Aircraft Accident/Incident Report

Holland, Michigan 49423
Saturday, October 9, 1999 15:10 EDT

NTSB Narrative Summary Released at Completion of Accident

The flight experienced a series of pitch oscillations while on descent to an assigned altitude of 11,000 feet mean sea level(msl). The flight attendant was seriously injured. The Captain reported that when he was at about 11,400 feet msl, it appeared the airplane was going to descend below the assigned altitude. The First Officer, who was the flying pilot in the left seat, reported that he pulled back on the airplane's yoke to initiate the level off without disengaging the autopilot. He reported that when he relaxed the back pressure on the yoke, the airplane pitched nose down violently and a series of three to four pitch oscillations occurred before the airplane was brought under control. The aircraft load factors reached magnitudes between +3.3g and -1.2 g. The flight attendant was not wearing a seat belt at the time of the incident. The inspection of the airplane revealed no pre-existing anomalies. Neither the autopilot's pilot manual nor the airplane's flight manual contained a Warning, Caution, or Note that explicitly stated not to manually override the autopilot. On October 18, 1999, Falcon Aviation issued Newsflash 52 that notified operators not to manually apply control yoke forces in an attempt to control the aircraft when the autopilot is engaged.

NTSB Probable Cause Narrative

The copilot's improper use of the autopilot system while leveling the flight from descent, resulting in an inadvertent pilot-induced pitch oscillation of the airplane. A factor was the flight attendant not wearing a seat belt at the time of the occurrence.

Event Information

Type of Event Accident
Event Date 10/9/1999
Event Day of the Week Saturday
Time of Event 1510
Event Time Zone Eastern Daylight Time
Event City HOLLAND
Event State MICHIGAN
Event Country --
Zipcode of the event site 49423
Event Date Year 1999
Event Date Month 10
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1453 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 160
Weather Observation Facility ID BIV
Elevation of weather observation facility 689
Distance of event from weather observation facility (units?) 22
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height 1900
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 9
Air Temperature at event time (in degrees celsius) 19
Dew Point at event time (in degress fahrenheit) 16
Wind Direction (degrees magnetic) 140
Variable Wind Indicator Unknown
Wind Speed (knots) 5
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 4
Injury Total Serious 1
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 1569
NTSB Notification Source --
NTSB Notification Date Oct 11 1999 12:00AM
NTSB Notification Time 1603
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Jan 23 2001 9:33AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N523AC
NTSB Number CHI00FA006
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Dassault
Aircraft Model DA-900B
Aircraft Series Identifier DA-900B
Aircraft Serial Number 139
Certified Max Gross Weight 46500
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 15
Number of Engines 3
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Sep 30 1999 12:00AM
Airframe hours since last inspection 9
Airframe Hours 2701
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name AMWAY CORPORATION
Aircraft Owner Street Address 7575 EAST FULTON
Aircraft Owner City ADA
Aircraft Owner State MI
Aircraft Owner Country
Aircraft Owner Zipcode 49355
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Executive/Corporate
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code PDX
Departure City PORTLAND
Departure State OR
Departure Country
Departure Time 900
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code GRR
Destination City GRAND RAPIDS
Destination State MI
Destination Country
Specific Phase of Flight Descent
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 23 2001 11:29AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --