Gulfstream Pilot error in Katz Crash?

If true I am surprised he lived as long as he did. I am also surprised anyone flew with him, especially the company chief pilot. Again, if true it makes you wonder about the culture of the entire company.

 

Leadership sets the tone for operations and in this case there was apparently a culture of complacency. Apart from reading this thread I don't know anything about the case but it sounds like a perfect case study that can be used to educate others on the dangers of complacency.

I dunno what maintenance is like on a Gulfstream but it doesn't surprise me that it's reliable enough that you could half ass preflight for a while until you get to the point where you blow them off completely. In a way I think flying a bunch of maintenance intensive planes is really useful for building your skills. Nearly every flight there is something going wrong and you really get to know the systems to troubleshoot and realize the importance of a good preflight.

 

There were NO checklists verbalized during the start up or taxi out. You can read the CVR transcript for yourself. Terrible.

I don't fly Gulfstreams, so my understanding may be half-baked, but from what I've read, the control lock must be disengaged before starting the engines. Once you start the engines and have hydraulic pressure on the system, the control lock can't be disengaged.

Now, there is a shortcut, if you make this mistake-- the hydraulic system can be shut off, with the engines running, and the control lock MAY disengage. It looks like that is what these guys might have done, although given that no one verbalized anything about anything except the taxi route, it's hard to say for sure.

The problem with this is that if you try this, you may end up in a situation where you can add power (the control lock will appear to be disengaged), and yet the controls are still locked. Obviously if you try this, you would think you would do a full control check and this would let you know if the controls were really free or not.

Even more pathetic, they got a warning message when they started to advance the power, questioned it, and kept going.

In addition to complacency and a total lack of professionalism, I think there was another thing at work here. To have to admit that they left the control lock on and shut down and restart the engines would represent a bit of a loss of face. Probably less than they might have thought at the time, but still... To abort the takeoff because of a message they couldn't understand-- another loss of face. So they took shortcuts and hoped it would work out.

These guys were incredibly unprofessional, and it killed them and, sadly, their innocent passengers and flight attendant.

 

Its a design flaw, not pilot error. Has to be. Arthur Wolk will ensure that.

 

Exactly why many endeavors that have such a big downside have routines that need to be followed. No one is perfect and no one has a fool proof memory. **** happens and tried and true routines are developed to prevent **** from happening.

These guys just thought they were smarter than all those that have gone before.

How does that go?

Kick the tires, light the fires, last one in the air is a chicken? Good joke but not good procedure.

 

Hopefully not, but you may very well be right...

 

In my opinion, there is a design flaw there. That doesn't excuse the crew in any way, however.

 

You can't fix (or design out) stupid.

 

The last time I flew with my cousin ( he has more than 25,000 hours) in one of his small planes I took the checklist out of his hand. He had it absolutely memorized, word for word. I asked it if he ever flew without reading it. He said, "Never, I read and follow every step, every time."
Some pilots have the discipline, some don't.

 

How many millions of Gulfstream flights over the years? This is the first incident like this in a Gulfstream. Based on the info right now, I don't think it's a design flaw.

Still more info to be released though.

 

The biggest problem in my mind is that if there is a design flaw the waters have been muddied by the actions of the aircrew. From the manufacturers perspective they have an enormous "out" on this one and are disincentivized from looking into it further. What would be interesting to see is if similar type issues have been discovered by crews which have done preflights and then have required maintenance action. It doesn't take a design defect to kill a crew that blew off the last hundred preflights.

As an instructor and flight evaluator I sometimes like to bring up how the CVR would sound in the context of a accident investigation. We get briefed on lots of investigation findings as do all Air Force flyers.... It's bad enough to have everyone hear your final moments played out but even worse for it to be clear to everyone that you killed yourself out of your own stupidity or complacency. Some people die in unfortunate circumstances yet are remsmebered for doing what they could up until the last moment, others are forgotten except for how they wrecked a perfectly good plane and killed a few people in the process.

