ERA14MA271

NTSB accident investigation · Gulfstream Aerospace G IV · Bedford, MA · June 1, 2014

Accident · FatalClass 1 · MajorFinal report
Date
May 31, 2014, 21:40 local (Jun 1, 2014, 01:40 UTC)
Place
Bedford, MA
Injuries
7 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N121JMGulfstream Aerospace G IV
Defining event
Takeoff-rejected takeoff: Runway excursion
Weather
Visual (VMC) · Night
Status
Completed · report September 28, 2015
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Eastern Region Aviation
Parties
Gulfstream Aerospace Corp., Honeywell Aerospace, Massport, FAA AVP-100, Rockwell Collins, UK - AAIB
Safety recommendations
Yes
FAA report
20140531024449A
Case key
89324

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The 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.

Findings · 14

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Flight control system: gust lock or damperAircraft › Aircraft systems · Incorrect use/operationGulfstream Aerospace G-IV: 1 caseAll aircraft: 14 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Flight crewGulfstream Aerospace G-IV: 1 caseAll aircraft: 440 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · Flight crewGulfstream Aerospace G-IV: 2 casesAll aircraft: 336 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleGulfstream Aerospace G-IV: 1 caseAll aircraft: 1,269 casesProbable cause
Personality/attitude: complacencyPersonnel issues › Psychological · Flight crewGulfstream Aerospace G-IV: 1 caseAll aircraft: 23 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · Flight crewGulfstream Aerospace G-IV: 2 casesAll aircraft: 894 casesProbable cause
Object/animal/substance: runway/taxi/approach lightEnvironmental issues › Physical environment · Contributed to outcomeGulfstream Aerospace G-IV: 1 caseAll aircraft: 106 casesProbable cause
Object/animal/substance: tower/antenna (incl guy wires)Environmental issues › Physical environment · Contributed to outcomeGulfstream Aerospace G-IV: 1 caseAll aircraft: 55 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Emergency services personnelGulfstream Aerospace G-IV: 1 caseAll aircraft: 792 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · Emergency servicesGulfstream Aerospace G-IV: 1 caseAll aircraft: 106 casesProbable cause
Oversight: oversight of reg complianceOrganizational issues › Support/oversight/monitoring · FAA/RegulatorGulfstream Aerospace G-IV: 1 caseAll aircraft: 14 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The 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

Factual narrative

The 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.

Aircraft

Registration
N121JM
Reported as
Gulfstream Aerospace G IV
Category
Airplane
Serial number
1399
Built
2000
Airframe hours
4,945
Engines
Rolls-Royce TAY 611-8, 13,850 lbs thrust, turbo fanRolls-Royce TAY 611-8, 13,850 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Executive/Corporate · Part 91
Operator
Arizin Ventures, LLC
Registered owner
Sk Travel LLC
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 20, 2013 · 250 hours before
Departed
BED · Bedford, MA
Destination
ACY · Atlantic City, NJ
Flight plan
IFR
Airport
BED · Laurence G Hanscom Fld, runway 11, 7,011 × 150 ft, asphalt
Equipment
Data recorder, Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system, Onboard weather, Electronic primary flight display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
5-point
Toxicology
Performed
Flight hours
11,270 total · 1,645 in this make and model · 53 in the last 90 days · 9 in the last 30 days · 1 in the last 24 hours
Role
Co-pilot
Age
61
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Restraint
5-point
Toxicology
Performed
Flight hours
18,560 total · 3,160 in this make and model · 53 in the last 90 days · 9 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 43 °F
Altimeter
30.28 inHg
Observed at
BED

Docket · 91

The files NTSB released with the investigation on April 8, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 240 MB in all.

