Flight controls free and correct?

You have a religion that says if I want to live, I’m going to run the checklist.

Robert Hulse

Last week the NTSB released lots of details on a fatal accident that will keep lawyers and human factors academics busy for years. It involves rich high-profile (newspaper publisher) passengers, an iconic Gulfstream IV jet, the failure of a basic airplane safety system and the repeated failure of basic airmanship. Maybe the best account of this two-factor crash is the online piece Deadly Failure On The Runway by McCoy and Purcell of the Philadelphia Inquirer. Fascinating reading. (The NTSB press release is also online.)

The human factors engineering factor is the failure of the gust lock system (that holds the elevators against wind damage while parked) fail-safe setting to prevent significant power lever positioning. It allowed takeoff power with the lock engaged. Seems like this basic failure has a long back-story involving design, incremental changes, similarity standards, and FAA certification. The article covers these details.

The human factors psychology factor is the failure of the pilots to do a control check before applying takeoff power. We’ve all made slips and errors. But what is truly worrying is that the NTSB supplies compelling evidence that this fundamental preflight check, common to all types of aircraft and operations, was routinely ignored by this experienced (18,000 and 10,000 hours total time) crew.

Analysis of data from the quick access recorder showed that out of the previous 175 takeoffs only two complete and 16 partial control checks were performed. Two full flight control checks in 176 flights?! This is a failure of basic airmanship. The NTSB states that the “flight crew’s habitual noncompliance with checklists was a contributing factor to the accident.”

There are four broad reasons why pilots don’t comply with standard operating procedures (see An empirically derived taxonomy of pilot violation behavior by English (yes me) & Branaghan). But nothing short of being shot at as you taxi justifies not checking the flight controls before taking off. It’s quicker to not do a control check on taxi out, slicker, cooler maybe for some. But it is stupid.

If you’re acting that way, you are just fooling yourself.

Robert Sumwalt, NTSB Board Member.

The failure of the gust lock system is disturbing. I think it shows that pilot-proof needs to be like idiot-proof — but double strength.

But the repeated failure to do control checks? That’s pathetic.

Airmanship requires discipline. Sometimes a lot, sometimes just a little. Don’t crash a perfectly good airplane because you failed to do a simple flight control check.

Credit: NTSB
Credit: NTSB

 (Jan 2017 Update: The NBAA followed the NTSB’s recommendation and conducted a large FOQA study. The results are eye-opening.)

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