Pilot error may have contributed to crash of Katz's jet

The National Transportation Safety Board has taken over the investigation into a plane crash that killed 7 people, Saturday at Hanscom Field. Philadelphia Inquirer co-owner Lewis Katz is among the seven people killed in a fiery plane crash in Massachusetts.
The National Transportation Safety Board has taken over the investigation into a plane crash that killed 7 people, Saturday at Hanscom Field. Philadelphia Inquirer co-owner Lewis Katz is among the seven people killed in a fiery plane crash in Massachusetts. (David L Ryan, Globe Staff)
Posted: June 15, 2014

Pilot error appears to have contributed to the jet crash that killed the businessman and philanthropist Lewis Katz and six others last month, a preliminary report released Friday by the National Transportation Safety Board suggests.

The jet's flight data recorder found no evidence that the two pilots performed a routine preflight check of the plane's flaps and rudder, the report said.

The Gulfstream GIV's tail flaps, known as elevators, were in a downward position during the attempted takeoff, the report said. Such a setting meant the plane could not leave the ground.

Instead, the pilot tried to stop but ran out of room. The jet hurtled beyond the runway at Hanscom Field in Bedford, Mass., hitting a tower and ground antennae, then plunging into a gully, where it burst into flames.

"Right now, it looks like crew failure to complete the checklist," said retired NTSB investigator Al Yurman after reviewing the brief report.

Robert C. Hulse, a former Continental Airlines pilot and expert witness in aviation lawsuits, said the check should have been performed.

"It appears that the cockpit discipline was missing," he said.

While the terse, 15-paragraph NTSB report stopped short of endorsing any cause for the accident, it stated for the first time that the jet's data recorder "did not reveal any movement consistent with a flight-control check."

The recorder, part of the plane's "black box," also found the downward position on the tail flaps was "consistent" with their being immobilized under the plane's "gust lock" system.

Pilots turn on this system when a Gulfstream is parked on an open airfield to protect aircraft from heavy winds. The system locks the elevators and rudder on the tail and the ailerons on the wings.

The report does not speculate whether the pilots failed to turn off the gust locks before takeoff.

The report raised questions that puzzled experts who reviewed it at the request of The Inquirer. While the recorder showed the tail elevators were down - as if locked to prevent damage from wind - the gust-control handle in the cockpit was found in an "off" position.

Moreover, as the report pointed out, the gust locks have a crucial safety feature. If deployed, they should have barred the jet from reaching anywhere near the 190 m.p.h. as it raced down the 7,011-foot runway.

The report did not attempt to resolve those apparent contradictions. A final NTSB report, to be released in six months or more, will render an official cause for the accident.

Two hours after the NTSB released the report, Gulfstream Aerospace Corp., a subsidiary of General Dynamics, sent an e-mail to owners of the 500-plane GIV fleet reminding them to make sure before takeoff that their flight controls are working and that the tail "elevators are free during the takeoff roll."

And, the Georgia-based company cautioned, pilots should make sure "gust lock is OFF prior to starting engines."

The accident killed Katz, who was 72, only four days after he had won an auction to resolve ownership of The Inquirer, the Philadelphia Daily News, and Philly.com.

After making a fortune in law and business, Katz became a big charitable giver, pledging millions to Temple University, Dickinson University Law School, and other beneficiaries.

The crew that day, highly experienced on that plane, was pilot James P. McDowell, 61, who had 18,500 hours in the air, and copilot Bauke De Vries, 45, who had 11,250 hours.

On the day of the crash, they and flight attendant Teresa Benhoff, 45, took off at 1:25 p.m. from the plane's base at New Castle County Airport near Wilmington for an eight-minute hop to Atlantic City.

There, Katz and three passengers - friends and associates Susan K. Asbell, 68; Marcella M. Dalsey, 59; and Anne B. Leeds, 74 - boarded and the jet took off at 2:56 p.m. for a 48-minute flight to Hanscom, outside Boston.

While the crew stayed behind with the $30 million plane, the group went to a charter-school fund-raiser at the home of the historian Doris Kearns Goodwin. No maintenance was requested for the plane during the layover, the NTSB said.

Upon their return to Hanscom, the plane sought to take off but never got airborne.

NTSB investigators had said in remarks at the crash scene that the plane raced down the runway at high speed before reaching the point where procedure called for it to go aloft.

At that point, the NTSB reiterated, the plane's voice recorder "captured comments concerning aircraft control."

The report did not say what those comments were. The full transcript of the 49-second takeoff will be released later.

The NTSB said it found no sign of any "catastrophic engine failures" of the jet's twin Rolls-Royce engines.

With the plane hitting a maximum speed of 190 m.p.h., pilots McDowell and De Vries put on the brakes and reversed thrust. Until the black box stopped recording data - seven seconds after the pilots hit reverse - it showed that the speed fell to 115 m.p.h.

Skidding 1,300 feet, shedding its nose gear and left main landing gear, the G-IV ended up severed in half and burning in the gully. In all, it traveled three-fifths of a mile once the pilots hit the brakes.

The medical examiner's office in Massachusetts has yet to release a cause of death for the seven victims.

Hulse, the former Continental pilot, said that it was possible the gust control malfunctioned. While the crash "may very well be a crew-cause accident," Hulse said, the NTSB still must further investigate mechanical issues.

John Hansman Jr., a professor of aeronautics and astronautics at Massachusetts Institute of Technology, and other experts said in interviews that they doubted that the crew had failed to turn off the gust check, given that the pilots were able to move the throttles to accelerate to the speed it reached.

Hansman said the crash appeared to reflect a tandem of mechanical and human failures. The NTSB report, he said, spotlighted an evident problem in the tail elevators that developed after the first two flights of the day - perhaps a dropped bolt or failed hydraulic piston. Such a problem, he added, "would have been picked up in the control check."

Tom Kinston, an aviation director for more than 30 years at Boston's Logan International Airport, said the NTSB report "indicates concern with the crew who was in charge of piloting the aircraft - pilot error."

While a preflight check may seem "mundane," Kinston said, it is vital for airplane safety. In this case, he agreed with other experts: A check might well have picked up some of the issues identified by the NTSB.

"These airplanes have gotten so good, so sophisticated, that the human factor tends to get taken out of the equation, " he added.

Anthony Brickhouse, an associate professor of aerospace and occupational safety at Embry-Riddle Aeronautical University's Daytona Beach, Fla., campus, said that some corporate fliers had a policy of only engaging in a full preflight check once a day.

"In my world," Brickhouse said, "you do a full pre-check before each and every flight."


cmccoy@phillynews.com

215-854-4821

Inquirer staff writer Dylan Purcell contributed to this article.

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