From the scene of the accident to the rendering of the probable cause, the National Transportation Safety Board follows an established process to determine why an aircraft crash happened. For the NTSB investigators that form a crash “Go Team” — experts chosen from a broad range of NTSB aviation specialties — that often means unraveling the mysteries behind a series of fatal mistakes that led to an accident. That was certainly the case for investigators when the call came in on the evening of May 31, 2014, after a Gulfstream GIV crashed in Bedford, Massachusetts. This is the inside story of the landmark crash investigation that followed.
On that May evening, at about 9:40 EDT, according to the NTSB report: “A Gulfstream GIV, N121JM, registered to SK Travel and operated by Arizin Ventures, crashed after it overran the end of Runway 11 during a rejected takeoff at Laurence G. Hanscom Field (BED) in Bedford, Massachusetts. The airplane careened through the paved overrun area and across a grassy area, collided with approach lights and a localizer antenna, passed through the airport’s perimeter fence and came to a stop in a ravine. The two pilots, a flight attendant and four passengers died. The airplane was destroyed by impact forces and the post-crash fire. The flight, which was destined for Atlantic City International Airport in New Jersey, was conducted under Part 91. An IFR flight plan was filed and night meteorological conditions prevailed at the time of the accident.” (Accident ID: ERA14MA271)
The Go Team
The call came at 11:15 that Saturday night. NTSB senior air safety investigator Luke Schiada and his family were visiting a friend in New Jersey. The caller informed Schiada that an accident involving a business jet had taken place at about 9:40 p.m. at Hanscom Field. Designated the investigator in charge (IIC), Schiada and an NTSB Go Team made arrangements to travel to the scene of the accident. Schiada and his family immediately drove back to their home in Brooklyn, New York. Wary of the effects of fatigue, Schiada slept for a few hours and departed for Bedford early the next morning, taking his “go bag” — a suitcase he keeps packed and ready to bring along at a moment’s notice. All NTSB Go Team members have such bags, although their contents differ depending upon each investigator’s needs. Schiada’s includes a few days’ worth of clothes, personal items and the tools of his trade, including a camera, notepad, hard hat, gloves, air respirator, evidence-collection bags and basic tools.
A 20-year veteran of the NTSB, Schiada has an impressive aviation background. He completed his airframe and power plant ratings while still in high school and his private pilot, commercial and instrument ratings before earning a college degree in aviation administration. “I was already very interested in the work of the NTSB, and when I heard a presentation by an NTSB investigator while in college, I knew that’s what I wanted to do,” he told Flying. At first, he worked as a volunteer for the NTSB, eventually moving up to his current position. So far, Schiada has investigated 650 accidents, 115 of them fatal.
Scene of the Accident
Schiada arrived at Hanscom Field at about 10:30 the next morning to find the grisly crash scene. “First,” he said, “I met with the on-site personnel to evaluate the security of the accident scene and any hazards to the investigators.” Satisfied that all was secure and safe, he met with his initial Go Team members: Adam Huray, airworthiness investigator; Peter Wentz, survival factors and airport response investigator; Ralph Hicks, a senior air safety investigator; Mike Crook, from the Transportation Disaster Assistance Division; and Peter Knudson, media relations officer. “Once we evaluated the accident site,” Schiada said, “we conducted an organization meeting to explain how the investigation would be conducted, identify the parties to the investigation, form the investigative groups and develop an initial work plan.” Over five days, Schiada and his groups gathered evidence. At the end of each day Schiada conducted progress meetings during which the team discussed the day’s activities, made future plans and discussed any additional assistance they needed.
The Working Groups
“Based on the information we collected at the site, I formed six working groups,” Schiada said. “As the investigation progressed, I involved additional specialists as necessary.” NTSB working groups are teams led by specialists from a variety of disciplines, each of which provides a factual report of its findings to the IIC. Through the reports of his groups, Schiada began to unravel a series of errors made by the pilots.
