Pinnacle Airlines aircraft incident
"Another example of junior jet pilots (IE: regional jet flight crews) provided insufficient high altitude performance training by the respective airline...with bad results"
You say another, list other RJ incidents in which these junior jet pilots screwed up at altitude. All things considered, they are doing better than your generation ever did.
Again, list some of the incidents.
You say another, list other RJ incidents in which these junior jet pilots screwed up at altitude. All things considered, they are doing better than your generation ever did.
Again, list some of the incidents.
Yes, danke, the NTSB report has the answers -- thanks.
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One of the saddest threads I have every read on Pprune and not just because of the unfortunate outcome but also, I’m afraid, because of the nature of some of the posts. I have been following this from the very start and I should congratulate some of the early posters for their insightful observations while the facts were still very thin on the ground.
We now have an NTSB report which gives us a much fuller picture of the tragic events that took place, but I am shocked by the callous and blinkered interuptation that some are putting on this report. It is clear to me that there are at least 4 significant contributers to this fatality but some are happy to pin the entire events on a reckless crew who were just having a bit of fun. Oh, how quick the authorities were to release that gem of a one liner. It was released in the hope that everyone would agree with their interuptation and go away quietly, and I am saddened at how quickly the aviation fraternity has obliged. We owe it to the unfortunate crew not to let this happen. I urge all to reread the report and re evaluate your opinions on the events that happened. Here is how I see it.
The Crew.
There can be no question that the crew took the a/c to it maximum certified limit of FL410 having been cleared to a much lower level, but as someone has already pointed out, it was the maximum certified limit and not beyond it. I am only too well aware of the “special” aerodynamic circumstances that exist at this altitude and that special training is required to both handle an a/c at that limit, and to recognise the onset of the various phenomena that occur there. This wasn’t provided nor was a lower limit imposed by the operator through a mandatory SOP or similar instrument at their disposal. I find it interesting that the report notes that the service agent who met the crew prior to them embarking, found them in very good mood and not at all tired looking. I suspect that the crew knew only too well that they were being handed the keys to the sweet shop and that the special circumstances surrounding the flight, a repositioning flight with no pax or cargo, would give them the opportunity to go for the magical 41. I would even speculate that they may have even discussed it before hand and would credit them with having probably evaluated the risks within the limits of their knowledge, however flawed this may have been. Unfortunately they were not prepared by the Operator for what was to come.
The Operator.
I hold this bunch in the highest contempt of all. Interviews with sim instructors and checkairmen revealed that high altitude climbs and recommended climb profiles were neither conducted, discussed or demonstrated during sim training sessions with crew on this type. They were simply discussed in the jet upset module of the ground studies. This to me is only acceptable if accompanied with an SOP or some other mandatory circular to all crew forbidding them from attempting to get to an altitude above say FL370. Further more, the report reveals that the only sim based upset training provided to new pilots consisted of 20 minutes where the operator didn’t even allow the pilots under instruction to climb to FL350 but positioned them there electronically to save money (or time as they quite disingenuously put it). This to me demonstrated this operator’s commitment to safety right there. Appalling. The report has a comment from a management pilot from another carrier who operate the same fleet, and he stated that his FDR data analysis from repositioning flights “seems to bring out the worst in his pilots” with unusual attitudes and other manoeuvres regularly being tried. I assume Pinnacle have similar data but didn’t use it to prevent this practice – it probably costs too much. Just look at the number of changes both Pinnacle and Bombardier have made to ops procedures since this incident – staggering in my opinion.
Bombardier
Why oh why would you apply for and get a certificate to operate an a/c at a flight level that required at the very least special training. Several pilots are on record that while they were able to climb to FL410 they were not able to maintain it due to deteriorating performance. If FL410 can’t be safely maintained, why is it certified??? One experienced instructor commented that FL410 required “extreme” attention while another stated that “FL410 is not a FL you want to be at very often” Because it was certified, the two crew in this accident probably felt that it could be safely achieved.
FAA
Why would they give a certificate to an a/c to operate at FL410 with these characteristics? Further more, they issued 59 violations against Pinnacle between ’98 and ’04, and some were not even remedied by them. However, the speed at which Pinnacle implemented every recommendation of this report suggests that something is very wrong.
