Continental TurboProp crash inbound for Buffalo
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Flying by the book can be dangerous. As pilots we should use our instincts to feel what the aircraft is doing to not repeat the AA DC10 crash. They probably would have been fine if the FO had kept flying the way he was. I always flew the check rides in the sim like the company wanted me to but in a real airplane knew I would probably not use the same procedure if I thought it would endanger our flight.
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To this we can add a concept that I once termed "automated interference with basic airmanship". During the Roselawn investigation, we determined that the upset initiated when the flaps were retracted following the overspeed warning during the descent. The captain was heard on the CVR to say "I knew we'd do that" in reference to the overspeed warning.
We found the flap handle in the wreckage selected to flaps 15. Simple good airmanship told the crew to restore the configuration to where it was before the upset initiated. Unfortunately, ATR at that time had a system in place that prevented the flaps from extending when the airpeed was beyond the appropriate speed limit. Had this not been in place, there is a chance that a recovery might have been completed.
Now, I am well aware of many other things the crew could have done, having been involved in the investigation from the night of the accident. But I have always been bothered by the idea that those fellows tried to do exactly what we are discussing here...common sense airmanship...and were inhibited by automation.
I have to confess a preference for the Boeing philosophy...two quick flexes of my thumb and I'm back to the 727. And it is fair to say that since 1994 a lot has been learned by all regarding the role of automation. But I sure do like being able to strip it off completely.
We found the flap handle in the wreckage selected to flaps 15. Simple good airmanship told the crew to restore the configuration to where it was before the upset initiated. Unfortunately, ATR at that time had a system in place that prevented the flaps from extending when the airpeed was beyond the appropriate speed limit. Had this not been in place, there is a chance that a recovery might have been completed.
Now, I am well aware of many other things the crew could have done, having been involved in the investigation from the night of the accident. But I have always been bothered by the idea that those fellows tried to do exactly what we are discussing here...common sense airmanship...and were inhibited by automation.
I have to confess a preference for the Boeing philosophy...two quick flexes of my thumb and I'm back to the 727. And it is fair to say that since 1994 a lot has been learned by all regarding the role of automation. But I sure do like being able to strip it off completely.
bubbers44;
I agree with you. Flew it, loved it, bread-and-butter airplane as honest as the DC8.
Trouble is, (and I posted at length on this elsewhere), de-regulation came along and the flying public were promised cheaper fares. The only way to do that was to build artificiality into an aviation system and industry, partially actually doing it cheaper and partially creating the illusion that it could be done cheaper. For cost-cutting, employees were low-hanging fruit.
Two pilots, not three or four (Nav's on overseas), huge weight savings, (the fbw B787 is the most dramatic yet), computerzation in every known corner increases accuracy, data-management and reduces staff...
Technology has rendered mechanical, navigational, weather, ergonomic, ATC-related and terrain-related accidents all but obsolete. Today it is human error that is the chief cause of aircraft incidents and accidents. That factor is stubbornly flatlined on the descending graph kept since the mid-60's and is about to begin climbing again as the promise of cheap aviation meets the aviation's natural barriers and constraints.
This brings us home to the fact that you can't sustain a "viable" aviation industry based upon B727 or DC8 numbers. Everyone from CEO, through flight operations through the bean-counters is asking of the manufacturers and crews, "what have you done for us lately?" and at presently very fine-tuned levels, there isn't much left to cut off the bone.
I think we both know that it's as plain as that.
All of us know how to fly a 727. A few know the laws of A320 automation.
Trouble is, (and I posted at length on this elsewhere), de-regulation came along and the flying public were promised cheaper fares. The only way to do that was to build artificiality into an aviation system and industry, partially actually doing it cheaper and partially creating the illusion that it could be done cheaper. For cost-cutting, employees were low-hanging fruit.
Two pilots, not three or four (Nav's on overseas), huge weight savings, (the fbw B787 is the most dramatic yet), computerzation in every known corner increases accuracy, data-management and reduces staff...
