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Safety Recommendation Details

Safety Recommendation A-15-034
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 NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 6/24/2017
Addressee(s) and Addressee Status: National Business Aviation Association (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: National Business Aviation Association
Date: 6/24/2017
Response: We are pleased to learn that, on September 20, 2016, you issued an NBAA report titled “Business Aviation Compliance with Manufactured-Required Flight-Control Checks Before Takeoff,” which includes your analyses of 143,756 business aviation flights made between January 1, 2013, and December 31, 2015. We note that, during that 3-year period, the overall noncompliance rate for manufacturer-required routine flight-control checks before takeoff was 17.66 percent, or 25,381 events. We also note that, on September 20, 2016, you issued a press release that highlighted this important safety issue and included a link to the full NBAA report. Because these actions satisfy the intent of Safety Recommendation A-15-34, it is classified CLOSED—ACCPTABLE ACTION.

From: National Business Aviation Association
To: NTSB
Date: 3/29/2017
Response: -From Mark E. Larsen, Senior Manager, Safety and Flight Operations: NBAA Actions to Respond to NTSB Recommendation A-15-34 Consistent with planned actions detailed in NBAA’s initial response letter to this recommendation, the following actions describe NBAA’s work to address recommendation A-15-34. 1. NBAA established a working group composed of representatives from NBAA staff, NBAA Safety Committee, industry safety leaders and relevant safety experts to collaborate with business aviation flight operational quality assurance groups to respond this NTSB Recommendation. 2. NBAA respected the governance of the business aviation flight operational quality assurance groups, including their decisions to participate in the working group and the data analyses the groups provided to this effort. 3. The working group established a baseline manner in which each program internally performed this analysis of manufacturer-required routine flight control checks before takeoff on its own data. 4. The working group established a manner in which the results of the data analysis performed by each program were aggregated for reporting purposes. The aggregation did not reveal a compliance rate associated with the name of any operator or name of any one flight operational quality assurance program. 5. The working group created a report highlighting a current collective compliance rate for the manufacturer-required routine flight control checks before takeoff by business aviation operators. 6. The report also highlights the value of participating in data analysis programs as a means to proactively analyze and assess risks to business aviation operations. 7. The report was publicly disseminated to NBAA Members via an NBAA Press Release issued on September 20, 2016, as part of NBAA’s data-driven safety agenda for business aviation. 8. Following the release of the report, NBAA presented the findings of this study at FAA’s InfoShare conference in September 2016. NBAA will continue to communicate the results of this study as appropriate future opportunities present. Through the completion of this work, NBAA believes that it has fully addressed both the letter and spirit of NTSB Recommendation A-15-34, and therefore respectfully requests closure of this recommendation. In closing, NBAA remains committed to addressing the risks of procedural non-compliance within the business aviation community, including those identified through the investigation of this accident in Bedford, Massachusetts.

From: NTSB
To: National Business Aviation Association
Date: 1/12/2016
Response: The establishment of the working group you described, composed of business aviation flight operational quality assurance groups, and the working group’s completion of a report on the current collective compliance rate for the manufacturer-required routine flight control checks before takeoff by business aviation operators will satisfy this recommendation. We ask that you send us a copy of the report produced by this group once it becomes available. Pending completion and distribution of the report, Safety Recommendation A-15-34 is classified OPEN—ACCEPTABLE RESPONSE.

From: National Business Aviation Association
To: NTSB
Date: 11/30/2015
Response: -From Mark E. Larsen, Senior Manager, Safety and Flight Operations: NBAA Actions to Respond to NTSB Recommendation A-15-34: The nature of this recommendation, combined with the fact that NBAA does not have any direct oversight or control of business aviation flight operational quality assurance groups, will require a unique approach to meet the recommendation’s intent. The following actions outline NBAA’s approach in responding to the recommendation. 1. NBAA will establish a working group to collaborate with business aviation flight operational quality assurance groups to respond to NTSB Recommendation A-15-34. The working group will be composed of representatives from NBAA staff, NBAA Safety Committee, industry safety leaders and relevant safety experts. 2. NBAA will respect the governance of the business aviation flight operational quality assurance groups, including their decisions to participate in the working group and the data analyses the groups will provide to this effort. 3. The working group will collaborate, and establish a baseline manner in which each program can internally perform this analysis of manufacturer-required routine flight control checks before takeoff on its own data. 4. The working group will collaborate and establish a manner in which the results of the data analysis can be aggregated for reporting purposes. Such aggregation will not reveal a compliance rate associated with the name of any operator or name of any one flight operational quality assurance program. 5. The working group will create a report highlighting a current collective compliance rate for the manufacturer-required routine flight control checks before takeoff by business aviation operators. 6. The report will highlight the value of participating in these data analysis programs as a means to proactively analyze and assess risks to business aviation operations. 7. The report will be disseminated to NBAA Members as part of NBAA’s data-driven safety agenda for business aviation. NBAA estimates that the establishment of the working group, further defining the analysis, data analysis, data aggregation, and report writing, approval and release will take approximately 1 year. In closing, NBAA is committed to working with the NTSB and with industry partners to better assess and address the risks of procedural non-compliance within the business aviation community, including those identified through the investigation of this accident in Bedford, Massachusetts. NBAA will update our response once the final report has been released.