Hanscom G-IV Crash - NTSB probable cause
 

How does a professional crew with a combined 29000+ hours and flying together for 12 years get into a routine of "habitual noncompliance with checklists"?

http://www.ntsb.gov/news/press-relea...R20150909.aspx

You've answered your own question.
Human factors, you get too 'comfortable' with each other.

This is troubling:

Continue when locked?
 

Not a pilot, but a former reliability guy for the major microprocessor manufacturer, and well aware that routine checks can get skipped by human beings who don't think they'll ever catch anything. But I'm genuinely puzzled by this:

My guess it that despite the recorded comment, somehow internally there was some combination of disbelief and of "success orientation", but that is a pretty wild guess.

Hanscom G-IV Crash - NTSB probable cause
 

Quick question: is the a way to unlock the flight control from the cockpit? Would that be an option instead of rejecting the take off?

Attack
 

There is: if you read the NTSB report you'd learn that the system incorporates a feature supposed to prevent the throttles to be advanced with flight controls locked. It simply didn't performed as supposed to.

What you suggest would be expensive and/or difficult to certificate.
Furthermore, it's impossible to design an airplane that protect itself from pilots displaying a complete lack of airmanship.

Hanscom G-IV Crash - NTSB probable cause
 

Sorry maybe I did not spell out my question correctly. I understand that the built in safeguard has failed here. My question was more: was there another option to the (late) RTO ? Could they have taken the aircraft into the air after having the flight control unlocked ?

Your understanding is wrong. What failed here were pilots who failed to perform basic checklist.

The Gust Lock is operated from the cockpit, via a lever near the flap handle. However, the gust lock cannot be disengaged if the Flight Power hydraulic assist system is already loading on the flight controls.

So normally the gust lock must be released early in the checklist, when the hydraulic system still unpressurized before the engine is started. Otherwise the gust lock will remain engaged until the engines are shut off again and hydraulic pressure is removed.

There is a Flight Power Shut-off Valve (FPSOV) which can be pulled in an emergency in case there is a jam in the hydraulic system. The FPSOV will relieve the hydraulic pressure. It can also be used as an unapproved way to disengage the gust lock once engines have been started (e.g., during taxi).

There's evidence that the crew pulled the FPSOV. But, it is not known if pulling the FPSOV during a take-off run will successfully disengage the gust lock, because now we're dealing with aerodynamic pressures loading on the flight controls, in addition to the hydraulic pressure.

Part of the reason is that they did not discover the issue until after v1, when they attempted to rotate. Pilots are trained with the mindset that problems before v1 == rejected take-off, while anything > v1 means continuing the flight.

Another reason is they might have initially thought that they were having a power hydraulics issue and so they tried to solve it by pulling on the FPSOV handle (as above) and tugging on the flight controls.

Pulling the FPSOV also disabled the ability to deploy the spoilers didn't it? That didn't help in the reject attempt.

The biggest issue is the lack of control checks. Whilst there may well indeed have been a fault/flaw with the gust lock mechanism which may have actually engaged as they started rolling down the runway- IF the crew had of been more professional and done a successful FULL control check prior to that takeoff I would expect that at the first sign of lack of control when barrelling down the runway their decisions and actions would have been different. I know mine would... Let's see I just did a successful control check before applying takeoff power, now my elevators are jammed and the lock is on and not releasing. No hope of getting airborne let's abort!

Control Checks
 

This poor practice and lack of knowledge is unfortunately not uncommon.

Not too long a go I was flying for a European scheduled airline as a line training and checking captain where I routinely saw the FOs do the control checks then if it was windy put the control locks back in. They would rely on memory to remove them before take off but never considered doing another control check.

The fact that I saw many different FOs do this indicates that it was normal practice in the airline which was also backed up by my questioning of the crews. They also saw nothing wrong with it and considered it to be normal practice. Believe it or not a couple even thought I was being awkward by insisting on a control check every time the locks were removed.

This unfortunately happens when small isolated groups of people do not either have or seek outside input to their operation.

MM

So normally the gust lock must be released early in the checklist, when the hydraulic system still unpressurized before the engine is started. Otherwise the gust lock will remain engaged until the engines are shut off again and hydraulic pressure is removed.

