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Continental TurboProp crash inbound for Buffalo

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Continental TurboProp crash inbound for Buffalo

Old 14th May 2009, 16:44
  #1121 (permalink)  
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Having read the Colgan Transcript, I agree that "flirting" is a misnomer, sounds like normal cruise chatter (except of course they weren't in the cruise). That itself reflects a lack of (sterile) discipline and almost certainly contributed to the scan degradation (leading to the failed recovery).

The (apparent lack of) upset training surely must rate as the major issue here though. Kinda Glaring.
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Old 14th May 2009, 17:09
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RE: Statement From Colgan Air Regarding Flight Crew Training

Like all Colgan pilots, Captain Renslow and First Officer Shaw had thorough initial and recurrent training on how to recognize an impending stall situation through the stick shaker and how to recognize the aircraft's response to a possible stall. This training is consistent with programs and training equipment employed at all major air carriers.
RE: Washington Post: Recorder Shows Pilots Discussed Anxiety Over Conditions, Training

"Minutes before crashing, Colgan Air pilots discussed their lack of experience flying planes under icing conditions and expressed anxiety about their training as they looked out of the cockpit windows and saw ice built up on the wings. The revelations came to light today when the National Transportation Safety Board released transcripts of the cockpit voice recorder. The board is holding three days of hearings on the Feb. 12, 2009, crash, which killed all 49 on board and one person on the ground.

First Officer Rebecca Shaw, in conversation with Captain Marvin Renslow, expressed wariness about the possibility of being promoted to captain without proper training.

"I've never seen icing conditions," Shaw tells Renslow. "I've never de-iced. I've never seen any-- I've never experienced any of that. I don't want to have to experience that and make those kinds of call[s.] You know I'd have freaked out. I'd have, like, seen this much ice and thought, 'Oh, my gosh, we're going to crash."

Full story can be found here: washingtonpost.com
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Old 14th May 2009, 17:19
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She was referencing a previous time when she was debating whether to upgrade on the Saab or stay right seat in the Q.

There is no way she flew through the winter in EWR and didn't experience ice.....
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Old 14th May 2009, 17:28
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According to NTSB, the calculated 1g stall speed, for actual configuration and weight, was 105 kt. The aeroplane stalled at 125kt and 1.42g.

Do the maths and see whether ice was a factor.
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Old 14th May 2009, 17:34
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Cream of the Crop

Sad fact is that US regionals are notorious for promoting their own to pilot management and training positions. These thin-resume aviators then function, with the concurrence of airline ownership/management, to perpetuate the abusive nature of the business (poor pay, sleeping on crew-lounge tables, etc.) as part of the rite of passage that "they" experienced, hiring only those who "fit the profile"....Capt Sullenberger would not be invited to attend. A better description would be "the selection of those who rise to the top of a cesspool, otherwise known as "skimming the cream" for further advancement. No,the only thing these operations have in common with American, United, or BA is that they both (most of the time, see Buffalo) utilize an AIRPORT. First step toward cleaning out vermin is to stop promoting them.
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Old 14th May 2009, 17:53
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The aeroplane stalled at 125kt and 1.42g.
Accelerated stall due to 'windshear'????

I've had stall buffeting in light planes 10 or more knots above the Vso on approach,...with only a 10 knot loss indicated,...They let the plane get too low energy then recovered incorrectly,....so how about that MPL?

actually I don't blame the pilots exclusively, I blame their training ,their CFI's the company training...and the pilots

this story is sad on so many levels
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Old 14th May 2009, 18:14
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The crew apparently bugged a Vref of 118kts, giving a Vso of 91kts. Assuming a 12kt margin on the shaker we would expect the AOA to reach its preset value and the shaker to fire at a speed of around 103kts in the F15 configuration. With the INCR speed switch active the approximate numbers would be Vref 138kts, Vso 106 and shaker at 118kts. However the aircraft was configured at flaps 5 with the flaps in transition to 15 but never actually moving beyond 10. I don't know the actual numbers for a F5 approach but let's add 15 kts.