Operations - Factual Report of Group ChairmanItem 1 · .PDF · 84 KBOperations - Attachment 1: NTSB Owner/Operator Accident ReportItem 2 · .PDF · 2.7 MBOperations - Attachment 2: Witness StatementsItem 3 · .PDF · 79 KBOperations – Attachment 3: Controller StatementsItem 4 · .PDF · 307 KBOperations - Attachment 4: Flight PlanItem 5 · .PDF · 164 KBOperations - Attachment 5: Pilot Training Records PIC – ExcerptsItem 6 · .PDF · 739 KBOperations – Attachment 6: Pilot Training Records SIC – ExcerptsItem 7 · .PDF · 1.0 MBOperations - Attachment 7: Pilot Logbook SIC – ExcerptsItem 8 · .PDF · 664 KBOperations - Attachment 8: Conversation Record – Pilots SpousesItem 9 · .PDF · 57 KBOperations – Attachment 9: Conversation Record – Contract MechanicItem 10 · .PDF · 58 KBOperations – Attachment 10: Conversation Record – Contract PilotItem 11 · .PDF · 52 KBOperations – Attachment 11: Conversation Record – GIII PilotItem 12 · .PDF · 52 KBOperations – Attachment 12: Airplane Flight Logs – January 2014 to May 2014Item 13 · .PDF · 4.0 MBOperations – Attachment 13: Airplane Flight Logs – January 2013 to December 2013Item 14 · .PDF · 37.3 MBOperations – Attachment 14: SK Travel Flight Operations Manual – ExcerptItem 15 · .PDF · 1.6 MBOperations – Attachment 15: SK Travel Audit ReportItem 16 · .PDF · 8.5 MBOperations – Attachment 16: Aircraft Dry Lease Agreement - ExcerptItem 17 · .PDF · 268 KBOperations – Attachment 17: Airplane Flight Manual – Excerpts (Checklists)Item 18 · .PDF · 63 KBOperations – Attachment 18: Airplane Operating Manual – Excerpts (Gust Lock System)Item 19 · .PDF · 95 KBOperations – Attachment 19: Airplane Operating Manual – Excerpts (Advisory Messages)Item 20 · .PDF · 1.9 MBOperations – Attachment 20: Airplane Operating Manual – Excerpts (Flight Control Emergency Procedures)Item 21 · .PDF · 16 KBOperations – Attachment 21: Flight Safety G-IV Training Material - ExcerptsItem 22 · .PDF · 460 KBCockpit Voice Recorder - Factual Report of Group ChairmanItem 23 · .PDF · 2 photos · 479 KBCockpit Voice Recorder - Factual Report of Group Chairman - Errata 1Item 24 · .PDF · 20 KBCockpit Voice Recorder - Factual Report of Group Chairman - AddendumItem 25 · .PDF · 206 KBFlight Data Recorder - Factual Report of Group ChairmanItem 26 · .PDF · 8 photos · 982 KBFlight Data Recorder - Factual Report AddendumItem 27 · .PDF · 3 photos · 1.0 MBFlight Data Recorder - Factual Report - Addendum 2Item 28 · .PDF · 599 KBFlight Data Recorder – Accident Power Cycle DataItem 29 · .CSV · 351 KBFlight Data Recorder – Previous Taxi DataItem 30 · .CSV · 14.5 MBAirworthiness – Factual Report of Group ChairmanItem 31 · .PDF · 14 photos · 3.3 MBMaterials Laboratory Factual Report No. 15-021Item 32 · .PDF · 5.9 MBMemorandum of Record - In-Service PLA DataItem 33 · .PDF · 108 KBSystem Safety & Certification – Factual Report of Group ChairmanItem 34 · .PDF · 1.1 MBSystem Safety & Certification – Attachment 1 - Compliance Checklist ReportItem 35 · .PDF · 415 KBSystem Safety & Certification - Attachment 2 – FAA 8110-3 FormsItem 36 · .PDF · 273 KBSystem Safety & Certification - Attachment 3 – Drawing 1159SCF451 – Gust Lock SectorItem 37 · .PDF · 410 KBSystem Safety & Certification - Attachment 4 – Qualification Test PlanItem 38 · .PDF · 405 KBAircraft Performance Study – ErrataItem 39 · .PDF · 1.1 MBSurvival Factors – Factual Report of Group ChairmanItem 40 · .PDF · 28 photos · 3.4 MBSurvival Factors – Attachment 1: FBI Finger Print ReportItem 41 · .PDF · 314 KBSurvival Factors – Attachment 2 – Injury Chart and Occupant LocationItem 42 · .PDF · 82 KBSurvival Factors – Attachment 3: Pilot Toxicology ReportsItem 43 · .PDF · 158 KBSurvival Factors – Attachment 4: SK Travel Flight Operations Manual - ExcerptItem 44 · .PDF · 433 KBSurvival Factors – Attachment 5: Flight Attendant Training RecordsItem 45 · .PDF · 360 KBSurvival Factors – Attachment 6: Dod/FAA Agreement on Inspection of DoD Firefighters at Joint Use AirfieldsItem 46 · .PDF · 515 KBSurvival Factors – Attachment 7: December 23, 2011 Letter from FAA to MassportItem 47 · .PDF · 133 KBSurvival Factors – Attachment 8: Dod/Massport contract for ARFF ServiceItem 48 · .PDF · 575 KBSurvival Factors – Attachment 9: 2012 Airport Table Top ExerciseItem 49 · .PDF · 7.1 MBSurvival Factors – Attachment 10: Hanscom AFB ARFF Apparatus and PersonnelItem 50 · .PDF · 30 KBSurvival Factors – Attachment 11: ARFF TimelineItem 51 · .PDF · 192 KBSurvival Factors – Attachment 12: Interviews and StatementsItem 52 · .PDF · 11.2 MBGulfstream G-IV Gust Lock & Autothrottle Systems Ground Test Plan (GIV-GER-0016)Item 53 · .PDF · 406 KBGulfstream G-IV Gust Lock & Autothrottle Systems Ground Test Report (GIV-GER-0017)Item 54 · .PDF · 1.3 MBGulfstream Flight Test Report – GIV Gust Lock System (GIV-GER-9978)Item 55 · .PDF · 814 KBGulfstream NTSB Flight Test Report – GIV Gust Lock System (GIV-GER-9980)Item 56 · .PDF · 696 KBGulfstream Operator Letter ALL-MOL-14-0015 Airplane Flight Manual ProceduresItem 57 · .PDF · 130 KBGulfstream Operator Letter ALL-MOL-14-0024 Gust Lock SystemItem 58 · .PDF · 190 KBGulfstream Operator Letter GIV-MOL-05-0018- Elevator and Aileron Actuator Load Relief Bungee Spring InspectionItem 59 · .PDF · 221 KBGulfstream Operator Letter GIV-MOL-06-0006- Elevator Actuator Load Relief Bungee Hardware InstallationItem 60 · .PDF · 181 KB
All 91 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.