Conclusion.
Come on folks; don’t let them take the easy way out.
.
May they rest in peace.
We now have an NTSB report which gives us a much fuller picture of the tragic events that took place, but I am shocked by the callous and blinkered interuptation that some are putting on this report. It is clear to me that there are at least 4 significant contributers to this fatality but some are happy to pin the entire events on a reckless crew who were just having a bit of fun. Oh, how quick the authorities were to release that gem of a one liner. It was released in the hope that everyone would agree with their interuptation and go away quietly, and I am saddened at how quickly the aviation fraternity has obliged. We owe it to the unfortunate crew not to let this happen. I urge all to reread the report and re evaluate your opinions on the events that happened. Here is how I see it.
The Crew.
There can be no question that the crew took the a/c to it maximum certified limit of FL410 having been cleared to a much lower level, but as someone has already pointed out, it was the maximum certified limit and not beyond it. I am only too well aware of the “special” aerodynamic circumstances that exist at this altitude and that special training is required to both handle an a/c at that limit, and to recognise the onset of the various phenomena that occur there. This wasn’t provided nor was a lower limit imposed by the operator through a mandatory SOP or similar instrument at their disposal. I find it interesting that the report notes that the service agent who met the crew prior to them embarking, found them in very good mood and not at all tired looking. I suspect that the crew knew only too well that they were being handed the keys to the sweet shop and that the special circumstances surrounding the flight, a repositioning flight with no pax or cargo, would give them the opportunity to go for the magical 41. I would even speculate that they may have even discussed it before hand and would credit them with having probably evaluated the risks within the limits of their knowledge, however flawed this may have been. Unfortunately they were not prepared by the Operator for what was to come.
The Operator.
I hold this bunch in the highest contempt of all. Interviews with sim instructors and checkairmen revealed that high altitude climbs and recommended climb profiles were neither conducted, discussed or demonstrated during sim training sessions with crew on this type. They were simply discussed in the jet upset module of the ground studies. This to me is only acceptable if accompanied with an SOP or some other mandatory circular to all crew forbidding them from attempting to get to an altitude above say FL370. Further more, the report reveals that the only sim based upset training provided to new pilots consisted of 20 minutes where the operator didn’t even allow the pilots under instruction to climb to FL350 but positioned them there electronically to save money (or time as they quite disingenuously put it). This to me demonstrated this operator’s commitment to safety right there. Appalling. The report has a comment from a management pilot from another carrier who operate the same fleet, and he stated that his FDR data analysis from repositioning flights “seems to bring out the worst in his pilots” with unusual attitudes and other manoeuvres regularly being tried. I assume Pinnacle have similar data but didn’t use it to prevent this practice – it probably costs too much. Just look at the number of changes both Pinnacle and Bombardier have made to ops procedures since this incident – staggering in my opinion.
Bombardier
Why oh why would you apply for and get a certificate to operate an a/c at a flight level that required at the very least special training. Several pilots are on record that while they were able to climb to FL410 they were not able to maintain it due to deteriorating performance. If FL410 can’t be safely maintained, why is it certified??? One experienced instructor commented that FL410 required “extreme” attention while another stated that “FL410 is not a FL you want to be at very often” Because it was certified, the two crew in this accident probably felt that it could be safely achieved.
FAA
Why would they give a certificate to an a/c to operate at FL410 with these characteristics? Further more, they issued 59 violations against Pinnacle between ’98 and ’04, and some were not even remedied by them. However, the speed at which Pinnacle implemented every recommendation of this report suggests that something is very wrong.
Conclusion.
Come on folks; don’t let them take the easy way out.
.
May they rest in peace.
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This topic has also become a hot topic on the airliners.net forums.
I would like to answer Ryan_not_fair on some of his comments.
The CRJ 200 (which I still fly), requires no special training to be flown at its certified ceiling. If you follow the Bombardier normal climb schedule and max weight/altitude planner (both available in the cockpit), you will arrive at FL410 at M.70 and if you have correctly interpreted your weight for altitude planner, you will accelerate to cruise speed. I have been to FL410 - it is a non-event.
