Pilots mistakenly left G-IV's flaps locked in place

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Maxed-out

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USA Today continues to NOT get it right on aviation.

"Investigators: pilots mistakenly left G-IV's flaps locked in place for crash that killed 7."

http://www.usatoday.com/story/news/...am-philadelphia-inquirer-lewis-katz/71922242/

Also:

Can someone tell me how the NTSB can make the following statement about this GIV crew?

"The crew skipped steps during 98% of their previous 175 flights, according to investigators."

That statement seems to indicate CVR recordings for the last 175 flights were available to them. Or maybe it's USA Today getting it wrong again.
I must be missing something.

Who knows anymore. Responsible journalism has gone right out the window. A simple fact-checking phone call by the writer to anyone on this forum could have made this story a little more credible.
 
Maxed-out said:
Can someone tell me how the NTSB can make the following statement about this GIV crew?

"The crew skipped steps during 98% of their previous 175 flights, according to investigators."

That statement seems to indicate CVR recordings for the last 175 flights were available to them. Or maybe it's USA Today getting it wrong again.
I must be missing something.
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I recall reading about this finding. I think they have flight data from essentially the GIV's entire flying history (that wouldn't be surprising). They were able to determine that 'controls free and correct' checks were not routinely performed - that from analyzing control movement against flight track. That is, the yoke wasn't typically moved until the takeoff roll.
 
Complacency is in every industry and comes in all forms.

I've seen STC drawings that had the wrong title that had been revised 4 times with three people reviewing the drawing each time. That means 12 people never saw the that the title on the drawing was wrong.

Owners changing engine oil without cutting the filters to inspect for debris. Refueling and not checking the fuel sumps. Crappy preflight checks. Its everywhere.
 
Follow the checklist,gives you a better chance when flying.
 
Controls free and correct is basic stuff but you the lawyers figure you can't trust pilots to do it. It's even more basic than make sure the rolly things are down before landing.
 
flyingron said:
Controls free and correct is basic stuff but you the lawyers figure you can't trust pilots to do it. It's even more basic than make sure the rolly things are down before landing.
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On the CRJ it's part of the pre-taxi check. The EICAS is set to the Flight Controls page which graphically represents all flight control surfaces. CA does a full deflection rudder test, after which the FO does elevators and ailerons to full deflection in both directions. The pre-taxi checklist isn't even run until that check is complete.

I'm surprised something similar isn't required on the G-IV.
 
LDJones said:
I'm surprised something similar isn't required on the G-IV.
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On the GIV (specifically the plane in the Hanscom crash) the checklists:

The engine start checklist has GUST LOCK...OFF as it's fourth item.

The after start checklist has:
16. Flight Controls / Bungee / Rudder Torque Limiter ……………...... CHECK

The FDR shows no attempt to make control inputs consistent with the flight control check.

There is nothing on the cockpit voice recorder that indicates any audible running of the checklists. On the takeoff roll there was an indication that something was wrong with the rudder 36 seconds before the V1 callout. At rotate the FO realized the lock was on but they're doomed to going off the end at that point.
 
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flyingron said:
On the GIV (specifically the plane in the Hanscom crash) the checklists:

The engine start checklist has GUST LOCK...OFF as it's fourth item.

The after start checklist has:
16. Flight Controls / Bungee / Rudder Torque Limiter ……………...... CHECK

The FDR shows no attempt to make control inputs consistent with the flight control check.

There is nothing on the cockpit voice recorder that indicates any audible running of the checklists. On the takeoff roll there was an indication that something was wrong with the rudder 36 seconds before the V1 callout. At rotate the FO realized the lock was on but they're doomed to going off the end at that point.
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A very costly lesson in the value of checklists.
 
If you're interested in additional info on this accident, check this NTSB video out. I think it was just released. Very interesting.

https://www.youtube.com/watch?v=GokKYNOcp20&t=127

Probable cause according the NTSB was the gust luck still being engaged during the attempted take off and the successful application of take off power with the gust lock engaged. No doubt the pilots screwed this one up and paid the ultimate price for it, but at least Gulfstream Aerospace has admitted to problems with it's interlock system.

