weasil
20th March 2007, 03:47
Mar 13, 2007
by Richard N. Aarons
I'VE BEEN WATCHING the activities of the NTSB and its air accident investigation predecessor, the Civil Aeronautics Board, for over 40 years and do not remember reading a finding of probable cause as brutally frank as that recently issued in the loss of the Pinnacle Airlines Bombardier RJ CL-619-2B19 that crashed on Oct. 14, 2004, in Jefferson City, Mo. And I believe the situation deserves harsh assessment.
Here's the finding: "The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots' unprofessional behavior, deviation from standard operating procedures and poor airmanship, which resulted in an inflight emergency from which they were unable to recover, in part because of the pilots' inadequate training; (2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident was (1) the engine core lock condition, which prevented at least one engine from being restarted, and (2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating."
Recently the industry has witnessed a number of accidents involving commercial and air transport rated pilots who seem to lack fundamental knowledge of aerodynamics, meteorology, powerplant theory and basic airmanship. (This problem is more prevalent, I think, in the airlines than it is in corporate aviation, mainly because the airlines tend to pay low initial salaries and hire from the bottom of the experience pool.)
In earlier times, most professional pilots came from the military and received extensive training in the fundamentals of their craft. Those pilots who came up on the civilian side knew they were competing against military-trained people and therefore saw to it that their own studies included rigorous explorations of the science of aviation as well as its hands-on practice.
Today, it seems, young pilots can arrive in the right (and left) seats of high performance airplanes woefully ignorant of swept-wing aerodynamics, flight engineering principles (including weight and balance), high-altitude meteorology and even survival strategies to employ when, as author Ernest K. Gann put it so well so long ago "some totally unrecognizable genie has once again unbuttoned his pants and urinated on the pillar of science."
The NTSB has asked the FAA to fix this problem. We couldn't agree more. It needs fixing. However, it's difficult to understand why the Safety Board has to make these recommendations at all. This is all the basic stuff of piloting. Anyway, here's most of what the NTSB has asked the FAA to do:
*Work with members of the aviation industry to enhance the training syllabi for pilots conducting high-altitude operations in regional jets. The syllabi should include methods to ensure that these pilots possess a thorough understanding of the airplanes' performance capabilities, limitations and high-altitude aerodynamics.
*Determine whether the changes to be made to the high-altitude training syllabi for regional jet pilots would also enhance the high-altitude training syllabi for pilots of all other transport-category jets and, if so, require that these changes be incorporated into those courses as well.
*Require that air carriers provide their pilots with opportunities to practice high-altitude stall recovery techniques in simulators, during which time the pilots demonstrate their ability to identify and execute the appropriate recovery technique.
*Convene a multidisciplinary panel of operational, training and human factors specialists to study and submit a report on methods to improve flight crew familiarity with and response to stick-pusher systems and, if warranted, establish training requirements for pilots of stick-pusher-equipped airplanes based on the findings of this panel. Verify that all Bombardier Regional Jet operators incorporate guidance in their double engine failure checklist that clearly states the airspeeds required during the procedure, and require the operators to provide pilots with simulator training on executing this checklist.
*Require FAR Part 121 regional air carriers to provide specific guidance on expectations for professional conduct to pilots who operate non-revenue flights.
*For those Part 121 regional air carriers that have the capability to review FDR data, require that the carriers conduct such reviews from non-revenue flights to verify that they're being flown according to standard operating procedures.
*Work with pilot associations to develop a specific program of education for air carrier pilots that addresses professional standards and their role in ensuring safety of flight. The program should include associated guidance information and references to recent accidents involving pilots acting unprofessionally or not following standard operating procedures.
*Require that all Part 121 operators incorporate into their oversight programs periodic Line Operations Safety Audit observations and methods to address and correct findings resulting from these observations.