Technology has rendered mechanical, navigational, weather, ergonomic, ATC-related and terrain-related accidents all but obsolete. Today it is human error that is the chief cause of aircraft incidents and accidents. That factor is stubbornly flatlined on the descending graph kept since the mid-60's and is about to begin climbing again as the promise of cheap aviation meets the aviation's natural barriers and constraints.
This brings us home to the fact that you can't sustain a "viable" aviation industry based upon B727 or DC8 numbers. Everyone from CEO, through flight operations through the bean-counters is asking of the manufacturers and crews, "what have you done for us lately?" and at presently very fine-tuned levels, there isn't much left to cut off the bone.
I think we both know that it's as plain as that.
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PJ2
you wrote about technology etc.
you went on to say that accidents have roots in human error.
But
Modern techology sometimes robs humans of that extra bit of something which can save the day...when technology can't cope.
Shades of Hal 9000.
you went on to say that accidents have roots in human error.
But
Modern techology sometimes robs humans of that extra bit of something which can save the day...when technology can't cope.
Shades of Hal 9000.
Could someone please explain to me what were the previous posters actually refering to, when they were writing about modern technology. Apart from EFIS, FADEC and FMS, I couldn't find anything else qualifying as modern on Q400.
Two crew flightdeck, perhaps?
Two crew flightdeck, perhaps?
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clandestino
I think we were lamenting the loss of stick and rudder skills, and fully integrating the man into the machine.
You also seem to forget the autopilot which is much more than a simple heading holding device, or altitude holding device.
With some crashes, I am not saying this one yet, relying on automation seems to lead to problems that hand flying wouldn't lead to.
You also seem to forget the autopilot which is much more than a simple heading holding device, or altitude holding device.
With some crashes, I am not saying this one yet, relying on automation seems to lead to problems that hand flying wouldn't lead to.
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...relying on automation seems to lead to problems that hand flying wouldn't lead to.
Remember this one?
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yes barit1, that L1011 crash is classic.
sorry boys and girls, modern pilots are failing in cockpit discipline, instrument flying skills and so much more. And this must be a reflection of safety culture and training at the airline in question.
just read about what caused the amsterdam crash.
Please remember, below 10,000 feet you better be all business and look at the instruments, including power settings.
sorry boys and girls, modern pilots are failing in cockpit discipline, instrument flying skills and so much more. And this must be a reflection of safety culture and training at the airline in question.
just read about what caused the amsterdam crash.
Please remember, below 10,000 feet you better be all business and look at the instruments, including power settings.
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Exactly...
Probably 90-95% of the time, FBW does what it is supposed to do...emotion is taken out of the equation and the aircraft is flown following very specific laws. Everyone is safe ! That 5-10% though is what is worrying. Thats when 'bad things' happen ( I didnt say 'accident' because in many cases the end result could have been avoided ) - Pilots find themselves in a unfamiliar situation...decisions needs to be made very quickly....emotion enters the equation...and the rest is history. Appropriate training and discipline are crucial in our world of man-machine interfaces.
Probably 90-95% of the time, FBW does what it is supposed to do...emotion is taken out of the equation and the aircraft is flown following very specific laws. Everyone is safe ! That 5-10% though is what is worrying. Thats when 'bad things' happen ( I didnt say 'accident' because in many cases the end result could have been avoided ) - Pilots find themselves in a unfamiliar situation...decisions needs to be made very quickly....emotion enters the equation...and the rest is history. Appropriate training and discipline are crucial in our world of man-machine interfaces.
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American Airlines 903, May 12 1997, NTSB Brief DCA97MA049 is interesting as well.
If I remember correctly, autopilot captured 16000 feet at the approach fix for Miami International, autothrottle disconnected at some point before that without the flight crew noticing, aircraft in holding pattern, speed bled off, aircraft stalled just before shaker for some reason, aircraft entered series of pitch and roll oscillations as crew tried to regain control.
If I remember correctly, autopilot captured 16000 feet at the approach fix for Miami International, autothrottle disconnected at some point before that without the flight crew noticing, aircraft in holding pattern, speed bled off, aircraft stalled just before shaker for some reason, aircraft entered series of pitch and roll oscillations as crew tried to regain control.
