Pinnacle Airlines aircraft incident
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hec7or
As a sim instructor on this aeroplane, let me say that I fully agree with your remark about the confusion induced by the relight procedure. When a crew has been insufficiently briefed before conducting this event in the FFS, it's a cluster f**k.
I always try to stress the importance of clearly understanding the QRH checklist and its' relevance to crew survival on a cold, dark and dreary night whilst running out of airspeed, altitude and ideas. Most students are quick to point out that their company does not provide individual crew members with a QRH of their own. Pity.
(Make way for the LCC.)
Therefore, they NEED to know, that the core windmilling rpm drops to approximately 3%, give or take, even with the fan turning at 20 + %!!!
The QRH also points out "WHEN ENGINE ROTATION IS ESTABLISHED". This can only be met, IF the crew drops the nose at 26,000 feet and accelerates "to 300 KIAS or greater to achieve the required N2" as informed." Which this crew did not manage to do.
Did they not realize N2 is what governs engine starts??? Were they looking at N1 perhaps and deciding well enough? I surely wouldn't know.
The ITT must be below 90 C and the core (N2) spinning at at least 12% above 15,000 and at least 9% below 15,000. ITT reduction is generally not a factor when the aircraft has already descended from 41 to 21. But, here's the rub.
The QRH Engine Failure checklist ALSO states "if neither engine is restarted: consider a forced landing or ditching." So, at what point to abandon the start attempts? I teach that following the initial attempts to look at RPMs. Core N2 zero, you've got engine damage because they should be turning. The one that IS, should be concentrated on. Were both engines on the accident aircraft turning or not turning? That is the question.
Beanbag
How right you are.
In the clear light of day, it seems your suggestion is spot on. Unfortunately, in the clouded reality of "Holy Sh*t", some of the balls get dropped. Perhaps this is part of what happened to this crew. The hearing pointed out that there were three useable airports short of Jefferson City the crew could have accepted.
What can I say? It was their call.
et al
It surprises me to watch Human Factors at work in the sim.
We hammer these crews with SOP, SOP, SOP!!! To the point where the strictest adherence to SOPs during an emergency are more of a distraction than a solution. In some cases, you have to pull out your Ace-In-the-Hole. That's the experience card.
Computers still operate on the premise "Garbage IN. Garbage OUT."
It is seriously flawed in some cases but it's what we're given to work with, isn't it? I don't advocate NOT following SOPs but I do advocate some sort of crisis intervention on the part of the experienced crewmember. Even if the action is preceeded with the phrase "non standard" for whatever action out of expedience.
B738
(good little aeroplane the NG)
You are spot on with regard to the SPS. Holding the AP/SP push button for more than 4 seconds disconnects the pusher.
So much for the deep stall theory. And, thanks for pointing it out.
As a sim instructor on this aeroplane, let me say that I fully agree with your remark about the confusion induced by the relight procedure. When a crew has been insufficiently briefed before conducting this event in the FFS, it's a cluster f**k.
I always try to stress the importance of clearly understanding the QRH checklist and its' relevance to crew survival on a cold, dark and dreary night whilst running out of airspeed, altitude and ideas. Most students are quick to point out that their company does not provide individual crew members with a QRH of their own. Pity.
(Make way for the LCC.)
Therefore, they NEED to know, that the core windmilling rpm drops to approximately 3%, give or take, even with the fan turning at 20 + %!!!
The QRH also points out "WHEN ENGINE ROTATION IS ESTABLISHED". This can only be met, IF the crew drops the nose at 26,000 feet and accelerates "to 300 KIAS or greater to achieve the required N2" as informed." Which this crew did not manage to do.
Did they not realize N2 is what governs engine starts??? Were they looking at N1 perhaps and deciding well enough? I surely wouldn't know.
The ITT must be below 90 C and the core (N2) spinning at at least 12% above 15,000 and at least 9% below 15,000. ITT reduction is generally not a factor when the aircraft has already descended from 41 to 21. But, here's the rub.
The QRH Engine Failure checklist ALSO states "if neither engine is restarted: consider a forced landing or ditching." So, at what point to abandon the start attempts? I teach that following the initial attempts to look at RPMs. Core N2 zero, you've got engine damage because they should be turning. The one that IS, should be concentrated on. Were both engines on the accident aircraft turning or not turning? That is the question.
Beanbag
How right you are.
