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Pinnacle Airlines aircraft incident

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Pinnacle Airlines aircraft incident

Old 20th Jun 2005, 14:33
  #141 (permalink)  
 
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I'm not sure that an NTSB typo really should call into question the rest of the story --
These NTSB preliminary reports are probably typed by someone who's more often doing train, bus, tanker, or pipeline reports - and they're probably not proofread.

e.g. "On February 20, 2005, a British Airways Boeing 757-400, registration G-BNLG, experienced an engine failure shortly after takeoff from Los Angeles International Airport, called PAN, and request to divert to Manchester, United Kingdom. The point of intended landing was Heathrow International Airport, London, United Kingdom. There were no injuries to the 370 persons on board and the airplane landed safely."

The "oopses" here don't invalidate the whole story, do they?
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Old 20th Jun 2005, 23:42
  #142 (permalink)  
 
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I read the CVR transcript from the Pinnacle airlines CRJ accident investigation released by the NTSB last week. Wow. The comments made by the crew near the top of climb and during level-off indicate that they were aware of the decreasing speed/increasing AOA condition they were in but did not take action to reverse this trend or discuss the implications. To those experienced in high altitude flight, the implications are obvious. Stop that trend now by reducing pitch attitude before we get too slow to recover our speed. For reasons as yet unknown to me, this crew appears not to have appreciated the critical nature of this trend. As pointed out by DA50driver, the rate of climb must be limited by the conservation of climb airspeed/mach number. Generally, a climb speed somewhat greater than that called for by the optimum climb profile is selected to provide a positive margin against the possibility of encountering less favorable atmospheric conditions during the remainder of the climb. Once the speed is allowed to decay below optimal climb speed, climb rate must be reduced to arrest the trend and reduced further to recover lost speed. If action to arrest the decay trend is delayed too long, a descent will be required to prevent a stall. Many corporate/charter jet pilots learned these truths in the air while serving as SIC under the tutelage of an experienced PIC. I would expect that many airline pilots have learned by a similar process. I wouldn't be suprised to see this scenario become a new focus in initial training. Hopefully, a reading and analysis of the facts gathered in this investigation will be of instructional value to many. Regardless of where the blame/responsibility is ultimately placed, the facts brought to light by this investigation provide us all with an opportunity to learn some valuable lessons from the mishaps experienced by others.
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Old 21st Jun 2005, 00:31
  #143 (permalink)  
 
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barit1,

'These NTSB preliminary reports are probably typed by someone who's more often doing train, bus, tanker, or pipeline reports - and they're probably not proofread."

I find it difficult to believe some of the cr*p on these forums, please tell me more about the 757 LAX-LHR.
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Old 21st Jun 2005, 00:55
  #144 (permalink)  
 
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Oopsie!

Sorry you missed it!
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Old 21st Jun 2005, 10:54
  #145 (permalink)  
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" have a little fun up there"

I don't know what's funny to be a FL410, except for extra shot of cosmic radiation.

Not a very mature crew, with an awful training record...
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Old 21st Jun 2005, 13:01
  #146 (permalink)  
 
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Often I find the quality of the responses to this or that posting much more interesting for what they say about the mindset of the person posting than for their actual content. There must be a lot of bitter and twisted souls out there just waiting for the chance to dump on someone for either a real or presumed mistake.

As to this 'incident': It sure does look as though the crew in question had not thought through the amount of energy required versus the amount of energy available for sustained flight at FL410.

The first high-altitude airplane I had any significant experience was a Cessna 441 fitted with the less-powerful, original engines (most have now been modified with flat-rated engines that allow them to climb much better).

I used to like to get it up to FL310 on the way from Kano to Lagos, when it would take me all the way to Bida just to reach that height. Well, a look in the book told the tale: conditions were ISA +15° C so that I was asking this machine to fly above its design density cruise altitude. Of course there I was operating a straight-wing airplane in day VMC with all the time in the world to watch what was happening; there were no distractions due to complying with ATC instructions or following an airway more than loosely, say. Too, I was hand-flying so that I could feel what the machine was doing. So I was fully set up for a learning experience, rather than just asking the machine to take me to a particular level simply because the label on the can read 'FL310'.

The Dornier 328 just stops at FL350. That's all the software will give you, although I suppose you could disengage the autopilot and play 'Test Pilot' if you really needed to risk that. When you check the book you will find that at that level Max Cruise and Long Range Cruise are the same, so why bother going higher? The airplane will reach that level with no trouble where I suppose it must run out of steam trying to go much higher, just as this accident aircraft seems to have done. So you might say the 328's designers chose to keep 'junior jet pilots' like me out of trouble.

