In closing, I would like to recognize the hard work of the NTSB staff in producing this report, and thank my fellow Board Members for their very thoughtful participation in the process.
In this investigation, we took a close look into the operation of a business airplane, and today’s recommendations, if acted upon, have the potential to make business aviation safer.
To their credit, Gulfstream Aerospace Corporation is working on modifications to the G-IV gust lock and the FAA intends to mandate the modifications once Gulfstream develops them. In support of that intent, we recommend that once the modifications are available, the FAA require implementation on all existing G-IV airplanes.
We also recommend that the FAA develop and issue guidance on the use of engineering drawing review in the design certification process.
Today, we call on the International Business Aviation Council to amend international auditing standards to verify that operators complete checklists according to best practices, using the challenge-verification-response format wherever possible.
As we have seen in the commercial aviation industry, data analysis is a key component to improving flight operations. Today, we ask the business aviation community to do the same. That is why we recommend the National Business Aviation Association and other business groups analyze data on compliance with manufacturer-required flight control checks, and provide the results of that analysis to their members.
While our recommendations today will make business aviation safer, it is important to remember that this accident was preventable. It could have been avoided by following established procedures. So, in addition to today’s recommendations, we will be issuing a Safety Alert – bringing everyone’s attention to the critical need to follow checklists to prevent procedural omissions such as failing to remove flight control locks and the need to perform flight control checks before every takeoff.
Complacency leading to procedural non-compliance has no place in aviation. Together, today’s safety recommendations and Safety Alert will reduce the risk of complacency and significantly increase the safety of flight. Owners of business aircraft and their passengers deserve this benefit.
This accident is proof positive for why procedural compliance is one of our 2015 Most Wanted List issues – procedural compliance saves lives. Methodically and routinely following procedures on each and every flight without skipping steps may seem mundane, but it is the cornerstone of safety in aviation and indeed, in all modes of transportation. Ensuring that procedures are always followed will save lives and prevent injuries.
We stand adjourned.