Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-12-059
Details
Synopsis: On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FLIGHT TEST SAFETY COMMITTEE: In collaboration with the Federal Aviation Administration, develop and issue flight test operating guidance for manufacturers that addresses the deficiencies documented in this report regarding flight test operating policies and procedures and their implementation, and encourage manufacturers to conduct flight test operations in accordance with the guidance.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Roswell, NM, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11MA076
Accident Reports: Crash During Experimental Test Flight, Gulfstream Aerospace Corporation GVI (G650), N652GD
Report #: AAR-12-02
Accident Date: 4/2/2011
Issue Date: 10/23/2012
Date Closed: 4/6/2017
Addressee(s) and Addressee Status: Flight Test Safety Committee (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Flight Test Safety Committee
Date: 4/6/2017
Response: We note that the FTSC developed a comprehensive and concise general operating guidance document, and you have posted this document on your website. We further note that you will be promoting this guidance at technical symposia, the Manufacturers Flight Test Council meetings, and flight test safety workshops throughout the year. These actions satisfy Safety Recommendation A-12-59, which is classified CLOSED--ACCEPTABLE ACTION.

From: Flight Test Safety Committee
To: NTSB
Date: 2/24/2017
Response: -From Gerald W. Whites, Chairman, Flight Test Safety Committee: The FTSC authored a comprehensive and concise general operating guidance document (“operating guidance” or “document”) which not only addresses the findings in the accident report but also includes complementary material which should be immensely helpful to both new and existing flight test organizations (enclosed). The document also includes several references (hyperlinked) that can provide further information on key concepts and provide resources to broaden test organization knowledge, and positively contribute to higher flight test safety performance and efficiency. The guidance document was reviewed and critiqued by the entirety of the FTSC membership (international composition) that includes current and former flight test experienced representatives from industry, academia and regulators that are committed to continual improvement in flight test safety. The FTSC has posted the document on its web site and intends to promote the operating guidance at technical symposia, the Manufacturers Flight Test Council meetings and Flight Test Safety Workshops throughout the year. The FTSC respectfully requests closure of this Recommendation. In summary: The FTSC appreciates the support and collaboration of the NTSB during the development, formalization and broadcasting of Recommendation products to the flight test community. The FTSC is committed to providing our industry with tools that will aid in continually improving flight test practices and prevent the repeat of tragic lessons through information sharing and community awareness. The NTSB Recommendations and key takeaways from the final report of Flight 153 provided a necessary stimulus to develop and document operating guidance that is scalable to the size and complexity of the test organization, yet provides tangible methods to organize a test team, establish a positive safety culture and ultimately, excel at test execution with risks that have been mitigated to as low as reasonably possible. The FTSC believes this operating guidance document will be a valuable living document that provides a wealth of best practice information to the flight test profession around the world.

From: NTSB
To: Flight Test Safety Committee
Date: 7/20/2016
Response: We were pleased to learn that the March 23, 2016, meeting between Mr. Tom Huff and NTSB staff helped to clarify our intent in issuing this recommendation and what further action was needed to satisfy it. We note that you have assigned a project team to produce a draft operating guidance document and plan to publish it soon. Pending the release of the completed document, Safety Recommendation A-12-59 remains classified OPEN—ACCEPTABLE RESPONSE.

From: Flight Test Safety Committee
To: NTSB
Date: 4/15/2016
Response: -From Gerald W. Whites, Chairman, Flight Test Safety Committee: The Flight Test Safety Committee appreciates the clarification of this recommendation in the NTSB response letter of June 18, 2015- specifically, that " ... you [FTSC] will also need to develop and issue the recommended flight test operating guidance document for manufacturers once you have collected and reviewed the information that you solicited." A subsequent face-to-face meeting between FTSC Board Member, Mr. Torn Huff and NTSB representatives Mr. Bill Bramble and Mr. Jeffrey Marcus of Mar 23, 2016 clarified the recommendation further, characterizing the general operational guidance document in terms of test team formation, flight test risk management processes, and test results data reviews. The FTSC has assigned a project team to produce a draft of this operating guidance document for further review and refinement prior to publishing on the Flight Test Safety web site (expected completion: Sep 2016).

From: NTSB
To: Flight Test Safety Committee
Date: 6/18/2015
Response: We note that, with the assistance of the FAA, you established the Flight Test Safety Database (FTSD) to provide the flight test community an easily accessible repository for test maneuver descriptions, test hazards, and hazard mitigation techniques. We further note that you issued a letter to manufacturers soliciting “best practice” information, optimized operating procedures, and useful guidance that could be shared among manufacturers and flight test community members. These are positive steps in addressing the recommendation. We point out, however, that, in order to satisfy Safety Recommendation A-12-59, you will also need to develop and issue the recommended flight test operating guidance document for manufacturers once you have collected and reviewed the information that you have solicited. Pending the development and issuance of that document, Safety Recommendation A-12-59 is classified OPEN—ACCEPTABLE RESPONSE.

From: Flight Test Safety Committee
To: NTSB
Date: 11/25/2014
Response: -From Gerald Whites, Chairman, Flight Test Safety Committee: The Flight Test Safety Database (FTSD) at: https://ftsd.grc.nasa.gov/ was established to provide the flight test community an easily accessible repository for test maneuver descriptions, test hazards and hazard mitigation techniques. To enhance the volume and breadth of content on the site, the FTSC issued a letter to manufacturers soliciting “best practice” information, optimized operating procedures and useful guidance that could be shared among manufacturers and flight test community members. Although the FAA declined to co-author the request letter, the FTSC will retain their participation in committee collection, collation and dissemination of manufacturer flight test policy, guidance, and procedural practices that may be beneficial on the FTSD. The FTSC will continue to promote flight test proven methods and lessons learned to the flight test community through well-established symposia, workshops and committee meetings while strongly encouraging usage of the FTSD. The Committee considers this recommendation OPEN until the best practice solicitation effort is complete and material uploaded to the FTSD (expected completion: Sep 2015). In summary, the FTSC is an all-volunteer committee that is part of the Society of Experimental Test Pilots (SETP) Foundation (501c(3) not-for-profit) chartered to enhance flight test safety through professional enrichment and industry-wide collaboration. The Committee is comprised of industry experts, manufacturer flight test safety representatives, and FAA/EASA flight test experienced personnel. Components of the NTSB recommendations are already being exercised, and with improvements to the FTSD resource center, the tools will be easily accessed and scalable to all flight test activities. The Committee is encouraged by increasing participation and collaboration among OEMs to share and embrace best practices that will ensure flight test risks are continually mitigated to the maximum extent practicable.

From: NTSB
To: Flight Test Safety Committee
Date: 10/3/2014
Response: In January 2014, NTSB staff spoke informally to some members of the FTSC regarding actions that you had planned to take in response to these recommendations. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Our recipients usually complete actions to implement our safety recommendations within 3 to 5 years of issuance. As these recommendations were issued almost 2 years ago, and to date we have received no formal reply from you regarding actions that you have either taken or planned in response to them, we would appreciate receiving a response within 90 days indicating such actions. Pending your timely reply, Safety Recommendations A 12 59 through 61 will retain their current classification of OPEN—AWAIT RESPONSE.