GULFSTREAM AEROSPACE G IVArizin Ventures, LLC
Bedford, MA, USA · 2014-06-01·N121JM
What happened
NTSB summary, verbatimThe 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
Photographs
5the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe 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.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · Prior to flightPreflight or dispatch event
- 2 · Takeoff-rejected takeoffRunway excursiondefining event
- 3 · Post-impactFire/smoke (post-impact)
Findings
14 causal · 0 contributing- CAUSEAircraft › Aircraft systems › Flight control system › Gust lock or damper — Incorrect use/operation
- CAUSEPersonnel issues › Action/decision › Action › Forgotten action/omission — Flight crew
- CAUSEPersonnel issues › Task performance › Use of equip/info › Use of checklist — Flight crew
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters — Attain/maintain not possible
- CAUSEPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Flight crew
- CAUSEPersonnel issues › Psychological › Personality/attitude › Complacency — Flight crew
- CAUSEPersonnel issues › Action/decision › Action › Delayed action — Flight crew
- CAUSEEnvironmental issues › Physical environment › Object/animal/substance › Runway/taxi/approach light — Contributed to outcome
- CAUSEEnvironmental issues › Physical environment › Object/animal/substance › Tower/antenna (incl guy wires) — Contributed to outcome
- CAUSEPersonnel issues › Action/decision › Action › Lack of action — Emergency services personnel
- CAUSEOrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Emergency services
- CAUSEAircraft › Aircraft systems › Flight control system › Gust lock or damper — Design
- CAUSEOrganizational issues › Development › Selection/certification/testing › Equip certification/testing — Manufacturer
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of reg compliance — FAA/Regulator
Safety recommendations
5 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Identify nonfrangible structures outside of a runway safety area during annual 14 Code of Federal Regulations Part 139 inspections and place increased emphasis on replacing nonfrangible fittings of any objects along the extended runway centerline up to the perimeter fence with frangible fittings, wherever feasible, during the next routine maintenance cycle.
TO THE FEDERAL AVIATION ADMINISTRATION: After Gulfstream Aerospace Corporation develops a modification of the G-IV gust lock/throttle lever interlock, require that the gust lock system on all existing G-IV airplanes be retrofitted to comply with the certification requirement that the gust lock physically limit the operation of the airplane so that the pilot receives an unmistakable warning at the start of takeoff.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop and issue guidance on the appropriate use and limitations of the review of engineering drawings in a design review performed as a means of showing compliance with certification regulations.
TO THE INTERNATIONAL BUSINESS AVIATION COUNCIL: Amend International Standard for Business Aircraft Operations auditing standards to include verifying that operators are complying with best practices for checklist execution, including the use of the challenge-verification-response format whenever possible.
TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.
Sequence of events
4 timed eventsfrom the FDR factual report · claude-sonnet-5- 2140 EDTTakeoff rollp.1Airplane crashed after a rejected takeoff and runway excursion at Laurence G. Hanscom Field (BED), Bedford, Massachusetts
- N/AAccident power cyclep.4FDR began recording accident flight (last flight on the recording), lasting approximately 9 minutes from FDR power on until the FDR stopped recording
- N/AAccident power cyclep.4QAR stopped recording approximately 6 seconds prior to the end of the FDR recording
- N/AAccident takeoff (takeoff number 176)p.5Accident takeoff was reviewed as part of QAR analysis of pre-takeoff control checks; elevator movement timing during takeoff roll did not match the pattern observed on other takeoffs (60-80 knots)
NTSB analysis
from the final reportThe 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