During the investigation into the Gulfstream GIV accident at Bedford, Massachusetts, in May 2014, the NTSB discovered the accident crew failed to perform a pre-takeoff flight control check. Investigators also learned that crews of the accident aircraft had failed to perform a similar standard pre-takeoff control check prior to the previous 175 takeoffs. Now, a new National Business Aviation Association survey has found the omission is common at other flight departments as well.
The Gulfstream crashed at Hanscom Field on May 31, 2014, when the pilots realized too late in their takeoff run that the flight controls were still locked. The airplane was unable to stop on the remaining runway. Seven people aboard the GIV died in the crash and ensuing fire, including the two pilots.
In its final report of the Bedford accident, the NTSB recommended NBAA work together with existing flight departments to learn how deeply into the pilot ranks the non-compliance with manufacturer recommendations for pre-takeoff flight control checks existed. The NBAA project team organized for the research effort used already-existing Flight Operations Quality Assurance (FOQA) numbers for its analysis. Data looked at information gathered in a de-identified format from flights over a variety of aircraft and operators flown between January 1, 2013, and December 31, 2015. No one-on-one interviews were conducted.
The results of the analysis outlined in Business Aviation Compliance With Manufacturer-Required Flight-Control Checks Before Takeoff were eye-opening. The team discovered various categories of non-compliance with pre-takeoff control checks in nearly 18 percent of the 144,000 flights reviewed. In the most serious situations, flight crews performed no flight control check of any kind, and in others, they may have checked the controls to some degree, but not enough to qualify as a full pre-takeoff check.
The results mean that one out of every five of the 144,000 takeoffs conducted by professionally trained flight crews failed to completely perform a simple task taught to every student pilot: moving the control wheel back and forth, as well as left and right, to confirm the ailerons and elevators are free and operating correctly. The big question, of course, is why?
Unfortunately, the why behind the results remains unknown, and probably will for some time to come. Although the NBAA recommendation in the report to flight crews to “Conduct flight-control checks before takeoff in accordance with manufacturers’ AFM/POH” stands as a solid reminder of the issue at hand, the industry owes it to itself, as well as to the passengers and other crewmembers riding along in the cabin, to continue to dig for those insights. Sources at NBAA told Flying they hope to continue the research into the why of pre-takeoff flight control non-compliance.
Therein lies the problem the industry faces with programs like FOQA. Normally, only companies and individuals that add data to the FOQA program itself are ever able to see the results of the data gathered. Anonymity of the pilot or operator, in fact, is the major element driving the gathering of FOQA data. Without that element of secrecy, there’s only a slim chance there would be any data at all to analyze. To date, only a tiny percentage of business aviation operators participate in the FOQA program.
Imagine the insights into other safety issues that could be gathered if more companies were able to share data with a FOQA system that was also somehow able to share more about what it was learning with the rest of the aviation industry. No one, except perhaps the FAA, cares which operators did what. All the industry safety leadership cares about is what issues the data could bring to light that might well prevent some future tragedy.