Board blames fatal overrun on pilot error.
Source: NTSB Issues Bedford Gulfstream IV Crash Report | Flying Magazine

Checklists were a major innovation in flying, and are now being pushed in health care. But as I research this, it’s clear that although pilots all swear by them, use is less than 100%. Perhaps less than 99% – and a 1% error rate is very high when there are hundreds of items on a flight.

It’s very hard to know the real number. But the pilots in this crash, both very experienced, did pre-takeoff control checks for less than 10% of their flights!

Data from a recorder installed in the airplane showed that in the previous 176 takeoffs, full flight control checks as called for on the GIV’s checklist were carried out only twice and partial checks only 16 times. The pilots on the evening of the accident skipped the flight control check, which might have revealed to them that the gust lock mechanism was still engaged.

This particular item – forgetting to unlock the “gust locks” – has been killing pilots since the first gust locks. Famous examples in the 1930s were the prototype B-17, and the head of the German Air Force. (Both discussed in my forthcoming chapter on standard procedures in aviation.)