The flight crew of a Gulfstream G-IV business jet that crashed on takeoff from Laurence G. Hanscom Field in Bedford, Massachusetts, last year failed to perform a flight control check, resulting in critical controls still being locked during the takeoff attempt, the National Transportation Safety Board said.
The crew delayed rejecting the takeoff after becoming aware of the problem, the NTSB said in a report that raised “troubling questions” about the pilots’ “long-term pattern of non-compliance” with standard operating procedures.
The two pilots, a flight attendant, and four passengers died when the Gulfstream G-IV taking off from the Boston-area airport overran the runway paved area, went through a fence, and crashed in a ravine at 9:40 p.m. May 31, 2014. A fire ensued.
“This investigation highlights the importance of following standard operating procedures and underscores the significance of procedural compliance,” said NTSB Vice Chairman T. Bella Dinh-Zarr at the Sept. 9 NTSB board meeting where the accident’s probable cause was announced. “Complacency does not have a place in the cockpit of any aircraft.”
The NTSB said the pilots, who had flown together for 12 years, failed to disengage the airplane’s gust lock system during the engine-start process. The flight data recorder and the cockpit voice recorder indicated that neither “had performed a basic flight control check that would have alerted them to the locked flight controls. A review of the flight crew’s previous 175 flights revealed that the pilots had performed complete preflight control checks on only two of them. The flight crew’s habitual noncompliance with checklists was a contributing factor to the accident.”
“This investigation raises troubling questions about how a long-term pattern of noncompliance was allowed to develop for this very experienced flight crew,” Dinh-Zarr said. “More importantly, our investigation asks whether this is a prevalent practice in the business aviation community, and how we can prevent these accidents from happening again.”
Contributing factors were “Gulfstream’s failure to ensure that the gust lock system would prevent an attempted takeoff with the gust lock engaged and the FAA’s failure to detect this inadequacy during the G-IV’s certification.”
“Performance calculations demonstrated that the interlock mechanism did not perform as intended,” the NTSB said, noting that a retrofit should ensure compliance with the certification requirement that the gust lock system provide an “unmistakable warning” that it is still engaged during a takeoff.
“Some lessons in aviation are universal,” said George Perry, senior vice president of the AOPA Air Safety Institute. “Airplanes need three basic things to fly: They must have fully functioning engine(s), be properly configured, and have working flight controls. The NTSB report highlights the fact that two of the three of these basic tenets were not adhered to.”
The report also made clear “that the pilots did not have adequate procedures in place to ensure the airplane was fit to fly, and they ignored warning signs that should have clued them in to that fact. Bottom line: A cockpit is no place for complacency. When in doubt there is no doubt. Stop and figure it out,” he said.
The NTSB issued five safety recommendations to the FAA, the International Business Aviation Council, and the National Business Aviation Association as a result of the accident.
Recommendations addressed to the FAA call for increased emphasis on replacing non-frangible fittings on objects along runway extended center lines with frangible fittings; the retrofitting of G-IV systems after Gulfstream modifies the gust lock/throttle lever interlock; and the development and issuance of “guidance on the appropriate use and limitations of engineering drawings” to show compliance with certification requirements.
The NTSB called on the International Business Aviation Council to amend its auditing standards to “include verifying that operators are complying with best practices for checklist execution, including the use of the challenge-verification-response format whenever possible.”
The agency recommended that the National Business Aviation Association work with quality assurance groups to “analyze existing data for non-compliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.”
The NTSB has also developed a Safety Alert for all pilots on the importance of following standard operating procedures and using checklists, the agency said.
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