NTSB Docket Reveals Cockpit Warning Before GIV Crash

 - April 8, 2015, 1:10 PM
The flight crew of the Gulfstream GIV that crashed on May 31, 2014, in Bedford, Mass., received a "rudder limit" advisory (blue) message while on rollout, according to more than 800 pages of data released today by the NTSB. The aircraft overrran the runway after a failed takeoff, struck lighting and an antenna assembly and came to rest in a gully before being consumed by a post-crash fire, killing all seven on board. (Photo: Massachusetts State Police)

The flight crew of the Gulfstream GIV that crashed on May 31, 2014, in Bedford, Mass., received a "rudder limit advisory (blue) message" while on takeoff roll, according to more than 800 pages of data released today by the NTSB. The aircraft overrran the runway after a failed takeoff, struck lighting and an antenna assembly and came to rest in a gully before being consumed by a post-crash fire. All seven people aboard—including Philadelphia Inquirer co-owner Lewis Katz, the two pilots and a flight attendant—were killed.

According to the cockpit voice recorder transcript, during takeoff roll the copilot reported the "rudder limit" advisory message. The captain asked whether the copilot was using the rudders, to which the copilot responded, "No." A sound similar to a power increase followed, then the copilot reported “V1” and “rotate.” Within a second the captain repeatedly reported, “Lock is on,” and then, “I can’t stop it.” The aircraft reached 165 knots on takeoff roll but did not lift off the runway.

An NTSB preliminary accident report issued in June focused on the twinjet’s control wheel mechanical gust-lock system. “After the rotate callout, the cockpit voice recorder captured comments concerning aircraft control,” the report noted. Gulfstream IV study materials instruct pilots to shut down the engines and bleed hydraulic pressure to zero if the engine is inadvertently started with the gust lock engaged. However, a contract pilot who had flown with the crew reported that he knew of instances when the gust lock was engaged during engine start and pilots used the flight power shutoff handle to remove hydraulic pressure without following the recommended engine shutdown procedure. The contract pilot did not specify whether these instances involved the crew of the accident flight.

The contract pilot also reported that the captain conducted complete flight control checklists before each of their flights but did not use a formal item-by-item checklist. Data from a quick access recorder installed in the airplane involved in the accident revealed that out of 176 takeoffs, only two complete and 16 partial control checks were identified. There was none identified for the accident flight.