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Cases › ERA14MA271 › The analyst

GULFSTREAM AEROSPACE G IVArizin Ventures, LLC

What the docket says, assembled. No language model is involved, so nothing on this page can be invented — every line traces to a recorder, a report page or the Board's own record.

14
timed facts
8
precedents
143
passages to ask

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passages, not paraphrases
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Every answer is a passage of the docket with the page it came from, or the words “not in the docket”. Nothing is summarised or reasoned for you — read the source.

One timeline

14 timed factsthe recorder events from the FDR report, with the transcript's warnings, callouts, the words nearest each event and the final seconds — on one clock, as printed in each report
  1. 21:10:19.7CVR CAMp.9
    “[unintelligible vocalizations].”
    read in context ↗
  2. 21:37:00.1CVR TWRcalloutp.13
    “* one two one Juliet Mike Hanscom tower turn right heading two five zero runway one one cleared for takeoff. ERA14MA271”
    read in context ↗
  3. 21:37:07.9CVR RDO-1calloutp.14
    “okay after departure it'll be a left turn heading two five zero and we're cleared for takeoff one two one Juliet Mike.”
    read in context ↗
  4. 21:38:33.9CVR CAM-2calloutp.14
    “we're cleared for takeoff?”
    read in context ↗
  5. 21:38:34.8CVR CAM-1calloutp.14
    “cleared for takeoff right turn heading two five zero. ERA14MA271”
    read in context ↗
  6. 21:39:58.9CVR CAM-1calloutp.16
    “rotate.”
    read in context ↗
  7. 21:40:05.2CVR CAMfinal secondsp.16
    “[sounds similar to thump and squeak]”
    read in context ↗
  8. 21:40:06.6CVR CAM-2final secondsp.16
    “(steer) lock is on.”
    read in context ↗
  9. 21:40:07.5CVR CAM-2final secondsp.16
    “(steer) lock is on.”
    read in context ↗
  10. 21:40:12.6CVR CAM-2final secondsp.16
    “(steer) lock is on.”
    read in context ↗
  11. 21:40:14.3CVR CAM-2final secondsp.16
    “I can't stop it.”
    read in context ↗
  12. 21:40:16.2CVR HOTfinal secondsp.16
    “[sound of triple chime].”
    read in context ↗
  13. 21:40:19.6CVR CAM-2final secondsp.16
    “oh no no.”
    read in context ↗
  14. 21:40:21.0CVR CAMfinal secondsp.16
    “[sound of impact]. ERA14MA271”
    read in context ↗
Recorder events without a clock time
  • 2140 EDTAirplane crashed after a rejected takeoff and runway excursion at Laurence G. Hanscom Field (BED), Bedford, Massachusetts
  • N/AFDR began recording accident flight (last flight on the recording), lasting approximately 9 minutes from FDR power on until the FDR stopped recording
  • N/AQAR stopped recording approximately 6 seconds prior to the end of the FDR recording
  • N/AAccident 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)
  • July 28, 2014Gust lock functionality tested with elevator preload applied
  • July 28, 2014Baseline functionality of gust lock tested when FPSOV handle pulled; gust lock handle moved from on to off position with no flight control preload
  • July 28, 2014Rudder preload applied with gust lock handle unlatched; when FPSOV handle pulled, gust lock handle sprang forward to unlocked position; amber CAS message and audible single chime activated
  • July 28, 2014PLA resulting from maximum thrust lever movement recorded with gust lock handle on
  • July 28, 2014Forward force applied to left thrust lever with gust lock unlatched under rudder preload via rudder trim; gust lock did not release despite gust handle moving forward
  • July 29, 2014Exemplar preflight stall barrier and flight control check performed
  • July 29, 2014Yaw damper authority to move rudder surface tested with gust lock on during turns in both directions while taxiing
  • July 29, 2014Blue Rudder Limit CAS message and gust lock handle behavior tested during turns with rudder preload and gust lock unlatched (hooks remained engaged); turning right illuminated Rudder Limit light; gust lock handle sprang forward during turn to left
  • July 29, 2014Repeat of Rudder Limit/gust lock unlatched turn test
  • July 29, 2014Autothrottle and engine behavior tested with gust lock handle unlatched to intermediate position; PLA reached 30° and EPR reached target of 1.59
  • July 29, 2014Autothrottle engagement at 1.17 EPR with target 1.59 EPR, gust lock on; thrust levers moved to gust lock interlock, PLA increased to 21.4 and 22.8 degrees before retreating to 18.7 degrees; autothrottles disconnected within three seconds
  • July 29, 2014Autothrottle engagement with thrust levers positioned against gust lock interlock; PLA momentarily increased; autothrottles disconnected within three seconds
  • November 13, 2014EPR/PLA relationship documented (left and right engine sweeps); test points conducted prior to start of video recording, time in raw subframe counts
  • November 13, 2014EPR attainable documented when power levers moved to gust lock interlock, with no pilot pressure and with firm pressure against interlock
  • November 13, 2014Speed at which control column began to move aft due to air loads documented with gust lock off, approximately 70 knots
  • November 13, 2014Aircraft accelerated to 70 knots with autothrottle on; copilot attempted to unlatch gust lock handle but was unable to on first run
  • November 13, 2014Repeat test runs; flight observer able to unlock gust lock to fully forward, unlocked position
  • November 13, 2014Second repeat run; observer began to unlatch gust lock handle at 80 knots instead of 70 knots to determine effect of higher air loads on gust lock hook
  • November 13, 2014High speed taxi tests with gust lock handle unlatched using FLEX EPR; rudder pedal input to preload gust lock system unsuccessful in first two tests; gust lock sprung to full forward position releasing gust lock
  • November 13, 2014Third attempt using rudder trim input to preload gust lock system; gust lock handle remained unlatched after being pulled back by observer; reduction in PLA and EPR observed coincident with gust lock handle being pulled back
  • November 14, 2014High speed taxi tests with gust lock handle unlatched using Rated EPR; gust lock snapped forward without pilot input during first two attempts
  • November 14, 2014Gust lock handle remained in unlatched position with no pilot input for entirety of test; yaw damper was disengaged for this attempt due to wind gusts
  • N/AThis addendum shows selected data parameters plotted for the accident takeoff roll and 20 takeoffs prior for comparison purposes
Flight Data Recorder - Factual Report of Group Chairman · 4 events extracted by claude-sonnet-5Flight Data Recorder - Factual Report Addendum · 22 events extracted by claude-sonnet-5Flight Data Recorder - Factual Report - Addendum 2 · 2 events extracted by claude-sonnet-5Cockpit Voice Recorder - Factual Report of Group Chairman · 14 of 89 lines shown
How the Board coded the sequence
  1. Prior to flight: Preflight or dispatch event→
  2. Takeoff-rejected takeoff: Runway excursion→
  3. Post-impact: Fire/smoke (post-impact)

