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Speeches

Opening Statement, Crash on takeoff of Gulfstream Aerospace Corporation G-IV
T. Bella Dinh-Zarr, PhD, MPH
NTSB Boardroom
9/9/2015

Good morning and welcome to the Boardroom of the National Transportation Safety Board. I am Vice Chairman Bella Dinh-Zarr, and it is my privilege to chair this meeting of the NTSB. Joining me are Member Robert Sumwalt and Member Earl Weener. Consistent with his ethics obligation, Chairman Christopher Hart has recused himself from the investigation that we are discussing today.

Today, we meet in open session, as required by the Government in the Sunshine Act, to consider a fatal runway overrun during a rejected takeoff at Laurence G. Hanscom Field in Bedford, Massachusetts, on May 31, 2014.

The accident involved a Gulfstream G-IV. The privately owned and operated business jet rolled beyond the paved overrun area and subsequently crashed into a ravine, where a post-impact fire ensued.

Tragically, the two pilots, the flight attendant, and all four passengers on board died.

On behalf of my fellow Board Members and the entire NTSB staff, I would like to extend our sincerest condolences to the families and friends of those who lost their lives in this accident.  We know that nothing can replace your loved ones, and we hope that the information we discuss today will answer some of your questions.  Please understand that in fully and frankly examining what went wrong, it is our purpose to identify ways to prevent similar accidents in the future, and to minimize the harm from accidents that do occur.

In a moment, staff will present the facts and analysis of the accident.  Much of this investigation centered on a mechanism called a gust lock.  As the name implies, the gust lock prevents wind gusts from moving the airplane’s flight control surfaces and damaging them when the aircraft is parked. When the gust lock is disengaged, pilots can move the flight control surfaces, such as the elevators, ailerons, and rudder, to control an airplane’s movement.

But as this flight crew prepared for takeoff, the gust lock remained engaged.  Simply put, an airplane cannot take off safely with the gust lock engaged.  As our investigators examined the data about this accident flight, they found that the flight crew routinely neglected performing complete flight control checks. These checks would have identified that the gust lock was still engaged before taxiing the aircraft for takeoff.

Each of the two pilots involved in this accident had thousands of hours of flying time. Their training and medical certificates were current. They had flown together for years as pilots on the accident airplane.

Complying with checklists, standard operating procedures, and company policies – referred to as “procedural compliance” - is critical to safe aviation.  This is not the first accident in which our investigators have found procedural non-compliance.  In fact, strengthening procedural compliance is presently on our Most Wanted List of transportation safety improvements.

This investigation raises important questions about how this flight crew developed a long term pattern of procedural non-compliance.  What quality assurances could have identified these lapses?  More importantly, is this procedural non-compliance a prevalent practice in the business aviation community? 

Mechanical protections in the design of the gust lock should prevent pilots from attempting to take off with the gust lock engaged.  This raised additional questions about: whether those protections were implemented on the Gulfstream G-IV; whether the FAA sufficiently reviewed the Gulfstream G-IV design, and whether a different review method could have uncovered a deficiency in the design of the gust-lock mechanism.

Finally, our investigation looked at the emergency response of the Airport Rescue and Firefighting (or ARFF) in this accident in order to provide lessons learned for ARFF operations both at Hanscom and other airports in the future.

Now Managing Director Tom Zoeller will introduce the staff.