The NTSB's Conclusions
Pinnacle Airlines (Northeast Airlink) Flight 3701, a Bombardier RJ, crashed into a residential area about 2.5 miles south of Jefferson City, Mo., Memorial Airport at 2215 CDT while being vectored to the airport after a double engine flameout. The airplane was on a repositioning flight from Little Rock to Minneapolis-St. Paul under Part 91. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. Visual meteorological conditions prevailed at the time of the accident.
You can find the facts of this incident (and a preliminary analysis) in the November 2005 Cause & Circumstance (page 138). At this writing, the Safety Board has (as usual) added its conclusions to the docket. They are worth your consideration, I think, because these conclusions tell the story clearly and dispassionately. Here's a brief look at issues in the case. (The emphasis is ours.)
*The captain and the first officer were properly certificated. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance. Flight crew fatigue and hypoxia were not factors in this accident.
?228-137?The accident airplane was properly certified, equipped and maintained. The recovered components showed no evidence of any structural or system failures or any engine failures before the time of the upset event.
*Weather was not a factor in this accident.
*The pilots' aggressive pitch-up and yaw maneuvers during the ascent and their decision to operate the airplane at its maximum operating altitude (41,000 feet) were made for personal and not operational reasons.
*The flight crew's inappropriate use of the vertical speed mode during the climb was a misuse of automation that allowed the airplane to reach 41,000 feet in a critically low energy state.
*The improper airspeed during the climb demonstrated that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to the published climb capability charts.
*The upset event exposed both engines to inlet airflow disruption conditions that led to engine stalls and a complete loss of engine power.
*The pilots' lack of exposure to high-altitude stall recovery techniques contributed to their inappropriate flight control inputs during the upset event.
*The captain did not take the necessary steps to ensure that the first officer achieved the 300-knot or greater airspeed required for the windmill engine restart procedure and then did not demonstrate command authority by taking control of the airplane and accelerating it to at least 300 knots.
*The first officer's limited experience in the airplane might have contributed to the failed windmill restart attempt because he might have been reluctant to command the degree of nose-down attitude that was required to increase the airplane's airspeed to 300 knots.
*Despite their four auxiliary power unit-assisted engine restart attempts, the pilots were unable to restart the engines because their cores had locked. Without core rotation, recovery from the double engine failure was not possible.
*The General Electric CF34-1 and CF34-3 engines had a history of failing to rotate during inflight restart attempts on airplanes undergoing production acceptance flight testing at Bombardier.
*Both engines experienced core lock because of the flameout from high power and high altitude, which resulted from the pilot-induced extreme conditions to which the engines were exposed, and the pilots' failure to achieve and maintain the target airspeed of 240 knots, which caused the engine cores to stop rotating; both of these factors were causal to this accident.
?228-137?The importance of maintaining a minimum airspeed to keep the engine cores rotating was not communicated to the pilots in airplane flight manuals (AFMs).
*The captain's previous difficulties in checklist management, the situational stress and the lack of simulator training involving a double engine failure contributed to the flight crew's errors in performing the double engine failure checklist.
*The pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, was a result of their intentional noncompliance with standard operating procedures, and this failure was causal to the accident.
*The pilots' unprofessional operation of the flight was intentional and causal to this accident because the pilots' actions led directly to the upset and their improper reaction to the resulting inflight emergency exacerbated the situation to the point that they were unable to recover the airplane.
*Revised high-altitude training for pilots who operate regional jet airplanes would help ensure that these pilots possess a thorough understanding of the airplanes' performance capabilities, limitations and high-altitude aerodynamics.
?228-137?Because most training for stalls occurs with the airplane at low altitudes, the training methods may introduce a bias in stall recovery techniques by encouraging pilots to minimize altitude loss and not fully recognizing other available recovery techniques.
*Additional training might improve pilot response to stick pusher activation, but such training, if not provided correctly, could have an adverse impact on existing stall recognition and recovery protocols.