This strikes as a classic case for having a takeoff configuration warning horn fitted, as per most airliners. This would act as a back up to the other system preventing takeoff power being selected, which didn't work.

Part of the reason is that they did not discover the issue until after v1, when they attempted to rotate. Pilots are trained with the mindset that problems before v1 == rejected take-off, while anything > v1 means continuing the flight.

At the end of the takeoff/RTO brief it usually goes on the "or if the a/c is unsafe to fly." Even if >V1 this scenario seems to fit into this category. How long was the runway? On longer than required runways stopping after V1 is often not a problem; if you react soon enough. There might have been a moment of astonished disbelief frozen in the headlights phobia.

Amazing! := :ugh:

I don't, the comment is justified in view of this... , quoting AOPA:

"A review of the flight crew’s previous 175 flights revealed that the pilots had performed complete preflight control checks on only two of them. The flight crew’s habitual noncompliance with checklists was a contributing factor to the accident.”

Easy Answer? No Such Thing
 

As others properly note, they got into this situation for exactly the reasons that the thread opener asks. High-time, long personal association, long experience on type (probably the same specific aircraft) and the like. Habits like these are nearly impossible to break and comments like, "We always do it this way," and "We know this airplane inside and out," are not rare.
One of the genuine hallmarks of the 'real' professional is to assume nothing and conduct the inspections and setups from scratch, Every Single Time. As this situation demonstrates, super-efficiency and perhaps saving a whopping five minutes is never worth the risk.
I do not know how to break that mold, but I hope someone figures out a good way to do so.
I must add that I do NOT understand how/why any pilot would/could release brakes without first performing a full range control surfaces test. If the results dictate a shutdown and further inquiry, so what? Even a C172 student pilot understands that one cannot control an airplane with locked controls - and V1 is darn sure not the place to discover the problem. Ouch!

Screw AOPA, that comment si from the NTSB report.

In any case, Let him who is without sin cast the first stone comes to mind.

• The crew failed
• The airplane failed
• Gulfstream failed
• The FAA failed

This is why an accident seldom has a single cause.

http://s3.amazonaws.com/rapgenius/Swiss-Cheese.jpg

The crew failed
The airplane failed
Gulfstream failed
The FAA failed

And what % of causal blame do you attribute to each? It would seem your list is in reverse order of occurrence, slightly. I'd put FAA at No.2., but still reverse order.

Has happened to operators with huge fleets and huge numbers of pilots as well. E.G. the takeoff warning CB in DC-9ers or was it the MD s in an american carrier that led to an flap/slatless T/O attempt...

See also my post in the GA Forum thread on the KBED accident (below). Such a shame that the crew realized a problem early on per the NTSB video but by the time they took action to stop, it was too late.

http://www.pprune.org/biz-jets-ag-fl...ml#post9111459

100%
 

All four get 100%. Had any one of them done the job correctly, this accident would not have happened. :ugh:

And that's why there will always be pilots on airplane: to ensure that the big corporations, airlines, aircraft manufactures and 'regulators' will walk away with a light slap on the wrist at the most.

NTSB VIDEO BRIEFING
 

You may not have found the NTSB video briefing here:

Not mentioned in the text so far, but mentioned in the video is that the crew observed a Blue rudder limit light as they turned onto the runway.
Apparently, for those that know the aircraft systems, this is a secondary indication that the gust lock is engaged!

You would think that they would have sorted that out before applying power-assuming that they knew their aircraft's systems.:hmm:

Commanding an aircraft is not part of a popularity contest.
Even if you're flying with your best buddy INSIST on doing it right.
If he wants to take it to the office then fine.
I never went to the office in forty years.

There's a saying I've come across from two Army guys: "The standard you walk past is the standard you accept."

How do they know ?
 

I looked at the pdf on line and what I does not say is how they know the crew was habitually not performing the required checklist. "the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the airplane, indicating that this oversight was habitual and not an anomaly."

I assume they must have the CVR data somewhere. Is there a requirement to store this data. If so for how long?

There is a lot of blame to go around here. Interesting and scary reading.