I do not want to bash the unfortunate crew of the Pinnacle flight, but they arrived at FL410 at M.64, on the wrong side of the drag curve. In no documentation or training that they have received will that MachNo be mentioned. The aircraft continued to decelerate until first the stick shaker and then the stick pusher operated. Fighting the stickpusher brought them to 75 KIAS and a full aerodynamic stall. This flamed out both engines. (No2 overtemping to 1250 degrees C).
Just as there is no reason to train pilots on other aircraft to fly at their respective certified ceilings, so there is no reason for the CRJ.
Bombardier and the operator made changes to their procedures as a typical kneejerk reaction.
Just as a 747 won't maintain FL410 at high weights, the CRJ can only do it when light. Does Boeing also have to recertify the 747?
Because RJ's mostly fly short sectors, we almost never have the right combination of weight and distance to get to FL410. Instructors at Pinnacle would almost certainly never have been there in the real a/c. All the CRJ sims that I have been in are much more unstable than the real thing and I think that the comments in the NTSB documentation are over the top.
I am not defending Bombardier, Pinnacle or the CRJ. I take issue with the fact that training is now suddenly necessary to fly an a/c at its certified ceiling or forcing Bombardier to limit the a/c to lower levels because one crew could not recognise and correct a low energy situation and then compounded the error by fighting the stickpusher.
I have looked at all the data available at the NTSB site. The aircraft operated as advertised.
I would like to answer Ryan_not_fair on some of his comments.
The CRJ 200 (which I still fly), requires no special training to be flown at its certified ceiling. If you follow the Bombardier normal climb schedule and max weight/altitude planner (both available in the cockpit), you will arrive at FL410 at M.70 and if you have correctly interpreted your weight for altitude planner, you will accelerate to cruise speed. I have been to FL410 - it is a non-event.
I do not want to bash the unfortunate crew of the Pinnacle flight, but they arrived at FL410 at M.64, on the wrong side of the drag curve. In no documentation or training that they have received will that MachNo be mentioned. The aircraft continued to decelerate until first the stick shaker and then the stick pusher operated. Fighting the stickpusher brought them to 75 KIAS and a full aerodynamic stall. This flamed out both engines. (No2 overtemping to 1250 degrees C).
Just as there is no reason to train pilots on other aircraft to fly at their respective certified ceilings, so there is no reason for the CRJ.
Bombardier and the operator made changes to their procedures as a typical kneejerk reaction.
Just as a 747 won't maintain FL410 at high weights, the CRJ can only do it when light. Does Boeing also have to recertify the 747?
Because RJ's mostly fly short sectors, we almost never have the right combination of weight and distance to get to FL410. Instructors at Pinnacle would almost certainly never have been there in the real a/c. All the CRJ sims that I have been in are much more unstable than the real thing and I think that the comments in the NTSB documentation are over the top.
I am not defending Bombardier, Pinnacle or the CRJ. I take issue with the fact that training is now suddenly necessary to fly an a/c at its certified ceiling or forcing Bombardier to limit the a/c to lower levels because one crew could not recognise and correct a low energy situation and then compounded the error by fighting the stickpusher.
I have looked at all the data available at the NTSB site. The aircraft operated as advertised.
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I certainly agree the training was lightweight (metaphorically speaking) but we have several unknowns:
What was SAT at 410? If the atmosphere was considerably off ISA, the speed margin in the coffin corner might have vanished. Could a highly experienced crew have handled the situation on that day? Probably depends on instability in the atmosphere. These guys plainly ran out of margin.
The mere fact that the aircraft was cert. to FL410 DOES NOT mean that it is safe in any and all atmospheric conditions way up there.
Relight training was also probably lacking.
What was SAT at 410? If the atmosphere was considerably off ISA, the speed margin in the coffin corner might have vanished. Could a highly experienced crew have handled the situation on that day? Probably depends on instability in the atmosphere. These guys plainly ran out of margin.
The mere fact that the aircraft was cert. to FL410 DOES NOT mean that it is safe in any and all atmospheric conditions way up there.
Relight training was also probably lacking.
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RTFQ
Sadly, West Coast, you did not properly read my statement.
