Gulfstream G-IV, N121JM, SK Travel LLC: Fatal accident occurred May 31, 2014 in Bedford, Massachusetts

National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf 

National Transportation Safety Board  -  Docket And Docket Items:   http://dms.ntsb.gov/pubdms

National Transportation Safety Board  -  Aviation Accident Data Summary: http://app.ntsb.gov/pdf

NTSB Identification: ERA14MA271
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 31, 2014 in Bedford, MA
Probable Cause Approval Date: 09/28/2015
Aircraft: GULFSTREAM AEROSPACE G IV, registration: N121JM
Injuries: 7 Fatal.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-15/03.

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, 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 Part 91. An instrument flight rules flight plan was filed. Night visual meteorological conditions prevailed at the time of the accident

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
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.

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-15/03.

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, 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 Part 91. An instrument flight rules flight plan was filed. Night visual meteorological conditions prevailed at the time of the accident.

NTSB Documents: http://dms.ntsb.gov

http://registry.faa.gov/N121JM

NTSB Identification: ERA14MA271
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 31, 2014 in Bedford, MA
Aircraft: GULFSTREAM AEROSPACE G IV, registration: N121JM
Injuries: 7 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

On May 31, 2014, about 2140 eastern daylight time, a Gulfstream Aerospace Corporation G-IV, N121JM, operated by SK Travel LLC., was destroyed after a rejected takeoff and runway excursion at Laurence G. Hanscom Field (BED), Bedford, Massachusetts. The two pilots, a flight attendant, and four passengers were fatally injured. Night visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight destined for Atlantic City International Airport (ACY), Atlantic City, New Jersey. The business flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

The airplane was based at New Castle Airport (ILG), Wilmington, Delaware, and co-owned by one of the passengers, through a limited liability company. According to preliminary information, the airplane departed ILG earlier in the day, flew to ACY, and then to BED. The airplane landed at BED about 1545 and remained parked on the ramp at one of the fixed base operators. The crew remained with the airplane until the passengers returned. No maintenance or fuel services were requested by the crew.

The airplane was subsequently cleared for takeoff from runway 11, a 7,011-foot-long, 150-foot wide, grooved, asphalt runway. A witness observed the airplane on the takeoff roll at a "high speed" with "little to no altitude gained." The airplane subsequently rolled off the end of the runway, on to a runway safety area, and then on to grass. The airplane continued on the grass, where it struck approach lighting and a localizer antenna assembly, before coming to rest in a gully, on about runway heading, about 1,850 feet from the end of the runway. A postcrash fire consumed a majority of the airplane aft of the cockpit; however; all major portions of the airplane were accounted for at the accident site. The nose gear and left main landing gear separated during the accident sequence and were located on the grass area between the safety area and the gully.

Tire marks consistent with braking were observed to begin about 1,300 feet from the end of runway 11. The tire marks continued for about another 1,000 feet through the paved runway safety area.

The airplane was equipped with an L-3 Communications FA-2100 cockpit voice recorder (CVR) and an L-3 Communications F1000 flight data recorder (FDR), which were recovered and forwarded to the Safety Board's Vehicle Recorders Laboratory, Washington, DC for readout.

Initial review of CVR and FDR data revealed that the airplane's ground roll began about 49 seconds before the end of the CVR recording. The CVR captured callouts of 80 knots, V1, and rotate. After the rotate callout, the CVR captured comments concerning aircraft control. FDR data indicated the airplane reached a maximum speed of 165 knots during the takeoff roll and did not lift off the runway. FDR data further indicated thrust reversers were deployed and wheel brake pressures increased as the airplane decelerated. The FDR data ended about 7 seconds after thrust reverser deployment, with the airplane at about 100 knots. The FDR data did not reveal evidence of any catastrophic engine failures and revealed thrust lever angles consistent with observed engine performance. Review of FDR data parameters associated with the flight control surface positions did not reveal any movement consistent with a flight control check prior to the commencement of the takeoff roll. The flap handle in the cockpit was observed in the 10 degree detent. FDR data indicated a flap setting of 20 degrees during the takeoff attempt.

