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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 2014 Gulfstream IV crash, caused by the flight crew failing to perform a flight control check and attempting takeoff with the control lock engaged, highlighted the catastrophic dangers of procedural noncompliance.
  • The article emphasizes that procedural noncompliance, even by highly experienced pilots, is a complex issue requiring more than just avoiding complacency, and often involves a failure to consistently follow established checklists.
  • It differentiates between varying risk levels associated with procedural errors (e.g., gear-up landing vs. locked controls takeoff), advocating for robust mitigation strategies like comprehensive checklists, crew resource management (CRM), and heightened situational awareness, especially for high-severity risks.
  • All pilots, regardless of aircraft type or crew size, must remain vigilant against procedural noncompliance, utilizing formal checklists and superior airmanship, and recognizing when routines change to prevent critical errors.
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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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