“I think this is an organization that fooled itself,” NTSB member Robert Sumwalt said of the Bedford GIV’s operator, citing the IS-BAO audit results.


“You can fool the auditors, but never fool yourself.”


LOCKED INTO ERROR


By Flight Safety Foundation Australia staff writers - 12/18/2016


How did an experienced crew, flying a modern business jet with an impeccable safety record, make such a simple, yet deadly, mistake?


It began as a typical business jet trip. Two pilots and a flight attendant in a Gulfstream IV were to return the millionaire who owned the jet to Atlantic City, New Jersey, a 43-minute flight from Boston. The millionaire was a philanthropist who had spent the afternoon attending a fundraising event with friends, during which time the crew relaxed in the aircraft and ordered pizza. They were experienced and had flown together for 12 years logging about 300 hours each year. The only time another pilot ever flew the privately owned Gulfstream was when one of them was away on holiday.


Their final trip together never left the ground.


About 2140 US eastern daylight time, in what the US National Transportation Safety Board (NTSB) report described as night visual meteorological conditions, the Gulfstream IV ran off the end of the runway and into a ravine at about 100 knots. The two pilots, a flight attendant and four passengers were not killed outright, but died in the ensuing fire. ‘All seven occupants were found unrestrained and in positions consistent with movement within the airplane after the crash,’ the NTSB reported. Fire had made the Gulfstream’s over- wing exits and rear door unusable, but nobody on board was able to open the main door.


The flight data (FDR) and cockpit voice recorders (CVR) survived the flames and provided answers with surprising speed. What was most revealing were the words missing from the CVR. There was a brief discussion of taxiway navigation, a confirmation that a phone call had been made, and momentary consideration of a rudder limit warning, but none of the litanies and incantations of checklist use.


Instead, a few terse words revealed the immediate cause of the crash.


At 21.39.59 the pilot said, ‘Steer lock is on,’ a remark he repeated six more times in the remaining 20 seconds of the flight. Fourteen seconds later he said, ‘I can’t stop it’.


There was no other discussion of the situation and the only other words before the recording stops were one of the flight crew saying, ‘Oh no, no’ as the aircraft sped towards the ravine that would trap it. Fire broke out ‘almost instantaneously’, in the words of a witness.


Investigation of the wreckage found the gust lock handle was off, as it should have been, despite no indication in the cockpit recording of it being moved. Unusually, another handle was in the activated position. It was the flight power shut-off valve, which disables hydraulic power to the control surfaces. The gust lock system locks the flight control surfaces to prevent them being damaged by winds while the aircraft is parked. It is, to say the least, incompatible with controlled flight, and its disengagement is a prominent item on the checklist of any aircraft that uses one.


CRM 2, TEM, Fatigue 12


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29