In the clear light of day, it seems your suggestion is spot on. Unfortunately, in the clouded reality of "Holy Sh*t", some of the balls get dropped. Perhaps this is part of what happened to this crew. The hearing pointed out that there were three useable airports short of Jefferson City the crew could have accepted.
What can I say? It was their call.
et al
It surprises me to watch Human Factors at work in the sim.
We hammer these crews with SOP, SOP, SOP!!! To the point where the strictest adherence to SOPs during an emergency are more of a distraction than a solution. In some cases, you have to pull out your Ace-In-the-Hole. That's the experience card.
Computers still operate on the premise "Garbage IN. Garbage OUT."
It is seriously flawed in some cases but it's what we're given to work with, isn't it? I don't advocate NOT following SOPs but I do advocate some sort of crisis intervention on the part of the experienced crewmember. Even if the action is preceeded with the phrase "non standard" for whatever action out of expedience.
B738
(good little aeroplane the NG)
You are spot on with regard to the SPS. Holding the AP/SP push button for more than 4 seconds disconnects the pusher.
So much for the deep stall theory. And, thanks for pointing it out.
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the way I see it: there are two joung pilots, both eager to join FL410 club, but overstress the aircraft, completely disregard the high AOA and low speed at high level, when they realize their mistake, they don't admit it, but rather try to save their face, all resulting in tragedy. I've seen it in my military flying days.
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So many people had to die to make aviation as safe as it is today, TCAS, EGWPS, WXR, Doppler, Stick pushers 
and on and on ... the educational value of this accident....IT'S NOT A GAME UP THERE, NEVER!!! 
" How One Fine Man is Ill-Used by Fate
And Another Dare's To Deceive It"
Ernest K. Gann-Fate is The Hunter
...Then as filed
,
rhov
and on and on ... the educational value of this accident....IT'S NOT A GAME UP THERE, NEVER!!! " How One Fine Man is Ill-Used by Fate
And Another Dare's To Deceive It"
Ernest K. Gann-Fate is The Hunter
...Then as filed
,rhov
Last edited by rhovsquared; 25th Aug 2006 at 19:11.
Longtimelurker
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Sad thing is if you go back say 30 yrs you will find somebody that has done this before.We seem hell bent to repeat our mistakes .One reason when I was younger I read lots of accident reports,just to make sure i didn't make the same mistake's as others.
W. Everlearn:
(It looks like you have) I jumpseated last month on the CRJ-my first time, and liked the c0ckpit. Remember comments that the plane has no autothrottles. On the EPR gauges, do they not always indicate with pointers which EPR is required in takeoff, climb, cruise, ga etc, as with the 757 and many others?
I felt it might be misunderstood to enquire about the accident while on the jumpseat: the guys who flew me were really tired, as always, and on the last leg of a long trip with about five legs per day, maybe more on some.
So, with the accident crew, should the EPR indicators have displayed higher power settings than the engines could produce for FL 410 etc? Or was there, generally speaking, a small, subtle message on the EICAS screen which warned about a minimum airspeed for such an extreme altitude, based on the ram air temp, assumed weight etc, or any other readable message displayed in either red or amber?
Maybe they should have glanced at a QRH or easy-to-read performance manual (it can be forgotten), as we do now and then, to know if a heavy plane can slow to 250-260 KIAS as requested by ATC?
(It looks like you have) I jumpseated last month on the CRJ-my first time, and liked the c0ckpit. Remember comments that the plane has no autothrottles. On the EPR gauges, do they not always indicate with pointers which EPR is required in takeoff, climb, cruise, ga etc, as with the 757 and many others?
I felt it might be misunderstood to enquire about the accident while on the jumpseat: the guys who flew me were really tired, as always, and on the last leg of a long trip with about five legs per day, maybe more on some.
So, with the accident crew, should the EPR indicators have displayed higher power settings than the engines could produce for FL 410 etc? Or was there, generally speaking, a small, subtle message on the EICAS screen which warned about a minimum airspeed for such an extreme altitude, based on the ram air temp, assumed weight etc, or any other readable message displayed in either red or amber?
Maybe they should have glanced at a QRH or easy-to-read performance manual (it can be forgotten), as we do now and then, to know if a heavy plane can slow to 250-260 KIAS as requested by ATC?