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As an outsider, though, it seems to me that the more the level of automation has increased, the lower the accident rate has become.
Don't get me wrong - I'm glad to have a professional pilot monitoring and flying as necessary. Still, automation eliminates errors as well as causing them.
Don't get me wrong - I'm glad to have a professional pilot monitoring and flying as necessary. Still, automation eliminates errors as well as causing them.
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Beausoleil
Still, automation eliminates errors as well as causing them.
The more we rely on computers the more we are subject to unforeseen and (sometimes) uncontrollable ELECTRONIC events, particularly where flying machines are concerned.
The jury is still out on BA038. Now we have the Buffalo Dash8 and and the Turkish B378. People are also reminding us of the TOM incident 2 years ago.
Too much reliance on technology is not a good thing. Bring back good airmanship!!
Last edited by Xeque; 7th Mar 2009 at 13:28.
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And the weakest link of all is the man who just cannot believe that highly trained, professional, multi-crews can make basic errors and miss 'obvious' signs of impending trouble.
Incredible some of the denial that has been evident on this and the AMS thread.
Incredible some of the denial that has been evident on this and the AMS thread.
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I have gone through as many psots as humanly possible and not found anything regrading this video on icing so if it has been included please forgive me for not knowing the 900 pages of posts. (last time I posted something a few guys just jumped on me with about 10 posts saying that I was filling up posts unecessarily 
- thats funny!)
Well I thought this video was quite good to show those that still think that icing is not a major problem.
YouTube - Shorts 360 icing
- thats funny!)Well I thought this video was quite good to show those that still think that icing is not a major problem.
YouTube - Shorts 360 icing
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N. T. S. B. Investigation Update
************************************************************
NTSB ADVISORY
************************************************************
National Transportation Safety Board
Washington, DC 20594
March 25, 2009
************************************************************
UPDATE ON NTSB INVESTIGATION INTO CRASH OF COLGAN AIR
DASH-8 NEAR BUFFALO, NEW YORK; PUBLIC HEARING SCHEDULED
************************************************************
In its continuing investigation into the crash of Colgan Air
flight 3407 in Clarence Center, New York, the National
Transportation Safety Board has released the following
factual information.
On February 12, 2009, about 10:17 p.m. Eastern Standard Time
(EST), a Colgan Air Inc., Bombardier Dash 8-Q400, N200WQ,
d.b.a. Continental Connection flight 3407, crashed during an
instrument approach to runway 23 at the Buffalo-Niagara
International Airport (BUF), Buffalo, New York. The crash
site was approximately 5 nautical miles northeast of the
airport in Clarence Center, New York, and mostly confined to
one residential house. The 4 crew members and 45 passengers
were fatally injured and the airplane was destroyed by
impact forces and post crash fire. There was one ground
fatality. Night visual meteorological conditions prevailed
at the time of the accident. The flight was a Code of
Federal Regulations (CFR) Part 121 scheduled passenger
flight from Liberty International Airport (EWR), Newark, New
Jersey to Buffalo.
The NTSB has voted to conduct a public hearing on this
accident. The hearing, which will be held May 12 - 14,
2009, at the NTSB's Board Room and Conference Center in
Washington, D.C., will cover a wide range of safety issues
including: icing effect on the airplane's performance, cold
weather operations, sterile cockpit rules, crew experience,
fatigue management, and stall recovery training. The public
hearing is part of the Safety Board's efforts to develop all
appropriate facts for the investigation.
"The tragedy of flight 3407 is the deadliest transportation
accident in the United States in more than 7 years," Acting
Chairman Mark V. Rosenker, who will chair the hearing, said.
"The circumstances of the crash have raised several issues
that go well beyond the widely discussed matter of airframe
icing, and we will explore these issues in our investigative
fact-finding hearing."
The hearing will be held "en banc," meaning that all Members
of the NTSB will sit on the Board of Inquiry. Parties that
will participate in the hearing will be announced at a later
time.
The aircraft wreckage has been moved from the accident site
to a secure location for follow-on inspections as may be
needed.