The airplane was equipped with a mechanical gust lock system, which could be utilized to lock the ailerons and rudder in the neutral position, and the elevator in the down position to protect the control surfaces from wind gusts while parked. A mechanical interlock was incorporated in the gust lock handle mechanism to restrict the movement of the throttle levers to a minimal amount (6-percent) when the gust lock handle was engaged.

The FDR data revealed the elevator control surface position during the taxi and takeoff was consistent with its position if the gust lock was engaged. The gust lock handle, located on the right side of the control pedestal, was found in the forward (OFF) position, and the elevator gust lock latch was found not engaged.

The wreckage was retained for further examination to be performed at a later date. The airplane was also equipped with a quick-access-recorder (QAR), which was retained for download.

The certificated airplane transport pilot, who was seated in the right seat, reported 18,500 hours of total flight experience on his most recent application for a Federal Aviation Administration (FAA) first-class medical certificate, which was issued on February 4, 2014.

The certificated airline transport copilot, who was seated in the left seat, reported 11,250 hours of total flight experience on his most recent application for an FAA first-class medical certificate, which was issued on April 15, 2014.

Both pilots completed a Gulfstream IV recurrent pilot-in-command course and proficiency check during September 2013. At that time, the pilot and copilot reported 2,800 and 1,400 hours of total flight experience in G-IV series airplanes; respectively.

Initial review of maintenance records revealed that at the time of the accident, the airplane had been operated for about 4,950 total hours and 2,745 landings.

The reported weather at BED, at 2156, included calm winds, visibility 10 miles; clear skies; temperature 8 degrees Celsius (C); dew point 6 degrees C; altimeter 30.28 inches of mercury.

SEPTEMBER 09, 2015 

NTSB: No preflight checks by Katz crew in 98 percent of flights

'Plain and simple, [this is] a case of pilots intentionally disregarding procedures,' NTSB member Robert Sumwalt said.


The National Transportation Safety Board said pilot error – especially "intentional, habitual" failure to perform safety checklists – caused the crash that killed philanthropist and former Philadelphia Inquirer co-owner Lewis Katz and six others.

The crew had a "long-term pattern" of failing to complete flight control checklists, Vice Chairwoman T. Bella Dinh-Zarr said in an opening statement of an accident review meeting.

She said with the Gulfstream's "gust lock" engaged as it hurtled down the runway, the plane "cannot take off safely." The gust lock prevents various flight controls, like the rudder and aileron, from moving and being damaged by winds while the plane is on the ground.

The NTSB also faulted the manufacturer, Gulfstream, and the Federal Aviation Administration for not assuring that the gust lock's locked position would have prevented any attempt at a takeoff by the flight crew.

The gust lock was engaged after the plane had landed in the Boston area, according to an NTSB investigator. The crew, he said, failed to do complete flight checks "98 percent of the time" in its previous 175 takeoffs.

The pilot repeatedly cried out, "The lock is on," before shouting, "I can't stop it."

Another NTSB investigator said the routine failure to perform preflight checks is a "procedural drift" that crews who routinely fly together over long periods of time are prone to fall into. The crew did just two full checks out of 175 examined by the NTSB. Partial checks were done sometimes.

"It appears that this, from my perspective, was plain and simple a case of pilots intentionally disregarding procedures," said NTSB member and pilot Robert L. Sumwalt III.

"There are so many things about this accident that bother me," added Sumwalt, who has operated a corporate flight service in his career.

He pointed out that the equipment and the crew were rated as among the best in the industry, but the failure to do flight checks changed that equation.

Sumwalt also said if the pilots had immediately shut off power when they noticed an issue, the plane could have safely stopped. Instead, the crew used precious seconds trying to troubleshoot the issue before pulling the power shutoff too late to save the aircraft.

Sumwalt introduced a new finding that the FAA had "missed an opportunity to detect insufficiencies" in the gust-lock system because it relied solely on engineering drawings and not field testing. He and two additional board members approved that finding.

The crash occurred on the night of May 31, 2014, after the jet accelerated down the runway at Hanscom Field in Bedford, Massachusetts. The plane never lifted off the runway and all aboard died.

Katz, who was 72, died just four days after winning an auction for ownership of The Inquirer, The Daily News and Philly.com.

