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  3. NTSB A-15-030
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NTSB · Safety Recommendation

Safety Recommendation A-15-030

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Identify nonfrangible structures outside of a runway safety area during annual 14 Code of Federal Regulations Part 139 inspections and place increased emphasis on replacing nonfrangible fittings of any objects along the extended runway centerline up to the perimeter fence with frangible fittings, wherever feasible, during the next routine maintenance cycle.

Safety Issue and Context

On May 31, 2014, about 2140 eastern daylight time, a Gulfstream Aerospace Corporation G-IV, N121JM, registered to SK Travel, LLC, and operated by Arizin Ventures, LLC, crashed after it overran the end of runway 11 during a rejected takeoff at Laurence G. Hanscom Field (BED), Bedford, Massachusetts. The airplane rolled through the paved overrun area and across a grassy area, collided with approach lights and a localizer antenna, passed through the airport’s perimeter fence, and came to a stop in a ravine. The two pilots, a flight attendant, and four passengers died. The airplane was destroyed by impact forces and a postcrash fire.

The corporate flight, which was destined for Atlantic City International Airport, Atlantic City, New Jersey, was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. An instrument flight rules flight plan was filed. Night visual meteorological conditions prevailed at the time of the accident. The NTSB determines that the probable cause of this accident was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked.

Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.

Response History

July 29, 2026 · Recipient Response · FAA

-From Bryan Bedford, Administrator: The Federal Aviation Administration (FAA) acknowledges that a significant runway overrun beyond the runway safety area (RSA) prompted the subject NTSB Recommendation, and while the excursion was severe, it represents a low-probability, high consequence scenario. The FAA recognizes the seriousness of the outcome; however, the event does not justify establishing a new systemwide practice to inventory and replace all non frangible structures outside of the RSA.

Instead, we will continue to address rare exceedance events through targeted, site-specific mitigations informed by incorporating lessons learned through established safety risk management practices and management of the FAA’s RSA Inventory Database and RSA Phase 2 program for situational awareness and proactive safety management.

The FAA does not routinely replace non-frangible structures outside the RSA with frangible ones, even at 14 CFR 139 airports, because the FAA standards limit prescriptive requirements to high-risk areas, and while the FAA prioritizes National Airspace System (NAS) reliability and durability, we must ensure eligibility and programmatic justification. Safety resources must be allocated where they reduce the greatest risk; systemwide replacement outside the RSA would not meet this threshold. Absent a highly probable, documented hazard or project trigger, such equipment retrofits are not regulatory, operationally prudent, or fiscally supportable.

Frangibility is a safety benefit only where the collision probability is high; outside of which, durability and operational continuity are of focus in balancing both safety and engineering. Replacing infrastructure outside of the RSA is not programmatically or fiscally justifiable in the absence of a high-probability hazard.

Consequently, the FAA did not consider the replacement of non-frangible equipment located outside the RSA along the extended runway centerline to be a requirement of the RSA program and therefore was not planned or funded. The program was intentionally scoped to address objects within the RSA. Extending replacement beyond the RSA would require substantial investment. In addition, some equipment beyond the RSA supports critical operational functions and cannot be replaced with frangible alternatives without degrading system performance.

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Recommendation Facts

Status
Open Acceptable Alternate Response
Issued
September 24, 2015
Priority
CLASS II
Recipient
FAA
Adopted
September 22, 2015
Related Investigation
ERA14MA271
Related Report
AAR-15-03
The RSA compliance is dynamic, and new findings occur due to changes such as airport reconfiguration, takeover of non-federally owned navigational/communication equipment, and continued inspection activity. At 14 CFR 139 airports, the FAA will continue to identify and replace non-frangible structures identified within the RSA during routine inspections. While the Runway Safety Area Inventory system itself is complete and operational, RSA data is continuously updated as airport conditions change, new inspections are conducted, and additional data is reported by airport operators, consistent with FAA’s approach to managing RSA compliance.

We are continuing our work on Phase 2 of our Runway Inventory Program to resolve reported discrepancies. Key Phase 2 factors include:

• Ongoing identification of post-2018 discrepancies through routine inspections and safety oversight.

• Operational and technical constraints that limit the immediate replacement or relocation of certain FAA-owned systems essential to NAS operations.