A preliminary examination of the airplane systems has
revealed no indication of pre-impact system failures or
anomalies. Investigators will perform additional
examinations on the dual distribution valves installed in
the airplane's de-ice system. The de-ice system removes ice
accumulation from the leading edges of the wings, horizontal
tail, and vertical tail through the use of pneumatic boots.
The dual distribution valves, which transfer air between
the main bleed air distribution ducts and the pneumatic
boots, were removed from the airplane for the examination.
The airplane maintenance records have been reviewed and no
significant findings have been identified at this time.
The ATC group has completed a review of recordings of
controller communications with the flight crew during the
accident flight and conducted interviews with air traffic
controllers on duty at the time of the accident. The group
has no further work planned at this time.
Further review of the weather conditions on the night of the
accident revealed the presence of variable periods of snow
and light to moderate icing during the accident airplane's
approach to the Buffalo airport.
Examination of the FDR data and preliminary evaluation of
airplane performance models shows that some ice accumulation
was likely present on the airplane prior to the initial
upset event, but that the airplane continued to respond as
expected to flight control inputs throughout the accident
flight. The FDR data also shows that the stall warning and
protection system, which includes the stick shaker and stick
pusher, activated at an airspeed and angle-of-attack (AOA)
consistent with that expected for normal operations when the
de-ice protection system is active. The airplane's stick
shaker will normally activate several knots above the actual
airplane stall speed in order to provide the flight crew
with a sufficient safety margin and time to initiate stall
recovery procedures. As a result of ice accumulation on the
airframe, an airplane's stall airspeed increases. To
account for this potential increase in stall speed in icing
conditions, the Dash 8-Q400's stall warning system activates
at a higher airspeed than normal when the de-ice system is
active in-flight to provide the flight crew with adequate
stall warning if ice accumulation is present.
Preliminary airplane performance modeling and simulation
efforts indicate that icing had a minimal impact on the
stall speed of the airplane. The FDR data indicates that
the stick shaker activated at 130 knots, which is consistent
with the de-ice system being engaged. FDR data further
indicate that when the stick shaker activated, there was a
25-pound pull force on the control column, followed by an up
elevator deflection and increase in pitch, angle of attack,
and Gs. The data indicate a likely separation of the
airflow over the wing and ensuing roll two seconds after the
stick shaker activated while the aircraft was slowing
through 125 knots and while at a flight load of 1.42 Gs.
The predicted stall speed at a load factor of 1 G would be
about 105 knots. Airplane performance work is continuing.
Since returning from on-scene, the Operations & Human
Performance group has conducted additional interviews with
flight crew members who had recently flown with and/or
provided instruction to the accident crew, as well as
personnel at Colgan Air responsible for providing training
of flight crews and overseeing the management and safety
operations at the airline. The group also conducted
interviews with FAA personnel responsible for oversight of
the Colgan certificate, which included the Principal
Operations Inspector (POI) and aircrew program manager for
the Dash 8 Q-400. The team has also continued its review of
documentation, manuals, and other guidance pertaining to the
operation of the Dash 8 Q-400 and training materials
provided to the Colgan Air flight crews.
The Operations & Human Performance group continues to
investigate and review documentation associated with the
flight crew's flight training history and professional
development during their employment at Colgan as well as
prior to joining the company.
Post-accident toxicological testing of the flight crew was
performed by the FAA Civil Aerospace Medical Institute
(CAMI) toxicology lab. Specimens taken from the first
officer were negative for alcohol, illicit substances, and a
wide range of prescription and over the counter medications.
Specimens taken from the captain were negative for alcohol
and illicit substances, and positive for diltiazem, a
prescription blood pressure medication that had been
reported to and approved for his use by the Federal Aviation
Administration.
The Safety Board is also examining several other areas
potentially related to the accident, including:
? The circumstances of a recent event involving a Dash
8-Q400, operated by Colgan Air, in which the
airplane's stick shaker activated during approach to
the Burlington International Airport (BTV) in
Burlington, Vermont. A preliminary review of the FDR
data from that flight shows the momentary onset of the
stick shaker during the approach phase of flight. The
airplane subsequently landed without incident. NTSB
investigators have conducted interviews with the
pilots and check airman on board this flight and will
continue to investigate the incident.
