Like many pilots, I read accident reports all the time. This may seem morbid to people outside “the biz”, but those of us on the inside know that learning what went wrong is an important step in avoiding the fate suffered by those aviators. And after fifteen years in the flying business, the NTSB’s recently-released report on the 2014 Gulfstream IV crash in Bedford, Massachusetts is one of the most disturbing I’ve ever laid eyes on.

If you’re not familiar with the accident, it’s quite simple to explain: the highly experienced crew of a Gulfstream IV-SP attempted to takeoff with the gust lock (often referred to as a “control lock”) engaged. The aircraft exited the end of the runway and broke apart when it encountered a steep culvert. The ensuing fire killed all aboard.

Sounds pretty open-and shut, doesn’t it? There have been dozens of accidents caused by the flight crew’s failure to remove the gust/control lock prior to flight. Professional test pilots have done it on multiple occasions, ranging from the prototype B-17 bomber in 1935 to the DHC-4 Caribou in 1992. But in this case, the NTSB report details a long series of actions and habitual behaviors which are so far beyond the pale that they defy the standard description of “pilot error”.

Just the Facts

Let me summarize the ten most pertinent errors and omissions of this incident for you:

There are five checklists which must be run prior to flying. The pilots ran none of them. CVR data and pilot interviews revealed that checklists simply were not used. This was not an anomaly, it was standard operating procedure for them. Obviously the gust lock was not removed prior to flying. This is a very big, very visible, bright red handle which sticks up vertically right between the throttles and the flap handle. As the Simon & Chabris selective attention test demonstrates, it’s not necessarily hard to miss the gust lock handle protruding six inches above the rest of the center pedestal. But it’s also the precise reason we have checklists and procedures in the first place. Flight control checks were not performed on this flight, nor were they ever performed. Hundreds of flights worth of data from the FDR and pilot interviews confirm it. The crew received a Rudder Limit message indicating that the rudder’s load limiter had activated. This is abnormal. The crew saw the alert. We know this because it was verbalized. Action taken? None. The Pilot Flying (PF) was unable to push the power levers far enough forward to achieve takeoff thrust. Worse, he actually verbalized that he wasn’t able to get full power, yet continued the takeoff anyway. The Pilot Not Flying (PNF) was supposed to monitor the engines and verbally call out when takeoff power was set. He failed to perform this task. Aerodynamics naturally move the elevator up (and therefore the control column aft) as the airplane accelerates. Gulfstream pilots are trained to look for this. It didn’t happen, and it wasn’t caught by either pilot. The Pilot Flying realized the gust lock was engaged, and said so verbally several times. At this point, the aircraft was traveling 128 knots had used 3,100 feet of runway; about 5,000 feet remained. In other words, they had plenty of time to abort the takeoff. They chose to continue anyway. One of the pilots pulled the flight power shutoff handle to remove hydraulic pressure from the flight controls in an attempt to release the gust lock while accelerating down the runway. The FPSOV was not designed for this purpose, and you won’t find any G-IV manual advocating this procedure. Because it doesn’t work. By the time they realized it wouldn’t work and began the abort attempt, it was too late. The aircraft was traveling at 162 knots (186 mph!) and only about 2,700 feet of pavement remained. The hydraulically-actuated ground spoilers — which greatly aid in stopping the aircraft by placing most of its weight back on the wheels to increase rolling resistance and braking efficiency — were no longer available because the crew had removed hydraulic power to the flight controls.

Industry Responses

Gulfstream has been sued by the victim’s families. Attorneys claim that the gust lock was defective, and that this is the primary reason for the crash. False. The gust lock is designed to prevent damage to the flight controls from wind gusts. It does that job admirably. It also prevents application of full takeoff power, but the fact that the pilot was able to physically push the power levers so far forward simply illustrates that anything can be broken if you put enough muscle into it.

The throttle portion of the gust lock may have failed to meet a technical certification requirement, but it was not the cause of the accident. The responsibility for ensuring the gust lock is disengaged prior to takeoff lies with the pilots, not the manufacturer of the airplane.

Gulfstream pilot and Code7700 author James Albright calls the crash involuntary manslaughter. I agree. This wasn’t a normal accident chain. The pilots knew what was wrong while there was still plenty of time to stop it. They had all the facts you and I have today. They chose to continue anyway. It’s the most inexplicable thing I’ve yet seen a professional pilot do, and I’ve seen a lot of crazy things. If locked flight controls don’t prompt a takeoff abort, nothing will.

Albright’s analysis is outstanding: direct and factual. I predict there will be no shortage of articles and opinions on this accident. It will be pointed to and discussed for years as a bright, shining example of how not to operate an aircraft.

