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Orescan: What Was Different This Time?

The chain of events can help us learn.


September 26, 2007
By Chris Orescan

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I was recently asked by a colleague to review the findings from the US
National Transportation Safety Board (NTSB) regarding the Gulfstream
III accident at Houston’s Hobby Airport in November 2004. The accident
received much media attention as the pilots had been dispatched to
Houston to pick up former President George H.W. Bush. The crew members
were both 62 years old, each had over 19,000 hours of experience and
both had a G-III type rating. They had most likely flown together on
numerous occasions in the same aircraft and flown numerous trips into
Hobby airport. I was asked, what was different this time? Why did this
happen to this very experienced crew on this particular trip?

The
NTSB performed a thorough investigation and its findings were not all
that surprising; it concluded that like many accidents, there were a
series of factors which led up to this one, and there were a few people
who could have prevented it from occurring. The NTSB said the crew
failed to adequately monitor and cross-check flight instruments during
the approach. Also, the crew failed to select the correct ILS frequency
in a timely manner and adhere to approved company approach procedures,
including stabilized approach criteria. The first officer informed
approach that he had the ATIS but identified the incorrect ATIS
identifier; ATC cleared them for the ILS Runway 4 approach “when able;”
the first officer acknowledged the clearance and read back that they
were cleared for the ILS 14; the controller did not question the
incorrect readbacks.

The aircraft was well equipped with dual
EFIS displays – that model has a fast/slow indicator which shows the
aircraft’s relative airspeed to target airspeed – this was also a
contributing factor. The NTSB believes that the crew was following that
indicator which looks similar to the G/S indicator when the F/O failed
to bring the ILS frequency up from the standby position. Ultimately the
aircraft struck a light standard at about 198 feet and 3.25 miles from
the Runway 4 threshold, killing all three on board and seriously
injuring someone on the ground.

The NTSB’s function is to
determine the cause of accidents, including the contributing factors
which led up to an accident. And depending on the class of the
accident, the other aspects which did or did not play a role may or may
not be investigated. However, after doing this exercise I personally
believe that the NTSB fundamentally falls short in assisting industry
to learn from these mistakes and helping to prevent them from happening
again. I believe the NTSB needs to take the investigations much further
and include more investigation into why, why today and why this crew?
What was different here?

You still need to find the hard
evidence and facts which ultimately caused this accident. The remainder
requires some degree of speculation; more extensive interviews need to
be completed. What was the crew’s state of mind prior to the flight?
How was their training? How proficient were they on the aircraft and
with its systems? This obviously requires reviewing training records
and interviewing training staff and family. How was their last line
check or did they even complete one? Was something going on in their
personal lives which may have affected their abilities?

As a
pilot group we could benefit enormously from finding the reasons and
factors which lead to accidents. We need to review attitudes – why did
this crew end up in this situation? Did age play a role? How many types
did this crew have on their licence? Avionics are becoming more
advanced and sophisticated; how proficient were they with this
equipment? How often did they shoot approaches to minimums or execute a
missed approach from DH (decision height)? Why didn’t they elect to
request time to sort things out and get set up properly?

The
hard evidence seems to be clear as to what the crew did or did not do,
but as a professional group we need to be asking ourselves why and what
was different this time. We are seeing an increase in incidents and
accidents and with a shortage of pilots and continued hiring, this is
only likely to increase. Understanding and identifying how events
contributed to the chain is an extremely effective tool to counteract
accidents. The skies are getting more crowded, aircraft systems are
changing and can be more complicated, and experience levels are
decreasing due to pilot shortages. Industry and government need to
address these issues now.