 

I just sat down to din din. Another member texted me about this thread.

 

OK, Please forgive if I ramble a bit.

By design, you are not supposed to be able to advance the throttles if the gust lock is on. After the Bedford crash, every GIV driver, including me asked to try it at recurrent training. The pilot crying out 'the lock is on' would be a normal panic induced scream IMHO. Correct me I am wrong, but the control lock was found to be in the down (unlocked) position by the NTSB. Lack of a control surface check after engine start, is not SOP and against any checklist. Control surface check is a must. If it wasnt done, bad pilot......but the throttles should have been locked to prevent take off thrust, even taxi thrust.

BUT how do you check the elevator? The elevator is not visible from the cockpit, in fact we have little mirrors to check the ailerons, ground spoilers/speed brakes.....but no way to check the elevator. There is a buried sentence in the QRH about checking control surfaces on take off roll. The only way to effectively tell if the the elevator is working properly is to hold back pressure upon take off roll and see if the nose lifts off before VR.

VNY had an unintentional speed bump in the first 2,000ft of the runway. To counteract this, I unintentionally apply premature back pressure to lesson the bobbing up and down of the nose out of my base airport. Its a technique I carry with me today regardless of airport.

A few months ago a GIV had loss of elevator effectiveness upon take off. The PIC is a friend of mine and we had a candid conversation about it. Ill paste a link to the NTSB prelim at the bottom. Major points I took away from him were:

A) He had a debrief meeting with the NTSB and various manufaturer Attornies. The contents I cannot discuss.

B) After his initial debrief, the NTSB locked him out from further discussion/information.

C) There have been other instances of the elevator loosing effectiveness on take off roll. The law firm representing the Bedford crash had links....too tired to dig them up.

D) There was a recall by Gulfstream regarding flight control surface actuators. Apparently the vendor changed the design. The new design caused a hydraulic lock.

CEN15IA139

DonV said, "Now, there is a shortcut, if you make this mistake-- the hydraulic system can be shut off, with the engines running, and the control lock MAY disengage. It looks like that is what these guys might have done, although given that no one verbalized anything about anything except the taxi route, it's hard to say for sure." If you started the engines with the gust lock on, I can guarantee you there would be a bunch of 'Oh Shi*s, CRAP, HOLD ON.....GET THE QRH.....What do we do.....Oh, ok look it up......Ok, Pull the flight power shut off handle, OK TRY IT NOW...IS IT DOWN? Whew, lets not do that again. etc." Starting engines with the gust lock on is a major event. Ive never done it, and the previous is speculative. But what I do know is that the CVR would have caught something to the effect of 'O Sh*T'.

This crash is really a head scratch-er for those of us who fly and operate GIV'S. They are so reliable with back up to back up systems. Thats why going for the low hanging fruit (pilot error) is so tempting. If no other cause is found, pilot error is the likely catchall.

Hope this sheds some light.

 

Christian-- read the CVR and FDR reports in the docket:

Accident ID ERA14MA271 Mode Aviation occurred on May 31, 2014 in Bedford, MA United States Last Modified on April 08, 2015 10:04 Public Released on April 08, 2015 11:04 Total 71 document items

There was NO verbalization of any sort of checklist, or in fact any discussion of the operation of the aircraft at all (with the exception of the taxi route) until they were on the roll.

There was NO check of the controls, verbalized or not.

After hearing the "Rotate" call, the flying pilot repeated "Lock is on" seven times.

I would agree with you that I would have absolutely thought that starting with the control lock on would generate some discussion in the cockpit. So maybe it was something else... but either way, a control check should have told them something. Of course, they didn't do a control check.

It happens that they can look at the FDR and see what has happened in the past. Out of 176 takeoff events recorded in the FDR, there were TWO control checks done! TWO! By "control check" they mean full deflection movement of the controls.

This was pilot error, plain and simple. Complacency, in my opinion-- in an extreme form.

