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On May 31, 2014, a Gulfstream G-IV (N121JM), operated by Arizin Ventures, LLC and owned by SK Travel, LLC, crashed on a rejected takeoff from Laurence G. Hanscom Field (BED) in Bedford, Massachusetts, bound for Atlantic City International Airport in New Jersey. There were two flight crew, one flight attendant, and four passengers onboard, including Lewis Katz, a prominent American businessman, philanthropist, and co-owner of the Philadelphia Inquirer.At 21:40 local time, the aircraft overran the end of the runway, rolled through the paved overrun area and across grass, hitting the approach lights and a localizer antenna. The aircraft continued through the airport's perimeter fence before crashing into a ravine and exploding in an intense fireball. Everyone onboard perished in the accident.What the NTSB foundThe National Transportation Safety Board (NTSB) conducted a thorough investigation into the accident and released a final report pointing to a mix of pilot error and mechanical design issues. They determined that the probable cause was the flight crews' failure to perform the flight control check before takeoff, attempting to takeoff with the gust lock system still engaged and the delay in rejecting the takeoff once they found that the controls were locked. Contributing to the event were the crews' habitual noncompliance with checklists.In addition, Gulfstream failed to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff, with the lock engaged, and the Federal Aviation Administration's (FAA) failure to detect this inadequacy during certification of the aircraft.Pilot errorDuring takeoff, the pilot-in-command (PIC) advanced the throttle levers manually, but the engine pressure ratio did not reach the level expected due to the throttles contacting the gust lock/throttle lever interlock. The PIC did not reject the takeoff immediately; he engaged the autothrottle instead, moving the throttle levers slightly forward, but the engines could not attain the correct engine pressure ratio.The takeoff roll continued, and the second-in-command (SIC) made the takeoff speed callouts. The aircraft reached 80 knots and the rotation speed, but when the PIC tried to rotate, he discovered that he could not move the yoke and called out "Steer lock is on."If the flight crew had initiated a rejected takeoff when the PIC had stated that the lock was on or up to 11 seconds afterward, the aircraft could have stopped on the paved surface. Instead, they delayed applying the brakes for another 10 seconds and delayed reducing power by 4 seconds, by which point the accident was unavoidable.Habitual checklist noncomplianceThe NTSB reviewed data from the aircraft's quick access recorder, and it revealed that the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the aircraft, indicating that this oversight was habitual and not an anomaly. Checking the flight controls is a mandatory standard procedure that would have immediately revealed the gust lock was still on.Design flawThe NTSB also cited a contributing design flaw in the Gulfstream G-IV. The system was intended to physically prevent the throttles from being advanced if the gust lock was engaged, but it failed to do so in this instance. Post-accident testing on nine in-service G-IV aircraft showed that with the gust lock handle in the ON position, the forward throttle lever movement that could be achieved on the G-IV was 3 to 4 times greater than the intended throttle lever angle of 6°.NTSB recommendationsUse of the challenge-verification-response format for checklist execution.Analysis of flight operational quality assurance data to define the scope of procedural noncompliance in business aviation.Replacement of non-frangible fittings with frangible fittings for any objects along the extended runway centerline up to the perimeter fence.Retrofit of the gust lock system on all existing G-IV airplanes to comply with the certification requirement that the gust lock limit the operation of the airplane so that the pilot receives an unmistakable warning if the lock is engaged at the start of takeoff.Guidance on the appropriate use and limitations of the review of engineering drawings in a design review performed as a means of showing compliance with certification regulations.To the International Business Aviation Council: "Amend International Standard for Business Aircraft Operations auditing standards to include verifying that operators are complying with best practices for checklist execution, including the use of the challenge-verification-response format whenever possible."To the National Business Aviation Association: "Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for non-compliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation."Lessons learnedWhat is most shocking about this accident is the habitual noncompliance with checklists, when both crew members were in fact very experienced. The PIC had several single and multiengine aircraft ratings and 11,250 hours of flight time. He had known the aircraft's owners for around 12 years and had more than eight years on the G-IV and 1,400 hours on type.The SIC had even more experience, with 18,530.4 hours of flight time and was certified to fly the G-II and III, G-IV and G-V and the Lockheed JetStar. He had 2,800 hours on type. He had worked for the aircraft's owners for 27 years and worked as chief pilot and director of maintenance. The two pilots flew together almost exclusively (NTSB flight-log data show they crewed the accident airplane together for 84.5 percent of its 2013 flight hours and 100 percent of its 2014 hours) and are reported to have swapped seats regularly [UNVERIFIED — needs source].The open question is how two pilots this experienced became this complacent. Checklists exist precisely because experience alone does not catch every failure mode, especially in the compressed, stressful seconds of a takeoff. The NTSB found the crew did not routinely use checklists or the challenge-verification-response format industry standards call for, and routine use of the flight control check would likely have prevented this accident.The pattern was not limited to this flight department. An NBAA survey conducted after the accident reviewed roughly 144,000 business aviation flights flown between January 2013 and December 2015 and found some form of noncompliance with pre-takeoff flight control checks in nearly 18 percent of them. Why the checks get skipped so often remains unknown.The harder problem for any aircraft owner or flight department is knowing whether pilots are actually following procedure when no one else is watching. Cockpit image recorders are one proposed fix beyond these five recommendations. The NTSB has repeatedly pushed for them on corporate aircraft, mainly to help future investigations reconstruct what happened on the flight deck.Because the aircraft belonged to a private flight department, no one was required to review the digital flight data recorder, so the crew's habitual shortcut went unnoticed for years. Two pilots with decades of experience and thousands of hours on type still skipped a routine check that took only minutes, and nothing in their operation was built to catch it. The NBAA has pushed for voluntary Flight Data Monitoring (FDM) adoption for years, which would likely have addressed this procedural issue before it turned into a tragedy. FDM can flag a skipped checklist or a missed callout before it becomes a habit, the way Flight Operational Quality Assurance (FOQA) already does at the airlines. Experience alone doesn't guard against complacency, but having an extra set of eyes and ears on the flight deck could help.