Read it again and you will clearly see that I referred to insuficient crew training provided by the respective operator.
Did the crew mis-handle the aircraft?
Clearly they did, however I fault the airline, not necessarily the pilots...they clearly did not know any better.
Should have, but did not.
I wonder if it is par for the course with regional jet operators?
Read it again and you will clearly see that I referred to insuficient crew training provided by the respective operator.
Did the crew mis-handle the aircraft?
Clearly they did, however I fault the airline, not necessarily the pilots...they clearly did not know any better.
Should have, but did not.
I wonder if it is par for the course with regional jet operators?
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Too slow at altitude
I fly corporate jets certified to 49000 and 51000 respectively. The number one issue regarding high altitude flight is speed. Do not let it get loe, climb at 100 feet per minute if you have to. Or go back down again. I used to fly with a guy who would follow the profile all the way to altitude, and we would not accelerate at all after level off. Going that slow makes it feel like you are balancing on a beech ball. A little turbulence can be enough to make you soil your shorts.
These are things that you should know by the time you are the PIC on a jet.
These are things that you should know by the time you are the PIC on a jet.
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NUGPOT
I cannot argue with your insightful response and I applaud you for your consistent stance on this tragedy. I also thank you for you link to the airliner.com forum which is most informative. I think I understand the stance you are consistently assuming in that the a/c does exactly what it say’s on the tin and these guy’s were unfortunately on the wrong side of the curve. Far too simplistic for me though.
My point is that they shouldn’t have been there in the first place as the operator had an obligation to train them in the handling of the a/c within the operating envelope of the a/c. The NTSB clearly state that this wasn’t provided.
I am also interested in your comments especially as you have been regularly operating this type at FL410, but my concern is that numerous other pilots have testified to the NTSB that this wasn’t possible for any prolonged period, regardless of configuration, and the longer they spent at this FL, the more unstable the performance of this a/c became. I think it highly relevant that the NTSB allowed a comment from a very experienced sim instructor, which said that “extreme attention” is required to fly this a/c at this FL – for God’s sake, the last thing that any pilot needs at any flight level is EXTREME ATTENTION to anything – don’t care whether you are 30 ft off the ground or at FL410.
Question – If certified to a specific FL, surely an SAT or TAT correction is specified in the perf data!!
I cannot argue with your insightful response and I applaud you for your consistent stance on this tragedy. I also thank you for you link to the airliner.com forum which is most informative. I think I understand the stance you are consistently assuming in that the a/c does exactly what it say’s on the tin and these guy’s were unfortunately on the wrong side of the curve. Far too simplistic for me though.
My point is that they shouldn’t have been there in the first place as the operator had an obligation to train them in the handling of the a/c within the operating envelope of the a/c. The NTSB clearly state that this wasn’t provided.
I am also interested in your comments especially as you have been regularly operating this type at FL410, but my concern is that numerous other pilots have testified to the NTSB that this wasn’t possible for any prolonged period, regardless of configuration, and the longer they spent at this FL, the more unstable the performance of this a/c became. I think it highly relevant that the NTSB allowed a comment from a very experienced sim instructor, which said that “extreme attention” is required to fly this a/c at this FL – for God’s sake, the last thing that any pilot needs at any flight level is EXTREME ATTENTION to anything – don’t care whether you are 30 ft off the ground or at FL410.
Question – If certified to a specific FL, surely an SAT or TAT correction is specified in the perf data!!
Last edited by Ryan_not_fair; 17th Jun 2005 at 00:38.
As 411A addressed, higher is better? This is the oldest theory regarding the most economical altitude for any jet.
Why let theory lead you into a very high workload situation where it is your decision to limit, distribute the workload in a manner which seems reasonable and prudent as PIC, never mind any compromise because of fatigue and/or weather, thereby allowing some possibility of CRM back-up?