• Site-specific consideration, including updated airport designs, airport geometry, terrain, utilities, security boundaries, and land availability.

At present, Phase 2 of the RSA Inventory Program does not have a predetermined end date. It reflects FAA’s understanding that RSA compliance is an ongoing responsibility, not a one-time effort. Currently, there is no Phase 3 planned because Phase 2 focuses on discrepancies of FAA owned facilities and equipment identified after December 31, 2018. These issues are addressed as they are discovered and prioritized based on the level of safety risk. FAA's Office of Airports continues the management of RSA inventory data and RSA determinations through surveillance activities by FAA airport certification, safety inspectors, and other field staff.

Events extending beyond the RSA are rare and often influenced by unique operational, environmental, or aircraft-specific factors. A single, extreme outlier event, while tragic, does not, on its own, warrant redefining protected areas or prescriptive requirements across the NAS. The Board’s safety recommendation to inventory non-frangible objects beyond the RSA and replace them with frangible structures would yield no defensible boundary for required mitigation and would expand protection zones indefinitely.

Such an approach would be inconsistent with foundational data that supports FAA’s established design standards, conflict with decades of data-driven standards development, and create open-ended obligations without a measurable safety benefit. The RSA represents a defined and finite safety envelope supported by empirical data. Extending prescriptive requirements beyond it based solely on rare exceedances would cause undue burden on airport operators while providing little safety benefit.

In closing, the Laurence G. Hanscom Field (BED) airport remains an FAA-certificated airport under 14 CFR 139 with a Class I airport operating certificate. We inspect BED every 9–15 months for conformity with regulatory standards. Additionally, the airport has received 10 periodic inspections since 2014, each noted with zero discrepancies related to runway or taxiway safety areas. The FAA appreciates the NTSB’s attention and focus on the importance of RSA designs, dimensions, and requirements at all airports in the NAS.

I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

November 26, 2024 · NTSB Correspondence · FAA

We note that you continue to work on the FAA’s RSA Inventory Program Phase 2 and, so far, have completed 19 projects resolving 51 infrangible structures at 14 CFR Part 139 airports. We also note that, although you currently do not have a designated funding program for replacing infrangible structure deficiencies at non Part 139 airports, airport sponsors routinely improve infrangible structures during runway improvement projects funded under the FAA’s Airport Improvement Program and other federally funded projects. In addition, we note that you are making improvements to the RSA Inventory Database that will improve the RSAs at all non-Part 139 federally obligated airports.

Specifically, frangible structures will need to be installed, to the extent practicable, to meet all FAA RSA design standards.

We continue to believe your ongoing efforts to evaluate all Part 139 airports and replace any infrangible structures located within the area (including the width of the runway surface and extending 3,000 ft beyond the end of the runway pavement) are responsive to this recommendation. We point out that, although 3,000 ft may be less than the distance to the fence line at an airport, it is enough distance to have prevented the overrun in the Bedford accident, and we believe it represents an adequate distance to mitigate similar overrun issues at other airports. We are also encouraged by your efforts to improve the RSAs at non-Part 139 airports.

Pending completion of your work to identify and replace all infrangible structures identified at Part 139 airports, Safety Recommendation A-15-30 remains classified OPEN-- ACCEPTABLE ALTERNATE RESPONSE.

October 3, 2023 · Recipient Response · FAA

-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) continues to implement the Runway Safety Area (RSA) Inventory Program Phase 2, which has completed 19 projects resolving 51 infrangible RSA structure deficiencies of FAA-owned facilities at 14 CFR Part 139 airports. While the FAA continues to assess and remediate affected RSAs, Phase 2 funding is extremely limited and provided on an annual basis.

Although the FAA tracks both FAA and non-FAA objects through the RSA Inventory Program’s RSA Inventory Database, there currently is not a designated funding program to address facilities owned by either the FAA or airport sponsors at non-Part 139 airports. However, airport sponsors routinely improve infrangible RSA structures during runway improvement projects funded under the Airport Improvement Program and other federally funded projects. We provided a list showing all federally obligated Part 139 and non-Part 139 airports to National Transportation Safety Board staff in August 2023.

Finally, the FAA is improving the RSA Inventory Database by undertaking an initiative to update the evaluation of RSAs at all non-Part 139 federally obligated airports to ultimately improve them to the extent practicable. To meet all FAA RSA design standards, it will be necessary to install frangible fittings, to the extent practicable and when applicable, in replaced, modified, or moved RSA structures.

