Checklists Are Important

"ttyymmnn" (ttyymmnn)
03/08/2019 at 11:35 • Filed to: wingspan, Planelopnik

The charred remains of Gulfstream IV N121JM. The crash killed all six passengers and crew. (Massachusetts State Police/NTSB)

On May 31, 2014, a Gulfstream IV (N121JM) business jet with two pilots, a flight attendant, and three passengers failed to lift off from Bedford-Hanscom Field (KBED) outside of Boston. The aircraft careened off the end of the runway, struck airport lighting, went through the perimeter fence, and came to rest in a ravine, where it caught fire. All on board were killed.

A Gulfstream IV at Austin Bergstrom International Airport. Note: this is not the accident aircraft. (Tim Shaffer)

NTSB investigators determined that the flight crew neglected to release the !!!error: Indecipherable SUB-paragraph formatting!!! , which prevents the control surfaces from moving in the wind while an aircraft is parked on the tarmac. The gust lock also prevents the pilots from moving the controls when they are trying to take off. But why did the crew not release the gust lock? Because they did not perform a required challenge-and-response checklist, nor did they cycle the controls, before takeoff. Investigators also learned that this particular flight crew, who had flown together often, did not perform complete checks of the flight controls on 98% of their previous 175 flights together.

(Gulfstream/NTSB)

Even though the crew left the gust lock engaged, the locking system on the G-IV is supposed to prevent takeoff by restricting the travel of the throttles to just six degrees, thereby limiting engine power. Ideally, it gives the crew a chance to realize their mistake by keeping the aircraft below takeoff speed. But investigators found that a design flaw in the system allowed the pilots to advance the throttles considerably more than six degrees, to a point where the automatic throttle took over. So the pilots were able to accelerate for takeoff, and only realized late into their roll that the control surfaces were still locked. And then, once the pilot realized his mistake, there was an inexplicable delay of 10 seconds before the crew acted to reject the takeoff. Had they responded immediately, investigators believe that the crash could have been avoided.

Peter Katz of Plane & Pilot wrote a compelling piece about the accident, and about how a combination of complacency by an experienced crew, coupled with a design flaw, can lead to tragedy. It’s a fascinating read. You can also read the full !!!error: Indecipherable SUB-paragraph formatting!!! here.

!!! UNKNOWN CONTENT TYPE !!!

You can find more stories about aviation, aviators and airplanes at !!!error: Indecipherable SUB-paragraph formatting!!! .

!!! UNKNOWN CONTENT TYPE !!!

DISCUSSION (28)

For Sweden > ttyymmnn
03/08/2019 at 11:40

The 98% number is likely the most important part of this case.

Too many operators think the absence of a failure is the absence of a hazard. After all, Murphy’s Law says that if something can go wrong, it will. Therefore, since nothing has gone wrong, nothing will go wrong.

Until it does.

ttyymmnn > For Sweden
03/08/2019 at 11:44

I don’t like to use hyperbolic Gawker words like “chilling” or “shocking,” but that number is truly shocking. These guys were literally an accident waiting to happen.

For Sweden > ttyymmnn
03/08/2019 at 11:48

So is GMG, but the libertarians won’t let us regulate dangerous industries!

facw > ttyymmnn
03/08/2019 at 11:50

FYI, that’s Hanscom Field (also Hanscom AFB), not Hansom . I live like 5 minutes away.

https://en.wikipedia.org/wiki/Hanscom_Field

shop-teacher > ttyymmnn
03/08/2019 at 11:51

“this particular flight crew, who had flown together often, did not perform complete checks of the flight controls on 98% of their previous 175 flights together.”

98%! That is a truly stunning number.

Although, with a crew that careless, I’m actually surprised they did check them even the 2% of the time.

ttyymmnn > facw
03/08/2019 at 11:51

Thanks. I think I got bit by autocorrect.

TheRealBicycleBuck > ttyymmnn
03/08/2019 at 11:54

Thanks for reinforcing my good behavior. Since I have at least a couple of weeks between flights, I find that checklists are the thing that keeps me on track. I’m pretty sure I’ll make up some custom checklists which add in detail that’s not on the airplane’s checklist sheet. Things like setting the radio and GPS correctly. The GPS wasn’t in the plane when I started flying it, so I’m a bit behind the curve on operating it.

After scheduling the next flying weekend (next Friday) , my instructor called me up to go over the plan. It will be a Friday afternoon/evening dual cross-country flight; a Saturday solo cross country flight; and a Sunday “Stage II” check ride with a senior instructor. After that, there are two lessons left, both of which are review and prep for my final FAA check ride!

ttyymmnn > shop-teacher
03/08/2019 at 11:56

With modern safety systems, I can see how it would be so easy to become complacent. They treated it like jumping into a car and driving away. As I read more and more about aviation history, air safety is a fascinating accrual of knowledge over more than 100 years of flying (this sort of gust lock crash has happened many times before; that’s why it’s in the checklist) . A lot of that is “tombstone technology,” where it took dead passengers to get something changed or to learn something, but most of it is a huge collection of best practices that, when followed, can make flying safer than driving a car.

ttyymmnn > TheRealBicycleBuck
03/08/2019 at 11:57

Busy busy! Best wishes for safe and happy flights.

benn454 > TheRealBicycleBuck
03/08/2019 at 12:01

Good luck

Just Jeepin' > For Sweden
03/08/2019 at 12:03

the absence of a failure is the absence of a hazard

I have this argument with people All. The. Time.

