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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 Gulfstream IV accident at Hanscom Field, caused by a locked control and the crew's failure to perform pre-takeoff checks, serves as a stark warning about the catastrophic risks of procedural noncompliance.
  • Even highly experienced flight crews can habitually skip vital checklist items, underscoring that the issue of noncompliance is more complex than mere complacency.
  • The severity of risks from procedural noncompliance varies significantly (e.g., "marginal" for a gear-up landing vs. "catastrophic" for locked flight controls), requiring different mitigation strategies.
  • Effective mitigation against procedural noncompliance requires not only strict checklist adherence but also strong Crew Resource Management (CRM), heightened situational awareness, and vigilance for any changes in routine.
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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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