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Safety Recommendation Details

Safety Recommendation A-15-033
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 INTERNATIONAL BUSINESS AVIATION COUNCIL: Amend International Standard for Business Aircraft Operations auditing standards to include verifying that operators are complying with best practices for checklist execution, including the use of the challenge-verification-response format whenever possible.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Bedford, MA, United States
Is Reiterated: No
Is Hazmat: 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: 3/15/2016
Addressee(s) and Addressee Status: International Business Aviation Council (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: International Business Aviation Council
Date: 3/15/2016
Response: We note that you have (1) added IS-BAO Standard 6.12.3, which directs operators to ensure that flight crews comply with best practices for checklist execution, and (2) included, in the implementation guidance to operators, information on best practices for checklist execution, including “challenge-verification-response.” Your actions satisfy Safety Recommendation A-15-30, which is classified CLOSED—ACCEPTABLE ACTION.

From: International Business Aviation Council
Date: 2/2/2016
Response: -From the International Business Aviation Council, Kurt H. Edwards, Director General: The International Business Aviation Council (IBAC) is a non-profit trade association representing the interests of business aviation operators around the world and principally at the International Civil Aviation Organization (ICAO). A top priority is the promotion of safety within our community through the International Standard for Business Aircraft Operations (IS-BAO), a global, voluntary code of best safety practices with a robust safety management system at its core. The IS-BAO is based on relevant ICAO Standards and Recommended Practices as well as best practices endorsed by business aviation industry experts from around the world on the IBAC Standards Board. More than 700 operators have chosen to implement voluntarily this code of best practice, and several safety regulatory authorities recognize conformity to IS-BAO as a means of compliance. The Standards Board reviews and updates annually the IS-BAO and its audit protocols to ensure the Standard keeps pace with safety developments. As you know, the NTSB issued a recommendation to IBAC in September 2015 (A-15-33): Amend International Standard for Business Aircraft Operations auditing standards to include verifying that operators are complying with best practices for checklist execution, including the use of the challenge- verification-response format whenever possible. In response to this recommendation, IBAC conducted an analysis of the core IS- BAO Program documents, including the Standard itself, the audit protocols, and implementation guidance, and presented the analysis to the Standards Board for review and discussion. Based on the Board’s advice, IBAC has taken the following actions: 1) Added IS-BAO Standard 6.12.3: “ The operator shall ensure that flight crews comply with best practices for checklist execution,” and 2) Included in the implementation guidance to operators information on best practices for checklist execution, including “challenge-verification-response”. The guidance refers to reports on the use and design of checklists by the National Aeronautics and Space Administration and Federal Aviation Administration, each of which was cited in the accident investigation report that resulted in recommendation A-15-33, among others. We believe these changes to the IS-BAO meet the intent of recommendation A-15-33, respect the various approaches to checklists recommended by aircraft manufacturers, and maintain the performance-based nature of the IS-BAO.