My colleague at AIN and former NTSB member John Goglia correctly asks in his “Torqued” column if the May 2014 Gulfstream GIV takeoff crash in Bedford, Mass., is a wakeup call for business aviation. The answer is a resounding yes, as this has been one of the most discussed topics that I’ve ever seen in the 20 years since I started covering this industry.
Crews have certainly paid attention to the prevailing message: complacency and noncompliance with checklists can kill. And in the case of the GIV crash it did, as the accident claimed the lives of both pilots, the flight attendant and all four passengers.
But the hazier message is whether the International Standards for Business Aircraft Operations (IS-BAO) are effective or even worth doing. After all, the two-person flight department that operated the Gulfstream was IS-BAO Stage 2, meaning that its safety management system (SMS) was “functioning with the results being measured,” according to the International Business Aviation Council (IBAC), which administers the IS-BAO program.
Since the flight department was Stage 2, it passed not one but two separate third-party audits to validate that its processes and procedures met or exceeded a recognized set of standards. Yet after all the work to draft a small bookcase full of manuals, putting every minor detail and procedure on paper, the pilots still crashed a perfectly good airplane.
According to the NTSB probable cause report, the crew did not verbalize any checklist before the accident flight and had not performed a flight control check–a procedure that assuredly would have broken the accident chain. Undoubtedly, using the checklist each and every time would have been one of the procedures listed somewhere, and possibly multiple times, in the IS-BAO-audited manuals.
Worse, data taken from the airplane’s quick access recorder found that the crew did not complete any flight control checks on 98 percent of the previous 175 flights in the airplane. This was the crew’s procedure, though it was unwritten.
Since the accident crew failed to consistently operate as per the written procedures, they did more harm than substantially destroying an airplane and killing seven people. In addition, they also cast doubt on a set of best practices that was intended to increase, not decrease, aviation safety.
This gave ready fuel to IS-BAO opponents, who quickly took to NBAA Air Mail and pilot message boards to complain that the best practices are just another paperwork exercise, with the result just more manuals that will likely collect dust after the operation expends the time, effort and money to create them.
But the problem is that IS-BAO takes more than just these three tangible ingredients; it also requires “buy in” by the whole department. Everyone from the scheduler to the aviation manager at the flight department, as well as the aircraft owners, must participate in the IS-BAO process and fully believe in and use the end product that is then audited.
And when the actual operating practices no longer match these written procedures, then it’s time to correct the problem via training or updating the IS-BAO manuals, which are intended to be living documents that change with the needs of the department, not dust collectors.
Pieces of paper certainly won’t prevent you from ever having an accident, but an ingrained safety culture, backed up by documentation that everyone believes in and adheres to, will go a long way to making sure that your emergency response plan is never put to use.