Also killed in the crash were Katz friends Susan K. Asbell, 68; Marcella M. Dalsey, 59, who ran a Katz-funded charter school in Camden; and Anne B. Leeds, 74; along with three flight crew members, Bauke de Vries, 45; James McDowell, 51; and Teresa Anne Benhoff, 48. 

Katz had flown with Asbell, Dalsey and Leeds from Cherry Hill earlier that Saturday to attend a social event in the Boston area. 

The jet was scheduled to fly to Atlantic City International Airport – Katz owned radio stations at the shore and had a house there – when it crashed.

The NTSB found that the accident itself was survivable, but the resulting fire blocking an exit made it impossible for those aboard to escape the plane.

The preliminary NTSB report in June 2014 suggested pilot error likely was a critical factor in the crash. The experienced crew did not appear to have performed a preflight check that would have alerted them to an issue with the jet's gust-lock system. 

A further review showed the crew was routinely lax about doing checks before takeoff.

In April 2015, the NTSB released a cockpit voice recorder transcript that revealed one of the pilots had repeated the phrase, "The lock is on," followed by, "I can't stop it" and "Oh no no" just prior to the crash.

Katz, who rose to prominence in business and law, was a former owner of the New Jersey Devils and Nets. 

In recent years, he became increasingly dedicated to charity, donating millions of dollars to educational institutions, including Temple University, the Dickinson School of Law and Katz Academy, a charter school in the Parkside section of Camden, where Katz lived as a child.

http://www.phillyvoice.com

WASHINGTON – A fiery business-jet crash that killed a co-owner of the Philadelphia Inquirer happened because pilots mistakenly left the Gulfstream IV’s wing flaps locked in place, as if the plane were parked, which prevented the aircraft from lifting into the air, federal investigators ruled Wednesday. 

The National Transportation Safety Board found that the plane's red-handled "gust-lock system" was engaged, which kept ailerons, elevators and rudder locked in place, even though it was supposed to be turned off before starting the engines. The board found that the gust lock prevented the plane from taking off on May 31, 2014, in Bedford, Mass.

Gulfstream designed a limit on its throttle so that a plane couldn't reach takeoff speed if the gust lock was engaged, according to investigators. But investigators discovered after the crash that the throttle could and did reach takeoff speed, despite the limitation.

The Federal Aviation Administration missed the design flaw in certifying Gulfstream's plane based solely on drawings, the board found.

As the plane hurtled down the runway and into a ravine, the experienced pilots can be heard on the cockpit voice recorder repeatedly saying the “lock is on," according to the transcript. “I can’t stop it,” a pilot said before the crash.

Bella Dinh-Zarr, the board's vice chairman, said the pilots had flown together for years and had thousands of hours of experience but habitually neglected steps in preflight routines. The crew skipped steps during 98% of their previous 175 flights, according to investigators.

“An airplane cannot take off safely with the gust lock engaged," Dinh-Zarr said. “The flight crew routinely neglected performing complete flight checks."

Robert Sumwalt, a board member and 32-year commercial pilot, said preflight checks aren't just for Gulfstream planes, but for the safety of all flights.

"If you’re acting that way, you are just fooling yourself," Sumwalt said. “You don’t have a good operation if you’re not following those procedures."

As Gulfstream modifies its gust lock to prevent a takeoff while it is engaged, the board recommended that the FAA should require the company to retrofit existing planes with the new equipment.

The flight was planned from Hanscom Field, about 20 miles northeast of Boston, to Atlantic City International Airport.

The crash killed seven people, including Inquirer co-owner Lewis Katz, three other passengers, two pilots and a flight attendant.

Katz, 72, was killed four days after putting together an $88-million deal to gain control of the media company that owns the Inquirer with an eye toward restoring the newspaper's stature.

The plane traveled 2,000 feet along the ground after rolling about 850 feet off the end of a runway without ever becoming airborne, a witness told NTSB.

The plane hit an antenna and smashed through a chain-link fence before going down an embankment into a gully filled partially with stream water. Witnesses said they heard an explosion and saw a fireball 60 feet in the air.