*Some of the changes made by Pinnacle Airlines to its double engine failure training and checklist guidance would benefit pilots at other air carriers that operate the Bombardier regional jet because such training would provide pilots with the opportunity to practice double engine failure restart procedures in the simulator and the guidance would ensure that pilots were aware of the minimum airspeeds needed during the procedures.
*More scrutiny of regional air carrier pilots during non-revenue flights would minimize the opportunity for unprofessional behavior to occur.
*Providing additional education to pilots on the importance of professionalism could help reduce the instances of pilots not maintaining cockpit discipline or not adhering to standard operating procedures.
*Line Operations Safety Audit observations can provide operators with increased knowledge about the behavior demonstrated by pilots during line operations.
*All air carriers would benefit from Safety Management System programs because they would require the carriers to incorporate formal system safety methods into the carriers' internal oversight programs.
*The establishment of an Aviation Safety Action Program and a Flight Operational Quality Assurance program at regional air carriers would provide the carriers with a means to evaluate the quality of their operations.
To be sure, the characteristic core spin-down of the GE engines is an issue and should be addressed. The NTSB has already issued several recommendations to the FAA to deal with that engine and jet engine certification in general.
But the overriding issue here, I think, is simply the matter of professionalism, or the lack thereof. The training system that took these crewmembers from their first solos to the wreckage in Jefferson City should be understood and improved. For the record, here's the background.
The 31-year-old captain had accumulated 6,750 hours total pilot time with 400 hours logged in the six months before the accident. He graduated from high school in spring 1990. From August 1990 to May 1995 he attended Embry-Riddle Aeronautical University and graduated with a Bachelor of Science degree in aeronautical science. He listed in a job application the following aviation positions held: glider tow pilot for Island Soaring in Maine, from May 1996 to August 1996; flight instructor for Embry-Riddle from August 1996 to October 1999; first officer at Trans States Airlines from January 1999 to May 2006; and captain at Gulfstream International Airlines, Inc., from June 2000 to September 2002.
His resume listed "FAA High-Altitude Physiological Training" as one of the items under the heading Certificates & Ratings. Instructors and check airmen who had flown with the captain had generally favorable comments about his abilities as a pilot. A check airman who flew with him on the line during his operational evaluation in August 2004 described the flights as unremarkable, and said the captain was well prepared and someone who exercised good judgment and showed deliberate and thoughtful actions.
However, not all comments about the captain's upgrade training were positive. An instructor who did part of that training stated that the biggest weakness he observed was the captain's decision-making and judgment. He noted decision-making and judgment problems in accomplishing checklist items, specifically mixing-up checklist items and pilot-flying and pilot-not-flying duties. He said that the captain did not have problems making decisions like diverting, determining how the airplane was to be flown or issuing commands.
The 23-year-old first officer reported 565 hours total pilot time, including about 140 hours PIC, 299 in turboprops, 63 actual instrument, 152 simulated instrument and 60 night. He held an Associate of Science degree in professional pilot technology from Broward, Fla., Community College. In October 2002, the first officer started training at Gulfstream Academy of Aeronautics. He subsequently became a first officer on a BE-1900 for Gulfstream International Airlines.
His personnel file contained favorable letters of recommendation from Gulfstream International Airlines pilots. A Pinnacle Airlines simulator instructor described the first officer as a good pilot with a positive attitude and someone who would have made a good captain in the future. He said the first officer was a pilot who had a friendly style in the cockpit but was also disciplined.
A simulator check airman who conducted the first officer's simulator checkride said he was a good pilot and a confident first officer. He said the first officer did a good job on his check ride and made only minor mistakes that were not uncommon for first officers to make.
All agreed that these pilots were basically good guys who had met the training and performance criteria of the FAA, the training organizations they attended and the air carrier for which they flew.