Ironically, the impetus for using checklists in airplanes came about because Boeing crashed the prototype B-17 due to the control lock being engaged during takeoff...

 

Don, thanks for the link. I just read the CVR transcript and it is pretty damning.


Couple of notes:

The below check is NOT taught at Flightsafety or Simuflite. Nor do they teach stuck Elevator on take off during take off roll. I have heard that they DO teach it to instructors at FSI but not at Simuflight as the sim is not programmed to simulate the failure.

"NOTE: At sixty (60) knots, the pilo
t shall confirm that the elevators are
free and the yoke has reached the neutral position.
NOTE: If the Flight Power Shutoff Handle is pulled at rotation due to a
flight control problem, high pull forces will be required to achieve the
takeoff attitude. There will be a de
lay in airplane rotation and, once
airborne, a push force will be necessary to maintain the climb attitude.
Application of forward trim will be required shortly after becoming
airborne. To avoid running out of forward trim, reduce speed as
necessary.
With respect to flight control malfunctions, the
Airplane Flight Manual, Section 4 – Emergency
Procedures, included procedures for ....."

If the FDR or equivalent says there was no control check, thats also fairly damning. My FO and I actually do two checks: On on the after engine start and one as we take the runway. I wasnt aware that the GIV had software that stores control movements. Learn something new everyday.

I would like to hear the NTSB's findings on how take off power was achieved with the gust lock on.

 

if they[pilots] turned off engs/shutting down hyds-then turned off ''gust lock'' then started up engs but still had some hyd pressure would that make them think gust lock was off -yet be able to use throttles?

im not pilot-but from what im reading pilots screwed the pooch

 

The two main hydraulic pumps are connected to the engines IE: when the engines are running you should have 3000PSI. You cant turn off one with out the other shutting down. When the gust lock is engaged it locks the ruder, control wheel (aileron and elevator) and throttles. If the gust lock wasnt designed to lock the throttles, this would be a short investigation.

This will be debatable but I could see failure of checklist use and failure of gustlock (throttles) as being the cause of the accident. The 'lack of checklist' factor does not apply to me but if there is a flaw in the Gust Lock or Elevator Actuator....that is cause for concern.

Regarding culture: Pt91 operators can be the gold standard or tinfoil. Some flight departments would put to shame airline procedures. But then you have the cowboys. I normally fly with the same guy. We know each others routine down pat, check then verify each others work. Our familiarity with each other creates a culture of safety by knowing what to expect. There is no pride between us and welcome challenge to the decision making process. We also like to incorporate 'nuggets of knowledge' from other guys we fly with.

 

Wild guess that you are not referring to me ?

I should try to upload that vid I took from your jump seat...clearly shows you both using the check list...

 

I think you're doing it the right way.

I've flown with plenty of cowboys, although oddly enough most of them were pretty good about checklist usage (not always so great on minimums, or fuel, or maintenance...).

 

Interesting and prophetic comment here: Wreckage of private jet that killed Lewis Katz and 6 others revealed | Daily Mail Online

Scroll down to the very last comment by "Frank" - posted right after the crash. He nailed it.

"Frank, Detroit - Michigan - USA, United States, 10 months ago
Rejected take-off, brakes were locked, as evident by skid marks, maybe the gust-control-locks were not removed during pre-flight.."

Jedi

 

could this also be the owner[katz] was allways in a hurry and the pilots were rushed all the time?,,wernt they his personal pilots?

 

The crash of the first Boeing Model 299 (B-17)was due to the gust locks not being removed before engine start and take off. This incident is supposed to have initiated the creation of the Pre-flight Check List.

 

Just throwing this out there-it may not mean anything.
The company out of RDU that managed the GIV also had managed a Baron 58 that crashed with two (all) fatals about two years earlier. It was a WX diversion to an approach to minimums, the airplane got too low on the glide slope and crashed into the ground about a mile short of the runway. If memory serves, the lady flying the Baron was a regular on the GIV and not a real high timer in either airplane.
A real coincidence???