airplane jetOn May 31, 2014, a Gulfstream IV executive jet overran the runway at Hanscom Airport in suburban Boston from which it had attempted to takeoff. It hurtled into a ravine off the end of the runway, crashed and burst into flames. The three crew members and four passengers all perished in the resulting fireball. The accident received widespread media attention because the passengers included Lewis Katz, a wealthy businessman, philanthropist and co-owner of the Philadelphia Inquirer, who was returning with his guests from an education fundraising event hosted by historian Doris Kearns Goodwin.

The Gulfstream’s black boxes were recovered following the accident. They showed that it had reached a speed of 162 knots before the pilots abandoned the takeoff, and too little runway remained to stop. The National Transportation Safety Board concluded that the pilots failed to disengage a control lock, and had failed to follow no fewer than three pre-takeoff check lists which included a checking the controls for free and correct movement. But that was not all. The black box data showed that these pilots had failed to perform this as well as other standard pre-takeoff procedures on 171 of their preceding 175 takeoffs in the plane — a shocking performance by highly experienced, professional air crew, which the NTSB labeled “intentional, habitual noncompliance.”

At the request of the NTSB the National Business Aircraft Association (NBAA) conducted a review of 144,000 business aircraft flights from 2013 through 2015. It showed that in 16% of the takeoffs only a partial check was performed, and in 2% no pre-takeoff control checks were performed.

Sadly, such accidents have a long history. The prototype of the famed WWII B-17 bomber crashed and burned under the same circumstances in 1935. Today, all aircraft have checklists calling for the pilot to check the controls for free and correct operation before takeoff. But no checklist will save a pilot who fails to use it.

What can be learned from the Bedford accident and the information it brought to light?

Pilots are constantly subject to pressures, both external and self-generated. The fundamental purpose of flying is to save time and surmount obstacles. Pilots by their nature are goal oriented problem solvers. It has been said that “target fixation” — becoming so focused on mission accomplishment that safety is overlooked — is a common problem in professional aviation activities. Yet there was no such pressure here. As the NTSB said, these pilots had knowingly and repeatedly violated proper operating procedures and fundamental standards of airmanship.

It is inexcusable to deliberately deviate from standard operating procedures other than for good reason to cope with an emergency. No such exigency was present here. A weekend pilot, flying alone, can easily overlook or forget a checklist item, but these were professional pilots, flying a sophisticated, high performance jet aircraft, backed up by a professional flight operations department which had undergone reviews and been found to comply with the International Standard for Business Aircraft Operations, considered the gold standard for safety.

The lesson of the Bedford tragedy is that even skilled, experienced pilots can fall prey to complacency and cutting corners. As one commentator has said, an expert can believe that his or her knowledge and experience gives license to deviate. Experience can generate over-confidence and arrogance.
The antidote for arrogance is humility. “A humble pilot realizes that even the best aviators make mistakes and that one’s guard can never be lowered, even when the title of ‘expert’ has been rightfully earned.”[1] Professionalism demands an attitude of humility, rather than over-confidence and arrogance (an imperative that is not limited to pilots or aviation).

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[1] James Albright, “Safety: Normalization of Deviance,” Business and Commercial Aviation, December 16, 2016, http://aviationweek.com/bca/safety-normalization-deviance.