But it certainly seems they fell through the cracks somewhere. It is that fact that must be addressed.
http://www.aviationweek.com/aw/generic/story_generic.jsp?channel=bca&id=news/bca0307b.xml&headline=Failing%20at%20the%20Fundamentals%20of%20Flight
by Richard N. Aarons
I'VE BEEN WATCHING the activities of the NTSB and its air accident investigation predecessor, the Civil Aeronautics Board, for over 40 years and do not remember reading a finding of probable cause as brutally frank as that recently issued in the loss of the Pinnacle Airlines Bombardier RJ CL-619-2B19 that crashed on Oct. 14, 2004, in Jefferson City, Mo. And I believe the situation deserves harsh assessment.
Here's the finding: "The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots' unprofessional behavior, deviation from standard operating procedures and poor airmanship, which resulted in an inflight emergency from which they were unable to recover, in part because of the pilots' inadequate training; (2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident was (1) the engine core lock condition, which prevented at least one engine from being restarted, and (2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating."
Recently the industry has witnessed a number of accidents involving commercial and air transport rated pilots who seem to lack fundamental knowledge of aerodynamics, meteorology, powerplant theory and basic airmanship. (This problem is more prevalent, I think, in the airlines than it is in corporate aviation, mainly because the airlines tend to pay low initial salaries and hire from the bottom of the experience pool.)
In earlier times, most professional pilots came from the military and received extensive training in the fundamentals of their craft. Those pilots who came up on the civilian side knew they were competing against military-trained people and therefore saw to it that their own studies included rigorous explorations of the science of aviation as well as its hands-on practice.
Today, it seems, young pilots can arrive in the right (and left) seats of high performance airplanes woefully ignorant of swept-wing aerodynamics, flight engineering principles (including weight and balance), high-altitude meteorology and even survival strategies to employ when, as author Ernest K. Gann put it so well so long ago "some totally unrecognizable genie has once again unbuttoned his pants and urinated on the pillar of science."
The NTSB has asked the FAA to fix this problem. We couldn't agree more. It needs fixing. However, it's difficult to understand why the Safety Board has to make these recommendations at all. This is all the basic stuff of piloting. Anyway, here's most of what the NTSB has asked the FAA to do:
*Work with members of the aviation industry to enhance the training syllabi for pilots conducting high-altitude operations in regional jets. The syllabi should include methods to ensure that these pilots possess a thorough understanding of the airplanes' performance capabilities, limitations and high-altitude aerodynamics.
*Determine whether the changes to be made to the high-altitude training syllabi for regional jet pilots would also enhance the high-altitude training syllabi for pilots of all other transport-category jets and, if so, require that these changes be incorporated into those courses as well.
*Require that air carriers provide their pilots with opportunities to practice high-altitude stall recovery techniques in simulators, during which time the pilots demonstrate their ability to identify and execute the appropriate recovery technique.
*Convene a multidisciplinary panel of operational, training and human factors specialists to study and submit a report on methods to improve flight crew familiarity with and response to stick-pusher systems and, if warranted, establish training requirements for pilots of stick-pusher-equipped airplanes based on the findings of this panel. Verify that all Bombardier Regional Jet operators incorporate guidance in their double engine failure checklist that clearly states the airspeeds required during the procedure, and require the operators to provide pilots with simulator training on executing this checklist.
*Require FAR Part 121 regional air carriers to provide specific guidance on expectations for professional conduct to pilots who operate non-revenue flights.
*For those Part 121 regional air carriers that have the capability to review FDR data, require that the carriers conduct such reviews from non-revenue flights to verify that they're being flown according to standard operating procedures.
*Work with pilot associations to develop a specific program of education for air carrier pilots that addresses professional standards and their role in ensuring safety of flight. The program should include associated guidance information and references to recent accidents involving pilots acting unprofessionally or not following standard operating procedures.
*Require that all Part 121 operators incorporate into their oversight programs periodic Line Operations Safety Audit observations and methods to address and correct findings resulting from these observations.
