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
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.
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.
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?
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.
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.
Managing Director Tom Zoeller will introduce the staff.