Gulfstream Accident 12/15/2021 Santo Domingo to Orlando Fatal 9

I was a lot more than 15 I just can't even remotely understand it.

" The NTSB is issuing a safety alert to underscore the importance of following checklist procedures and is asking NBAA to analyze data to determine the extent of procedural noncompliance in business aviation after the investigation into the crash of a Gulfstream IV on May 31 last year revealed that the pilots did not verbalize any checklist before the accident flight and that a flight control check had not been completed on 98 percent of the previous 175 flights in the airplane. "
That's 171 out of 175 !!!



wow.
(I have nothing else to add)
 
If I recall correctly, there was evidence that they didn't use any checklists for the previous 15 flights, too.

Not exactly. The airplane didn’t record it. Doesn’t mean it wasn’t done. The airplane only records a control check is held at each stop for 2 seconds.

Nobody holds full right for two seconds…then full left for 2 seconds, then full back, etc etc.
 
Not exactly. The airplane didn’t record it. Doesn’t mean it wasn’t done. The airplane only records a control check is held at each stop for 2 seconds.

The airplane records the control surface positions. Two seconds is a courtesy to the recorder, but isn't a binary yes/no thing and less than the documented procedure may still be accepted for the statistics.

Nobody holds full right for two seconds…then full left for 2 seconds, then full back, etc etc.

I don't mean to make a big deal of it, but there absolutely are operations in 91/135 world where every crew does the full check every time, and they are the majority.

A FSF and NBAA study found that ~18% of crews are not performing a full control check (not all surfaces moved or not a sufficient amount), with ~1.5%-3% performing no functional check at all. The NTSB's conclusion that that crews did not perform a sufficient control check on more than half the prior flights identifies that operation as an outlier.

It was neat that the study found more control checks started being performed after the NTSB report on Bedford was released, but then returned to a baseline behavior over time.

Bad Habits - Flight Safety Foundation

NBAA Report: Business Aviation Compliance With Manufacturer-Required Flight-Control Checks Before Takeoff (PDF)
 
No names or anything, I'd be interested to hear from guys/gals flying corporate if the level of "procedural non-compliance" is really at that level or not.

I've heard stories of no checklists and no procedures and wackadoodles for decades now. Very little in the way of firm data other than seeing guys sleeping in FBO couches.
 
Back in my charter life we always did a flight control check prior to the runway or on the taxi out or after start checklist depending on the airframe. 100 percent of the time.

current 121- we do it after the flaps are set now.
 
No names or anything, I'd be interested to hear from guys/gals flying corporate if the level of "procedural non-compliance" is really at that level or not.

I've heard stories of no checklists and no procedures and wackadoodles for decades now. Very little in the way of firm data other than seeing guys sleeping in FBO couches.
Have never seen that. Heard stories, too, but no evidence.
 
Having to sit and watch an airplane as it starts up and watching the pilots go through the checklist as a mechanic before it leaves can be very uncomfortable. Once they taxi out it's a little less stress, watching them fly away is a huge relief. But every once in a while they taxi back before they leave, normally those are bad days for the company and the mechanics (but good days for the passengers in the long term). Watching something you might've disassembled and reassembled getting put back into service is highly stressful for me, I know there are mechanics that seem to not care, once they clock out they also are able to just leave whatever they've done behind and not care. That sort of thing baffles me, I'll wake up in the middle of the night and start either second guessing myself or start overthinking issues I can't control. It's a character flaw that I recognize and have been trying to remedy.
 
That sort of thing baffles me, I'll wake up in the middle of the night and start either second guessing myself or start overthinking issues I can't control. It's a character flaw that I recognize and have been trying to remedy.

I think it shows that you care a lot about the work you do.

A “character flaw” sounds harsh but I do the same type of thing, get paranoid about all kinds of work related stuff. And wish I didn’t.

But usually the people who think the most about that kind of thing are the least likely to make major screw-ups.
 
I think it shows that you care a lot about the work you do.

A “character flaw” sounds harsh but I do the same type of thing, get paranoid about all kinds of work related stuff. And wish I didn’t.

But usually the people who think the most about that kind of thing are the least likely to make major screw-ups.
I can guarantee that watching others mistakes end up as smoking holes will probably ingrain those feelings or attitude in most folks, but there is a portion of people that seem unaffected. I'm not talking about people directly involved, I'm thinking of others who witness bad events and believe that others mistakes are beneath them and they'd never make such a simple mistake. Those people scare me and I don't trust them.
 
Having to sit and watch an airplane as it starts up and watching the pilots go through the checklist as a mechanic before it leaves can be very uncomfortable. Once they taxi out it's a little less stress, watching them fly away is a huge relief. But every once in a while they taxi back before they leave, normally those are bad days for the company and the mechanics (but good days for the passengers in the long term). Watching something you might've disassembled and reassembled getting put back into service is highly stressful for me, I know there are mechanics that seem to not care, once they clock out they also are able to just leave whatever they've done behind and not care. That sort of thing baffles me, I'll wake up in the middle of the night and start either second guessing myself or start overthinking issues I can't control. It's a character flaw that I recognize and have been trying to remedy.

Very different line of work for me but lives were often hanging in the balance of my immediate choices long before the “troops” arrived on-scene. Nearly three years of retirement have been … healing … for me. I can say with absolute certainty, though, that there were a lot of nights when sleep wouldn’t come as I replayed my role in someone’s emergency. Those eight or ten or twelve minutes until the Medic arrived with their bag of magic potions seemed like an eternity most times when our pre-arrival instructions to a panicked loved one were the thin thread which kept someone going until the next level of care arrived.