The 44-year-old pilot in command had 11,250 hours of flying experience, according to investigators. The other pilot, who was 61 years old, had 18,530 hours of flying, investigators said.

http://www.usatoday.com

Cockpit transcripts of the last moments before a Gulfstream jet crashed last year in Massachusetts, killing Inquirer co-owner Lewis Katz and six others, show the pilots suddenly realizing they had tried to take off with their elevators and rudder locked. 

"Lock is on," the pilot says seven times as the plane accelerated down the runway at Hanscom Field, outside Boston.

His next words were "I can't stop it," then "oh no no."

The plane crashed and burst into flames at 9:40 p.m. on May 31 as it sought to take off for Atlantic City after Katz and his friends had attended a Saturday fund-raiser at the home of historian Doris Kearns Goodwin.

The National Transportation Safety Board on Wednesday made public 800 pages of analytical reports on the crash but stopped short of providing an official cause. That will come in the fall in a final NTSB report on the fiery crash everyone aboard Katz's $30 million jet.

Still, the NTSB experts returned repeatedly to a theme of pilot error first suggested when the agency released its initial preliminary report shortly after the accident.

The new documents again state there was no evidence that the pilots performed preflight checks before the fatal takeoff - and disclosed for the first that the experienced crew routinely took off without doing checks.

This meant the pilots tried to take off without realizing that they had failed to unlock the elevators and rudder on the plane's tail, the NTSB documents suggest. But a plane cannot go aloft if the elevators are locked.

Upon landing, pilots routinely lock them down so when planes are parked on open fields such as Hanscom, aircraft are not blown around by the wind.

In a seeming paradox, the preliminary NTSB report noted that while the elevators were locked, the gust lock was in a "off" position.

Some analysts have said that the pilots, in hopes of continuing with a takeoff, may have flipped the gust locks off even as the plane was rolling down the runway - a violation of procedure. Even so, the analysts say, their action failed for some reason to free up the elevators, setting the scene for the fatal crash.

The accident killed Katz, 72, just four days after he had won an auction for ownership of The Inquirer, The Philadelphia Daily News and Philly.com. After making his fortune in business and law, Katz had become a major charitable giver, pledging millions of dollars to Temple University, the Dickinson School of Law and others.

Others killed in the crash included three Katz friends - Susan K. Asbell, 68, Marcella M. Dalsey, 59, and Anne B. Leeds, 74 - and three crew members - pilots Bauke De Vries, 45, and James McDowell, 61, and flight attendant Teresa Ann Benhoff, 48.

Tuesday's report stated that McDowell served as pilot for the fatal flight and De Vries was his copilot.

Victims of plane crashes or their relatives have up to two years from an accident to file lawsuits. So far, relatives of two victims have brought suits.

The family members of Leeds and Dalsey have filed a lawsuit in Philadelphia courts against Gulfstream; other makers of parts and controls for the plane; and the company owned by Katz and a Katz friend who owned the jet.

Arthur Wolk, the lawyer representing those families, said he found the report released Thursday incomplete and "raised more questions that it answered."

"If you want to blame dead pilots," he said, "it's a great report."

He said the report's investigation of the plane's gust locks showed that the system is "clearly an inconsistent and problematic component of an extremely expensive airplane."

Earlier on May 31, the Gulfstream left its Hanger No. 9 at New Castle County Airport near Wilmington and flew to Atlantic City, an eight-minute hop. After Katz and South Jersey passengers boarded there, the plane took off again and landed at Hanscom Field, in Bedford, Mass., at 3:44 p.m., waiting there for its passengers to return.

Lightly loaded, with only about half its maximum number of passengers, on a long runway, and helmed by two highly experienced pilots, the Gulfstream was making a routine takeoff when it crashed.

The plane had flown for 4,950 hours over its 14-year life. In all, Gulfstream, a subsidiary of General Dynamic, built about 500 Gulfstream IV's between 1987 and 2003. More are still aloft. Accidents involving the Gulfstream are extremely rare.

The crash in Massachusetts was only the 18th accident involving a Gulfstream IV - out of a total fleet time aloft that is the equivalent of almost 500 years.

It was only the fourth time a crash resulted in death and the second time a Gulfstream IV has crashed on takeoff.

