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Accident Case Study

We are told that on May 31, 2014, the professional pilot world got a wake up call when two pilots crashed their Gulfstream IV and killed all on board. The NTSB rightfully calls their performance an act of "intentional, habitual noncompliance" but this is being charitable. As a pilot once qualified in the same aircraft type, I heard everything I needed to know within 24 hours, to know what had happened. The aircraft never rotated and the tire skid marks didn't begin until the last 1,500' of runway. But I didn't want to believe it. The next week I spent five hours with a flashlight in my airplane and several manuals trying to really understand the airplane's gust lock system. (The G450 gust lock system is almost identical to that in the GIV.) I posted a lengthy page about how to really guard against mechanical failure of the gust lock: G450 Gust Lock. But I knew that wasn't it.

As the NTSB slowly but surely let details of the mishap come out, it became plainly evident that these were not professional pilots, at least not according to my definition. The incremental news releases were painful. They failed to disengage the gust lock prior to engine start. They failed to perform a flight control check after engine start and before takeoff. They failed to check elevator freedom of movement at 60 knots. They ignored a rudder limit message. They failed to reject the takeoff when takeoff thrust wasn't achieved.

When the report finally came out we learned these pilots attempted to disengage their flight control system while careening down the runway in a futile attempt to disengage the gust lock. We further learned that they did not run a single checklist (of four) between engine start and takeoff. And then we learned that in 98 percent of their previous 175 takeoffs they neglected to do a flight control check. I was speechless.

We are also told that this mishap will serve as a wake up call against pilot complacency and for stronger checklist discipline and compliance. I have my doubts. If you are reading this page you probably get it. You have been doing your flight control checks and you have been on guard against the forces of complacency that overtook this pilot team. I think about half of us get it. The other half? They aren't reading this page or any professional journals, they only give the news of this crew a passing glance. They don't believe they are at risk because nobody ever confronts them. There is a way to change that and we all have a role to play.


Mishap Case Study: Gulfstream IV N121JM


The NTSB report is quite good and worth reading, cover-to-cover. It spends a great deal of time on the aircraft's gust lock system, the airport's emergency response, and the survival aspects of the crash. All that is important, but for us pilots it is more important to look at professionalism, checklist philosophy, and complacency. Click the photo and we'll do that.

Checklist Philosophy


In 1935 a prototype of the B-17 bomber crashed on takeoff because the pilots forgot to disengage the elevator lock prior to takeoff. The program was temporarily cancelled because the Army Air Corps thought the airplane was too complicated for any pilot to operate. The Boeing Company came up with a novel idea to fix that problem: the checklist.



How do pilots of such caliber end up guilty of intentional, habitual noncompliance? They succumbed to complacency. We are all at risk. Those of us in small flight departments who fly with the same pilots over and over again are at greatest risk.

Line Operation Observations (LOOs)


There is a way to combat complacency and to find out if you are guilty of having become a less than professional pilot. It is simple, cost effective, and you can do it soon. All you need to do is invite another pilot, a pilot you respect, to fly along on a "live" trip (with passengers) and watch. Done correctly, this will yield more information than a simulator checkride or even a line check (14 CFR 135.299 or otherwise). You need to do this.

If you've read this far you are more than likely already in the fold, you are a professional pilot and this mishap gets under your skin. But it isn't enough to make pilots like us angry. We need to get to those that don't get it. If you have evidence someone you know is guilty of what the NTSB calls intentional, habitual non-compliance, you need to be aggressive. Confront them, present them the evidence. Shame them. If none of that works, ostracize them. Show them that this kind of behavior is worth ending a friendship. Perhaps that will shock them into the fold. Good luck.

Revision: 20151201