NBAA Report: Flight Crews Skip Checks

[In The News]

A study conducted by NBAA has found that 15 percent of flights in business jets begin without a complete flight-control check, the association reported last week. The NTSB suggested a need for the study after its investigation of a fatal 2014 accident involving a Gulfstream G-IV at Hanscom Field, in Bedford, Mass. The safety board found the crew had not performed a flight-control check before takeoff, and as a result, they had no way of knowing the aircraft's gust lock was engaged. The jet ran off the runway and caught fire, killing all seven on board.

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[Don Hudson]

 

A Gulfstream Crash Triggers A Finding Of Unsettling Data

 

The data points to a systemic problem

Nov 25, 2016 William Garvey | Aviation Week & Space Technology

An easily preventable takeoff accident that turned a Gulfstream into a deadly fireball has led to revelations of systemic safety lapses within business aviation. 

On May 31, 2014, Lewis Katz, a wealthy businessman, philanthropist and co-owner of The Philadelphia Inquirer, flew with guests in his Gulfstream IV from Atlantic City, New Jersey, to Hanscom Field outside Boston to attend an education fundraiser hosted by historian Doris Kearns Goodwin, a longtime friend. Once the event ended, Katz’s party returned to Hanscom for the short flight home. Unfortunately, the Gulfstream never left the ground.

Rather, the aircraft accelerated down Runway 11, reaching a speed of 162 kt. before the pilots attempted to abort the takeoff. However, only 2,337 ft. remained, not enough room to stop. The aircraft zoomed off the pavement, blasted through a perimeter fence, crashed into a ravine and erupted into flames. Katz, three guests, a flight attendant and both pilots died. 

The NTSB determined that the aircraft had failed to take off because the gust lock was engaged, preventing flight. Furthermore, the pilots had failed to follow a checklist that would have flagged that fact and to perform a preflight control check to confirm the ailerons, elevator and rudder were movable, a procedure that is supposed to occur before every flight.

There was more. NTSB investigators downloaded data from the Gulfstream’s quick access recorder (QAR), which stores information from the aircraft’s flight data recorder, and determined that the pilots had neglected to perform complete flight-control checks before 98% of their previous 175 takeoffs. So their behavior was habitual, not an anomaly.

What made these discoveries so unsettling was that the pilots were seasoned veterans who had flown together for years, knew their airplane well and trained regularly. 

In addition, the flight operation had voluntarily undergone reviews by auditors and had been found to comply with the International Standard for Business Aircraft Operations, considered the gold standard of safety.  

Alluding to the disconnect between the pilots’ operational appearance and actual practice, NTSB Member Robert Sumwalt noted, “There is a saying, ‘You can fool the auditors, but never fool yourself.’ These crewmembers made the critical mistake of attempting to fool both.”

Among the NTSB’s several recommendations stemming from the investigation was one suggesting the National Business Aviation Association (NBAA) work with corporate operators in flight operational quality assurance (FOQA) groups to analyze existing data and determine how widespread the failure to conduct preflight control checks might be. 

By way of background, a growing number of business aircraft are equipped with QARs, and some of their operators—a relative few—pool their deidentified data through service providers to help spot operational weaknesses and trends. 

With the cooperation of these and other sources, an NBAA-led working group analyzed 143,756 flights between Jan. 1, 2013, and Dec. 31, 2015, conducted by 379 business aircraft. What the team discovered was that the pilots involved in those flights performed only partial flight-control checks before 15.62% of the takeoffs and performed no checks on 2.03%, which means 2,923 flights proceeded in the same cursory manner as the Katz Gulfstream. 

Upon releasing its report in September 2016, NBAA President and CEO Ed Bolen described the findings of the Hanscom accident and subsequent FOQA industry data as “perplexing” and added that “complacency and lack of procedural discipline have no place in our profession.” Since it can be argued that those FOQA groups include some of the most safety-conscious operators in the business, one is left to wonder how many business aircraft take to the air after a partial control check—or none at all. 

The NBAA wants more operators to establish a flight-data-monitoring program—currently only 1% of them have one—and plans to create a council of data-collection/sharing experts to identify issues and disseminate safety alerts based on that body of information. Considering the evidence, those moves are sensible and timely.