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The Cost of Procedural Noncompliance

The safety consequences associated with procedural noncompliance-failing to correctly perform normal checklists-have become hot button issues within the business aviation community and the NTSB. All general aviation pilots should heed the warnings raised.

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Key Takeaways:

  • The fatal 2014 Gulfstream IV crash, caused by flight crew procedural noncompliance (failure to perform a flight control check with the lock engaged), underscored the catastrophic risks of neglecting pre-takeoff procedures.
  • This incident highlighted that while checklists are crucial, effective risk mitigation for procedural noncompliance, especially in complex aircraft, also requires strong Crew Resource Management (CRM) and constant situational awareness.
  • The lessons from this and similar events emphasize that all pilots, regardless of aircraft complexity or crew size, must be alert to the hazards of procedural noncompliance and recognize when routines change or something is abnormal.
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On May 31, 2014, a Gulfstream IV ran off the end of the runway at Hanscom Field (KBED) in Bedford, Mass. The aircraft went into a ditch at high speed, disintegrated and caught fire. All seven occupants suffered fatal injuries. The accident’s circumstances provided a wake-up call for the business aviation community: Professionally flown Gulfstreams just don’t run off the end of a runway. As a result of this high-profile accident, the safety consequences associated with procedural noncompliance—failing to correctly perform normal checklists—have become hot button issues within the business aviation community and the NTSB. All general aviation pilots should heed the warnings raised.

As the NTSB reported in its 800-plus-page accident investigation docket, the very experienced flight crew had failed to perform a basic flight control check before takeoff. They didn’t discover the control lock was engaged until well into the takeoff roll and failed to abort the takeoff as crucial seconds ticked by. By the time they finally took action to abort in the last few hundred feet of runway, the aircraft had reached 162 knots and it was too late to avoid what happened next.

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