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Safety Recommendation Details

Safety Recommendation A-15-030
Details
Synopsis: On May 31, 2014, about 2140 eastern daylight time, a Gulfstream Aerospace Corporation G-IV, N121JM, registered to SK Travel, LLC, and operated by Arizin Ventures, LLC, crashed after it overran the end of runway 11 during a rejected takeoff at Laurence G. Hanscom Field (BED), Bedford, Massachusetts. The airplane rolled 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 a postcrash fire. The corporate flight, which was destined for Atlantic City International Airport, Atlantic City, New Jersey, was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. An instrument flight rules flight plan was filed. Night visual meteorological conditions prevailed at the time of the accident. The NTSB determines that the probable cause of this accident was the flight crewmembers’ 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 were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Identify nonfrangible structures outside of a runway safety area during annual 14 Code of Federal Regulations Part 139 inspections and place increased emphasis on replacing nonfrangible fittings of any objects along the extended runway centerline up to the perimeter fence with frangible fittings, wherever feasible, during the next routine maintenance cycle.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Bedford, MA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ERA14MA271
Accident Reports: ​Crash on takeoff of Gulfstream Aerospace Corporation G-IVRunway Overrun During Rejected Takeoff, Gulfstream Aerospace Corporation G-IV, N121JM
Report #: AAR-15-03
Accident Date: 5/31/2014
Issue Date: 9/24/2015
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/21/2017
Response: You write that you plan to evaluate FAA-owned equipment located within the area spanning the width of the runway surface and extending 3,000 feet beyond the runway pavement at 62 large and medium US airports. We are aware that you replaced the nonfrangible fittings at BED with frangible fittings after the accident. We are concerned, however, that the remaining 477 Part 139 airports that do not fall into either the large or medium categories, including BED, would not be evaluated under your proposed plan. We are aware that all Part 139 airports currently receive an annual certification inspection in which inspectors check structures within RSAs for frangibility. We believe that you could include, as part of this annual inspection, a procedure for inspectors to also identify all nonfrangible structures that are within 3,000 feet of the RSA. In addition, we believe that inspectors should notify airports of any nonfrangible structures identified that do not belong to the FAA. Pending our review of a plan that addresses these concerns, Safety Recommendation A-15-30 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/6/2017
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has determined it is not feasible to evaluate obstacles for frangibility all the way to the perimeter fence, as this distance varies considerably by airport. However, we have determined it is practicable to evaluate FAA-owned equipment within an area spanning the width of the runway surface and extending 3,000 feet beyond the runway pavement. The FAA will make frangibility feasibility determinations in the area described above at all 62 large and medium U.S. airports (list enclosed). These airports account for 88 percent of the total passenger enplanements in the U.S. We estimate it will take 1 year to produce a report detailing which fittings can feasibly be made frangible. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by December 2017.

From: NTSB
To: FAA
Date: 3/15/2016
Response: We note that you intend to evaluate the feasibility of placing frangible fittings on any FAA owned equipment that extends past the runway safety area at the width of the runway to the perimeter fence. In a recent meeting, we also learned that the Air Traffic Organization (ATO) has been tasked to complete a list of all privately owned or non-FAA equipment. Pending our review of the findings from your evaluation and completion of the recommended action, Safety Recommendation A-15-30 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/9/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) will review FAA-owned equipment extending past the runway safety area at the width of the runway to the perimeter fence and evaluate the feasibility of placing frangible fittings on any FAA-owned equipment found. As part of that effort, the FAA will develop a plan to identify and evaluate the equipment by November 2016. This plan will include a timeline for evaluating whether the FAA will retrofit specific equipment or not, and when. The FAA's Air Traffic Organization maintains a list of affected equipment and a schedule of maintenance for this equipment. Therefore, inspections conducted under part 139 are not affected.