Timothy Sorensen, leader of the Operational Factors group, spent hours interviewing witnesses, controllers, co-workers of the pilots and so on, with the help of NTSB human performance investigator Dr. William Bramble. Sorensen also dug deeply into the operational practices of the jet’s owner-operator. Among other things, their interview with a contract pilot who had flown with the accident pilot revealed that he had memorized the checklist and never used a printed checklist. Eventually, investigators found this was a habitual practice of the accident pilot, a clear violation of industry best practices. The report of the Airworthiness group, led by Huray, contains an extensive technical discussion of the Gulfstream GIV’s gust-lock system, a safety system that locks the ailerons, elevators and rudder in place to prevent wind damage while the airplane is parked. Tragically, the pilots didn’t ensure the gust lock was disengaged before takeoff as the Gulfstream’s checklist mandated — a failure that directly contributed to the crash.
Joseph Gregor and his Cockpit Voice Recorder group confirmed the pilots didn’t use a verbal checklist. In addition, the pilot in command made seven consecutive references to the gust lock being on during the takeoff roll, specifically “(steer) lock is on” — without receiving a verbal response from the copilot. A report from John O’Callaghan and his Aircraft Performance group’s tests determined that the Gulfstream could have stopped on the pavement if the flight crew had rejected the takeoff any time from when the pilot in command first said “lock is on” until about 11 seconds later.
Especially telling was flight-data-recorder specialist Christopher Babcock’s report, which revealed the accident pilots rarely performed a flight-control check. In fact, out of this Gulfstream’s 176 takeoffs, the flight crew made only two complete pretakeoff control checks and 16 partial checks — that’s an astonishing 98 percent of the takeoffs without any flight-control check at all. Before the accident flight, the flight crew made no pretakeoff flight-control check, missing the opportunity to disengage the gust lock. The data also showed that instead of aborting the takeoff, the pilots made a desperate attempt to disengage the gust lock during the takeoff roll, perhaps unaware of the fact that the lock won’t disengage with the engines running.
Spearheaded by Mike Hauf, the System Safety and Certification group discovered that the GIV’s gust-lock system, approved from design drawings, didn’t meet FAA certification requirements to limit the amount of throttle available to give “an unmistakable warning” at the beginning of the takeoff roll if the gust lock was on.
Wentz and his Survival Factors group also found that the airport’s medium-intensity approach lighting system and localizer antenna weren’t made to break away upon impact, likely contributing to the rupture of the Gulfstream’s fuel tanks that ignited the deadly fire.
Parties to the Investigation
“As IIC, it’s my responsibility to designate party members,” said Schiada. “However, the group chairmen may identify the need for other parties.” The purpose of the parties — individuals, government agencies, companies and so forth, whose personnel, service or products were involved in the accident — is usually to provide technical assistance. They can also help in the rapid dissemination of safety-related information to operators. By law, the FAA is automatically a party. Other parties might include the aircraft manufacturer and a parts manufacturer, both of which were parties to the Gulfstream investigation. “We usually receive a lot of cooperation from the parties,” said Schiada. “Many of them consider it a privilege to be a part of the process.” In this investigation, the parties included Gulfstream Aerospace Corp., the manufacturer of the airplane; Massachusetts Port Authority, the owner and operator of BED; Rockwell Collins; and Honeywell.
In addition to profound pilot error, the main finding was that the Gulfstream’s gust-lock system didn’t meet FAA certification standards. One can assume that if it had, the flight crew’s failure to use a checklist and to check the flight controls wouldn’t have been enough to cause the accident. Citing the NTSB Survival Factors report, Gulfstream concluded that the occupants could have likely survived if the jet hadn’t caught fire.
“The most difficult part of my job is knowing the unbearable situation of the families,” Schiada said. The NTSB’s Transportation Disaster Assistance Division coordinates with the IIC to provide information and other assistance to family members. Seven people died in the accident, including Lewis Katz, co-owner of the Philadelphia Inquirer; three other passengers; a flight attendant; and the two pilots. The Final Report
The adoption of the NTSB’s final report by board members closed the 13-month investigation of the Gulfstream accident. The 83-page document summarizes more than 800 pages of descriptions, data analyses and drawings submitted by Schiada, the working groups, parties to the investigation and others. It also includes safety recommendations that, if implemented, could keep this type of accident from happening again.