The plane's relative safety is also borne out by statistics. Over the last five years, Gulfstream G-IV jets have had about one accident for every 600,000 hours flown. In contrast, the industry wide rate for all such business jets is 2.6 accidents per 600,000 hours aloft.

Source: http://www.philly.com

Pilot Bauke “Mike” de Vries with the plane that crash at Hanscom Field. 

 NTSB Senior Air Safety Investigator Luke Schiada speaks during a news conference at Hanscom Field in Bedford, Mass.,  June 2, 2014, regarding the investigation into  Gulfstream G-IV (N121JM) plane which plunged down an embankment and erupted in flames during a takeoff attempt there on May 31. Lewis Katz, co-owner of the Philadelphia Inquirer newspaper, and six other people died in the crash. 

Gulfstream jet pilots received notice from the company that a safety device designed to prevent accidents like the one that killed sports-franchise mogul Lewis Katz can be foiled in some circumstances.

The system is supposed to keep pilots from setting engines for takeoff power if control panels on the wings and tail are locked, Gulfstream told operators in an Aug. 18 letter obtained by Bloomberg News. Instead, it may be possible to add thrust “if proper unlock procedures are not followed,” it said.

The letter helps explain why Katz’s Gulfstream IV reached a speed of 190 miles (306 kilometers) an hour on the ground without lifting off as it tried to depart Bedford, Massachusetts, on May 31. It’s too early to determine if Gulfstream needs to modify its planes or pilots’ preflight procedures, said Steve Cass, a company spokesman.

“We’ll need to continue to get input and once we have sufficient input then we’ll decide if there’s any type of change that we need to make either to our procedures or to the aircraft itself,” Cass said by telephone. “I think it’s premature to make that conclusion right now.”

Gulfstream, a General Dynamics Corp. (GD) unit, has more than 2,000 aircraft in operation and all the company’s models have the gust-lock except for the G650, which uses different technology, he said.

Pilots are supposed to lock control panels on the wings and tail of the airplane when it’s parked at an airport to eliminate the risk of wind damage. Gulfstream’s flight manual requires pilots to switch off the gust-lock before starting the engines.
 
NTSB Probe

Four corporate pilots who have flown the Gulfstream IV said in interviews that they had all made the mistake of forgetting to switch off the gust-lock before starting the engines. They asked not to be identified because their employers don’t permit them to be interviewed.

While such an error wasn’t common, it was easy to forget to switch off the gust-lock in the proper sequence during the busy process of readying a plane for flight, they said.

When flight controls are held in position by the gust-lock mechanism, the nose of the airplane is forced down and liftoff is prevented even after the plane accelerates.

In the Katz crash, there was no evidence the cockpit crew attempted to check whether the control surfaces were working after starting the engines and taxiing to the runway, according to the U.S. National Transportation Safety Board’s review of the crash-proof flight data recorder.
 
Plane Controls

Katz’s jet rolled down the 7,011-foot (2,136-meter) runway before sliding into a field, where it slammed into a gully and burst into flames. Katz and six others died.

The NTSB isn’t commenting on the accident beyond its previous statements and updates, Keith Holloway, a spokesman, said yesterday.

The Gulfstream notice reminded pilots to ensure they have switched off the gust-lock before starting the engines and to always check the flight controls before takeoff. The notice didn’t specifically reference the Katz crash.

The four pilots interviewed said that once the engines start driving the plane’s hydraulic system, which in turn moves the plane’s flight controls, it becomes difficult to release the gust-lock. It’s still possible to force the locking mechanism’s switch into the off position, they said.

If the gust-lock lever is in the on position, it limits engine power to slightly above idle, according to the plane’s manual.
 
Flight Manual
 
None of the pilots said they knew it was possible to move the switch in a way that allowed takeoff power while retaining the lock on the flight control panels on the wing and tail. Gulfstream’s manuals don’t mention this scenario.

If pilots forget to switch off the gust-lock, Gulfstream’s flight manual advises shutting the engines down before releasing it, a time-consuming process.

In the Katz crash, the plane’s elevator, which raises and lowers the nose, was in a position “consistent” with being locked during the takeoff attempt, according to a preliminary report released June 13 by the NTSB.

The gust-lock lever was found in the off position in the wreckage, the NTSB said.

