I first wrote about the crash of the Gulfstream IV that took the lives of seven people (among them David Katz, owner of the Philadelphia Inquirer) in August last year. The NTSB had issued a very preliminary report that raised questions about whether the crew had performed a routine pre-takeoff check of the flight controls and whether the failure to perform that routine check could have led to the accident. At the time, it was too early to reach any conclusions about what the crew had or had not done. But it led me to consider the implications of a possible lackadaisical attitude toward checklists and the dangers that poses to aviation safety, and I wrote about guarding against a culture of complacency.
On May 31, 2014, at about 9:40 p.m., the GIV crashed after a rejected takeoff at Hanscom Field (KBED) in Bedford, Mass. The aircraft was unable to stop and overran the runway, hitting approach lights and a localizer antenna, finally stopping in a ravine outside the airport perimeter fence. The post-impact fire killed all seven people on board: the two pilots, a flight attendant and four passengers. The aircraft was operated as a corporate flight under Part 91 and was returning to Atlantic City.
Now the NTSB report has been completed and the Board has issued its determination of probable cause. The NTSB concluded that the probable cause of this accident “was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked.”
While this probable-cause finding was not unexpected given the preliminary report, what was shocking was one of the contributing factors: “the flight crew’s habitual noncompliance with checklists.” (The other contributing factors are also significant: “Gulfstream Aerospace Corporation’s failure to ensure that the GIV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the GIV’s certification.”)
This was not a low-time crew perhaps inexperienced with the significance of checklist compliance. This was a senior and seasoned crew. The pilot-in-command, 44 years old, held an ATP certificate with single and multi-engine airplane ratings and type ratings for the BE-400, GII/III, Learjet and MU-300, as well as the GIV. At his last medical, about a month before the crash, he reported 11,250 hours. According to information in the NTSB accident file, the captain was “associated with the accident airplane owners for approximately 12 years, about 8.5 years in the GIV.”
The copilot, 61 years old, was an even more senior and experienced airman, reportedly with the airplane owners for 27 years. He held an ATP with single and multi-engine airplane ratings and type ratings for the GII/III, JetStar and GV, as well as the GIV. He also held a flight instructor certificate with single and multi-engine airplane, and instrument airplane ratings and an A&P mechanic certificate.
According to the report, the accident crew were familiar with flying together, they normally flew together, trading seats between flights as they were both qualified in the aircraft. The copilot on the accident flight served as the chief pilot and director of maintenance. He was not only a crewmember but also had management responsibilities for the operation and maintenance of the aircraft.
So how does this incredibly experienced, long-time crew end up with a habitual failure to comply with checklists? How does that happen? Checklists are the foundation of the standardization that preserves safety in aviation. They are particularly critical during taxi, takeoff and other high-stress activity when attention to detail is especially critical. It’s hard to imagine that a crew this senior was unaware of this. And yet the Board determined that during the accident flight, the crew failed to discuss checklists and failed to perform a flight control check. It further determined that the crew failed to perform complete flight control checks on almost all of their last 175 flights.
According to the NTSB: “The flight crewmembers’ total lack of discussion of checklists during the accident flight and the routine omission of complete flight control checks before 98 percent of their last 175 flights indicate that the flight crew did not routinely use the normal checklists or the optimal challenge-verification-response format. This lack of adherence to industry best practices involving the execution of normal checklists and other deficiencies in crew resource management eliminated the opportunity for the flight crewmembers to recognize that the gust lock handle was in the on position and delayed their detection of this error.” It seems that not only was this accident fully preventable by use of a routine checklist, but that the crew likely never used checklists, since the investigators found that the crew did not perform complete flight control checks on 171 earlier flights. I can’t imagine how heartbreaking that must be for the families and friends of the victims. Or what a sense of betrayal the aircraft owner’s family must feel for the complete dereliction of duty of their long-time crew.
A number of aircraft owners have taken this finding to heart, wondering whether they and their families are vulnerable to pilots who don’t perform their jobs properly, especially when it comes to critical items such as checking the flight controls. I know you can’t cite one accident to generalize about the professionalism of thousands of other corporate pilots. But that’s not what aircraft owners want to hear when they entrust their own lives and the lives of their families and friends to these pilots. They want to know how they can be absolutely assured that their pilots are complying with industry best practices when it comes to checklists in general and, crucially, pretakeoff control checks.