I appreciate your perspective as someone invested enough to care about important things.
 
Very different line of work for me but lives were often hanging in the balance of my immediate choices long before the “troops” arrived on-scene. Nearly three years of retirement have been … healing … for me. I can say with absolute certainty, though, that there were a lot of nights when sleep wouldn’t come as I replayed my role in someone’s emergency. Those eight or ten or twelve minutes until the Medic arrived with their bag of magic potions seemed like an eternity most times when our pre-arrival instructions to a panicked loved one were the thin thread which kept someone going until the next level of care arrived.

I appreciate your perspective as someone invested enough to care about important things.
My experience dealing with the real hard parts of life pales in comparison to yours. The fact that we can both sleep at night is a gift, but I have to confess I use a small fan on my bedside table for the breeze and the white noise, absolute silence just let's my mind sometimes run in circles. When I got married I had a big fan but my wife didn't like it so she got me a smaller fan, and then another even smaller fan, eventually I ended up with what I have now. I'm divorced, I should go buy a big fan.
 
My experience dealing with the real hard parts of life pales in comparison to yours. The fact that we can both sleep at night is a gift, but I have to confess I use a small fan on my bedside table for the breeze and the white noise, absolute silence just let's my mind sometimes run in circles. When I was married I had a big fan but my wife didn't like it so she got me a smaller fan, and then another even smaller fan, eventually I ended up with what I have now. I should go buy a big fan.

I’d encourage you to buy the big fan.

I go to sleep every night with a steady, hard rain playing on my IPad.

And a big fan blowing a nice breeze without regard to the outside temperature.
 
To the extent that I ever did Stuff That Matters, which wasn't very much (fixed wing air ambo isn't exactly Hero Poop, even if you do get to wear nomex pajamas), I do miss it. Didn't do it long enough to burn out, I guess. But there is a definite, eh..."thrill" isn't quite the right word, but there's something that sharpens up your subjective experience of driving the aviation appliance when there are at least putative "lives on the line". Particularly when it's all down to you whether the thing goes or not.

And of course thinking that way is what gets people killed. I'd be flat out lying if I claimed that I never pushed things just a *little* bit further than I otherwise might have because there were some highly skilled pros in the back looking to me to, you know, save the day and get them to the dying child who only they could save, etc. etc. etc.

Now, naturally, nine times out of ten, or maybe even 95 times out of 100, the kid was going to be fine, and we were flying it because some bored attending didn't want to wear the brown liability-helmet if it unexpectedly expired during the five hour ground ambo ride, but it was always *possible* that it was serious, and so it always felt like it was.

My hat's off to the dudes who do that stuff day in and day out for 30 years (and that includes maintainers). I have to make (or fail to challenge) a lot of bad decisions, and press a WHOLE LOT of wrong buttons to kill anyone, these days. Which is, of course, good. But it's not very gratifying.
 
To the extent that I ever did Stuff That Matters, which wasn't very much (fixed wing air ambo isn't exactly Hero Poop, even if you do get to wear nomex pajamas), I do miss it. Didn't do it long enough to burn out, I guess. But there is a definite, eh..."thrill" isn't quite the right word, but there's something that sharpens up your subjective experience of driving the aviation appliance when there are at least putative "lives on the line". Particularly when it's all down to you whether the thing goes or not.

And of course thinking that way is what gets people killed. I'd be flat out lying if I claimed that I never pushed things just a *little* bit further than I otherwise might have because there were some highly skilled pros in the back looking to me to, you know, save the day and get them to the dying child who only they could save, etc. etc. etc.

Now, naturally, nine times out of ten, or maybe even 95 times out of 100, the kid was going to be fine, and we were flying it because some bored attending didn't want to wear the brown liability-helmet if it unexpectedly expired during the five hour ground ambo ride, but it was always *possible* that it was serious, and so it always felt like it was.

My hat's off to the dudes who do that stuff day in and day out for 30 years (and that includes maintainers). I have to make (or fail to challenge) a lot of bad decisions, and press a WHOLE LOT of wrong buttons to kill anyone, these days. Which is, of course, good. But it's not very gratifying.

sometimes I get an approval request for a medevac direct TEB and I’m like of course yes and then it’s a freaking medevac Cirrus. I’m like how urgent is this really?
 
sometimes I get an approval request for a medevac direct TEB and I’m like of course yes and then it’s a freaking medevac Cirrus. I’m like how urgent is this really?

There's Medevac and then there's MEDEVAC. Unfortunately, the system is abused regularly. We always used the N number unless we had a patient onboard, but even then, the vast majority of them weren't critical enough that 3 minutes was going to matter. Like I think I maybe flew two in ~three years where we legitimately needed to get them on the ground right now. Obviously, the exigency is much greater with the helos.

Edit: Not quite true that we never used medevac without a patient. I used it a couple of times when doing workover for an adult ship base and we were flying in to pick up a gunshot wound or car crash victim out on the Rez. Out there you wind up doing more helo-level-serious transports because the distances involved rule out using a whirly-gig. But in general, the point stands. A fixed-wing air ambo is about 95% likely to be basically a charter flight with someone in the back who is laying down and ventilated. The problem is you can't tell which are the 5% from your dank, radar-screened, battle-lighting bunker.
 
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sometimes I get an approval request for a medevac direct TEB and I’m like of course yes and then it’s a freaking medevac Cirrus. I’m like how urgent is this really?
Just do your job and stop acting like it costs you anything, if your feelings get hurt kick it up the chain.
 
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