Gulfstream’s preflight procedures include several steps designed to prevent inadvertent gust-lock errors. In addition to guidance about how to turn the lock on and off, pilots are required to test the control surfaces each time they start the plane. Gulfstream also recommends pilots test the elevator again while accelerating on the runway.
 
Newspaper Owner

The letter “is really to remind folks about that,” Cass said.

Katz, 72, had flown to Bedford to attend an event at the Concord, Massachusetts, home of Richard Goodwin and historian Doris Kearns Goodwin. Katz was a lawyer and businessman who once owned the New Jersey Nets basketball team, New Jersey Devils hockey team and ran a billboard company and parking-lot operator. He won control of the Philadelphia Inquirer newspaper and its sister publication at a court-ordered auction four days before the crash.

The other passengers were Susan Asbell, 67, of Cherry Hill, New Jersey; Marcella Dalsey, 59, of Williamstown, New Jersey, and Anne Leeds of Longport, New Jersey. A flight attendant, Teresa Ann Benhoff, 48, of Easton, Maryland, was also aboard.

The business jet was being flown by Captain James McDowell, 51, of Georgetown, Delaware, and co-pilot Michael De Vries, 45, of Marlton, New Jersey, according to the Middlesex County district attorney’s office.

Both pilots had more than 10,000 hours of flight experience, according to the NTSB.

- Source:   http://www.bloomberg.com

(NECN: Peter Howe, Boston) - Stressing that it was still a preliminary report, the National Transportation Safety Board said Friday it found evidence of a possible mechanical problem with the equivalent of a parking brake for the Gulfstream IV jet that crashed and killed Philadelphia Inquirer co-owner Lewis Katz and six others at Hanscom Field in Bedford May 31.

But the NTSB also said it found no evidence that pilots conducted the kind of fundamental pre-flight check of their controls that they should have – and which could well have alerted them to a problem with the “gust lock” if that was a key factor that caused the jet to fail to get airborne, run off the runway and crash and burn in a gully, killing Katz, three of his friends, and both pilots and a flight attendant.

“The key piece of information that I saw in that preliminary report was the fact that the pilot failed to run a checklist,’’ aviation safety expert John Goglia said in an interview Friday. He served for nine years as a member of the NTSB, the first member of the board to hold a Federal Aviation Administration aircraft mechanic’s certificate. Goglia is a former Professor of Aviation Science and Director of the Center for Integrated Emergency Management at Saint Louis University’s Parks College of Engineering, Aviation and Technology.

In the NTSB report,  investigators wrote, in part, “Review of FDR” or flight data recorder/”black box” information “did not reveal any movement consistent with a flight control check prior to the commencement of the takeoff roll." Goglia said that’s a standard thing pilots are taught to do before every single takeoff, turning the control wheel right and left, moving the control column or “yoke” forward and back, testing the rudder pedal movements on both sides, and other checks.

The NTSB also said black-box data “revealed the elevator control surface position during the taxi and takeoff was consistent with its position if the gust lock was engaged." The gust lock, deployed to protect a plane when it is parked on the ground, is roughly analogous to a parking brake for a car and in the case of a jet, freezes the plane’s elevator and flaps in positions that prevent the plane from getting airborne. When investigators combed the wreckage, they discovered the “gust lock handle, located on the right side of the control pedestal, was found in the forward (OFF) position, and the elevator gust lock latch was found not engaged.’’

Two possibilities this suggests are that there was a mechanical problem between the gust lock handle and the lock itself, so that moving the handle to the off position failed to release the lock, or that the pilots had begun to taxi and take off with the gust lock on and while moving tried to shut it off as they also deployed “thrust reversers” and wheel brakes to try to stop the plane from crashing.

“He may have forgotten the gust lock,’’ Goglia said, “but the bigger issue is, he didn't run the checklist, so it immediately makes him suspect for being a problem.’’

However, Boston attorney Peter Black, a partner with Meehan, Boyle, Black & Bogdanow P.C., an expert in aviation litigation who was a U.S. Navy pilot in Vietnam and business jet pilot before becoming an attorney, said after reviewing the NTSB report, “There are a lot of questions that need to be answered, and the preliminary report, I think, just makes more questions.’’

