Mr. Westhawk (et al):
Methinks ye may have read too much into my earlier post. I was not, in any way, chiding you – quite the contrary – my sincere compliment was directed toward all who seemed to have a more professional approach to the circumstances and media “buzz” surrounding a post-accident inquiry such as this – and particularly to yourself! If you misunderstood my attempt to compliment you, I apologize.
I completely agree with you about the utility of forums such as these! It is my opinion that you and I do not disagree on the value of post-accident discussions -- and any disagreement that may exist (or come to light) is very likely to be almost exclusively due to my past experiences – which, as I’ve indicated, have not always been what professionals would desire. As a result, I am, and I’ll probably continue to be, very cautious when leaping into discussions about post-accident information that “leaks” out or is published as preliminary findings. Please understand, when the facts are that a pilot has screwed up, you’ll not find me trying to white wash the concept. But I do hope that in my comments about such a pilot one would not find my focus on the fact that he screwed up, but rather would find my focus on what can be learned so that other pilots will be less likely to find themselves in similar circumstances and prone to make the same mistakes.
Please understand, I am not offended, at all, by examining the evidence and following it wherever it leads. What I was cautioning against, and what I will continue to caution against, is that we don’t jump to conclusions or attempt to find justification for preconceived opinions. My overall impression is that this occurrence developed because two pilots decided, for whatever reason, to abandon their normal operating procedures – and one could certainly surmise that this was done because, in their eyes, “the rules are relaxed when we don’t have passengers aboard.” They apparently elected to use the autopilot climb rate rather than speed (airspeed or mach – I don’t know the autopilot setup in the CRJ). Both crewmembers seemed to recognize that this was a “non-routine” event, decided upon to “have some fun.” Had they elected to use the speed mode, there is a chance that they would have realized that FL410 was beyond the airplane’s capability that night. And, after reaching FL410, the Captain left the cockpit and the F/O apparently didn’t believe it necessary to don his O2 mask. Was this a symptom of the “relaxed rules” thinking? Both pilots apparently recognized what was an “unusually high pitch attitude.” They both apparently realized that their airspeed was slow and getting slower. They both apparently recognized that they were not going to be able to sustain that altitude. I’m not at all sure what other clues may have been necessary to suggest to them that they were where they shouldn’t be and that they should do something about it – right now.
However, whatever clues may have been available were not used and the problems began. What about them? At first look, it would seem that a lot, quite a lot perhaps, and some would say virtually all, of the information necessary has been obtained and all that is left is the sifting of that information and reaching a conclusion. My experience has shown that very often it seems that some of the most pertinent questions go unasked – and therefore unanswered. It is also my opinion that in at least some circumstances an observer’s opinion of the situation may well color the observation being made. For example: looking at the FDR traces and reading the narrative that accompanies those traces – it would appear that the investigator has concluded that after the stick shaker activated, followed by the stick pusher firing, one of the pilots pulled the control column with a force calculated to be 25 pounds and then released the control pressure.
The questions that I would have thought should have been raised during the discussion that led up to this statement would have been the following:
1) Other than pilot action, what could cause the autopilot to disconnect?
2) If there were no pilot intervention, would the stick shaker activation electrically disconnect the autopilot?
3) If not, would the stick pusher activation electrically disconnect the autopilot?
4) If not, would the stick pusher cause physical pressure on the control column that would override the autopilot and result in a “brute-force” disconnect of the autopilot?
5) Does the stick pusher provide a forward control column movement to a specific attitude, to an angle of attack, or to some other parameter?
6) At what point does the stick pusher disconnect?
7) If there were no pilot intervention, given that the autopilot may have been disconnected because of an overpowering of the pitch attitude to which the autopilot had trimmed the airplane, what would be the expected reaction of the airplane upon stick pusher release?
8) If, upon stick pusher release, would it be expected that the airplane would attempt to return to the previously trimmed condition?
9) If so, would this physically move the control column?
10) If the control column would be expected to move, what would be the recorded movement and could that be interpreted to be a 25-pound pull on the control column?
11) What would be the effect of decaying airspeed on any tendency to return to a previously trimmed flight condition?
12) If there were no pilot intervention, what would be the expected short term response of the airplane?
A second series of questions that might have been asked might have included the following:
1) During training for recoveries from approaches to stall, in those circumstances where the pilot allowed the stick pusher to fire, what were the tendencies of that pilot during and immediately after the stick pusher activation? In other words, was the pilot attempting to dampen the stick pusher input during its input? And if so, what did the pilot do with the controls when the stick pusher deactivated?