From the Associate Press
Company, FAA Working on Gulfstream IV Jet Fail-Safe Problem
Aug 1, 2015 7:34 P.M EDT

Gulfstream Aerospace Corp. said in a document released by the NTSB that the Gulfstream IV has an interlock system that is supposed to keep the plane's throttle from being moved past 6 degrees, thereby limiting acceleration, while hinged tail sections, called elevators, are immobilized. But the company told the National Transportation Safety Board last spring that the interlock system actually allows the throttle to be moved to an average 21 degrees. The company said the issue "remained undiscovered on more than 500 aircraft over 25 years and more than 2 million takeoffs."

Still, Gulfstream contends the crash was due to the flight crew's failure to check if the gust lock system, which locks the tail sections, was engaged and to immediately abort the flight once it was clear there was a problem.
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Holy crap, what a line up of errors. Who in their right mind would engage the auto throttles when they can't get the manual throttles to work properly an take off initiation, especially when you have a light telling you you have a lock still on? At this point I dismiss the claims against Gulfstream on the throttle limiter. It may not have worked properly, but even if it had, the dude would still likely have hit the AT. Who the hell trained these guys?
 
Maxed-out said:
Can someone tell me how the NTSB can make the following statement about this GIV crew?

"The crew skipped steps during 98% of their previous 175 flights, according to investigators."

That statement seems to indicate CVR recordings for the last 175 flights were available to them. Or maybe it's USA Today getting it wrong again.
I must be missing something.
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There is a box called the 'quick access recorder' that takes the FDR datastream and archives it for maintenance management purposes. The statement about the lack of a complete control check in 173 of 175 takeoffs is based on analysis of the control surface position data in the QAR.
 
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Some corporate guys like to run their checklists silently. I'm not a big fan of that...I've seen more checklist items missed, including control locks, when PMs run checklists silently. I had to confront the DO early in my jet flying career because there were 3 items consistently missed. Turns out they weren't missed-he just wasn't doing them because he didn't know how.

When something bad happens in an airplane, company callouts and SOPs, if used normally and conscientiously, can take you from "two pilots in the same airplane on the way to the same accident" to "a crew" that is able to solve a problem and bring about a safe result. Silent checklists do the opposite, IMO.
 
MauleSkinner said:
Some corporate guys like to run their checklists silently. I'm not a big fan of that...I've seen more checklist items missed, including control locks, when PMs run checklists silently. I had to confront the DO early in my jet flying career because there were 3 items consistently missed. Turns out they weren't missed-he just wasn't doing them because he didn't know how.

When something bad happens in an airplane, company callouts and SOPs, if used normally and conscientiously, can take you from "two pilots in the same airplane on the way to the same accident" to "a crew" that is able to solve a problem and bring about a safe result. Silent checklists do the opposite, IMO.
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Even if they did the control check silently it would have shown up on the FDR. That's my interpretation anyway, that the FDR records control surface movements. The CVR is what records voice.
 
LDJones said:
On the CRJ it's part of the pre-taxi check. The EICAS is set to the Flight Controls page which graphically represents all flight control surfaces. CA does a full deflection rudder test, after which the FO does elevators and ailerons to full deflection in both directions. The pre-taxi checklist isn't even run until that check is complete.

I'm surprised something similar isn't required on the G-IV.
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Just a dumb non-jet-guy question... how do you check the control surfaces that you can't see? I assume you use the ramper? Or is there another indicator that the control surface has actually moved as commanded?
 
petrolero said:
Just a dumb non-jet-guy question... how do you check the control surfaces that you can't see? I assume you use the ramper? Or is there another indicator that the control surface has actually moved as commanded?
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My understanding is the control movement displayed on our F/CTL page is derived from proximity sensors at each component.
 
Everskyward said:
Even if they did the control check silently it would have shown up on the FDR. That's my interpretation anyway, that the FDR records control surface movements. The CVR is what records voice.
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The finding that they failed to verbalize the checklist in a challenge-response manner is established off the CVR recording.

