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.
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 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.
The NTSB announced a public meeting for Wednesday, September 9 to determine the probable cause of the crash last May of the Gulfstream IV airplane that killed Philadelphia Inquirer owner, Lewis Katz. Mr. Katz, a lawyer and businessman, was a former owner of the NJ Nets and Devils. The private jet, en route to Atlantic City, NJ, crashed while attempting to takeoff from Hanscom Field in Bedford, Massachusetts. The plane never left the ground, ran off the end of the runway and crashed into airport lights and an antenna, ending up in a ravine. The resulting fire destroyed the aircraft, killing everyone on board. In addition to Mr. Katz, the crash also claimed the lives of 3 other passengers, both pilots and a flight attendant.
At the public meeting to determine the accident’s probable cause, the NTSB investigators will present their report to the Board Members for their consideration. The Board Members will typically ask the investigators questions regarding the report and deliberate in public. Then, they will announce their decision on the probable cause of the crash. In addition to the probable cause determination, the Board Members will make findings of fact and issue recommendations to prevent a similar accident from occurring in the future. Of particular interest to many, including aircraft manufacturers, is what recommendations, if any, the NTSB will make to the FAA regarding its certification of aircraft, in particular the certification of similar aircraft models.
Documents in the NTSB public docket on the Gulfstream IV accident investigation indicate that the most immediate – and therefore probable – cause of the accident is likely to be the failure of the pilots to disengage the gust lock mechanism. The public record indicates that the gust lock mechanism was not disengaged prior to the attempted take off which prevented the aircraft from lifting off. Gust locks are used to prevent the aircraft’s primary flight controls (elevator, ailerons and rudder) from being damaged by surface winds up to 60 miles per hour when the aircraft is parked on the ground. Left in the locked position, they prevent the aircraft controls from functioning properly. The documents in the public docket indicate that the failure to disengage the gust locks was likely due to the pilots’ failure to use mandatory checklists.
However, of perhaps greater interest than the probable cause determination in this accident is whether the NTSB will make any recommendations regarding changes to the FAA’s aircraft certification requirements. Documents in the record indicate not only that the pilot failed to disengage the gust lock but that the gust lock fail-safe system failed, which allowed the throttle to be advanced to take off power while the flight controls were still locked. FAA design certification standards require that if a gust lock is not disengaged, and the system does not automatically disengage, the pilot has to receive an “unmistakable warning at the start of takeoff.”
It appears to me from Gulfstream’s response to questions from investigators that the gust lock on the G-IV did not meet this design requirement. Specifically, when the gust lock was engaged the throttle was not supposed to move more than 6 degrees, limiting the amount of power to the engines and thereby providing the crew with the required “unmistakable warning”. However, according to the information provided to the NTSB by Gulfstream, a test of the gust lock indicated that the throttle could move beyond the fail-safe design criteria. The failure of the fail-safe design raises questions about how the FAA certifies aircraft designs, especially how it certifies design changes when a manufacturer introduces an update to a previously FAA-approved aircraft, as was the case with the G-IV.
According to the report prepared by the NTSB Certification Group Chairman investigating the accident, “the certification basis for changed aeronautical products allows an aircraft manufacturer to introduce a derivative model as a design update on a previously certificated aircraft and add the changed product onto an existing [type certificate or TC]. The FAA approves such changes if it finds that the changes are not significant enough to warrant application for a new TC. This process enables a manufacturer to introduce derivative aircraft models without having to resubmit the entire aircraft design for certification review. The manufacturer can use the results of some of the analyses and testing from the original type certification to demonstrate compliance, in which case the regulations that were in effect on the date of the original TC apply.”
Currently, aircraft manufacturers are able to update aircraft design models without the lengthy and expensive FAA certification required for new type certificates. It will be interesting to see what if any changes the NTSB recommends to this process. Of course, the NTSB can only recommend changes. It would be up to the FAA to adopt the changes, in whole or in part.
Original article can be found here: http://www.forbes.com
Only one article mentioned it, the pilot had a high ehthonal level in blood, like .35, it seems some is present in most reports I see on here but that looks high on the autopsy report
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