In the Sunday edition of the Philadelphia Inquirer, there is a long but excellent article dealing with the crash of a Gulfstream GIV jet in May 2014 which killed six people, including Lewis Katz, a businessman who had recently purchased the Inquirer. After failing to take off and speeding off the runway, the jet crashed into a gully at over 180 miles per hour and burst into flames. Gulfstream has attributed the crash to pilot error, most notably the failure to perform required safety checks before takeoff which would have revealed that the elevators on the jet’s tail were locked, preventing it from leaving the ground.
However, as the Inquirer article reveals, the story is more complex than that. Although a series of irresponsible decisions by the pilots doomed the flight, evidence suggested that poor design of the aircraft and a failure of oversight by regulators also played fatal roles. In particular, a design flaw in the jet’s gust lock allowed it to be set to a position where the elevators were locked while enabling the jet to reach full takeoff speed. A fail-safe is supposed to be built in to prevent the jet going above taxiing speed when the gust lock on. What emerges is a case of systemic failures causing the deaths of six people.
My Gut Reaction: As stupid as the pilots were, I’m a lot more concerned about the Federal Aviation Administration’s failure to catch a fatal design flaw, a failure apparently caused by its willingness to rely solely on the manufacturer’s word regarding the jet’s safety.
More detail and analysis below the fold….
The most direct responsibility for the crash has to go to the pilots, who failed to perform the most basic safety checks before the flight. Black box examinations of flights before the crash reveal that this was habitual, with checks performed in only 18 out of nearly two hundred previous flights. In particular, they failed to pull back the yoke while they were taxiing – which would have revealed that the elevators were locked. (The elevators are locked after landing to prevent damage from gusts of wind.)
The pilots compounded their error with a series of fatal mistakes in the minutes before the crash. They dismissed a warning signal – the rudder limit light – which could have warned them about the locked elevators. Furthermore, when they finally realized the elevators were locked, the pilots pulled the Flight Power Shutoff Handle in an attempt to regain control while the plane accelerated. Had they put on the brakes and powered down, they would have stopped several hundred feet short of the end of the runway.
The pilots’ burden of guilt for their own and others deaths should not be underestimated. As experienced aviators, they should have realized the importance of such basic safety measures to protect the lives of the crew and passengers flying with them.
That said, what the article revealed about the relationship between aviation companies and the FAA was arguably more disturbing than the pilots’ cavalier attitude toward flight safety. The issue with the gust lock was not something that cropped up after years of service due to parts deteriorating. It had been an inherent problem with the jet’s design from the get go. However, the FAA failed to catch it because, as the article describes, the agency decided that “Gulfstream was not required to test how the gust lock interlocked with the throttles,” the fail-safe that would have prevented the crash. The FAA accepted Gulfstream’s word that the design was similar to that of previous Gulfstream jets, obviating the need for tests. Adding to the design flaws, the Rudder Limit Light which the pilots failed to heed could signify several problems, making it confusing for pilots to know what the issue was.
The failure of the FDA to detect design flaws and demand rigorous testing of aviation companies is beyond disturbing. Pilot errors are, in the end, limited to specific individuals and do not reflect a systemic failure. The FDA’s failure as an effective regulator in this case, on the other hand, suggests a threat to the safety of everyone who flies. How can we know the planes we fly on are really safe if the FDA just takes manufacturers’ assurances that everything is up to standard. American fliers deserve a rigorous safety agency.