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.
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
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
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
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.
Photographer: by Jim Davis/The Boston Globe via Getty Images
The General Dynamics Corp. Gulfstream IV never left the ground even though it reached a speed of 190 miles (306 kilometers) an hour, the NTSB said in a briefing June 3.
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.
The General Dynamics Corp. Gulfstream IV never left the ground even though it reached a speed of 190 miles (306 kilometers) an hour, the NTSB said in a briefing June 3.
Six-foot high piles of
foam created from remnants of fire-retardant chemicals used on Gulfstream G-IV (N121JM) plane crash at Hanscom Field on May 31, 2014 that killed seven
people were seen at the Ballardvale dam. Officials say the
foam poses no known health risk.
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