The 2014 fatal crash of a Gulfstream IV at Hanscom Field in Bedford, Mass., and a subsequent NBAA report finding an 18-percent non-compliance rate with manufacturer-required pre-takeoff flight-control checks are warnings that the business aviation industry needs to focus on leadership and professionalism, industry experts say.
“The tragic GIV accident at Bedford, Mass., on May 31, 2014, provided ample stimulus to probe more deeply into business aviation procedural non-compliance,” NBAA said in the safety report released in September. “It is equally disturbing that the data highlights a lack of professional discipline among some crews in not accomplishing manufacturer-directed checklists—particularly items critical to safety of flight.”
In the 2014 Hanscom Field accident, the NTSB found that the crew did not perform a flight-control check before takeoff, leaving it unaware that the gust lock was engaged. The aircraft crashed on takeoff and all seven aboard died in the accident. The NTSB investigation further revealed that the flight crew failed to complete flight control checks on 98 percent of the previous 175 takeoffs in the aircraft involved in the accident.
As a result of the findings, the NTSB recommended that NBAA work with industry on a study of the extent of non-compliance with pre-takeoff flight checks. NBAA subsequently assembled a team comprising business aviation Flight Operational Quality Assurance (FOQA) groups and associated vendors, NBAA staff, NBAA Safety Committee members and other safety experts to study compliance within the business aviation industry.
The team gathered and analyzed de-identified data from business aviation FOQA programs, releasing its findings in a report titled “Business Aviation Compliance with Manufacturer-Required Flight Control Checks Before Takeoff.” The data covers 143,756 business aviation flights between Jan. 1, 2013, and Dec. 31, 2015.
The report revealed that 16 percent of those flights took off with only a partial check of flight controls, meaning that not all control surfaces were found to be checked. Further, there was no flight control check conducted on 2,923 flights, or 2 percent. A valid flight-control check was defined in the report as “full-deflection control surface movement in each direction (i.e. stop to stop).”
The team chose “stop to stop” as its measure of full deflection “to eliminate any judgment by the industry in determining what a full check is/was,” noted Mark Larsen, senior manager of safety and flight operations for NBAA. “For example, does 75 percent of a full deflection count as a completed check, or is 65 percent OK? Rather than try to artificially set a limit, we elected to use full deflection as we could not know if a movement less than a full check was as a result of intentional crew action to move the surface, or was an inadvertent movement.” Further, many OEMs specify that a flight control check is over the full range of motion, he added.
The team also reviewed when the noncompliance incidents occurred to see if the initial facts in the NTSB preliminary report or the findings in the NTSB final report had any effect. In fact, the incidence of partial checks dropped noticeably the month before release of the final report, but gradually climbed back to the average rate. The results were similar for cases involving no checks. This level of non-compliance dropped to 1 percent for five months after the accident occurred, but returned to the average warning noncompliance rate of 2 percent by the end of December last year, or three months after the NTSB released the final accident report.Safety
Starts at the Top
The NBAA-assembled team made several recommendations as a result of the report. For operators, the report stresses the need to ensure that a standard operating procedure is in place to address manufacturer-required flight-control checks before takeoff. The report also recommends operators establish flight-data monitoring programs. NBAA notes that only one in a hundred operators currently has such a program in place. The report is urging operators to participate in safety-data collections such as the FAA’s Aviation Safety Information Analysis and Sharing (ASIAS) system.
The report recommends that Part 142 training centers emphasize the importance of these pre-flight checks and that manufacturers provide clear requirements and procedures. NBAA, meanwhile, is tasked with facilitating a council of data-collection/-sharing experts to inform and guide the business aviation community.
“As perplexing as it is that a highly experienced crew could attempt a takeoff with the gust lock engaged, the data also reveals similar challenges across a variety of aircraft and operators,” said NBAA president and CEO Ed Bolen. “This report should further raise awareness within the business aviation community that complacency and lack of procedural discipline have no place in our profession.”
“The report is sounding the alarm that we have, and probably have had for a long time, a leadership deficit in our industry,” added Sonnie Bates, who recently joined safety specialist Baldwin Aviation as v-p and COO after directing the IS-BAO program for IBAC for five years. The leadership training must involve the highest levels of the companies—from CEOs to aviation directors to crews—to build the communications skills and facilitate a culture where professionalism can be emphasized, Bates said.
The leadership must step forward and say, “I am not seeing professionalism,” he said. “That is the other dimension of safety. We have the tools and we have processes and procedures. We need tools, but we need the attitude of safety.”
Professionalism, he added, has a “direct connection to complacency. A strong professional code is going to combat complacency.” Bates noted that this goes back to pre-takeoff flight control checks. “When you see an absence of flight control checks, that’s screaming, ‘I’m complacent.’ It’s also screaming, ‘I’m not professional.’ To be effective in safety, you have to tell the operator, I want professionalism.”
Greg Marshall, v-p of global programs for the Flight Safety Foundation (FSF), agrees that the Bedford accident “highlighted the view…that intentional noncompliance is a problem.” Marshall, however, stresses that it is not a widespread problem; many operators, particularly larger organizations, have mature systems that have strong safety management systems in place and “great demonstrations of safety leadership.”
But others struggle with complacency, and that can be found throughout some organizations. “This goes back to safety leadership,” he further agreed. “If you don’t have appropriate safety leadership, disciplines and processes established throughout an organization—and it must come from the top and permeate all levels of an organization—then you will continue to see incidences of complacency. Non-compliance will arise.”
Marshall, who noted that this was a topic recently discussed by the FSF’s Business Advisory Committee, added that education and training is a way to reinforce leadership and combat complacency. The business aviation community must reach out to emphasize leadership skills, particularly with start-up organizations, he said. “If you don’t have safety leadership in an organization, then the organization is set up to fail,” he said.