On one of our flight plans for a very short leg, it stated that the fuel burn at about 12,000' was the same fuel burn as a climb to FL200, followed by an immediate descent. The flight planning software apparently was created by Jeppesen for airline Dispatchers. Why work your butt off to go up then back down like a 105 mm. howitzer shell if it is three times the work, especially for the non-flying pilot in a plane with no automation except for altitude hold []? Navigating, figuring crossing restrctions, setting hydraulic pumps, manual cabin, ATIS etc; none of this is done automatically (remembering to somewhere check the remaining fuel) . This does not include distractions from the cabin or weather, nor a nagging cabin altitude that won't descend at idle with airfoil anti-ice on.
Why let theory lead you into a very high workload situation where it is your decision to limit, distribute the workload in a manner which seems reasonable and prudent as PIC, never mind any compromise because of fatigue and/or weather, thereby allowing some possibility of CRM back-up?
On one of our flight plans for a very short leg, it stated that the fuel burn at about 12,000' was the same fuel burn as a climb to FL200, followed by an immediate descent. The flight planning software apparently was created by Jeppesen for airline Dispatchers. Why work your butt off to go up then back down like a 105 mm. howitzer shell if it is three times the work, especially for the non-flying pilot in a plane with no automation except for altitude hold [
]? Navigating, figuring crossing restrctions, setting hydraulic pumps, manual cabin, ATIS etc; none of this is done automatically (remembering to somewhere check the remaining fuel) . This does not include distractions from the cabin or weather, nor a nagging cabin altitude that won't descend at idle with airfoil anti-ice on.
Last edited by Ignition Override; 19th Jun 2005 at 05:39.
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"The airplane was at Mach 0.070 when the flight encountered a downdraft and the stick shaker activated."
Not surprising really, I'm impressed the plane was flying at all at that speed.....
Not surprising really, I'm impressed the plane was flying at all at that speed.....
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In case it's lost on anyone:
1. it's sarcasm
2. if the NTSB can make such a simple error in an abstract, perhaps one should consider VERY carefully the veracity of ANY information, whatever its source, and not leap to conclusions ....
1. it's sarcasm
2. if the NTSB can make such a simple error in an abstract, perhaps one should consider VERY carefully the veracity of ANY information, whatever its source, and not leap to conclusions ....
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I'm not sure that an NTSB typo really should call into question the rest of the story -- however, I DO think that ALL the facts need to be determined BEFORE someone starts trying to build a case in any particular direction; and I would wager there are at least some who are trying to do just that. The problem is, for us who are interested but not connected, trying to determine if a specific "fact" is truly a fact or something placed in that light to lead us interested but not connected persons to come to a conclusion desired by an interested AND connected party.
It's like the song in the musical "Mary Poppins," ("...a spoonful of sugar helps the medicine go down...") Para-phrasing, a spoonful of truth helps the not-so-true get swallowed. Watch carefully. Read carefully. Accept little if anything on face value. Been there; Done that; Had the experience of having otherwise well meaning people try to force sugar-coated "non-facts" down my throat despite my loud protestations.
AirRabbit
It's like the song in the musical "Mary Poppins," ("...a spoonful of sugar helps the medicine go down...") Para-phrasing, a spoonful of truth helps the not-so-true get swallowed. Watch carefully. Read carefully. Accept little if anything on face value. Been there; Done that; Had the experience of having otherwise well meaning people try to force sugar-coated "non-facts" down my throat despite my loud protestations.
AirRabbit
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Mach Transducers
The CRJ mach transducers display the equivalent mach on the PFDs. Climbing, it is first displayed at an equivalent mach value of .45 and above. Descending, mach is removed at .40.
This is clearly, I suggest, the misplacement of a 'decimal'.
The CRJ mach transducers display the equivalent mach on the PFDs. Climbing, it is first displayed at an equivalent mach value of .45 and above. Descending, mach is removed at .40.
This is clearly, I suggest, the misplacement of a 'decimal'.
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No comment on the initial decision to fly this a/c at an unfamiliar altitude/regime.
As a past instructor on the 604, very similar to the RJ's systems, I have observed many difficulties in the operation of the (very simple) bleed air system - the correct selection of the (4) switch-lights would be essential for the success of an APU start of the first engine, and if attempting a relight at below 13000 with the incorrect bleed settings, a mundane selection of one switchlight would have precluded any attempt at a relight and the ground would seem very close at that point.