For Black, what doesn’t make sense is that in addition to freezing the elevator and flaps in a position that would have prevented the plane from getting airborne, the gust lock also should have held the idle speed of the jet engines at a very low level – and yet, the NTSB report said the Gulfstream IV was moving as fast as 165 knots, or close to 190 m.p.h., while racing down the runway, and was still moving about 115 m.p.h. when it crashed and burned past the end of Hanscom’s Runway 11.

“If the gust lock was engaged, if things were functioning properly, they never should have been able to advance the engine’’ to anything close to takeoff speed, “so I think at this point there's still a question as to what happened out there.’’

“If the gust lock was engaged, as I understand it, there was a mechanical lock that should have prevented the throttles from being advanced, so if it were engaged, even though the crew wouldn’t have had the control movement they also wouldn’t have been able to add power to take off. They would have been sitting at the end of the runway saying: ‘Something’s wrong,’ ‘’ Black said.

Goglia said he agrees that there are questions that still need to be answered about just what if anything was malfunctioning with the plane’s gust lock. But he said it appeared the most important takeaway lesson is one drilled into pilots during training: Just don’t ever, ever, ever skip the pre-flight controls check.

Had it been run on that plane on the night of May 31, Goglia said, any gust lock problem would have been “a non-event. It would have been found and rectified before he left.’’

http://www.necn.com


 June 12, 2014 
  
Flame retardant from plane crash billows along Shawsheen 

Flame retardant used to douse a burning plane at Hanscom Field in Bedford earlier this month floated down the Shawsheen River last week, appearing at the Ballardvale dam, where huge piles of light, white, fluffy foam were seen forming over the rocks and floating into the air.

Pockets of it remained late last week and small pieces continued to float into the air around the dam, located just north of the Andover Street bridge. Smaller pockets of foam also were reported at the Stevens Street dam in Andover.

Environmental officials said the flame retardant used at the crash site floated down the river as “residuals” that aren’t visible unless the water gets stirred up, which is what happened due to the turbulence of the water at the base of the dams. However, it presented no environmental or health threat, they said.

But it certainly created a curiosity.

Charlie MacNeil, co-owner of Andover Hardware, an industrial supply company with an office on the river, said he saw the foam last Wednesday afternoon, June 4, and assumed it was created by dish soap thrown into the river.

“It was like someone had a bubble-maker,” he said. “It was floating up into the air.”

He said a fisherman who had waded into the river was enveloped by the foam as he cast his line.

“He was surrounded by it,” he said. “It was interesting to see.”

The fire-retardant foam was used to douse the flames in a May 31 plane crash that killed seven people. At 9:40 p.m., the Gulfstream IV aircraft was attempting to take off from Hanscom, but apparently never left the ground. Instead, it hurtled off the runway, across a field and into a ravine where it exploded into flames. Federal officials are continuing to investigate the cause of the crash.

The point where the plane crashed and burned is also where the Shawsheen River begins. According to the Shawsheen River Watershed Association, the river starts at Hanscom Field and runs 25 miles through a half-dozen cities and towns before dumping into the Merrimack River near the Interstate 495 overpass in Lawrence.

The dam in Ballardvale is the first dam on the river after the headwaters.

In Bedford, town officials shut down the wells used to pump drinking water from the Shawsheen due to the crash. Environmental cleanup crews installed booms and other devices to soak up the oil and fuel that spilled after the accident.

The booms did not, however, contain the fire-retardant foam.

For a short time, the origin of the foam at the Ballardvale dam was something of a mystery, Andover Conservation Commission agent Bob Douglas said.

He said he was at the commission’s regular, monthly meeting on Tuesday, June 3, when someone showed him pictures of the foam, which was building up at the base of the Ballardvale dam, blowing around in the breeze and floating down the river.

Conservation volunteer Andy Menezes of 3 Waverly Drive, who was also at the commission meeting, said he became extremely curious about where the foam came from after viewing the photos.

“I live down there, so after the meeting, I went down there at about 10:30 that night and stood on the wall,” he said. “I could see some pieces of it floating around. It didn’t smell, and to the touch it was very dry. I figured it was some kind of chemical dispersant from some kind of spill. But that’s usually slimy. This was dry.”