I will keep the Board informed of the FAA’s progress on Safety Recommendation A-15-30 and anticipate providing an update by September 30, 2024.

May 23, 2023 · NTSB Correspondence · FAA

We note that, as part of the FAA’s RSA Inventory Program, you plan to evaluate all federally obligated Part 139 and non-Part 139 airports. We also note that, so far, you have completed more than 1,400 projects, which have addressed 2,300 nonfrangible structures. We also note that you have started assessing and remediating RSA violations at FAA-owned facilities at Part 139 airports.

According to the FAA’s website, there are 517 Part 139 airports; however, it is unclear how many of those Part 139 airports are federally obligated. Therefore, we request a list of all federally obligated Part 139 and non-Part 139 airports, and which have been evaluated so far.

Although this recommendation asks you to evaluate the area along the runway centerline to the perimeter fence, we previously informed you that evaluating a reduced area, which includes the width of the runway surface and extends 3,000 ft beyond the end of the runway pavement, is responsive to this recommendation. We believe evaluating this area will still minimize the potential for damage to an airplane that is unable to stop within the RSA during a runway overrun and, therefore, represents an acceptable alternate solution to that part of the recommendation.

Pending our review of the requested information and completion of your work to identify and replace all nonfrangible structures identified at Part 139 airports, Safety Recommendation A-15-30 is classified OPEN-- ACCEPTABLE ALTERNATE RESPONSE.

September 22, 2022 · Recipient Response · FAA

From Billy Nolen, Acting Administrator, Federal Aviation Administration: In our previous letter dated October 27, 2020, the Federal Aviation Administration (FAA) stated that it actively monitors objects within the Runway Safety Area (RSA). As a result, there is an ongoing FAA initiative, known as the RSA Inventory Program, to inventory and evaluate RSAs at all federally obligated Part 139 and non-Part 139 airports, which includes large and medium hub airports. This program supports the National Plan of Integrated Airport Systems. The FAA tracks both FAA and non-FAA objects through the RSA Inventory Program’s RSA Inventory Database.

The inventory of all items located in the RSA is reviewed during each certificated airport’s annual periodic inspection. For those structures that are to be replaced, modified, or moved, frangible fittings will be installed to meet all FAA RSA design standards to the extent practicable. To date, the RSA Inventory Program has accomplished the following: • RSA Phase 1 - More than 1,400 projects were completed, during which 2,300 infrangible structure deficiencies were addressed, as noted in our previous letter. • RSA Phase 2 - The FAA has since initiated the beginning stages of this phase, which continues to assess and remediate RSA violations among FAA-owned facilities at Part 139 airports.

I will keep the Board informed of the FAA’s progress on this safety recommendation and provide an update by September 30, 2023.

May 17, 2021 · NTSB Correspondence · FAA

We note that, as part of the FAA’s RSA Program, you maintain a database of all FAA and non-FAA owned objects, including infrangible structures, that are located within an area that extends 3,000 feet from the end of the runway pavement and is the width of the runway surface. Any infrangible structures in this area are made frangible to the best extent practicable. We also note that, in cooperation with airport sponsors, you have completed more than 1,400 projects, which have addressed 2,300 infrangible structure deficiencies.

We believe your actions thus far to identify FAA and non-FAA owned infrangible structures at Part 139 airports and, if feasible, make them frangible are responsive to this recommendation. However, because you previously told us that you planned to only evaluate large and medium Part 139 airports, we would like to know whether the FAA’s RSA Program tracks FAA and non-FAA owned infrangible structures at all Part 139 airports and, if not, how you intend to address these other airports. Pending our review of this additional information and completion of the recommended action, Safety Recommendation A-15-30 is classified OPEN-- ACCEPTABLE RESPONSE.

October 27, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: As stated at our March 6, 2019, meeting with National Transportation Safety Board staff, the Federal Aviation Administration (FAA) keeps track of objects within the Runway Safety Area (RSA), including an area spanning the width of the runway surface and extending 3,000 feet beyond the end of the runway pavement. The FAA tracks both FAA and non-FAA objects in our RSA Inventory Database for Part 139 airports.