The finding that they didn't perform a full control check on the accident flight is based off the FDR data. The rudder never moved more than 1deg despite the 'rudder limit' light coming on.

The finding that they performed an incomplete control check on 10% of the prior 175 flights and a complete control check on 2% of the flights is based on the data in the QAR.
 
So, clearly Gulfstream will be sued for a faulty interlock.

Question; would Gulfstream be better off omitting such an interlock from the aircraft? Instead depending on proper use of checklists to ensure removal of the gust locks.

After all, Gulfstream's statement that the interlock issue "remained undiscovered on more than 500 aircraft over 25 years and more than 2 million takeoffs." suggests that proper checklist use was sufficient. And that pilot error by this particular crew is solely to blame (true in fact but not in court).
 
Bill Watson said:
So, clearly Gulfstream will be sued for a faulty interlock.

Question; would Gulfstream be better off omitting such an interlock from the aircraft? Instead depending on proper use of checklists to ensure removal of the gust locks.

After all, Gulfstream's statement that the interlock issue "remained undiscovered on more than 500 aircraft over 25 years and more than 2 million takeoffs." suggests that proper checklist use was sufficient. And that pilot error by this particular crew is solely to blame (true in fact but not in court).
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They probably would have been better off leaving it off. A general principle in tort law is even if you have no duty to act, once you do act you are then expected to meet some minimum standard of care. They'll definitely get dinged on this, but only for a percentage. I'm guess it will still be a big number.
 
Bill Watson said:
So, clearly Gulfstream will be sued for a faulty interlock.

Question; would Gulfstream be better off omitting such an interlock from the aircraft? Instead depending on proper use of checklists to ensure removal of the gust locks.

After all, Gulfstream's statement that the interlock issue "remained undiscovered on more than 500 aircraft over 25 years and more than 2 million takeoffs." suggests that proper checklist use was sufficient. And that pilot error by this particular crew is solely to blame (true in fact but not in court).
Click to expand...

Thing is, the interlock wasn't faulty, it was over ridden by engaging the Auto Throttle.
 
Henning said:
Thing is, the interlock wasn't faulty, it was over ridden by engaging the Auto Throttle.
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It was faulty. By certification it was supposed to stop the power lever at a 6deg angle. In this and other GIVs, the lever could be advanced to 23deg before it hit the stop.

Gulfstream is re-designing the system as we speak.
 
Bill Watson said:
Question; would Gulfstream be better off omitting such an interlock from the aircraft? Instead depending on proper use of checklists to ensure removal of the gust locks.
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An interlock of some sort that precludes takeoff or gives an 'unmistakable indication' that the gust-lock is on is required under part 25.

Other aircraft have all kinds bells and whistles go off if you advance power with the gust-lock in place.

What is so puzzling is the fact that the gust-lock lever is huge and sticks straight up from the pedestal while engaged. You can't even put your cup of starbucks on the pedestal with the thing engaged. The investigation has not established whether the lever was truly in the locked position or somewhere intermediate during the accident in question. The pin that holds it in the locked position was sheared, but that could have been an impact artifact.

After all, Gulfstream's statement that the interlock issue "remained undiscovered on more than 500 aircraft over 25 years and more than 2 million takeoffs." suggests that proper checklist use was sufficient. And that pilot error by this particular crew is solely to blame (true in fact but not in court).
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As we speak, there is an army of young lawyers at Gulfstream reading through every email and internal memo sent in the past 40 years to make certain that they were in fact ignorant on this issue.
 
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weilke said:
It was faulty. By certification it was supposed to stop the power lever at a 6deg angle. In this and other GIVs, the lever could be advanced to 23deg before it hit the stop.

Gulfstream is re-designing the system as we speak.
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Semi faulty in t it moved further than it should, but it had the effect it was used to, they could not push the throttles forward to TO power. They had 2 blatant tells that they had the control locks engaged early in the roll and a third further in the roll. They just weren't thinking.
 