At daylight Wednesday, June 4, Menezes said he went out and took a closer look and noticed that the material was bright white, so it couldn’t have been organic. He said organic foam is usually slightly brown.

He then went home and did some research about the cleanup of the plane crash. He saw photos and read accounts of fire-retardant foam being used. He wrote up a memo and sent it to Douglas. 


“Most of the stuff is supposed to be nontoxic,” Menezes said. “I think it’s benign, but they used a lot of it. The headwaters of the Shawsheen are right at the end of the runway. I thought about those poor people who died, then I thought about the river.”

Douglas said that after he got the email from Menezes, he immediately began making inquiries, calling or emailing local, state and federal officials to find out if, in fact, it was fire-retardant foam that was showing up in Andover. And if it was, he wanted to know if it was toxic to humans or the environment.

“First, I notified public health,” he said. “They said they’d already been called. The DPW had also been called. I also called the Fire Department to find out if it was hazardous.”

Finally, he forwarded one of the emails to Pam Merrill, a wetlands expert with the state Department of Environmental Protection in Wilmington. She investigated and soon found some answers.

Merrill spoke with the DEP’s Emergency Response team, which was able to confirm that the foam was “in fact residuals from the fire suppression used at Hanscom .... They did assure me that the foam fire suppression was applied properly and is not an environmental concern.”

She said the product, a combination of oxygen, hydrogen and carbon compounds, breaks down in water.

“However, when the ‘residuals’ are agitated in the stream, due to an increase of water velocity, moving through some rocks/vegetation in the river or over a dam, it turns into foam again, which is exactly what you’re seeing at the Ballardvale Street dam,” she wrote in an email to Douglas last week.

“There is no need to contain the residuals as it will eventually be diluted. Emergency Response has been overseeing the remediation efforts from the fuel spill by Clean Harbors at the impact site and there has been zero fish kill reported.”

Ed Colletta, the public relations director for Mass. DEP, said Merrill’s email pretty much summed up the situation.

“The thought is that it will continue to dissipate and not be a concern environmentally,” he said. “Especially once it gets into the Merrimack River. It should be pretty well diluted by then.”

He added, “it’s not a health hazard. I’m not sure if you’d want kids to play in it, but if you touched it, or got it on your clothes, there is no health issue in that form.”

He said DEP would continue to monitor the presence of the foam through the local conservation agents in the towns along the Shawsheen River. “We are aware of it and are keeping an eye on it,” he said.

Someone else keeping an eye on it was Fire Chief Mike Mansfield, who got a call from Bedford Fire Chief David Grunes, who filled him in on the situation.

“I talked to the chief and he didn’t think enough went downstream to create a problem,” Mansfield said. “The state DEP is not that concerned about it. It will work its way out through the system, but it’s going to create a foam by-product.”

He noted that different types of foam are used by firefighters in different situations. In this case, he said, the type used was Aqueous Film-Forming Foam, or AFFF.

“It creates a blanket,” he said. “It separates the oxygen in the atmosphere and shuts down the ability to have combustion occur.”

He said it doesn’t absorb hydrocarbons, so that the foam appearing in Andover doesn’t contain oil or fuel products.

“It’s used extensively on motor vehicle fires, or any kind of oil or gasoline spills,” he said. “It’s very effective.”

Mansfield checked out both the Ballardvale and the Stevens Street dams, reporting that he saw signs of the foam in both places.

“There’s no threat to anybody’s safety at all with this stuff,” he said. “If there was, we would have been notified by the DEP and state and federal agencies that oversee this type of thing.”

A Bedford fire official said the foam was put on the plane by the Hanscom Field Fire Department. A call to the base spokeswoman was not returned.

- See more at: http://www.andovertownsman.com

Six-foot high piles of foam created from remnants of fire-retardant chemicals used on an airplane crash at Hanscom Field earlier this month that killed seven people were seen at the Ballardvale dam last week. Officials say the foam poses no known health risk.  

Foam built up at the base of the Ballardvale dam on the Shawsheen River last week. The foam was caused by fire retardant used on a plane crash at Hanscom Field earlier this month that killed seven people.