The May 31 crash of a Guflstream GIV at Hanscom Field in Bedford, Massachusetts, that killed all on board refocuses attention on the potential risks of yielding to external pressures, particularly those coming from passengers.

On the day of the crash, the aircraft arrived from Atlantic City and parked at an FBO at about 3:45 p.m. The four passengers were attending a fundraiser at the Concord River Institute. The crew remained with the aircraft at the FBO while the passengers were at the function.

About 6 hr. later, the passengers returned, boarded the aircraft and the crew started both engines without delay. The flight plan called for returning to Atlantic City, a short night flight of about 45 min. With clear skies, calm winds and cool temperatures, conditions for the flight seemed ideal as the crew taxied to Runway 11, a 7,011-ft.-long asphalt strip. Once cleared for takeoff, the aircraft briskly accelerated through 80 kt., then V1 and rotate speeds.

But racing down the runway, the aircraft didn’t respond to control inputs. The pilots couldn’t move the elevators to change the nose attitude as the aircraft continued to accelerate.

The CVR indeed indicates that the crew remarked about “aircraft control,” according to the NTSB. Well above V2, the aircraft remained firmly planted to the pavement. Unable to get the aircraft airborne more than halfway down the runway, the pilots finally attempted a high-speed abort at about 165 kt.

They deployed the thrust reversers and applied the brakes with maximum effort, but their efforts were in vain. Speed was too high to stop the aircraft on the remaining 3,300 ft. of runway and 1,000 ft. of clear way.

The aircraft careened through a grassy area, shearing off the left main and nose gear. It then struck a localizer antenna array and approach lights before it dove down into a gully 1,850 ft. from the runway end and burst into flames. The two pilots, flight attendant and four passengers perished in the fiery aftermath.

While the preliminary NTSB reports provide sparse data, evidence does indicate that the crew failed to perform a post-start flight control freedom of movement check. NTSB investigators found the gust lock in the off position at the crash scene, but the elevators appeared to be locked. A Gulfstream memo to operators reminds pilots both to release the gust lock before engine start and to check flight controls for freedom of movement and correct control surface response to inputs after start.

The two pilots together had logged nearly 20,000 flight hours. All evidence indicates that they were experienced, skilled, well-trained and capable airmen. There is nothing in the CVR or FDR recordings to indicate that there was a mechanical malfunction with the aircraft, its engines or its systems. There were fewer than 5,000 hr. on the airframe.

Ruling out lack of pilot ability, aircraft malfunction or adverse environmental factors, it’s reasonable to consider what other things may have played a role in the accident. Were the pilots in a rush and, if so, why?

Managing external pressures, including meeting passenger expectations, is as key to risk management as mitigating pilot, aircraft and environmental risk factors. If the crew closes the cabin door before resolving such psychological issues, it can be as hazardous as intentionally flying into a severe thunderstorm. In fact, the FAA says external pressures may outweigh all other accident risk factors.

If the principal passenger states, “I bought this airplane to save time. I expect the first engine to be turning when I set foot on the airstair,” and the pilots accept this standard, they’re voluntarily escalating risk to please the boss.

Air charter pilots may experience external pressures, not from passengers, but from their dispatchers, marketing team or general manager, said Adam Tyler, a former FAR Part 135 charter pilot who now works for a corporate flight department with a strong safety culture. Making the transition to Part 91 flying was a “paradigm shift” for the better, he said.

“In 135 ops, the pressure always was there. We had two Citation Bravos and an Excel, plus nine pilots, four mechanics and support staff. We were told we had to fly each aircraft [at least] 600 hr. per year to be making money. As for weather, we were expected to pick our way through with weather radar because we had to help the company make payroll.”

During winter months, Tyler said, the company required crews to get permission from the home office for ground deicing. As an alternative, pilots were expected to remove accumulated frost with brooms and plastic binder covers used as scrapers whenever possible.

“The pressure came from management, always pushing to complete the mission. It rarely came from passengers,” he said. “It came down to the dollar sign at the end of the day.”

A third source of external pressure may come from the pilots themselves. They’re mission completion oriented and they don’t like failure. This attitude can be especially hazardous when flying empty legs to a destination to pick up passengers. Pilots feel a special obligation to show up on time to meet passenger expectations, often regardless
of other factors, even without direct external pressure from passengers or management.

Robert E. Breiling, president of the Boca Raton, Florida, business aviation safety consulting firm bearing his name, provided a sobering statistic: You’re 4.4 times more likely to suffer an accident on a positioning flight than on a leg with passengers aboard.

Putting External Pressures Into Perspective

Pilots generally share a “can-do” attitude. They’re hard wired not to give up on goals. That can lead to poor decision making under high-pressure circumstances, said John and Martha King, active Falcon 10 owner pilots and cofounders of King Schools.

“Those goals can kill you,” said John King. “You have to work up [risk] mitigation strategies. No one can make a pilot go where he or she doesn’t want to go. The pilots have to redefine what they care about.”