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • DCA11MA0762011-04-024 fatalmatch 64
    GULFSTREAM GVI · GULFSTREAM AEROSPACE CORPORATION
    Roswell, NM
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Development › Selection/certification/testing
    • ●Organizational issues › Support/oversight/monitoring › Oversight
    • +1 more shared findings
    Fire/smoke (post-impact)Preflight or dispatch event
  • DCA08MA0982008-09-204 fatalmatch 54
    Learjet LR60 · Global Exec Avaition
    Columbia, SC
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Development › Selection/certification/testing
    • ●Organizational issues › Support/oversight/monitoring › Oversight
    • +2 more shared findings
    Fire/smoke (post-impact)Runway excursion
  • CEN16MA0362015-11-109 fatalmatch 51
    BRITISH AEROSPACE HS 125 700A · Execuflight
    Akron, OH
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Development › Selection/certification/testing
    • ●Organizational issues › Management › Policy/procedure
    • +2 more shared findings
  • DCA20MA0022019-10-181 fatalmatch 51
    Saab 2000 · Peninsula AviationServices Inc.,
    Unalaska, AK
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Organizational issues › Management › Policy/procedure
    • ●Organizational issues › Support/oversight/monitoring › Oversight
    • +1 more shared findings
    Runway excursion
  • CEN15MA2902015-07-031 fatalmatch 50
    AIRBUS HELICOPTERS INC AS350B3E · AIR METHODS CORP
    Frisco, CO
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
    Fire/smoke (post-impact)Preflight or dispatch event
  • DCA13MA0812013-04-297 fatalmatch 50
    BOEING 747-400 BCF · National Air Cargo
    Bagram, AF
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Aircraft › Aircraft systems › Flight control system
    • ●Organizational issues › Management › Policy/procedure
    • +2 more shared findings
  • DCA09MA0212008-12-21substantialmatch 50
    BOEING 737-524 · CONTINENTAL AIRLINES INC
    Denver, CO
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Task performance › Use of equip/info
    Runway excursion
  • DCA17IA0202016-10-27no fatalitiesmatch 49
    BOEING 737 7L9 · Eastern Airlines Group, Inc.,
    New York, NY
    • ●Aircraft › Aircraft oper/perf/capability › Performance/control parameters
    • ●Personnel issues › Action/decision › Action
    • ●Personnel issues › Action/decision › Info processing/decision
    • +1 more shared findings
    Runway excursion

What the record says

a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 4 of 8Runway excursion
  • 3 of 8Fire/smoke (post-impact)
  • 2 of 8Aerodynamic stall/spin
  • 2 of 8Preflight or dispatch event
  • 2 of 8Collision with terr/obj (non-CFIT)
  • 2 of 8Loss of control in flight
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft oper/perf/capability › Performance/control parameters
  • Development › Selection/certification/testing
  • Management › Policy/procedure
  • Support/oversight/monitoring › Oversight
  • Action/decision › Action
  • Action/decision › Info processing/decision
  • Task performance › Use of equip/info
Cited here, not seen in the precedents
  • Physical environment › Object/animal/substance
  • Psychological › Personality/attitude
Common in the precedents, not cited here
  • Aircraft systems › Hydraulic power system
  • Aircraft systems › Landing gear system
  • Conditions/weather/phenomena › Wind
  • Development › Design
  • Support/oversight/monitoring › Training

A teaching device, not a verdict: what the record would have looked at, next to what the Board found.

