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Safety Recommendation Details

Safety Recommendation A-12-062
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 GULFSTREAM AEROSPACE CORPORATION: Commission an audit by qualified independent safety experts, before the start of the next major certification flight test program, to evaluate the company’s flight test safety management system, with special attention given to the areas of weakness identified in this report, and address all areas of concern identified by the audit.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Roswell, NM, United States
Is Reiterated: No
Is Hazmat: 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: 4/16/2015
Addressee(s) and Addressee Status: Gulfstream Aerospace Corporation (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: Gulfstream Aerospace Corporation
Date: 4/16/2015
Response: We note that, following two external independent safety review audits, you developed two safety management system (SMS) auditing protocols specifically tailored to flight test operations. We also note that an independent auditor used one of these protocols to evaluate your flight test program, which found all items to be either “present and suitable” or “operational and effective.” We understand that you have shared this protocol with the flight test community and that it is now included in the Flight Test Safety Committee’s flight test safety database. Accordingly, Safety Recommendation A-12-62 is classified CLOSED—ACCEPTABLE ACTION.

From: Gulfstream Aerospace Corporation
Date: 4/9/2015
Response: -From Larry Flynn, President: Gulfstream' s previous update letter of September 2013 described the external Independent Safety Review Team audits ("ISRT 1.0" and "ISRT 2.0") that were commissioned shortly after the accident and then 19 months later. The second of these Safety Review Team audits in part assessed Gulfstream's progress in implementing a number of safety and flight test Safety Management System (SMS) initiatives, many of which related to the NTSB findings and recommendations from the Flight 153 accident investigation. Gulfstream accepted and implemented all recommendations from ISRT 1.0 and ISRT 2.0 and, further, provided verification of these completed actions to the FAA Atlanta Aircraft Certification Office (ACO) in support of Gulfstream's Partnership for Safety Plan for the GVII (G500/G600) program. Due to the timing of Gulfstream's implementation of a formal SMS within Engineering (and thus Flight Test) and the previously scheduled ISRT 2.0, we could not evaluate the effectiveness of the GAC Flight Test SMS program with the ISRT 2.0 audit. Accordingly, and as explained in the NTSB Update letter of September 2013, Gulfstream considered Recommendation A-12-62 open until another external, independent flight test SMS audit could be conducted. Gulfstream developed two SMS auditing protocols that were specifically tailored to flight test operations, but based on the familiar aviation industry standards: International Standards for Business Aviation Operations (IS-BAO) and the Safety Management International Collaboration Group (SMICG). Gulfstream chose the latter protocol as the basis for the flight test SMS program audit, because this protocol was currently used elsewhere in the company for annual assessments, and it was the favored protocol of the professional SMS auditor contracted to perform the audit. The SMICG-based audit was conducted in November 2014 with the final report published in February 2015. The auditor interviewed 18 individuals and reviewed 41 source documents in support of his assessment. The final report was very thorough and provided detailed feedback across all SMS components, effectively benchmarking the flight test SMS for future audits and validating the effectiveness of the tailored auditing protocol. The auditor noted "present and suitable" for many of the key SMS functions, and "operational and effective" for the most critical safety processes. There were 36 recommendations to further enhance the foundational activities and documentation requirements to pursue "operational and effective" levels of performance across all domains. Gulfstream solicited critique from the auditor regarding the appropriateness and robustness of the auditing protocol that was developed based on the SMICG framework. Gulfstream then shared this tailored SMS auditing protocol to the broader flight test community based on positive feedback from the auditor after his first experience conducting such an extensive flight test SMS evaluation. This protocol was further made available to the NASA Flight Test Safety Database (FTSD) which is the designated repository for flight test "best practices" information that is maintained by the Society of Experimental Test Pilots' Flight Test Safety Committee (FTSC). Based on the extensive ISRT reviews and the detailed external SMS flight test audit that specifically addressed NTSB findings and offered excellent feedback on SMS architecture and performance, Gulfstream respectfully requests closure of NTSB Recommendation A-12-62. Summary: Gulfstream appreciates the opportunity to provide you with this update about our progress in implementing various safety initiatives taken since the Flight 153 accident, and the external flight test SMS audit described above. The latest SMS-specific flight test audit further complemented the immensely informative reviews provided by the highly experienced flight test and aviation experts that served as members of both ISRT groups. In addition, the recommendations from the Board were quite useful in this endeavor and those recommendations helped us identify positive and lasting changes company-wide. Gulfstream has also remained fully committed to sharing the information gained from these efforts with industry and the flight test community. We trust these extensive efforts will serve to satisfy Recommendation A-12-62.

