Learning from a preventable accident

On May 31, 2014, a Gulfstream IV crashed after an aborted takeoff at Hanscom Field in Bedford, Massachusetts. It overran the runway, hitting approach lights and an antenna before stopping in a ravine outside the airport’s perimeter. A post-impact fire killed all seven people on board: the two pilots, a flight attendant, and four passengers. A National Transportation Safety Board report subsequently identified several probable causes for the accident and noted that one contributing factor was “the flight crew’s ­habitual noncompliance with checklists.”

This was shocking, especially since the crew was far from inexperienced. The pilot-in-command held several single- and multi-engine airplane ratings and type ratings and had 11,250 hours of flight time; and, according to the NTSB’s files, he had been associated with the accident airplane’s owners for about 12 years, including more than eight years in the GIV. 

The 61-year-old copilot was even more experienced. Certified to fly the GII/III, JetStar, GIV, and GV, he had worked for the airplane’s owners for 27 years and served as their chief pilot and director of maintenance. (According to the NTSB report, the accident crew normally flew together, trading seats between flights.) 

So how does such an experienced crew habitually fail to comply with checklists? Checklists are the foundation of the standardization process 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 NTSB determined that at the beginning of the accident flight, they failed to discuss checklists and to perform a flight control check. The Board further concluded that the crew had 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.” 

It seems that not only could this accident have been prevented by use of a routine checklist but that the crew likely never used checklists. I can’t imagine how heartbreaking that news must have been for the families and friends of the victims. Or what a sense of betrayal the aircraft owner’s family must feel for the dereliction of duty of their long-time crew.

Having read about the NTSB report, some aircraft owners undoubtedly now wonder 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 corporate pilots. But that’s not what aircraft owners want to hear when they entrust their lives and the lives of their families and friends to these pilots. They want to know how they can be assured that their pilots are complying with industry best practices when it comes to checklists in general and, crucially, pre-takeoff control checks.

The NTSB makes two recommendations regarding flight control checks. 

First, it recommends that 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 the National Business Aviation Association, 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 excellent suggestions, 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 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 video cameras are probably the most cost-effective way of assuring owners that their pilots are conforming to professional standards.


John Goglia, who has worked in the aviation industry for more than 40 years, served on the National Transportation Safety Board from 1995 to 2004. He contributes regularly to BJT sister publication Aviation International News.

Show comments (2)

This article leaves the reader wondering what the pilots missed by failing to use a checklist. I know from other sources that they failed to disengage the gust lock, which in turn prevented flight control surfaces, such as the elevator, from operating properly.

Also, the article fails to mention how the NTSB concluded that the pilots failed to use checklists on almost all of their last 175 flights. Perhaps the checklists were computer generated, requiring inputs from the pilots that could later be verified? This is relevant because the author goes on to advocate having cameras in the cockpit to monitor pilot conformance with required operating procedures. If the NTSB was able to verify that the pilots didn't use checklists on previous flights, couldn't the airplane's owner have used the same information to monitor the pilots? If so, why didn't they do this? Safeguards like cameras only work if someone is actually reviewing the footage.

Was this crew attending regular recurrent simulator training as a crew? All professional accident reviews should include this information.

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