In this incident it sure does look as though the crew were surprised by something they probably already knew about, but hadn't bothered to think about. Given that they paid such a high price we could probably relax a bit and wait for the official report before going much further than that.
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Old 22nd Jun 2005, 04:12
  #147 (permalink)  
 
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Hey Dude, we're at 410 !

Just Before Dying, a Thrill at 41,000 Feet

By MATTHEW L. WALD
Published: June 14, 2005
WASHINGTON, June 13 - Alone in their 50-seat commercial jet, the two young pilots decided to see what it could do.

According to documents released Monday by the National Transportation Safety Board, they climbed so fast that they were pushed down into their seats with 2.3 times the normal force of gravity, zooming toward 41,000 feet, the limit of their Bombardier CRJ200.

"Ooh, look at that," said the second-in-command, Peter R. Cesarz, 23, apparently referring to cockpit readings. "Pretty cool."

"Man, we can do it," said the captain, Jesse Rhodes, 31. "Forty-one it," he said, referring to the maximum altitude.

A few minutes later, though, both engines were dead, and the pilots were struggling to glide to an emergency landing at an airport in Jefferson City, Mo. "We're going to hit houses, dude," one of them said.

The plane crashed two and a half miles from the runway, missing the houses but killing the pilots.

On Monday, the safety board opened three days of hearings into the crash, which occurred last Oct. 14 on a night flight from Little Rock, Ark., to Minneapolis, to reposition the plane for the next day's schedule.

Among the questions at issue is whether the plane's two engines, which are designed to be capable of restarting in flight, may have seized up, resisting four efforts to get them running. Another is whether the airline, Pinnacle, which is rapidly growing and moving young pilots from turboprops into jets, provided appropriate training.

Some investigators say the pilots flew the plane far harder than an airline would fly with passengers on board, and in testimony on Monday, Terry Mefford, Pinnacle's chief pilot, agreed.

"If there's people in the airplane," he said, "you can count that the crew members are pretty much going by the book."

Mr. Mefford also said that since the accident, he had heard talk of a "410 club," whose members had flown the Bombardier to Flight Level 410, or 41,000 feet. Investigators for the safety board apparently heard similar talk. "Investigators formed the impression," a board report said, "that there was a sense of allure to some pilots to cruise at FL 410 just to say they had 'been there and done that.' "

The two pilots had set the autopilot to take the plane to its 41,000-foot limit, but instead of specifying the speed at which it should fly while climbing, they specified the rate of climb. When the jet reached the assigned altitude, it was flying relatively slowly.

The transcript of their conversation as captured by the cockpit voice recorder suggests exhilaration. An air traffic controller with jurisdiction over the flight asked at one point, "3701, are you an RJ-200?"

"That's affirmative," one of the pilots replied.

"I've never seen you guys up at 41 there," she said.

Then there was laughter in the cockpit.

"Yeah, we're actually a, there's ah, we don't have any passengers on board, so we decided to have a little fun and come on up here," one of the pilots answered.

In the thin air, though, the engines had less thrust, and the plane slowed further. The nose pitched up as the autopilot tried to keep it at the assigned altitude, and then an automatic system began warning that the plane was approaching a "stall," in which there is too little lift to maintain flight.

"Dude, it's losing it," one pilot said, using an expletive. "Yeah," the other said.

But as an automatic system tried to push the nose down, to gain speed and prevent the stall, the pilots, for reasons that are unclear, overrode it.

So the plane did stall, and the turbulent air flowing off the wings entered the engines, shutting them down.

"We don't have any engines," one of the pilots said. "You got to be kidding me."

At that point, the safety board says, the plane was within gliding range of five suitable airports. Yet the pilots did not tell the controller the full extent of their problem, reporting that they had lost one engine, not both, and it was not until 14 minutes later that one said: "We need direct to any airport. We have a double engine failure."

The airline has denounced the pilots.

"It's beyond belief that a professional air crew would act in that manner," said Thomas Palmer, former manager of Pinnacle's training program for that model of jet. He said the crew had evidently disregarded "training and common airmanship."

But the Air Line Pilots Association says Pinnacle's safety program had crucial gaps, including lack of training for high altitudes. It also maintains that the engines suffered "core lock," in which engines running at high thrust are shut down suddenly and, when the parts cool at different rates, some rotating components bind up.

General Electric, which built the engines, says they did not seize up.