? Reports of airplane deviations resulting from
distortion of the instrument landing system (ILS)
signal for runway 23 at BUF. There is an existing
Notice to Airmen (NOTAM) related to this distortion
condition. To date, investigation into these reports
has not revealed any connection to the accident
flight.
-30-
Media Contact: Keith Holloway, (202) 314-6100
[email protected]
************************************************************
NTSB ADVISORY
************************************************************
National Transportation Safety Board
Washington, DC 20594
March 25, 2009
************************************************************
UPDATE ON NTSB INVESTIGATION INTO CRASH OF COLGAN AIR
DASH-8 NEAR BUFFALO, NEW YORK; PUBLIC HEARING SCHEDULED
************************************************************
In its continuing investigation into the crash of Colgan Air
flight 3407 in Clarence Center, New York, the National
Transportation Safety Board has released the following
factual information.
On February 12, 2009, about 10:17 p.m. Eastern Standard Time
(EST), a Colgan Air Inc., Bombardier Dash 8-Q400, N200WQ,
d.b.a. Continental Connection flight 3407, crashed during an
instrument approach to runway 23 at the Buffalo-Niagara
International Airport (BUF), Buffalo, New York. The crash
site was approximately 5 nautical miles northeast of the
airport in Clarence Center, New York, and mostly confined to
one residential house. The 4 crew members and 45 passengers
were fatally injured and the airplane was destroyed by
impact forces and post crash fire. There was one ground
fatality. Night visual meteorological conditions prevailed
at the time of the accident. The flight was a Code of
Federal Regulations (CFR) Part 121 scheduled passenger
flight from Liberty International Airport (EWR), Newark, New
Jersey to Buffalo.
The NTSB has voted to conduct a public hearing on this
accident. The hearing, which will be held May 12 - 14,
2009, at the NTSB's Board Room and Conference Center in
Washington, D.C., will cover a wide range of safety issues
including: icing effect on the airplane's performance, cold
weather operations, sterile cockpit rules, crew experience,
fatigue management, and stall recovery training. The public
hearing is part of the Safety Board's efforts to develop all
appropriate facts for the investigation.
"The tragedy of flight 3407 is the deadliest transportation
accident in the United States in more than 7 years," Acting
Chairman Mark V. Rosenker, who will chair the hearing, said.
"The circumstances of the crash have raised several issues
that go well beyond the widely discussed matter of airframe
icing, and we will explore these issues in our investigative
fact-finding hearing."
The hearing will be held "en banc," meaning that all Members
of the NTSB will sit on the Board of Inquiry. Parties that
will participate in the hearing will be announced at a later
time.
The aircraft wreckage has been moved from the accident site
to a secure location for follow-on inspections as may be
needed.
A preliminary examination of the airplane systems has
revealed no indication of pre-impact system failures or
anomalies. Investigators will perform additional
examinations on the dual distribution valves installed in
the airplane's de-ice system. The de-ice system removes ice
accumulation from the leading edges of the wings, horizontal
tail, and vertical tail through the use of pneumatic boots.
The dual distribution valves, which transfer air between
the main bleed air distribution ducts and the pneumatic
boots, were removed from the airplane for the examination.
The airplane maintenance records have been reviewed and no
significant findings have been identified at this time.
The ATC group has completed a review of recordings of
controller communications with the flight crew during the
accident flight and conducted interviews with air traffic
controllers on duty at the time of the accident. The group
has no further work planned at this time.
Further review of the weather conditions on the night of the
accident revealed the presence of variable periods of snow
and light to moderate icing during the accident airplane's
approach to the Buffalo airport.