Not about flying, which I know diddly/squat about, but primarily driving.

If we want driving to be safe, it’d go a long way towards that goal if cars had ways to detect poor decisions and immediately crash in the safest way possible.

As kids we learn not to touch a hot stove because bad decisions lead to immediate pain. Behind the wheel, we almost never get penalized.

For Sweden > Just Jeepin'
03/08/2019 at 12:07

That’s why I keep a paintball gun in the passenger seat; negative reinforcement of driving behavior.

ttyymmnn > For Sweden
03/08/2019 at 12:13

Murphy was an optimist.

ttyymmnn > For Sweden
03/08/2019 at 12:14

I was thinking of using a cattle prod on my 16yo son.

Just Jeepin' > ttyymmnn
03/08/2019 at 12:45

Here’s a brilliant anecdote I hope every parent follows when it comes time to their kids getting licenses.

https://oppositelock.kinja.com/1831418042

Rusty Vandura - www.tinyurl.com/keepoppo > For Sweden
03/08/2019 at 13:19

What is GMC?

WilliamsSW > TheRealBicycleBuck
03/08/2019 at 13:26

Treat every pre-flight and runup like you’ve never seen the airplane before in your life , and expect the engine to fail any time you’re close to the ground. Do that, make sure the airplane has fuel, don’t fly VFR into IMC and you’ve eliminated the causes of most fatal accidents.

You’ll be fine - have fun! !

Full of the sound of the Gran Fury, signifying nothing. > ttyymmnn
03/08/2019 at 14:02

At work I made a form to standardize a daily procedure, and at the bottom of it were some check boxes to confirm that the various actions and notifications had been completed. I intentionally left them blank so that you would have to manually check them off, but the next person on graveyard after I had that shift for a quarter just decided to fill them all in with ‘X’s, making the checklist function irrelevant. There was never a problem when this form was used under my watch, but now it’s useless since the shortcutters don’t bother to see if these tasks are done since they’re already marked as complete, and in the process have saved themselves maybe 32 seconds over an eight hour shift, and perhaps caused 15-30 minutes of extra work for the morning shift provided a driver doesn’t need to return to base for equipment. Checklists don’t do squat if you don’t use them properly or understand why they’re needed or why they were created.

Kinja'd!!!

When I worked on the ramp at the airport I would schedule an extra 15 minutes for the crews to do a FOD walk before their flight arrives. Nobody bothered, usually taking that time for a smoke break or to make personal phone calls. I worked a few of the flights myself and did the FOD walk solo, and always found dangerous crap all over the ramp. And even when we would destroy tires on aircraft (or worse) by having them run over/through d ebris, with the ensuing delays and penalties and costs, management still didn’t crack down on the crews not doing this important safety check. You get what you pay for in outsourced handling, and we didn’t pay much. Most people had a high-school education at best, two weeks of training and then sent out there around 300-400 million dollar pieces of equipment and told not to break anything. It’s a wonder we didn’t damage more aircraft than we did...

ttyymmnn > Full of the sound of the Gran Fury, signifying nothing.
03/08/2019 at 14:05

Any system is only as good as the people who use them. Or are required to use them.

Kinja'd!!!

Eury - AFRICA TWIN!!!!!!! > shop-teacher
03/08/2019 at 15:15

I’ m curious how they determine that number.

ttyymmnn > WilliamsSW
03/08/2019 at 15:31

Most of the cases of celebrities dying in plane crashes that I have written about were caused by pilots flying IFR who had no business doing so.

WilliamsSW > ttyymmnn
03/08/2019 at 15:42

Yep - VFR into IMC is a very effective way to kill everyone on board the aircraft.

I counted 5 obvious errors by the crew in a 10 minute span between engine start and the crash - removing * any* one of those would have save the lives of everyone one board (with the possible exception of the last error). Awful.

shop-teacher > Eury - AFRICA TWIN!!!!!!!
03/08/2019 at 22:32

I am too, and it began the question: if they had this data, why the hell didn't someone figure out they weren't doing proper checks before they killed themselves and everyone on board?

pip bip - choose Corrour > ttyymmnn
03/09/2019 at 06:04

whoops

ttyymmnn > pip bip - choose Corrour
03/09/2019 at 10:15

Big whoops. Six-people-dead whoops.

Spanfeller is a twat > ttyymmnn
04/28/2019 at 12:53

Remember the one time that Mexico’s Vice President was killed because the pilot of his plane was too fucking stubborn to listen to ATC and sticked right behind a B 767 at low altitude?

Kinja'd!!!

ttyymmnn > Spanfeller is a twat
04/28/2019 at 17:04

I do. I think you wrote about it at the time.

Spanfeller is a twat > ttyymmnn
04/28/2019 at 17:19

It was in 2008