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Safety Recommendation Details

Safety Recommendation A-12-063
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: Provide information about the lessons learned from the implementation of its flight test safety management system to interested manufacturers, flight test industry groups, and other appropriate parties.
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: 12/3/2013
Addressee(s) and Addressee Status: Gulfstream Aerospace Corporation (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: Gulfstream Aerospace Corporation
Date: 12/3/2013
Response: We are pleased with the numerous presentations that Gulfstream made to the international flight test community and to all the commercial and business aircraft manufacturers to address Safety Recommendation A-12-63. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: Gulfstream Aerospace Corporation
Date: 9/30/2013
Response: -From Larry Flynn, President: Gulfstream has presented the Flight 153 accident lessons learned and subsequent engineering, flight test, and safety process improvements to a wide international flight test community and all of the commercial/business aircraft manufacturers. Many of these presentations were conducted jointly with members of the NTSB Flight 153 investigation team. The presentations included Gulfstream's experience in adapting the FAA AC 120-92A SMS model to an engineering flight test organization and the accompanying implementation challenges. A summary of the briefings conducted to date include: -2012 European Flight Test Safety Workshop (Joint NTSB/Gulfstream) -2013 North American Flight Test Safety Workshop -2013 Edwards Flight Test Center/NASA Dryden Safety Day (Joint NTSB/Gulfstream) -2013 Society of Experimental Test Pilots (SETP) Central Section Symposium -2013 Boeing Safety Day -2013 Pax River Test Wing Atlantic Safety Day (Joint NTSB/Gulfstream) -2013 SETP Annual Symposium Upcoming briefs include: -2013 Society of Flight Test Engineers (SFTE) Annual Symposium -2013 European Flight Test Safety Workshop -2014 Naval Air Warfare Center China Lake Safety Day Gulfstream is experiencing unprecedented cooperation among manufacturers, the FAA Air Certification Offices, and the two primary flight test professional organizations - Society of Experimental Test Pilots (SETP) and Society of Flight Test Engineers (SFTE)- to highlight and share valuable best practices in the aircraft development-to certification continuum. The Flight Test Safety Committee, a not-for-profit foundation of SETP, has broadened its membership base to address NTSB recommendations, and Gulfstream is now represented on the Board of Directors. The Committee reports NTSB recommendation progress to the flight test Societies and is well underway in capturing lessons learned/best practice information and hosting it on an easily navigable web-based portal. Documented, easily accessible, non-propriety flight test methods and safety information will provide a valuable reference to flight test teams, and a repository will ensure this critical information transcends time and does not become known only among a few select community experts. Gulfstream intends to participate long-term in this effort. We request closure of recommendation A-12-63. Summary: Gulfstream was encouraged by the results of ISRT 2.0, confirming our commitment to safety improvement and cultural change. Moreover, the collaboration among OEMs and aviation safety groups has been the catalyst for real and substantive community change. Gulfstream is fully committed to continuing the safety journey and anticipates providing our next update to NTSB recommendations following the Spring 2014 audit.

From: NTSB
To: Gulfstream Aerospace Corporation
Date: 3/26/2013
Response: Your letter described a number of initiatives that Gulfstream has planned or completed to provide lessons learned from implementation of its flight test SMS to interested parties, as recommended. We ask that you provide us with an update on the progress of these activities 1 year from now. In the meantime, pending completion of the activities described, Safety Recommendation A-12-63 is classified OPEN—ACCEPTABLE RESPONSE.

From: Gulfstream Aerospace Corporation
Date: 1/4/2013
Response: -From Larry Flynn, President: Gulfstream has undertaken the following in order to provide lessons learned from implementation of its flight test Safety Management System: 1. Gulfstream has become a member of the Flight Test Safety Committee (FTSC), a sub-group of the Society of Experimental Test Pilots (SETP). Gulfstream's Aviation Safety Officer is now included as a member of the FTSC Board of Directors and is participating in the sub-committee formed to address the 10 NTSB recommendations to the Federal Aviation Administration (FAA), the FTSC and Gulfstream. 2. Gulfstream joined the NTSB staff in jointly briefing the European Flight Test Safety Workshop in November 2012, addressing the results of the Flight 153 accident investigation, lessons learned, and subsequent corrective actions by Gulfstream. 3. Gulfstream will join the NTSB staff in participating in several 2013 briefing opportunities across the flight test community as well as other appropriate venues including safety symposia sponsored by the International Society of Aviation Safety Investigators (ISASI), the National Business Aviation Association (NBAA), and the Flight Safety Foundation (FSF). Gulfstream is a safety committee member of each of the aforementioned organizations, all of which have significant international flight department participation and industry original equipment manufacturer (OEM) membership/sponsorship. 4. Gulfstream has coordinated with the major commercial aircraft OEMs to develop and share common aircraft certification hazards, risks, and mitigation strategies. In summary, Gulfstream is committed to sharing lessons learned and doing everything possible to ensure that these lessons endure over time. The tragedy of Flight 153 shall stand as a constant reminder of the inherent dangers in conducting high risk flight testing, and the need to mitigate those risks. Gulfstream is further determined to instill throughout its operations a robust safety culture that places absolute priority on safety and quality over cost and schedule. We will update our response once our 2013 ISR T audit has been completed.