They’re the stuff of a strong safety culture…
Adhering to routine procedures is a necessary requirement for all aviators, regardless of hours logged or years employed as PIC. Even the most mundane trip flown by a highly experienced crew demands consistent use of checklists and SOPs, notes Jack Olcott.
While the factors that lead to an aircraft accident are many and varied, the NTSB offers perspectives that stimulate introspection. Each tragedy analyzed by the Board presents the opportunity to avoid a similar event, such as the loss of a Gulfstream G-IV during takeoff from Bedford, Massachusetts, the night of May 31, 2014.
The trip originated in Wilmington, Delaware with a deadhead leg to Atlantic City, New Jersey to enplane four passengers for a flight to Bedford, a few miles west of Boston where the passengers attended a charity event. Both pilots were Airline Transport Pilot rated, had thousands of flight hours, recent G-IV recurrent training and authorization to fly as the Gulfstream’s PIC, and they had flown together extensively as co-captains.
Upon returning from dinner in Boston, the passengers boarded the G-IV and the crew initiated the departure routine, which involved five specific checklists to be completed before takeoff—Before Starting Engines, Starting Engines, After Starting Engines, Taxi/Before Takeoff, and Lineup.
While parked at Bedford, the aircraft’s internal system for locking the flight controls to prevent movement in gusts and to restrict throttle movement was engaged per normal procedures. The ‘Before Starting Engine’ checklist calls for disengaging the gust lock, and the ‘After Starting Engine’ checklist specifies full control movement to confirm that all yoke and rudder motion is free and correctly oriented.
As the aircraft turned onto the runway for takeoff, the words RUDDER LIMIT appeared on the aircraft’s Engine Instrument and Crew Advisory System display, and the Cockpit Voice Recorder captured conversation between the pilots regarding the “rudder limit light” activating, which indicated that the rudder was restricted from reaching its commanded position.
After taxing into position with a takeoff clearance, the PIC advanced the G-IV’s throttles manually but normal takeoff power was not achieved.
To correct that situation, the captain engaged the aircraft’s auto-throttle, which resulted in the aircraft’s engine pressure ratios (EPR) increasing from 1.4 to 1.6 and then stabilizing at 1.53 but less than normal takeoff power.
Procedures presented in the G-IV’s Airplane Flight Manual call for the captain to confirm, upon reaching 60 KIAS during the takeoff roll, that the elevators are free and the control yoke has moved aft from the full forward to neutral position. According to FDR information, the elevator position remained constant at about 13-degrees trailing edge down.
Based upon analysis, the NTSB stated that none of required control checks were conducted and movement of control surfaces was restricted during the aircraft’s taxi and takeoff attempt.
The Second-in-Command gave the proper callout at 80 KIAS and then said “V1” followed four seconds later by “Vr”. Almost immediately thereafter the PIC said “(steer) lock is on”, and then repeated that statement six time over the next 12.7 seconds. An abort was initiated less than five seconds later, but the aircraft’s ground speed was 162 Knots 10 seconds after the call to rotate, and less than 1,400 feet of KBED’s 7,011 foot-long Runway 11 remained.
Sixteen seconds after reaching Vr the Gulfstream exited the runway, rolled over the paved and subsequent grass overrun area, and burst into flames as it stopped in a small gully about 1,800 feet beyond the runway’s departure end. Both pilots, the flight attendant and all four passengers perished.
Overlooked, or Ignored?
All jobs have their share of routine, much of it boring. Aviation is no different—with one huge exception: What may be overlooked or ignored, such as checklists that indicate gust lock engagement, can be fatal. Searching the accident aircraft’s DFR, the NTSB found that crew of the fatal G-IV had failed to undertake complete flight control checks on 98 percent of their previous 175 flights.
The government’s safety analysts concluded that the co-captains routinely did not follow normal checklists or the optimal challenge-response format of standard operating practices.
Troubled by what they felt was limited information about checklist use prior to takeoff, the NTSB requested that National Business Aviation Association (NBAA) convene a committee to examine the nominal practices of the Business Aviation community, and the results of that study should be a wake-up call for all aviators.
Examining three years of data from Flight Operations Quality Assurance programs of business aircraft operators encompassing 143,756 flights, NBAA found that on average crews conducted no manufacturer-required flight control checks prior to takeoff 2.06 percent of the time and conducted only partial control checks on 15.62 percent of flights.
Stated in the aggregate, nearly one of every five flight crews failed to conduct a complete take-off checklist prior to departure during the three years of data studied by the Association.
Checklists are Essential
They may seem repetitious, possibly overly simplistic for the experienced pilot—even boring and time consuming—but checklists are the stuff of a strong safety culture. Checklists are the first line of defense against being lulled into taking safety for granted because the trip is routine or the crew has thousands of hours, including many in the aircraft being flown.
Years of successful missions can dull the sense of challenge and generate the presumption that it is OK to cut corners such as relying on memory. But that feeling of bored self-confidence presents its own risk.
Absolute commitment to using a complete checklist is a key element in combating complacency, the silent killer of professional aviators.