The NTSB's Conclusions
Pinnacle Airlines (Northeast Airlink) Flight 3701, a Bombardier RJ, crashed into a residential area about 2.5 miles south of Jefferson City, Mo., Memorial Airport at 2215 CDT while being vectored to the airport after a double engine flameout. The airplane was on a repositioning flight from Little Rock to Minneapolis-St. Paul under Part 91. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. Visual meteorological conditions prevailed at the time of the accident.
You can find the facts of this incident (and a preliminary analysis) in the November 2005 Cause & Circumstance (page 138). At this writing, the Safety Board has (as usual) added its conclusions to the docket. They are worth your consideration, I think, because these conclusions tell the story clearly and dispassionately. Here's a brief look at issues in the case. (The emphasis is ours.)
*The captain and the first officer were properly certificated. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance. Flight crew fatigue and hypoxia were not factors in this accident.
?228-137?The accident airplane was properly certified, equipped and maintained. The recovered components showed no evidence of any structural or system failures or any engine failures before the time of the upset event.
*Weather was not a factor in this accident.
*The pilots' aggressive pitch-up and yaw maneuvers during the ascent and their decision to operate the airplane at its maximum operating altitude (41,000 feet) were made for personal and not operational reasons.
*The flight crew's inappropriate use of the vertical speed mode during the climb was a misuse of automation that allowed the airplane to reach 41,000 feet in a critically low energy state.
*The improper airspeed during the climb demonstrated that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to the published climb capability charts.
*The upset event exposed both engines to inlet airflow disruption conditions that led to engine stalls and a complete loss of engine power.
*The pilots' lack of exposure to high-altitude stall recovery techniques contributed to their inappropriate flight control inputs during the upset event.
*The captain did not take the necessary steps to ensure that the first officer achieved the 300-knot or greater airspeed required for the windmill engine restart procedure and then did not demonstrate command authority by taking control of the airplane and accelerating it to at least 300 knots.
*The first officer's limited experience in the airplane might have contributed to the failed windmill restart attempt because he might have been reluctant to command the degree of nose-down attitude that was required to increase the airplane's airspeed to 300 knots.
*Despite their four auxiliary power unit-assisted engine restart attempts, the pilots were unable to restart the engines because their cores had locked. Without core rotation, recovery from the double engine failure was not possible.
*The General Electric CF34-1 and CF34-3 engines had a history of failing to rotate during inflight restart attempts on airplanes undergoing production acceptance flight testing at Bombardier.
*Both engines experienced core lock because of the flameout from high power and high altitude, which resulted from the pilot-induced extreme conditions to which the engines were exposed, and the pilots' failure to achieve and maintain the target airspeed of 240 knots, which caused the engine cores to stop rotating; both of these factors were causal to this accident.
?228-137?The importance of maintaining a minimum airspeed to keep the engine cores rotating was not communicated to the pilots in airplane flight manuals (AFMs).
*The captain's previous difficulties in checklist management, the situational stress and the lack of simulator training involving a double engine failure contributed to the flight crew's errors in performing the double engine failure checklist.
*The pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, was a result of their intentional noncompliance with standard operating procedures, and this failure was causal to the accident.
*The pilots' unprofessional operation of the flight was intentional and causal to this accident because the pilots' actions led directly to the upset and their improper reaction to the resulting inflight emergency exacerbated the situation to the point that they were unable to recover the airplane.
*Revised high-altitude training for pilots who operate regional jet airplanes would help ensure that these pilots possess a thorough understanding of the airplanes' performance capabilities, limitations and high-altitude aerodynamics.
?228-137?Because most training for stalls occurs with the airplane at low altitudes, the training methods may introduce a bias in stall recovery techniques by encouraging pilots to minimize altitude loss and not fully recognizing other available recovery techniques.
*Additional training might improve pilot response to stick pusher activation, but such training, if not provided correctly, could have an adverse impact on existing stall recognition and recovery protocols.