Examination of the FDR data and preliminary evaluation of
airplane performance models shows that some ice accumulation
was likely present on the airplane prior to the initial
upset event, but that the airplane continued to respond as
expected to flight control inputs throughout the accident
flight. The FDR data also shows that the stall warning and
protection system, which includes the stick shaker and stick
pusher, activated at an airspeed and angle-of-attack (AOA)
consistent with that expected for normal operations when the
de-ice protection system is active. The airplane's stick
shaker will normally activate several knots above the actual
airplane stall speed in order to provide the flight crew
with a sufficient safety margin and time to initiate stall
recovery procedures. As a result of ice accumulation on the
airframe, an airplane's stall airspeed increases. To
account for this potential increase in stall speed in icing
conditions, the Dash 8-Q400's stall warning system activates
at a higher airspeed than normal when the de-ice system is
active in-flight to provide the flight crew with adequate
stall warning if ice accumulation is present.
Preliminary airplane performance modeling and simulation
efforts indicate that icing had a minimal impact on the
stall speed of the airplane. The FDR data indicates that
the stick shaker activated at 130 knots, which is consistent
with the de-ice system being engaged. FDR data further
indicate that when the stick shaker activated, there was a
25-pound pull force on the control column, followed by an up
elevator deflection and increase in pitch, angle of attack,
and Gs. The data indicate a likely separation of the
airflow over the wing and ensuing roll two seconds after the
stick shaker activated while the aircraft was slowing
through 125 knots and while at a flight load of 1.42 Gs.
The predicted stall speed at a load factor of 1 G would be
about 105 knots. Airplane performance work is continuing.
Since returning from on-scene, the Operations & Human
Performance group has conducted additional interviews with
flight crew members who had recently flown with and/or
provided instruction to the accident crew, as well as
personnel at Colgan Air responsible for providing training
of flight crews and overseeing the management and safety
operations at the airline. The group also conducted
interviews with FAA personnel responsible for oversight of
the Colgan certificate, which included the Principal
Operations Inspector (POI) and aircrew program manager for
the Dash 8 Q-400. The team has also continued its review of
documentation, manuals, and other guidance pertaining to the
operation of the Dash 8 Q-400 and training materials
provided to the Colgan Air flight crews.
The Operations & Human Performance group continues to
investigate and review documentation associated with the
flight crew's flight training history and professional
development during their employment at Colgan as well as
prior to joining the company.
Post-accident toxicological testing of the flight crew was
performed by the FAA Civil Aerospace Medical Institute
(CAMI) toxicology lab. Specimens taken from the first
officer were negative for alcohol, illicit substances, and a
wide range of prescription and over the counter medications.
Specimens taken from the captain were negative for alcohol
and illicit substances, and positive for diltiazem, a
prescription blood pressure medication that had been
reported to and approved for his use by the Federal Aviation
Administration.
The Safety Board is also examining several other areas
potentially related to the accident, including:
? The circumstances of a recent event involving a Dash
8-Q400, operated by Colgan Air, in which the
airplane's stick shaker activated during approach to
the Burlington International Airport (BTV) in
Burlington, Vermont. A preliminary review of the FDR
data from that flight shows the momentary onset of the
stick shaker during the approach phase of flight. The
airplane subsequently landed without incident. NTSB
investigators have conducted interviews with the
pilots and check airman on board this flight and will
continue to investigate the incident.
? Reports of airplane deviations resulting from
distortion of the instrument landing system (ILS)
signal for runway 23 at BUF. There is an existing
Notice to Airmen (NOTAM) related to this distortion
condition. To date, investigation into these reports
has not revealed any connection to the accident
flight.
-30-
Media Contact: Keith Holloway, (202) 314-6100
[email protected]
************************************************************
The NTSB has voted to conduct a public hearing on this
accident. The hearing, which will be held May 12 - 14,
2009, at the NTSB's Board Room and Conference Center in
Washington, D.C., will cover a wide range of safety issues
including: icing effect on the airplane's performance, cold
weather operations, sterile cockpit rules, crew experience,
fatigue management, and stall recovery training
accident. The hearing, which will be held May 12 - 14,
2009, at the NTSB's Board Room and Conference Center in
Washington, D.C., will cover a wide range of safety issues
including: icing effect on the airplane's performance, cold
weather operations, sterile cockpit rules, crew experience,
fatigue management, and stall recovery training
Sounds like they are on the "pilot-thing", 4 out of 6 points go to crew/company