To be certified by the Federal Aviation Administration, engines must be capable of restarting in flight. One issue that the safety board will have to resolve is whether the engines on this plane met that rule.
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Old 22nd Jun 2005, 07:45
  #148 (permalink)  
 
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<<The airline has denounced the pilots.>>

That's typical. The operator usually starts there following a tragedy. If the pilots are not enough, the search for a suitable scapegoat will continue for as long as it takes to deflect attention away from their own culpability. Don't get me wrong, these pilots appear to exhibit a suprising lack of maturity, responsibility and general airmanship by the statements attributed to them on the CVR transcript. What I find objectionable is that Pinnacle mangement would be the ones to denounce them! Pinnacle leadership was responsible for screening, selecting, training and assigning these pilots to their duties. They also determine, by example, the corporate safety and ethics culture for the entire company and all of it's employees. It is the responsibility of every employee to do what they know is right and to always act in a way that represents the stated company safety objectives while performing their assigned duties. It is the responsibility of the company to support this expectation of professional behavior by taking every reasonable step to ensure that employees assigned to positions of such vital importance as that of a flight officer are fully trained and encouraged to exersise discretion and good leadership. Easy to say and hard to do because human behavior is not an exact science. But how does any company come to assign two crewmembers to a flight when niether of them understand the basics of jet climb performance or impending stall indications? They commented on the indications but did not demonstrate any understanding of their implications until entering the stall. Suprise! No, Pinnacle cannot escape responsibility for this outcome simply by saying the crew did not follow company procedures. Even though this statement appears to be true, it is not the whole story. Had either of these two pilots posessed even a basic understanding of jet flight characteristics, the airplane would never have stalled. Are they the only ones who screwed up? The company could have done better too. Maybe it costs to much to employ knowledgable, experienced pilots. Yeah, that's the ticket! We gotta get 'em on line cheap. As for everything that happened after the stall, they were in a very uncommon scenario that may have demanded more than they had to give. You think this one will be included in future sim training?
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Old 22nd Jun 2005, 08:10
  #149 (permalink)  
 
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Excuse my ignorance, does the RJ200 have no auto throttle?

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Old 22nd Jun 2005, 09:45
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Level change

Something not mentionned yet is how the crew got to F410. My company has a SOP to use level change (IAS) mode to climb. This has as a consequence that the "natural" tendency of an A/C to "level off", e.g reaching max 500' min ROC, at its optimum climb mach will warn you that with today's OAT, GW and thrust available, it is time to ask ATC for an intermediate level off.
Even flying a piper cub, everyone knows that as from a certain altitude and below a certain IAS, an A/C cannot be accelerated anymore?? Not to blame the crew involved, the constant use of AP has generated a "'marble ass" generation of pilots. Any opinion on this? More "unusual attitude/altitude" training required?
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Old 22nd Jun 2005, 20:45
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Why couldn't they restart the other (left) engine ? The is no mention of much damage to that engine in the NTSB documents.
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Old 23rd Jun 2005, 00:08
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For what it’s worth guys – those of you who chose to decline the opportunity to “jump” on the pilots, who advocated a “wait-and-see-what-ALL-the-facts-are” policy, and particularly those of you who pointed out that our collective responsibility now is to learn some valuable lessons from the mishaps experienced by others (yes, Mr. Westhawk – that last comment was directed at you), please accept my most sincere compliments for a refreshing professional attitude. There are way too many “beginners” who log onto these forums to see “what the pros think” about various and sundry things. And instances like this are way too important to the understanding and future development of the younger aviators for them to see a “rush-to-vilify” other aviators. Yes, perhaps we’ll find that the circumstances surrounding this accident were self-designed and maybe self-ignored, but we may be surprised as well. Also, we may find that the airline should have, could have, would have … about a lot of things ... but maybe not.

I whole-heartedly recommend that ALL of the FACTS be determined – and I’m not just talking about “factoids” that can be used to push someone on the outside of the knowledge base toward a position that was pre-determined by the disseminator of the “factoids.” I would hope that the professionals here would not only be willing to wait, but demand that others wait as well, until the FACTS, all of the FACTS, are gathered. And then, only then, would careful consideration of those FACTS be used to determine logical, rational, and correct conclusions about what really happened. And even then, I would counsel everyone to read the facts for themselves; and not take the word of someone else, before anyone draws his/her own conclusions.

_______
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Old 23rd Jun 2005, 03:53
  #153 (permalink)  
 
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This is not the first time that an autopilot climb in VS mode has resulted in a stall.