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Ignition Override
First of all, this or any other airline crew, as you've suggested, should have looked at the "chart" to see if they could make the intended change in altitude. Perhaps this crew did, I wouldn't know. According to the "chart" this aircraft was capable of FL410 if it was flown as it should have been flown. It wasn't. They apparently used a zoom climb technique which is simply using airspeed to produce rates of climb to get you there. Unfortunately, at a cost. Airspeed. When they finally reached FL410, they were about M0.54 when they should have flown a constant M0.74. The complication at altitude is acceleration to the required cruise mach. Preferably one above the stall. M0.54 is a stall speed. Thrust is set to the 'carrot' for max CRZ (or MCT, which is likely to match CRZ at this point). Now the dilemma gets realized. At this max power setting you get the thrust the engine is capable of producing at FL410 and that thrust is insufficient to overcome the aerodynamic drag and allow the aircraft to accelerate to point 7 4 out of the stall region.
The CRJ has N1 'carrots' for all Max. power settings (including CRZ) and like it's CF6 lineage, the CF34 displays N1s and N2s separated by the ITTs. So it would be simple and straight forward enough for this crew to see what their maximum cruise N1 setting would be at FL410. The carrots automatically (reduce) adjust as you climb. The difficulty in attaining and maintaining the required cruise speed (M0.74) from the reported M0.54 speed at which they levelled off, would be virtually impossible as it is most probable they were at maximum TLA resulting in maximum CRZ thrust and nowhere near the required Thrust vs Drag to recover. Aerodynamic drag being greater than the actual thrust available from the engine at that altitude. Therefore, stalling was imminent.
Also, at that altitude, lowering the nose would have had to have been gentle rather than abrupt to avoid shaker. Based on the number of reported initial shaker and pusher events noted in the report, they might have been a little aggressive in stall recovery which in turn induced secondary stalls. It's also reported that the aircraft recovered at FL290. A substantial loss of altitude.
I wonder if the recent Tu-154 crash in the Ukraine might have been the result of an aircraft being too high for performance, stalling and entering a flat spin out of control. All in an effort to avoid Thunderstorms.
Willie
First of all, this or any other airline crew, as you've suggested, should have looked at the "chart" to see if they could make the intended change in altitude. Perhaps this crew did, I wouldn't know. According to the "chart" this aircraft was capable of FL410 if it was flown as it should have been flown. It wasn't. They apparently used a zoom climb technique which is simply using airspeed to produce rates of climb to get you there. Unfortunately, at a cost. Airspeed. When they finally reached FL410, they were about M0.54 when they should have flown a constant M0.74. The complication at altitude is acceleration to the required cruise mach. Preferably one above the stall. M0.54 is a stall speed. Thrust is set to the 'carrot' for max CRZ (or MCT, which is likely to match CRZ at this point). Now the dilemma gets realized. At this max power setting you get the thrust the engine is capable of producing at FL410 and that thrust is insufficient to overcome the aerodynamic drag and allow the aircraft to accelerate to point 7 4 out of the stall region.
The CRJ has N1 'carrots' for all Max. power settings (including CRZ) and like it's CF6 lineage, the CF34 displays N1s and N2s separated by the ITTs. So it would be simple and straight forward enough for this crew to see what their maximum cruise N1 setting would be at FL410. The carrots automatically (reduce) adjust as you climb. The difficulty in attaining and maintaining the required cruise speed (M0.74) from the reported M0.54 speed at which they levelled off, would be virtually impossible as it is most probable they were at maximum TLA resulting in maximum CRZ thrust and nowhere near the required Thrust vs Drag to recover. Aerodynamic drag being greater than the actual thrust available from the engine at that altitude. Therefore, stalling was imminent.
Also, at that altitude, lowering the nose would have had to have been gentle rather than abrupt to avoid shaker. Based on the number of reported initial shaker and pusher events noted in the report, they might have been a little aggressive in stall recovery which in turn induced secondary stalls. It's also reported that the aircraft recovered at FL290. A substantial loss of altitude.
I wonder if the recent Tu-154 crash in the Ukraine might have been the result of an aircraft being too high for performance, stalling and entering a flat spin out of control. All in an effort to avoid Thunderstorms.
Willie
carrots
Willie
It's carets not carrots, a caret is a graphical symbol and is used in EFIS displays as a target.
A carrot would not have been much use to this crew.
Nor indeed was the EFIS.
It's carets not carrots, a caret is a graphical symbol and is used in EFIS displays as a target.