The Safety Recommendations
“Recommendations are the most important part of our investigation,” said Schiada. “In this case, a lot of things had to happen for the accident to take place.” Only the NTSB can make safety recommendations — not its investigators or the parties, although they provide the information upon which the board can base its recommendations.
The Gulfstream accident produced five recommendations, including three to the FAA. The agency was asked to identify and replace, when feasible, any objects along the extended runway centerline up to the perimeter fence that don’t give way upon impact; mandate that Gulfstream retrofit all GIV aircraft with a modified gust-lock system that meets certification requirements; and provide guidance on the appropriate use and limitations of using the review of engineering drawings as a way to show compliance with certification requirements. The final two recommendations addressed verifying that pilots use checklists for every flight. The recommendations were readily accepted, and implementation has either been completed or is in progress.
The Board Meeting
The NTSB met on Sept. 9, 2015, to adopt the final report and announce the probable cause. Several of the investigators made presentations at the hearing. In a chilling but brief accident summary, Schiada reported: “Pilots did not discuss checklists or takeoff planning; pilots did not perform flight-control check; gust lock remained engaged.” In a statement, NTSB vice chairman T. Bella Dinh-Zarr emphasized, “This investigation highlights the importance of following standard operating procedures. … Complacency does not have a place in the cockpit of any aircraft.”
The Probable Cause
The NTSB cited the probable cause as: “The flight crew members’ failure to perform the flight-control check before takeoff, their attempt to take off with the gust-lock system engaged and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident was the flight crew’s noncompliance with checklists, Gulfstream Aerospace Corp.’s failure to ensure that the GIV gust-lock/throttle-lever interlock system would prevent an attempted takeoff with the gust lock engaged and the FAA’s failure to detect this inadequacy during the GIV’s certification.”
The mission of the NTSB is to improve transportation safety. To make sure it remains focused on that goal, none of its findings can be used as evidence in court. Basically, that means we’re promised a fair shake should we have the misfortune to be involved in an accident. Hopefully, we’ve all learned from the series of mistakes of this Gulfstream’s flight crew.
On the Scene By Luke Schiada
I was the first NTSB investigator to arrive at the accident site. The fire was out, but the smell of burnt wreckage and jet fuel permeated the air. I was escorted to near the end of Runway 11 and began walking on the centerline toward the airplane. I noted tire marks from heavy braking near the end of the runway that continued until just before the end of the paved 1,000-foot overrun.
The ground sloped down from the end of the overrun to a small service road, and then there was grass. As I walked on the grass, I saw three distinct sets of ruts consistent with the tires on the airplane’s nose, left main and right main landing gear. As I continued walking, I saw the debris path, which included a portion of the nose gear assembly, left main gear door, a 6-foot-long section of the left flap and the left main landing gear assembly. I also noted that some approach lighting structures, the localizer antenna and multiple support poles had been knocked down. Around that point, the grass was charred, which extended to the ravine where the airplane came to rest, about 1,900 feet from the end of the runway.
The Gulfstream was destroyed by fire aft of the forward nose section. The nose section, which included the cockpit, was resting on the far side of the ravine. A large portion of the airport’s perimeter fence was still wrapped around portions of both wings. I knew that the location of the airplane was going to make the retrieval of the flight recorders, documentation of the airframe and engines, and the recovery of the wreckage more difficult.
We were very fortunate to have support from the airport authority, Massachusetts State Police and other local personnel, which helped to facilitate the on-site documentation and recovery efforts. I want to add that a key part of evaluating an accident site includes assessing the hazards and ensuring to the greatest extent possible the safety and protection of personnel participating in the investigation.
After my walk around the accident site, my thoughts turned to the arrival of my colleagues and the upcoming organizational meeting, where we would establish the initial working groups, designate parties to the investigation and begin the on-site documentation efforts.
Shortly after my initial walk around the accident site, my thoughts turned to the arrival of the investigative team, party members, and other personnel, and the upcoming Organizational Meeting, where we would establish the initial NTSB led investigative groups, designate parties to the investigation, and begin the onsite documentation efforts.