The Kings created a four-part PAVE checklist for use in preflight planning as an effective way to mitigate risk. The checklist, which follows, has been incorporated into Chapter 17 of the FAA’s Handbook of Aeronautical Knowledge:

Pilots — Qualifications, training, rested, physically and mentally fit for flight

Aircraft — Condition, deferred maintenance items, performance, flight manual limitations, range versus payload capabilities

enVironment — Day/night, weather, winds, terrain, obstacles, airport, navaids, lighting systems, runway length and surface condition, airspace, survival gear

External Pressures — Passenger pickup point expectations, mission completion fixation, pride versus skill level

Of those four items, managing external pressures is the most important risk mitigation strategy because failing to do so can cause pilots to discount or ignore some or all of the other three factors.

Adherence to comprehensive standard operating procedures (SOPs) is an effective way to manage external pressures because gray areas largely are obviated by them and published policies.

SOPs serve as critical buffers that allow a flight crew sufficient time to prepare for the flight, run checklists and deal with known delays. Using written SOPs, top flight departments make passengers aware of the lead times necessary to meet expectations of arriving on time at the destination. When passengers also buy into the SOPs, external pressure on the flight crew is eliminated.

“We need to ask ourselves, ‘Are we properly educating our passengers as to what is possible versus what is prudent?’” said Robert Agostino, an aviation director in the Dallas-Fort Worth area. “From the time the entry door closes, we know that it takes 6 min. to start the engines and another 6 min. to run the checklists. So we built 15 min. into the schedules. And we tell passengers to plan on adding 17 to 25 min. to block flight time.” And more time padding is added for known delays for weather, along with airport and airspace congestion.

“This enables us to make schedule within 5 min. 95% of the time and 3 min. 89% of the time,” he said.

The Kings fully acknowledge the value of SOPs, but they also point out that the urge to complete the mission increases as the aircraft gets closer to the destination. If the flight doesn’t go according to plan because of changing conditions, the flight crew may not recognize the emergence of new risk factors.

“Can you get yourself to deal with the reality of those changes?” asked Martha King. The crew may have tunnel vision, blinding them to problems that creep up. It’s possible that winds are not as forecast, thereby eating into fuel reserves. ATC may delay arrival at the destination because of route changes or holding. Perhaps the weather deteriorates. Maybe certain radio navaids are not available.

To develop risk mitigation under such conditions, the Kings use CARE, another four-part checklist:

Consequences — What happens if we don’t change the original plan?

Alternatives — What are our options?

Reality — Are we recognizing what’s happening now?

External Pressures — What psychological factors could alter our objective decision-making process?

But tamping down or eliminating external pressures from the decision-making process may not be easy, especially if you’re not the one who owns and operates the aircraft.

High-Level Negotiations

“Don’t forget who signs your paycheck” is the ultimate trump card used to intimidate pilots and get them to make decisions based upon external pressure rather than objective reasoning.

“That inspires a kiss up/kick down flight department management style,” said Agostino. Fortunately, such autocratic leadership styles are becoming increasingly rare in business aviation. Today, top management is more likely to be safety conscious and thus receptive to safety considerations presented by the flight department.

But CEOs haven’t lost focus on the importance of mission completion. And they don’t expect the flight department to be any less focused.

“High-powered executives are used to finding lots of alternative solutions to problems that come up in business. They’re going to get the deal done whenever it’s feasible,” said Agostino. “But at the same time they’re not willing to do a deal at any cost. They will avoid needless risks.”

Similarly, when flight department managers are faced with unexpected hurdles to mission completion, they need to explore all feasible alternatives and present them to management. This may involve considerable diplomacy. Flight department managers have to keep upper management well educated, but tactfully. “Managers not only have to be technically astute,” Agostino cautioned, “they also need to be politically competent.”

Timing is crucial. Top management doesn’t like surprises, so the flight department can earn points by developing a list of mission alternatives from which the passengers may choose well ahead of departure time.

If, for instance, environmental factors make it unlikely that flight crews can safely complete a mission as initially planned and land at the intended destination, then, well in advance of departure, the flight department might suggest filing for an alternate airport and arrange for a change in ground transportation.

Another example is the need to plan an en route fuel stop because of unfavorable winds aloft or if the probability of arrival delays at the destination would cut into safe fuel reserves.

Such changes in plans often result in longer block times. Most passengers, however, are willing to adjust their times of departure in order to arrive on time at the final destination.

“Managing passenger expectations is a bilateral process, a dialogue about the needs and expectations of the passengers. As with good CRM in the cockpit, the key is to use authority with participation and exercise assertiveness with respect,” said Agostino.

“In my view, this all has to be taken care of as a philosophical issue,” said Martha King.

“You brief your passengers that it’s your job to get them somewhere safely,” said John King. “Your highest priority is to keep them alive. As a matter of personal ethics, it’s the pilot’s job. If they get killed, you don’t have a job.”

If you can’t control external pressures at your current aviation job, it’s time to move on. “There isn’t just one answer to relieve external pressures. We all have the option to vote with our feet,” said Agostino. After all, allowing external factors to dominate your aeronautical decision-making can cost you your license, your aircraft and even your life.