I'm not excusing the crew for overriding the stall protection, but I wonder why the FAA certifies autopilots that allow the airspeed to decay as much as happened here.

I would like to see a minimum airspeed of best angle/rate of climb no matter what the autopilot mode.
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Old 23rd Jun 2005, 08:10
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Anybody who hires their FO's out of Gulfstream Intl.'s "program" is more concerned about cutting costs & corners than safety and professionalism.
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Old 23rd Jun 2005, 08:15
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I know that we were cautioned on the transition course for the Dornier 328 about using VS (Vertical Speed) mode, that it can give problems with speed decay as the (stupid) autopilot tries to maintain a certain rate despite the engines simply running out of thrust with increasing altitude.

We have an SOP in place that requires the use of FLCH (Flight Level CHange) mode for continued climb, but good airmanship should tell you not to use VS anyway.

It can be rather interesting to watch the way the autopilot flies the aircraft, often duplicating beginner's mistakes such as failing to anticipate a turn or a level-off, or 'chasing' a signal. Of course one can put this down to poor management of the machine by the pilot, but it's not a simple 'set and forget' piece of equiptment.

When I was trained I was often told that 'the autopilot can fly this airplane far better than you can, so always use it!' That doesn't actually seem to be the case, does it?
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Old 23rd Jun 2005, 09:33
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It can be rather interesting to watch the way the autopilot flies the aircraft, often duplicating beginner's mistakes such as failing to anticipate a turn or a level-off, or 'chasing' a signal. Of course one can put this down to poor management of the machine by the pilot, but it's not a simple 'set and forget' piece of equiptment.
IMHO; if you ever let that Autopilot do things like that, you should be going back to the sim for a refresher.

The aluminium tubes we steer through the air are not toy's and yes flying a turbo prop is more fun than jets, simple reason, you should not be doing things with jets which you can with turboprops(a bit off topic), however, i use the autopilot as an extention of my skill and knowledge

It seemd that the accident involved was one where indepth knowledge of systems was absent (just my personal thought), if the autopilot is not doing what you want, you probably are using it the wrongway eg wrong mode/status for that phase of the flight.

But to repeat my question: did it have autothrottle?

Pointer

Last edited by Pointer; 23rd Jun 2005 at 10:05.
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Old 23rd Jun 2005, 09:50
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\\....but I wonder why the FAA certifies autopilots that allow the airspeed to decay as much as happened here.\\

Autopilots are certified to properly fly the aeroplane, in various configurations.
The particular mode of autopilot operation is normally determined by the flying pilot, after attending a properly designed ground course, base (if required) and sim training, and the very necessary line training required by the respective airline, in conformity with the operators operations specifications.

The operative word in the above scenario is proper, IE: that level of instruction that is required for the particular aircraft.

The old saying...garbage in, garbage out, certainly applies.
IF regional airlines continue to operate with reduced levels of crew training, more accidents will surely follow.
Jet transport flying is not new, and the lessons learned so very long ago by the 'oldtimers' apply just as well today, IE: get too slow, when too high, expect big trouble to follow.

Now, having said all this, the US regional airlines flying turbofan equipment have a remarkably good safety record.
Just a bit more FAA oversight is required, I believe, to ensure continued success.
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Old 23rd Jun 2005, 12:15
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VS mode

This is not the first time that an autopilot climb in VS mode has resulted in a stall.
The important message is the while the Pinnacle bird stalled at min GW at FL410, the same thing will happen at lower altitudes & higher GW. Are there no Vmin limits in this mode? What about other types' autopilots?

I have preached for many decades that the more the engineers "Murphy-proof" a system, the more they contribute to raising a new and improved generation of Murphys.

All the more reason for increased AOA awareness; Can't beat raw data.
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Old 23rd Jun 2005, 12:43
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NTSB public hearing webcast

Here is a link to THREE DAYS of public hearings held last week about this crash. Note that these hearings do not happen regularly, but rather only when circumstances are very unusual. As an example, the most recent was AA587 in NYC. This is where all the dirt comes out! If you like courtroom TV, then this is for you!

I am not done day one yet, and already I am engrossed (and I can't stand courtroom TV). Everybody who has posted on this thread should take some time and watch as much as they can. Interesting testimony by Bombardier training as well as Pinnacle's training people!

Enjoy!
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Old 23rd Jun 2005, 22:46
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I agree with Mr. Moose -- I watched a couple of hours over the weekend -- and it is riviting -- and everyone here should take some time and watch/listen to what is being said. The NTSB site also has a link to all the documents that were presented. Very interesting stuff there!

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