*Some of the changes made by Pinnacle Airlines to its double engine failure training and checklist guidance would benefit pilots at other air carriers that operate the Bombardier regional jet because such training would provide pilots with the opportunity to practice double engine failure restart procedures in the simulator and the guidance would ensure that pilots were aware of the minimum airspeeds needed during the procedures.
*More scrutiny of regional air carrier pilots during non-revenue flights would minimize the opportunity for unprofessional behavior to occur.
*Providing additional education to pilots on the importance of professionalism could help reduce the instances of pilots not maintaining cockpit discipline or not adhering to standard operating procedures.
*Line Operations Safety Audit observations can provide operators with increased knowledge about the behavior demonstrated by pilots during line operations.
*All air carriers would benefit from Safety Management System programs because they would require the carriers to incorporate formal system safety methods into the carriers' internal oversight programs.
*The establishment of an Aviation Safety Action Program and a Flight Operational Quality Assurance program at regional air carriers would provide the carriers with a means to evaluate the quality of their operations.
To be sure, the characteristic core spin-down of the GE engines is an issue and should be addressed. The NTSB has already issued several recommendations to the FAA to deal with that engine and jet engine certification in general.
But the overriding issue here, I think, is simply the matter of professionalism, or the lack thereof. The training system that took these crewmembers from their first solos to the wreckage in Jefferson City should be understood and improved. For the record, here's the background.
The 31-year-old captain had accumulated 6,750 hours total pilot time with 400 hours logged in the six months before the accident. He graduated from high school in spring 1990. From August 1990 to May 1995 he attended Embry-Riddle Aeronautical University and graduated with a Bachelor of Science degree in aeronautical science. He listed in a job application the following aviation positions held: glider tow pilot for Island Soaring in Maine, from May 1996 to August 1996; flight instructor for Embry-Riddle from August 1996 to October 1999; first officer at Trans States Airlines from January 1999 to May 2006; and captain at Gulfstream International Airlines, Inc., from June 2000 to September 2002.
His resume listed "FAA High-Altitude Physiological Training" as one of the items under the heading Certificates & Ratings. Instructors and check airmen who had flown with the captain had generally favorable comments about his abilities as a pilot. A check airman who flew with him on the line during his operational evaluation in August 2004 described the flights as unremarkable, and said the captain was well prepared and someone who exercised good judgment and showed deliberate and thoughtful actions.
However, not all comments about the captain's upgrade training were positive. An instructor who did part of that training stated that the biggest weakness he observed was the captain's decision-making and judgment. He noted decision-making and judgment problems in accomplishing checklist items, specifically mixing-up checklist items and pilot-flying and pilot-not-flying duties. He said that the captain did not have problems making decisions like diverting, determining how the airplane was to be flown or issuing commands.
The 23-year-old first officer reported 565 hours total pilot time, including about 140 hours PIC, 299 in turboprops, 63 actual instrument, 152 simulated instrument and 60 night. He held an Associate of Science degree in professional pilot technology from Broward, Fla., Community College. In October 2002, the first officer started training at Gulfstream Academy of Aeronautics. He subsequently became a first officer on a BE-1900 for Gulfstream International Airlines.
His personnel file contained favorable letters of recommendation from Gulfstream International Airlines pilots. A Pinnacle Airlines simulator instructor described the first officer as a good pilot with a positive attitude and someone who would have made a good captain in the future. He said the first officer was a pilot who had a friendly style in the cockpit but was also disciplined.
A simulator check airman who conducted the first officer's simulator checkride said he was a good pilot and a confident first officer. He said the first officer did a good job on his check ride and made only minor mistakes that were not uncommon for first officers to make.
All agreed that these pilots were basically good guys who had met the training and performance criteria of the FAA, the training organizations they attended and the air carrier for which they flew.
But it certainly seems they fell through the cracks somewhere. It is that fact that must be addressed.
http://www.aviationweek.com/aw/generic/story_generic.jsp?channel=bca&id=news/bca0307b.xml&headline=Failing%20at%20the%20Fundamentals%20of%20Flight