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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.
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
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.
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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