20driver

The data is not from the CVR but from the QAR (Quick Access Recorder) database. The QAR is similar to the FDR but may record many more parameters and often at a higher sample rate. However the QAR is not designed to survive a crash.

These days many airlines & flight departments will periodically download and analyze QAR data in accordance with their Flight Operations Quality Assurance (FOQA) program. The data is kept in an archival database and is used to provide safety oversight.

FOQA is part of a larger Safety Management System (SMS). It's a pity that this particular operation apparently had an audited SMS in place, but clearly no one really paid attention to basic practices like making sure checklists are being followed.

FOQA and SMS are voluntary in the US although they will soon become mandatory for Part 121 and is already in wide use among airlines and many biz jet ops.

Hanscom G-IV Crash - NTSB probable cause
 

Indeed if they had an SMS in place this should have raised some alerts...

The "holes in the cheese" argument is tripped out on every conceivable occasion. Sometimes it's valid, and sometimes it's not. It isn't just the non-aviators here who seem to coveniently ignore that good Captaincy and Airmanship will prevent the holes lining up. If you willfully ignore those 2 key facets to flight safety, at some point the "contributory factors" may catch you out. In this case no less than 4 of the most basic Captaincy and Airmanship gates were missed and the holes lined up. So stop blaming this amorphous factor and accept that poor training and decision making is still a key factor in aircraft accidents.

That's all undeniably true.

But it reinforces, rather than invalidates, the Swiss cheese model.

Given that the late abort decision was suicide, could the Horizontal Stab have been trimmed to get it to rotate?

Flying with the controls locked would be friggin dangerous, but it might buy time and opportunity compared to the abort decision.

How the heck are you going to find a flight control issue if you don't cycle the controls? They stopped being defensive pilots long before this accident.

Given that the late abort decision was suicide, could the Horizontal Stab have been trimmed to get it to rotate?
Flying with the controls locked would be friggin dangerous, but it might buy time and opportunity compared to the abort decision.

You are asking that question on here as a Monday morning quarterback and with lots of hindsight & thinking time. They had seconds to make a decision. The question you ask would take a superior pilot to action & answer. Take a look at the thread about a C140 engine failure on takeoff at 50' where the pilot waggled the wings to drip some fuel into the engine from supposedly empty tanks. I suspect, strongly, that some where deep in his subconscious memory an old sage had dropped that pearl of survival wisdom where it germinated and lay dormant just for that fateful day. In this case there was no such pearl.

Interesting question about using trim to rotate. While they might have gotten off the ground and may also have cleared obstacles, additional attempts to free the controls would likely have been just as unsuccessful in the air due to aerodynamic loading on the controls. The end result of an airborne high performance aircraft with no primary flight controls would likely be all aboard perished, plus the impact site at Burlington Mall, Lahey Clinic hospital, scores of residential buildings, etc.

During my flying career, I looked at many difficult incidents that ended badly and asked myself, how could a better result be accomplished. I would hope that the rest of you are attempting to learn from others adversity and analyze possible solutions. This generally requires some detailed systems knowledge and curiosity.

No one is going to write a procedure for rotating an aircraft with locked controls so as to go flying. This aircraft was not supposed to be able to do that in the first place, the throttle was supposed to be limited with the controls locked. The flight crew was supposed to check for free controls before taking the runway, but crap happens. Maybe there would have been sufficient control motion to keep the shiny side up despite the control lock if they could have gone flying.

Know your procedures and follow them accurately. But have some backup plans in your hip pocket. You will be a better pilot for it.

Periodic sampling and compliance analysis of QA data
 

No wonder flight ops management across the majors are acquiring the latest data analysis toolkits to perform quality assurance and procedural compliance analysis.

Interesting times.

Excessive safety?
 

Two career lab rat, precision military systems, retired.
RE the 98% fail to perform, for what a penny or two might be worth.

It takes about 21 repetitions to develop a new habit. (Including changing a current habit to a new requirement) The 'Oh Yes I need to change that' events are part of the process of changing a habit.

In the current make everything ultra safe policy world cutting a corner most often provides a positive reward for the negative performance.
The saved time, the saved fuel, the saved cost and there is no negative consequence until well after the habit was formed.