2) If the pilot was actively pulling on the controls during stick pusher activation, did the pilot tend to over-control the pitch when the stick pusher deactivated?
3) If so, did the pilot tend to enter a secondary stall / stick pusher event?
4) If so, did the pilot attempt to dampen the second stick pusher input – as he did initially?
5) If so, what were any continuing actions between the pilot, the stick pusher, and the pitch attitude?
I see no evidence that these, or similar questions, were asked/answered nor do I see any information provided to understand that this information was made available. Prudence, I would have thought, would have required these answers or, at least, a discussion of this information would have been necessary to enlighten the on-going investigation. I say this because it would appear, from investigator statements, that a phugoid-type of oscillation occurred.
This airplane has a particularly disagreeable tendency to “dutch-roll” (rather significantly I might add) when the yaw damper is disengaged – and this is particularly true at higher altitudes.
With the loss of electrical power (when the engines failed) did the yaw damper control disengage? If so, was it ever re-engaged? If not, did a “dutch-roll” develop?
In talking with several persons close to the investigation, I understand that a careful analysis was made of the number of times a bleed-air re-configuration was made during the futile attempts to start one or both of the engines. I understand this configuration was changed some 16 times by one or both of the crew. I also understand from persons knowledgeable about the CRJ200, that while not an overly complex panel, if just a single error was made in that configuration, it would be unlikely that someone would have been able to retrace the selections made to negate the initial error.
In my very brief review of the “core lock” phenomena, I wasn’t able to fully digest the causes and/or if there were any in-flight resolutions to that particular problem. I believe that it is, at least, noteworthy, and perhaps worthy of more scrutiny, to recognize that it was apparently a routine practice that engines undergo “core lock” testing before being shipped. I would think that someone would want to ensure that a correction to eliminate that potential would be appropriate prior to releasing such an engine for revenue service.
In reviewing the transcript of the CVR, it seems to me that the Captain was content to let the F/O continue to fly for quite a while. Later, when he decided to take control, it appears that he was about to deal with an emotional situation that was likely to result in losing his F/O from conscious participation; and I believe the Captain did quite a nice job of returning that F/O to the job at hand without spending unnecessarily long in the process.
It sounded to me like the primary concern of the Captain was getting the engine to start – and because of that focus, the focus of the F/O was directed largely to that end as well. He seemed to be riveted on that problem – almost to the exclusion of the flight status of the airplane (where they were headed, the rate of descent, etc.). In fact, it seems to me that he was so intent on getting the engine started that he was willing, saying so on a couple of occasions, to trade altitude for airspeed to wind mill the engine to facilitate a start.
So, is it training? Should the airline have provided high altitude simulator training? Should all airlines do this? I am under the impression that the FAA Flight Standardization Board Report on the CRJ200 did discuss recommended training or familiarity (I haven’t read the report) with high altitude operations, specifically regarding the tendencies for dutch-roll, and I believe it referenced the complexity of the bleed air control panel for engine starting. Perhaps it is past time that the FAA make that report a regulatory requirement instead of a set of recommendations that may or may not be heeded by the industry. Should simulators be qualified only after demonstrating that they do, in fact, perform and handle at high altitudes, just like they do at intermediate and lower altitudes? Should we begin training crewmembers on recovery from stalls rather than training on recovery from approaches to stall? Should we require each crewmember to understand the power-off glide ratio of his/her airplane and practice dead-stick approaches from above FL400 in the simulator? Do we require direct reading AOA indicators in commercial airliners? Do we go back and review each ground training program for its inclusion of high altitude operations and the effects of temperature inversions, lapse rates, density altitude, service ceilings, etc.?
It is almost easy to answer in the affirmative to most if not all of the questions here. But I recognize that training is an expensive effort, particularly today. Airlines are not rolling in money – they must spend it wisely. Training is always “on the bubble;” and it is primarily because of the costs involved in training. Should the regulator step in and mandate these things – regardless of the cost? The arguments on both sides are substantial – and what usually results is an attempt to find a happy medium between the two opposing points. However, it is my experience that in doing so, there is rarely any “happy” and almost never a “medium.”
I recognize that I have only raised a lot of questions and haven’t really taken on the answers to many of them. Its not that I can’t or won’t. It’s just that this post is already much too long. I don’t have any problem with providing anyone here with my opinion of what the answers to some of those questions should be – but I’ll wait to see if anyone is really interested in hearing any more of what I may have to say. Until then, I’ve probably said enough – at least for now.
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AirRabbit