From: NTSB
To: Gulfstream Aerospace Corporation
Date: 12/3/2013
Response: We appreciate receiving information about the second external Independent Safety Review Team audit that Gulfstream conducted March 24-29, 2013. We are encouraged to learn that many of the recommendations resulting from this audit have been completed and that the rest are scheduled for completion before the next audit. We note that, because of the timing of implementation of a safety management system (SMS) within Gulfstream’s engineering organization (of which the flight test organization is a part), the review team was unable to fully review the SMS in the flight test organization, but that it plans to do so. Pending the results of that additional auditing, Safety Recommendation A-12-62 remains classified OPEN—ACCEPTABLE RESPONSE.

From: Gulfstream Aerospace Corporation
Date: 9/30/2013
Response: -From Larry Flynn, President: Gulfstream conducted a second external Independent Safety Review Team ("ISRT 2.0") audit from March 24-29, 2013 at the Gulfstream Headquarters in Savannah, Georgia. Six of the team members participated in the 2011 review, while three were new to this audit. Although the focus of this review was primarily flight test process, preparation and execution, the team was unconstrained and looked across other influencing activities such as program management, Organizational Designation Authority (ODA), Human Resources staffing and vendor quality management/technology readiness. Particular emphasis was placed on evaluating the efficacy of the Safety Management System (SMS) and its application throughout flight test and complementary organizations. Results from this audit were very favorable, with no major findings and suggested recommendations to further enhance safety culture, SMS effectiveness, and flight test readiness. This review team witnessed the sweeping changes Gulfstream implemented as part of the first ISRT audit and the NTSB investigation, and reaffirmed the progress towards a more vibrant safety system company-wide. The ISRT 2.0 paid close attention to new programs and those essential elements that have direct consequences to flight test preparation and risk management. Of particular focus was the development of executable flight test schedules that address stakeholders' inputs and align processes within an ODA-managed test program. Many of the recommendations of the ISRT 2.0 have been completed and the remainder are on a monitored schedule with completion required before the next audit. As a consequence of the implementation of SMS within the engineering organization only a short time before the audit, the review team was unable to comment on the maturity and effectiveness within the subordinate flight test organization. Therefore, Gulfstream considers this recommendation open pending further engineering/flight test SMS auditing, anticipated in the Spring of 2014.

From: NTSB
To: Gulfstream Aerospace Corporation
Date: 3/26/2013
Response: We are encouraged that Gulfstream is recommissioning the Independent Safety Review Team to review the safety management system (SMS) that was put in place after the accident and that, if Gulfstream begins a new major certification flight test program more than 2 years after the team’s audit is completed, the company will commission and complete another audit before initiating the new certification flight test program. Pending completion of these actions, Safety Recommendation A-12-62 is classified OPEN—ACCEPTABLE RESPONSE.

From: Gulfstream Aerospace Corporation
Date: 1/4/2013
Response: -From Larry Flynn, President: Following the accident, Gulfstream commissioned a Flight Test Operations Safety Review and Audit, conducted in June/July 2011 by an Independent Safety Review Team (ISRT) comprised of highly experienced test pilots, a flight test engineer, and aviation safety consultants. Gulfstream is re-commissioning the same (or substantially the same) ISRT used in its post-accident Flight Test Operations Safety Review and Audit to conduct the NTSB recommended audit during the spring of2013. The scope of this second audit will include a review of the Safety Management System (SMS) that was put in place for the Flight Test Organization after the accident, with a particular focus on the issues raised by the NTSB in its final report. Pursuant to our SMS, if this second audit is completed more than two years before the start of our next major certification flight test program, Gulfstream will commission and complete another audit before commencing such program.