In response to the crash, former NTSB member John Goglia has called for video cameras in the cockpit, with footage to be regularly reviewed to ensure pilots are completing checklists. Despite the good intentions, this proposal would not achieve the desired end. Pilots are already work in the presence of cockpit voice recorders, flight data recorders, ATC communication recording, radar data recording, and more. If a pilot needs to be videotaped too, I’d respectfully suggest that this person should be relieved of duty. No, the problem here is not going to be solved by hauling Big Brother further into the cockpit.

A better model would be that of the FOQA program, where information from flight data recorders is downloaded and analyzed periodically in a no-hazard environment. The pilots, the company, and the FAA each get something valuable. It’s less stick, more carrot. I would also add that this sort of program is in keeping with the Fed’s recent emphasis on compliance over enforcement action.

The Normalization of Deviance

What I, and probably you, are most interested in is determining how well-respected, experienced, and accomplished pilots who’ve been through the best training the industry has to offer reached the point where their performance is so bad that a CFI wouldn’t accept it from a primary student on their very first flight.

After reading through the litany of errors and malfeasance present in this accident report, it’s tempting to brush the whole thing off and say “this could never happen to me”. I sincerely believe doing so would be a grave mistake. It absolutely can happen to any of us, just as it has to plenty of well-trained, experienced, intelligent pilots. Test pilots. People who are much better than you or I will ever be.

But how? Clearly the Bedford pilots were capable of following proper procedures, and did so at carefully selected times: at recurrent training events, during IS-BAO audits, on checkrides, and various other occasions.

Goglia, Albright, the NTSB, and others are focusing on “complacency” as a root cause, but I believe there might be a more detailed explanation. The true accident chain on this crash formed over a long, long period of time — decades, most likely — through a process known as the normalization of deviance.

Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety. People grow more accustomed to the deviant behavior the more it occurs. To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.

This concept was developed by sociologist and Columbia University professor Diane Vaughan after the Challenger explosion. NASA fell victim to it in 1986, and then got hit again when the Columbia disaster occurred in 2003. If they couldn’t escape its clutches, you might wonder what hope we have. Well, for one thing, spaceflight in general and the shuttle program in particular are specialized, experimental types of flying. They demand acceptance of a far higher risk profile than corporate, charter, and private aviation.

I believe the first step in avoiding “normalization of deviance” is awareness, just as admitting you have a problem is the first step in recovery from substance addiction. After all, if you can’t detect the presence of a problem, how can you possibly fix it?

There are several factors which tend to sprout normalization of deviance:

First and foremost is the attitude that rules are stupid and/or inefficient. Pilots, who tend to be independent Type A personalities anyway, often develop shortcuts or workarounds when the checklist, regulation, training, or professional standard seems inefficient. Example: the boss in on board and we can’t sit here for several minutes running checklists; I did a cockpit flow, so let’s just get going!

Sometimes pilots learn a deviation without realizing it. Formalized training only covers part of what an aviator needs to know to fly in the real world. The rest comes from senior pilots, training captains, and tribal knowledge. What’s taught is not always correct.

Often, the internal justification for cognizant rule breaking includes the “good” of the company or customer, often where the rule or standard is perceived as counterproductive. In the case of corporate or charter flying, it’s the argument that the passenger shouldn’t have to (or doesn’t want to) wait. I’ve seen examples of pilots starting engines while the passengers are still boarding, or while the copilot is still loading luggage. Are we at war? Under threat of physical attack? Is there some reason a 2 minute delay is going to cause the world to stop turning?

The last step in the process is silence. Co-workers are afraid to speak up, and understandably so. The cockpit is already a small place. It gets a lot smaller when disagreements start to brew between crew members. In the case of contract pilots, it may result in the loss of a regular customer. Unfortunately, the likelihood that rule violations will become normalized increases if those who see them refuse to intervene.

The normalization of deviance can be stopped, but doing so is neither easy or comfortable. It requires a willingness to confront such deviance when it is seen, lest it metastasize to the point we read about in the Bedford NTSB report. It also requires buy-in from pilots on the procedures and training they receive. When those things are viewed as “checking a box” rather than bona fide safety elements, it becomes natural to downplay their importance.

Many of you know I am not exactly a fan of the Part 121 airline scene, but it’s hard to argue with the success airlines have had in this area. When I flew for Dynamic Aviation’s California Medfly operation here in Southern California, procedures and checklists were followed with that level of precision and dedication. As a result, the CMF program has logged several decades of safe operation despite the high-risk nature of the job.

Whether you’re flying friends & family, pallets of cargo, or the general public, we all have the same basic goal, to aviate without ending up in an embarrassing NTSB report whose facts leave no doubt about how badly we screwed up. The normalization of deviance is like corrosion: an insidious, ever-present, naturally-occurring enemy which will weaken and eventually destroy us. If we let it.