The Board makes two recommendations regarding requirements for flight control checks. First, it recommends the International Business Aviation Council “amend International Standard for Business Aircraft Operations 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.” And to NBAA it recommends: “Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, 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.”
These are certainly excellent recommendations but I would make one more: install video cameras in the cockpits of corporate aircraft that can be regularly reviewed to ensure that crews are properly complying with safety protocols, including checklists and flight control checks. While video cameras in the cockpits of airliners have been controversial with pilot unions, the NTSB has recommended their installation to aid in accident investigations. The same union issues do not apply to most corporate operations and are probably the most cost-effective way of assuring owners that their pilots are conforming to professional standards on their flights.
November 3, 2015 - 5:45pm
Very good article and excellent recommendations from the alphabet groups. I too wrote an opinion to the FAA within hours of viewing the first release of the accident site aerial photos. I have discussed this particular accident with other industry experts at the highest levels within Gov't and Corporate industry. Yes, the crew really fouled up here no denying that however, something else is missing: where was management? No business allows any particular division to operate autonomously, there are checks and balances everywhere to ferret out wrong doing of performance requirements. This accident is going to be the "Poster Child" of Corp aviation for a couple of decades and we are already responding predictably. This group, that group etc. We have become OVER QUALIFIED with all of the "Special" status of Titles and International standards, none of which prevented or revealed the crew behavior in the cockpit. The means to detect their shortcoming was installed in the aircraft and it was the source of the "Smoking Gun" cause of the accident. We do not need any more 'gadgets in the cockpit, why oh why are we not extracting FDR data as a matter of routine as an inhouse tool to support SMS, SOP and plain ol, Common Sense? There are many other flight crews that match this crew within the industry; they will change or die as this crew did. Its a matter of "attitude" not monitoring/recording equipment. Just posing a question: what if the GIV had a cockpit video recorder; it would not have made any difference now would it? If operators refuse to use the tools available to enforce the correct behavior all the cameras in the world will never fix this issue.
November 4, 2015 - 11:31am
An element I have seen as a possible contributor in some accidents is an inappropriate response to a developing emergency. In this case of the GIV gust lock accident, the delay in executing a reject when it became apparent a problem existed may have been key to the eventual overrun. So what could cause this inappropriate response? I offer that 'corporate culture' within a some small flight departments where every diversion from expected perfection is questioned and jobs are threatened can be a consideration in a case such as this. The thinking could be that there will be no need for explanation if the aircraft manages to struggle off the ground. There are other inappropriate actions that have contributed to a bad result such as the Sikorsky S-76C+ departing 34th Street Heliport where the aircraft settled into the East River and sank without floats being deployed even after the copilot reportedly asked whether the captain wanted to deploy them. The thinking might have been that a post flight explanation at destination would have been less damning than relating why the aircraft was floating in the river. The Gulfstream that touched a light standard while trying to land below minimums due to early morning fog at Hobby Houston on a mission to pick up former President George H. W. Bush could be given as another example of pressure to succeed. There are others, and I have seen little consideration of such a contributor in most accident investigations.
With respect to the absence of performing control checks; this reveals a total disregard for safety perhaps related to an over confidence in the equipment. Could anything within the systems of a Gulfstream ever fail or not be ready for the ensuing safe flight? Ice during cold operation, corrosion, wear, a control over-travel that occurred during positioning, and certainly a gust lock still deployed are several that justify the prudent action of completing the checks daily and/or after maintenance.
With respect to checklists; the tendency of performing some of the cockpit procedures without a disciplined use of checklists was likely revealed to their instructor during recurrency training in the simulator if they attended training together as a crew. I would expect the instructor to document in the crew's folder at minimum any failure to head the fundamentals that are stressed during such training to include CRM and the disciplined use of command and response checklist. As an aside, it should be the standard that crews bring their own operation's checklist with them for training to avoid an unfamiliarity excuse and that this checklist is kept in the trainer's records.
Lastly, I do not necessarily agree with comment (1) concerning the value of cockpit recorded video regarding the policing effect of it. I believe a CVR that cannot be erased for some period after a flight would serve the same purpose and be less intrusive. It would serve like a watchdog that encourages the crew to use the checklist on the chance someone may review the CVR periodically.