A carrot would not have been much use to this crew.
Nor indeed was the EFIS.
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hec7or
Good grief, what was I thinking about? It usually takes a few pints before English is my second language!!
Thanks for straightening this out. Especially for the carets.
Willie
Good grief, what was I thinking about? It usually takes a few pints before English is my second language!!
Thanks for straightening this out. Especially for the carets.
Willie
jetsy
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Joy ride at fl410 in a commuter jet..
http://www.kctv5.com/Global/story.asp?S=5915192
"Pilots Jesse Rhodes and Richard Peter Cesarz were ferrying the 50-seat Pinnacle Airlines regional jet from Little Rock, Ark., to Minneapolis without passengers when they decided "to have a little fun" according to the cockpit voice recorder transcript.
They took the plane to an unusually high altitude of 41,000 feet, performed aggressive flight maneuvers, switched seats during the flight and ignored repeated cockpit warnings that the plane was about to stall.
First one, then the second engine stalled. But the pilots didn't follow the proper procedures to restart them and didn't tell air traffic control than both engines had shut down.
"Overall, the pilots' behavior during this flight was not consistent with the degree of discipline, maturity and responsibility required of professional pilots," said Evan Byrne, the NTSB's acting deputy director of aviation safety.
Both men died after the plane crashed in a residential area. No one was injured on the ground.
The safety agency also found the plane's engines had a history of locking up at high altitudes during test flights and that flight manuals did not explain the importance of keeping a minimum air speed to keep engine cores rotating.
[ ]
NTSB investigators said there seemed to be an unusual curiosity among some Pinnacle pilots about flying at 41,000 feet and some pilots used the term "410 club" during investigation interviews."
As the saying goes... curiosity killed the cat. Just tragic
"Pilots Jesse Rhodes and Richard Peter Cesarz were ferrying the 50-seat Pinnacle Airlines regional jet from Little Rock, Ark., to Minneapolis without passengers when they decided "to have a little fun" according to the cockpit voice recorder transcript.
They took the plane to an unusually high altitude of 41,000 feet, performed aggressive flight maneuvers, switched seats during the flight and ignored repeated cockpit warnings that the plane was about to stall.
First one, then the second engine stalled. But the pilots didn't follow the proper procedures to restart them and didn't tell air traffic control than both engines had shut down.
"Overall, the pilots' behavior during this flight was not consistent with the degree of discipline, maturity and responsibility required of professional pilots," said Evan Byrne, the NTSB's acting deputy director of aviation safety.
Both men died after the plane crashed in a residential area. No one was injured on the ground.
The safety agency also found the plane's engines had a history of locking up at high altitudes during test flights and that flight manuals did not explain the importance of keeping a minimum air speed to keep engine cores rotating.
[ ]
NTSB investigators said there seemed to be an unusual curiosity among some Pinnacle pilots about flying at 41,000 feet and some pilots used the term "410 club" during investigation interviews."
As the saying goes... curiosity killed the cat. Just tragic
jetsy
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Considerably Bemused Wannabe
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Level 45 deg AoB turns at M0.84 and FL410 were part of the IR profile on the mighty Vulcan over 30 years ago!
We also flew at FL 500+ and most definitely did 'prat about' doing fighter affiliation against F4s and Lightnings. The Vulcan had huge reserves of thrust and wing!
But the accident in the Pinnacle aircraft shows poor discipline, poor knowledge of jet aircraft performance limits, buffet boundaries, engine failure procedures.......
Leave the 'pratting about' to those trained for it - and fly airliners within the limits stated by the Aircraft Flight Manual. Assuming that an aircraft certificated to fly at FL410 will always be capable of reaching that height, irrespective of weight, shows unbelievably poor understanding of aircraft performance limitations.
We also flew at FL 500+ and most definitely did 'prat about' doing fighter affiliation against F4s and Lightnings. The Vulcan had huge reserves of thrust and wing!
But the accident in the Pinnacle aircraft shows poor discipline, poor knowledge of jet aircraft performance limits, buffet boundaries, engine failure procedures.......
Leave the 'pratting about' to those trained for it - and fly airliners within the limits stated by the Aircraft Flight Manual. Assuming that an aircraft certificated to fly at FL410 will always be capable of reaching that height, irrespective of weight, shows unbelievably poor understanding of aircraft performance limitations.
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