Henning said:
Semi faulty in t it moved further than it should, but it had the effect it was used to, they could not push the throttles forward to TO power. They had 2 blatant tells that they had the control locks engaged early in the roll and a third further in the roll. They just weren't thinking.
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The system didn't do what Gulfstream told the FAA it would do. The original design of this mechanical gust-lock dates back to the GII and during each further development step, they just told the FAA that it is 'unchanged' from the prior model. What has changed is that the thrust of the engines between GII, GIII and GIV has increased and that the turbofan engines used today produce much more thrust in the 0-23deg PLA range than the engines used on the GII.

Had the PL hit a hard stop at 6deg as it was supposed to, they wouldn't have gotten past a fast taxi.
 
With the GIV in the news, I noticed a recent GIV "incident" where the crew aborted a takeoff from Eagle County Regional Airport (EGE), Eagle, Colorado on February 7, 2015. “Failure of the aircraft to rotate,” was the reason according to a Gulfstream operator letter.

TO: All Gulfstream Operators
SUBJECT: General (ATA 05) – Gulfstream IV Aborts Takeoff

On February 7, 2015, a Gulfstream IV operator aborted a takeoff due to failure of the aircraft to rotate. The aircraft was slowed and taxied from the runway, at which time a fire was observed coming from the right brakes. The fire was extinguished and all passengers and crew safely disembarked from the aircraft. Gulfstream is assisting the regulatory authorities with their investigation. Any fleet action resulting from this event will be communicated accordingly.
If you should have questions or comments regarding this communication, please contact Customer Support at 800-810-GULF (4853).

Sincerely,
Mitchell A. Choquette
Director, Product Support & Field Service
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http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150209X74707&key=1

It's old news now, but that event must have initially caused some "angst" (a feeling of deep anxiety or dread) at the FAA and Gulfstream. It occured less than year after the Hanscom crash (May 31, 2014). The NTSB has said that their was no indication that the circumstances of the incident were related to any previous G-IV takeoff accidents or incidents. The CVR and a review of any additional non-volatile memory on-board the airplane is pending. The aircraft was not equipped with an FDR.
 
weilke said:
The system didn't do what Gulfstream told the FAA it would do. The original design of this mechanical gust-lock dates back to the GII and during each further development step, they just told the FAA that it is 'unchanged' from the prior model. What has changed is that the thrust of the engines between GII, GIII and GIV has increased and that the turbofan engines used today produce much more thrust in the 0-23deg PLA range than the engines used on the GII.

Had the PL hit a hard stop at 6deg as it was supposed to, they wouldn't have gotten past a fast taxi.
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Until he hit Auto Throttle, then it would have spooled right up.
 
A Part 91 operation. Once a year trip to a training center where there is no chance of a failure, no standardization and no SOP's.

Gee, what could go wrong........
 
Back in 1989 I watched as a GIII crew taxi out with a very large ORANGE towbar-head attached to the nose-wheel. Had to send one of my lineman racing down the ramp to stop them!!! That was only one of countless events I witnessed over the 5 years I worked at that facility. SH_t Happens ALL THE TIME... If we're lucky, someone is watching and takes action that protects the innocent from the actions of those that don't pay attention to the details, or don't follow the procedures adopted in an attempt to protect us from our human shortfalls...
 
RotorAndWing said:
A Part 91 operation. Once a year trip to a training center where there is no chance of a failure, no standardization and no SOP's.
.
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You didnt bother to read up on the accident I guess.
 
RotorAndWing said:
NTSB ERA14MA271, right?
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Yes.

Go in the docket, document 15 is the report of an IBAC audit. They had all the shiny three-ring binders on the shelf. Flight operations manual (document #44 is an excerpt) including a training, maintenance, emergency response, security threat assessment and safety sections. A SMS with a couple of reports in the folder, committees the works. I am sure there is a consultant out there who made a nice penny plugging 'SK Travel' into all the right spots in his canned corporate ISBAO compliant FOM. Everything was signed in the right spots, everyone had clicked through the requisite number of powerpoints, all the right certifications were posted on the office wall.

