed the aircraft."

A witness who was traveling eastbound on Hintz Road reported seeing, "Large amount of orange and yellow flame[s] and black smoke coming from the underside of the jet on the pilot's side near where the wing meets the fuselage." (See Witness Group Chairman's Factual Report)

PERSONNEL INFORMATION

Both crewmembers were certificated in accordance with Federal Aviation Administration (FAA) certification requirements. No accidents, violations or other enforcement actions were recorded for either crewmember in the Federal Aviation Administration records reviewed.

Pilot in Command (PIC)

The PIC, born January 7, 1943, was hired by Aon Corporation in May 1989. The following background information concerning the PIC was reconstructed from available documents. The PIC held an Airline Transport Pilot certificate with Airplane Multiengine Land and Commercial privileges and Airplane Single Engine Land ratings. The PIC possessed a 2nd Class Medical Certificate, dated July 16, 1996. His medical certificate had the limitation: "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision." Co-workers stated the PIC customarily wore glasses, however, it could not be determined if he was wearing glasses at the time of the accident.

A copy of the PIC's resume, undated, which was found in the accident aircraft listed his flight times as follows:

Total Time: 17,086 hours

Instrument: 14,658 hours

P.I.C.: 16,812 hours

S.I.C.: 274 hours

Multi-Engine: 16,558 hours

Jet: 6,691 hours

G-IV: 496 hours

The PIC's most current ground training, flight training and flight checks according to Aon and Flight Safety International records were as follows:

October 21-24, 1996: Flight Safety G-IV Pilot Recurrent Ground Instruction

October 22-24, 1996: Flight Safety G-IV Simulator Flight Training

Interviews were conducted with associates who had flown with the PIC or had observed his flight tendencies. The characterization that emerged as a result of the interviews indicated that the PIC was a very experienced pilot who displayed good "stick and rudder" piloting skills in the Citation and Gulfstream IV. The PIC had difficulty with the Flight Management System (FMS) and was not comfortable with the "glass cockpit" procedures. With a "laid back" and quiet personality, he tended to defer to the pilot with more expertise or knowledge, whether that pilot was flying right or left seat. He tended not to initiate checklists and did not verbalize aborted takeoff procedures during pre-takeoff briefings. The PIC tended to unload the nose wheel on the G-IV during takeoff to make it easier on the airplane on rough runways.

The PIC had successfully completed recurrent G-IV training on October 24, 1996. Crew Resource Management (CRM) had been emphasized during the training since the PIC had been described as being a "little weak in that area." An instructor reported that the PIC was not very assertive, although he possessed good natural piloting techniques.

Pilot not flying (PNF)

The PNF, born on January 17, 1946, was hired by Alberto-Culver on November 19, 1994. He held an Airline Transport Pilot certificate with Airplane Multiengine Land and Commercial privileges and Airplane Single Engine Land ratings. The PNF possessed a 1st Class Medical Certificate, dated September 3, 1996. His medical certificate had the limitation: "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision while exercising the privileges of his airman's certificate." Co-workers stated the PNF customarily wore glasses; however, it could not be determined if he was wearing glasses at the time of the accident.

Flight times reconstructed from the PNF's pre-Alberto-Culver employment resume and segments of his logbook were as follows:

Total Time 12,595.1 hours

P.I.C. 9,514.4 hours

G-IV 2,281.4 hours

G-III 1,100.0 hours

G-II 1,405.0 hours

Falcon 20 1,550.0 hours

Grumman E2 1,680.0 hours

The PNF's most current ground training, flight training, and flight checks according to his logbooks and Alberto-Culver records were as follows:

June 3-6, 1996: Simuflight G-IV Pilot Recurrent Ground Instruction

June 4-6, 1996: Simuflight G-IV Simulator Flight Training

June 7, 1996: Simuflight G-IV, Simulator L.O.F.T.

The PNF had been a pilot on the Flight Operations staff of Gulfstream Aerospace, Inc., from May 1983 to August 1985. He had flown the G-II, G-III, and the G-IV while working for Gulfstream.

Interviews were conducted with associates who had flown with the PNF or had observed his flight tendencies. The PNF was described as an excellent airman with very good systems knowledge of the G-IV. He was described as being quiet and professional, but not an assertive, outgoing person. He was comfortable with being the pilot-in-command when he was assigned that position. He made decisions and initiated checklists. As a co-pliot, the PNF was described as someone who would "respect the left seat," and not one to jump in and "take over the airplane."

The PNF had successfully completed recurrent G-IV training on June 7, 1996. He was described by an instructor pilot as being very good at procedures. He would initiate corrective actions to emergencies and did not have to be prompted. He was identified as one of the top 30 pilots the instructor pilot had known.

The PNF's logbook listed at least three previous occasions when he and the PIC comprised the same G-IV flight crew; November 22, 1995, March 10, 1996 and August 11, 1996. (See NTSB Operations Group Chairman's Report) Alberto-Culver aircraft logs indicate that the PNF and PIC had comprised the same G-IV flight crew on April 19 and 22nd, 1996, and also on August 12, 1996.

FLIGHT OPERATIONS INFORMATION

Interchange Agreement and Mixed Crews

Alberto-Culver and Aon leased their respective G-IV's to each other under an Interchange Agreement authorized under FAA regulation 14 CFR 91.501 (c) (2). The Interchange Agreement stipulated that each company would maintain operational control of its respective airplane. Due to operational necessity, mixed crews were occasionally utilized, which meant that a pilot from each company served together and made up the flight crew for the operation. However, there was no mention made in the Interchange Agreement concerning mixed crews, nor was there any reference to mixed crew operations in either company's operations manual. Furthermore, in the event of a mixed crew operation, there were no written or otherwise formal procedures for integrating the differences in company operating procedures.

Airplane and Company Differences

The Alberto-Culver G-IV airplane, N23AC and the Aon G-IV, N18AN, were not identical in the layout of their cockpits. The respective companies also had different operating procedures for some of the airplane components.

Both airplanes had a switch which could disable all nose wheel steering. This switch was commonly called the "Nose Wheel Steering" switch. The "Nose Wheel Steering" switch was a production switch and installed on every G-IV produced. It was located on the nose wheel steering control panel forward of the tiller on the left console. The switch was guarded by a red guard and was in the "ON" position when the red guard was

NTSB Probable Cause

failure of the pilot-in-command (PIC) to maintain directional control of the airplane during the takeoff roll in a gusty crosswind, his failure to abort the takeoff, and failure of the copilot to adequately monitor and/or take sufficient remedial action to help avoid the occurrence. Factors relating to the accident included the gusty crosswind condition, the drainage ditch, the flight crew's inadequate preflight, the Nose Wheel Steering Control Select Switch in the "Handwheel Only" position, and the lack of standardization of the two companies' operations manuals and Interchage Agreement.