Through FAA funding and the congressionally mandated RSA Program, the FAA’s Air Traffic Organization and Office of Airports jointly work with airport sponsors to mitigate FAA and non-FAA infrangible objects within the RSA, by relocating them from the RSA, moving them to a location within the RSA that is further from the runway, and/or making it frangible, to the best extent practicable.

The RSA Program corrects known deficiencies through its Airport Improvement Program (AIP) budget. These AIP funds can be used to make improvements to airport-owned equipment to address frangibility. If AIP funds are being used, then the local sponsor must comply with Advisory Circular 150/5370-10, Standard Specifications for Construction of Airports, and choose from the equipment listed in Advisory Circular 150/5345-53, Airport Lighting Equipment Certification Program (both available at rgl.faa.gov). The FAA also notes that AIP funds cannot be used to make improvements to FAA-owned equipment to address frangibility as this is considered budget augmentation.

However, if an FAA-owned facility impedes an AIP funded project (e.g. runway extension), AIP funds can be applied under a reimbursable agreement to relocate the equipment. The FAA would then expect fixed-by-function components to be made frangible as part of the project.

To date, the program has completed more than 1,400 projects, during which 2,300 infrangible structure deficiencies were addressed. Corrective measures include physically relocating equipment; however, some “fixed by function” structures contain systems that are operationally required to remain within the RSA and cannot be relocated. In these circumstances, frangibility modifications are applied by rebuilding the structure to be frangible. Although great progress has been made, more work is needed in order to successfully fulfill the intent of the RSA Program.

I will keep the Board informed of the FAA’s progress on this recommendation and provide an update by October 31, 2021.

June 21, 2017 · NTSB Correspondence · FAA

You write that you plan to evaluate FAA-owned equipment located within the area spanning the width of the runway surface and extending 3,000 feet beyond the runway pavement at 62 large and medium US airports. We are aware that you replaced the nonfrangible fittings at BED with frangible fittings after the accident. We are concerned, however, that the remaining 477 Part 139 airports that do not fall into either the large or medium categories, including BED, would not be evaluated under your proposed plan. We are aware that all Part 139 airports currently receive an annual certification inspection in which inspectors check structures within RSAs for frangibility.

We believe that you could include, as part of this annual inspection, a procedure for inspectors to also identify all nonfrangible structures that are within 3,000 feet of the RSA. In addition, we believe that inspectors should notify airports of any nonfrangible structures identified that do not belong to the FAA. Pending our review of a plan that addresses these concerns, Safety Recommendation A-15-30 is classified OPEN—UNACCEPTABLE RESPONSE.

April 6, 2017 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has determined it is not feasible to evaluate obstacles for frangibility all the way to the perimeter fence, as this distance varies considerably by airport. However, we have determined it is practicable to evaluate FAA-owned equipment within an area spanning the width of the runway surface and extending 3,000 feet beyond the runway pavement.

The FAA will make frangibility feasibility determinations in the area described above at all 62 large and medium U.S. airports (list enclosed). These airports account for 88 percent of the total passenger enplanements in the U.S. We estimate it will take 1 year to produce a report detailing which fittings can feasibly be made frangible.

I will keep the Board informed of the FAA's progress on this recommendation and provide an update by December 2017.

March 15, 2016 · NTSB Correspondence · FAA

We note that you intend to evaluate the feasibility of placing frangible fittings on any FAA owned equipment that extends past the runway safety area at the width of the runway to the perimeter fence. In a recent meeting, we also learned that the Air Traffic Organization (ATO) has been tasked to complete a list of all privately owned or non-FAA equipment. Pending our review of the findings from your evaluation and completion of the recommended action, Safety Recommendation A-15-30 is classified OPEN—ACCEPTABLE RESPONSE.

December 9, 2015 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) will review FAA-owned equipment extending past the runway safety area at the width of the runway to the perimeter fence and evaluate the feasibility of placing frangible fittings on any FAA-owned equipment found. As part of that effort, the FAA will develop a plan to identify and evaluate the equipment by November 2016. This plan will include a timeline for evaluating whether the FAA will retrofit specific equipment or not, and when. The FAA's Air Traffic Organization maintains a list of affected equipment and a schedule of maintenance for this equipment.

Therefore, inspections conducted under part 139 are not affected.