In the Board’s words — the closest cases
  • DCA11MA0762011-04-02 · GULFSTREAM GVI · GULFSTREAM AEROSPACE CORPORATION
    The National Transportation Safety Board determines the probable cause(s) of this accident as follows: an aerodynamic stall and subsequent uncommanded roll during a one engine-inoperative takeoff flight test, which were the result of (1) Gulfstream’s failure to properly develop and validate takeoff speeds for the flight tests and recognize and correct the takeoff safety speed (V2) error during previous G650 flight tests, (2) the G650 flight test team’s persistent and increasingly aggressive attempts to achieve…
  • DCA08MA0982008-09-20 · Learjet LR60 · Global Exec Avaition
    The operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of criti…
  • CEN16MA0362015-11-10 · BRITISH AEROSPACE HS 125 700A · Execuflight
    The flight crew's mismanagement of the approach and multiple deviations from company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach, a descent below minimum descent altitude without visual contact with the runway environment, and an aerodynamic stall. Contributing to the accident were Execuflight's casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company's lack of…
  • DCA20MA0022019-10-18 · Saab 2000 · Peninsula AviationServices Inc.,
    The landing gear manufacturer’s incorrect wiring of the wheel speed transducer harnesses on the left main landing gear during overhaul. The incorrect wiring caused the antiskid system not to function as intended, resulting in the failure of the left outboard tire and a significant loss of the airplane’s braking ability, which led to the runway overrun. Contributing to the accident were (1) Saab’s design of the wheel speed transducer wire harnesses, which did not consider and protect against human error during maint…
  • CEN15MA2902015-07-03 · AIRBUS HELICOPTERS INC AS350B3E · AIR METHODS CORP
    Airbus Helicopters' dual-hydraulic AS350 B3e helicopter's (1) preflight hydraulic check, which depleted hydraulic pressure in the tail rotor hydraulic circuit, and (2) lack of salient alerting to the pilot that hydraulic pressure was not restored before takeoff. Such alerting might have cued the pilot to his failure to reset the yaw servo hydraulic switch to its correct position during the preflight hydraulic check, which resulted in a lack of hydraulic boost to the pedal controls, high pedal forces, and a subseque…
What it recommended after them
  • A-12-054TO THE FEDERAL AVIATION ADMINISTRATION: Inform domestic and foreign manufacturers of airplanes that are certified under 14Code of Federal Regulations Parts 23 and 25 about the circumstances of this accident and advise them to consider, when… · DCA11MA076Closed - Acceptable Action
  • A-12-055TO THE FEDERAL AVIATION ADMINISTRATION: Work with the Flight Test Safety Committee to develop and issue detailed flight test operating guidance for manufacturers that addresses the deficiencies documented in this report regarding flight tes… · DCA11MA076Closed - Acceptable Action
  • A-12-056TO THE FEDERAL AVIATION ADMINISTRATION: Work with the Flight Test Safety Committee to develop and issue flight test safety program guidelines based on best practices in aviation safety management. · DCA11MA076Closed - Acceptable Action
  • A-12-057TO THE FEDERAL AVIATION ADMINISTRATION: After the Flight Test Safety Committee has issued flight test safety program guidelines, include these guidelines in the next revision of Federal Aviation Administration Order 4040.26, Aircraft Certif… · DCA11MA076Closed - Unacceptable Action
  • A-12-058TO THE FEDERAL AVIATION ADMINISTRATION: Inform 14 Code of Federal Regulations Part 139 airports that currently have (or may have in the future) flight test activity of the importance of advance coordination of high-risk flight tests with fl… · DCA11MA076Closed - Acceptable Action
  • A-12-059TO THE FLIGHT TEST SAFETY COMMITTEE: In collaboration with the Federal Aviation Administration, develop and issue flight test operating guidance for manufacturers that addresses the deficiencies documented in this report regarding flight te… · DCA11MA076Closed - Acceptable Action
  • A-12-060TO THE FLIGHT TEST SAFETY COMMITTEE: In collaboration with the Federal Aviation Administration, develop and issue flight test safety program guidelines based on best practices in aviation safety management, and encourage manufacturers to in… · DCA11MA076Closed - Acceptable Action
  • A-12-061TO THE FLIGHT TEST SAFETY COMMITTEE: Encourage members to provide notice of and coordinate high-risk flight tests with airport operations and aircraft rescue and firefighting personnel. · DCA11MA076Closed - Acceptable Action

This is the pattern in the NTSB’s own record across similar accidents — which findings it cited, what it coded, what it recommended. It is drawn from the record, not written about this case, and it never assigns blame: investigations exist to prevent the next accident (ICAO Annex 13).