The problem in this operation was not the section of the FAR they operated under or the lack of procedures in three-ring binders and certifications on the wall. The problem was that the second the cockpit door closed, all that stuff was ignored and the plane was flown by two single pilots who just happened to sit in the same cockpit. Whenever they went to flight safety, everything was done by the book, the moment they were back in 'their plane', they went back to 'their way' of doing things. The lines of responsibility in the company were very short. The next level above the combined DO/DM/CP were the two co-CEOs of the company, Katz and Solimine. While they operated that flight department company for a long time, I doubt they had the aviation knowledge to pick up that their crew was not giving them their moneys worth.
 
weilke said:
Yes.

Go in the docket, document 15 is the report of an IBAC audit. They had all the shiny three-ring binders on the shelf. Flight operations manual (document #44 is an excerpt) including a training, maintenance, emergency response, security threat assessment and safety sections. A SMS with a couple of reports in the folder, committees the works. I am sure there is a consultant out there who made a nice penny plugging 'SK Travel' into all the right spots in his canned corporate ISBAO compliant FOM. Everything was signed in the right spots, everyone had clicked through the requisite number of powerpoints, all the right certifications were posted on the office wall.

The problem in this operation was not the section of the FAR they operated under or the lack of procedures in three-ring binders and certifications on the wall. The problem was that the second the cockpit door closed, all that stuff was ignored and the plane was flown by two single pilots who just happened to sit in the same cockpit. Whenever they went to flight safety, everything was done by the book, the moment they were back in 'their plane', they went back to 'their way' of doing things. The lines of responsibility in the company were very short. The next level above the combined DO/DM/CP were the two co-CEOs of the company, Katz and Solimine. While they operated that flight department company for a long time, I doubt they had the aviation knowledge to pick up that their crew was not giving them their moneys worth.
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OK. You just confirmed what I stated earlier. You can go to a training center, fly the profiles, have binders full of procedures, but without oversight and adherence to standards it's basically useless.
 
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As I believe Weilke mentioned earlier in the thread, the issue of whether the GIV met the design requirements of Part 25 certification has become a major factor in this investigation. The company that owned the GIV sent an 11 page non-party submission to the NTSB's docket on June 15 of this year addressing the issue.

Owner's statement:

“The GIV gust lock system was required to comply with 14 CFR §25.679, which mandates that, if the gust lock system, when engaged, prevents normal operation of the control surfaces by the pilot, then it must either ‘automatically disengage when the pilot operates the primary flight controls in a normal manner’ (§25.679(a)) or ‘limit the operation of the airplane so that the pilot receives unmistakable warning at the start of the takeoff.’ (§25.679(b)).
“The accident aircraft did not either automatically disengage the gust lock system when the accident flight crew moved the primary flight controls or provide the accident flight crew ‘unmistakable warning at the start of the takeoff’ that the gust lock system was engaged.”
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The owner is definitely inferring that “the accident aircraft did not comply with the requirements” of FAR Part 25.679.

[/QUOTE] Link to the owner “non-party submission” at:

http://dms.ntsb.gov/public/57000-57499/57175/578150.pdf
 
Everskyward said:
Even if they did the control check silently it would have shown up on the FDR. That's my interpretation anyway, that the FDR records control surface movements. The CVR is what records voice.
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It's not the check I'm referring to...it's the checkLIST. "Doing the checklist silently" is an excellent way to miss or intentionally skip items. All of the major F-ups I've seen in takeoff configuration followed checklists that were "done silently". If the flying pilot is paying attention, he'll notice items that haven't been accomplished, but if he agrees that a silent checklist is a good idea, he's basically saying that the checklist completion is none of his business, so he's probably not paying attention.
 
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RotorAndWing said:
OK. You just confirmed what I stated earlier. You can go to a training center, fly the profiles, have binders full of procedures, but without oversight and adherence to standards it's basically useless.
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Well, that's not what you stated.

A Part 91 operation. Once a year trip to a training center where there is no chance of a failure, no standardization and no SOP's.
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They had SOPs and standardization, they just chose to ignore them.

Whenever someone looked at their operation or flying, they managed to put on a good show and stick to the script. There is no reason to believe that they couldn't have passed their twice a year ride with the FAA to maintain for example a 135 certificate.
 
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