Some learned folks in sociology are now examining have we have become so risk adverse we provide far too much positive reinforcement for negative behaviors. First time, no negative effect, second, third,... a very infrequent problem may let you run a long way on thinning ice.

On the gust lock. Not an aircraft control in this case.
NTSB stated that the gust lock was a physical external strap left attached and was visible to ground personnel as they were departing.

Fly safe.

G

System description
 

I suspect he may have misinterpreted something on that report. I didn't read it that way.

From a system description posted by Mutt on the other thread on this subject:

This aircraft was not supposed to be able to do that in the first place, the throttle was supposed to be limited with the controls locked.

In my list of slices with holes lining up from the time they entered the runaway I forgot one. I do not know about the 'throttle inhibiting system' but the PF did state that he could not achieve planned thrust manually, they then engaged A/T and it also failed to achieve planned thrust. This could be interpreted as an inhibition, perhaps not to manufacturer's spec.
However, the missing slice would have been the lack of expected and experienced acceleration. Surely they knew this a/c and airport. They should have sensed it was all going too slowly and the end of the runway was getting closer than usual. Not only was the RTO delayed for an inexplicable reason, by BOTH PIC & SIC, who has brakes, but it would have happened further down there runway anyway. They were in a double whammy situation. Delayed RTO and with less runway than expected.
I still can not understand the lack of self preservation in their awareness. You are about to go aviating into a hostile environment, where Mother nature and gravity are trying to deter you from such arrogant intrusion, and yet they tried to do so with dulled senses. Hm?

So who was watching the store
 

Peekay4 - thanks for the reply.

My question is - what was this audit organization doing? I'm sure they sent in a bill every year or whatever, but what did they do? Like the pilots it seems they were captured by habit, signing off without looking. I have experience with this happening in my field. Supervisors signing off on failing test reports because they always see passing tests.

To me it looks like the killer here was too much familiarity. Crew worked together for eons, no hostile outsiders, or new perky book trained new crew, to upset the well greased cart. Wouldn't surprise me one bit if the auditors visit was an occasion for a nice lunch out on the owners tab.

Makes you question how SMS is supposed to work. Maybe some unannounced visits by some nosey parker with a grudge from the local XAA who has no financial stake in the process is what is needed.

Sad thing is the owners, who were literally along for the ride, would have no doubt paid whatever they were told was needed to keep them, and their families, safe.

Contrary to what many on here would have you believe, its not just about spending more.

The really slow uptake by the crew on the scope of their problem almost looks like some sort of debilitation.

I'll be anxiously awaiting the full accident report in a few weeks to give that area particularly close scrutiny.

Of course, that critical gust lock lever was hiding in the darkened cockpit, in the wrong position, just waiting to cause trouble.
The elevator was locked in the nose down position. Really hard to believe that no one gave the yoke even a tug before adding power.

It would be interesting to know which company supplied the recurrent training for these guys.

Maybe a more important question is 'What were the management of the operation doing?'.

Audits done by a safety regulator should be nothing more of confirmation - to the operators - that they are doing a good job.

In the bizjet world there is a standard operating model called IS-BAO (International Standards for Business Aircraft Operations) which is in turn is based on ICAO SARPS.

IS-BAO is really a set of best practices. E.g., among others, IS-BAO requires that an SMS is established; that a formal training program must exist; and more relevant to this accident, that SOPs and checklists are to be followed.

There are different stages (levels) to an IS-BAO audit, but basically the audit is primarily a document checking exercise.

E.g., on the use of checklists, the auditor might see that: 1) the company's FOM requires use of checklists; 2) current and correct checklists are onboard the aircraft; and 3) that the company pilots must take recurrent (annual) proficiency training at Flight Safety including proper use of checklists.

Based on documentation of those three things, the auditor then passes the checklist requirement.

But what the auditor has not done is to personally fly with the pilots to see if they actually use checklists, since in-flight inspection is not required for an IS-BAO audit. Nor has the auditor gone through the FOQA data him/herself to see if there's evidence that checklist items are being missed.

These are things which are expected to be done by the flight department internally. But one problem with small ops is the lack of segregation of duties. It's difficult to police yourself.