This situation would see the crew attempting to function in a very noisy and very non-standard environment:
The ADG would have been deployed - noisy, vibrates tremendously, and very distracting
I think the autopilot disconnects on an RJ with power loss? It does not on a 604. Somebody needs to hand-fly?
Reading the QRH with a flashlight?
There would have been a stack of messages on the EICAS with the associated chimes and flashing Cautions/Warnings
Getting the APU started?
ATC?
O2 masks? If so, difficult communications between crew with loud Darth Vader noises (that's a second area where finger-trouble is common)
Navigating? Where the hell is that airport? Is someone attempting to program the FMS and operate the QRH?
Will the APU start?
F/O overload? Probably.
Stress level off the scale - a long time to contemplate the end.
The wreckage was inverted - another stall? Probably they were very unfamiliar with hand-flying, and following the correct (seemingly too-fast) airspeed means giving up a lot of altitude.
Once these guys lost the two engines, and recovering from the initial stall, doing the rest correctly and in a timely fashion would be stressful enough in the sim, let alone in the real a/c, and you must be trained to make the right decisions when it all happens. E.G: do you driftdown initially to evaluate? If you decide to do this, planning eventually to start the APU, you initially decrease your airspeed to about 210 knots for very leisurely descent. This low speed would probably cause the N2 cores to "lock;" returning to windmill speed would require giving up a LOT of altitude, and the engines are 6.2:1 ratio so you would get a very lackadaisical response from the N2...you would have to hold that dive for a long time.
As your altitude decreased you would also have to decrease your driftdown (=VFTO?) and this would also always be the slowest speed you fly at...another page in the QRH.
Or do you immediately point the nose at the ground, right after stall recovery, effectively diving the a/c to get the cores to spin, and decreasing the time you have to "manage" this "event?"
A bad one, gentlemen, rife with speculation for sure, but I have seen this screwed up in the sim in a 604, so I can see the pitfalls.
As a past instructor on the 604, very similar to the RJ's systems, I have observed many difficulties in the operation of the (very simple) bleed air system - the correct selection of the (4) switch-lights would be essential for the success of an APU start of the first engine, and if attempting a relight at below 13000 with the incorrect bleed settings, a mundane selection of one switchlight would have precluded any attempt at a relight and the ground would seem very close at that point.
This situation would see the crew attempting to function in a very noisy and very non-standard environment:
The ADG would have been deployed - noisy, vibrates tremendously, and very distracting
I think the autopilot disconnects on an RJ with power loss? It does not on a 604. Somebody needs to hand-fly?
Reading the QRH with a flashlight?
There would have been a stack of messages on the EICAS with the associated chimes and flashing Cautions/Warnings
Getting the APU started?
ATC?
O2 masks? If so, difficult communications between crew with loud Darth Vader noises (that's a second area where finger-trouble is common)
Navigating? Where the hell is that airport? Is someone attempting to program the FMS and operate the QRH?
Will the APU start?
F/O overload? Probably.
Stress level off the scale - a long time to contemplate the end.
The wreckage was inverted - another stall? Probably they were very unfamiliar with hand-flying, and following the correct (seemingly too-fast) airspeed means giving up a lot of altitude.
Once these guys lost the two engines, and recovering from the initial stall, doing the rest correctly and in a timely fashion would be stressful enough in the sim, let alone in the real a/c, and you must be trained to make the right decisions when it all happens. E.G: do you driftdown initially to evaluate? If you decide to do this, planning eventually to start the APU, you initially decrease your airspeed to about 210 knots for very leisurely descent. This low speed would probably cause the N2 cores to "lock;" returning to windmill speed would require giving up a LOT of altitude, and the engines are 6.2:1 ratio so you would get a very lackadaisical response from the N2...you would have to hold that dive for a long time.
As your altitude decreased you would also have to decrease your driftdown (=VFTO?) and this would also always be the slowest speed you fly at...another page in the QRH.
Or do you immediately point the nose at the ground, right after stall recovery, effectively diving the a/c to get the cores to spin, and decreasing the time you have to "manage" this "event?"
A bad one, gentlemen, rife with speculation for sure, but I have seen this screwed up in the sim in a 604, so I can see the pitfalls.