138 + 15 = Vref 153kts, VsF5 118kts and shaker at 130kts. Which is about were the shaker initialy fired according to the NTSB data.

Absent significant actual icing contamination this was likely a false indication of an imminent stall resulting from the lower AOA programmed into the stall warning system by selection of the INCR speed switch. Regardless, the recovery procedure would be the same as for an actual imminent stall - apply full power, pitching forward to reduce AOA and accelerate out of the imminent stall while minimizing altitude loss. Instead we got the opposite with the pilot inducing a full stall by pulling back and pitching up, further reducing airspeed and increasing AOA until the pusher fires at around 100kts. Thereafter things go from bad to worse as the FO retracts the flaps during the 1st wingover, while the nose never goes below the horizon until the final unrecoverable wingover/dive.
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Old 14th May 2009, 18:17
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Situational awareness

If we look at the five recent major accidents (geese/Hudson, approach-stall/Buffalo, approach-stall/Amsterdam, tail-strike/Melbourne, and hard-touchdown/Narita), it seems like situational awareness was a key factor in the first four. Sully had the worst problem (two engines out over the middle of a huge metro area) but the best "luck" in terms of an overpoweringly unmistakable problem, and good visiblity to help literally see the big picture outside the aircraft. The others had minor situations (decaying airspeed, bad altimeter, bad weight numbers) that were allowed to deteriorate through some amount of inattention.

On the question of the Colgan FO putting the flaps back up - well, there's an old rule-of-thumb that if you do something, and everything immediate goes haywire, the first thing you do is to UNDO whatever your just did. Throttle back and the engine quits - the first thing you do is firewall the throttle. The FO moved the flaps to 15, and within a second the plane is upset - I can see the motivation to immediately "undo" the change in flap setting.

That doesn't mean it was the right thing to do, and obviously the flight was already in a bad place regardless of the flap setting.

The bottom line on experience-vs-management-vs-training is: You don't put people into jobs they aren't competent to handle. If you don't know enough about your employees to determine if they are competent, you're screwing up as a manager. The standard is not to check all the boxes on an FAA form, it is to not crash airplanes.
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Old 14th May 2009, 18:18
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That's not entirely correct. The stick shaker fired at 125kts. The pusher fired around 105kts.

As they say, "working as designed".
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Old 14th May 2009, 18:26
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Blame the training?

"Since the accident, Colgan has also instituted stick pusher demonstrations in a flight simulator, despite the fact that flight simulator training on this issue is not required by the FAA and is not standard in the airline industry. This is one of a number of additions that Colgan has made to its training and safety programs in the wake of the accident."

As somebody working my way up the ladder to the airline industry, the section I've bolded is one of my biggest fears. Many or most airlines these days train simply to the bare minimum proficiency. Why is something as basic as this not included in the FAA curriculum?

Looking back to my PPL training, there seemed to be a pretty long list of tasks to complete. Now, after some more experience, I can conclude that the pilot who only has the minimum required knowledge is NOT a safe pilot. There's a whole lot more to learn before you become a safe pilot. For example, although not required, my instructor demonstrated spin recovery a few times.

What's worrying is that now, if I want to learn something, I can just ask my instructor and it'll get done because I'm paying. I doubt that airline crews have this flexibility, as I keep hearing stories of "rushed" sim sessions because there's only so much time to check the required boxes.

Surely an airline can find time to train it's pilots above and beyond the bare minimum required by law. It seems the Colgan crew wasn't trained to the stick pusher (full stall), only the stick shaker (impending stall). Why is this the standard? Why not go the extra few knots and know how to deal with a stalled airplane? Does it really take that much time?

Everything can't be taught in the sim, but with all the time spent in the box, shouldn't crews be exposed to more training exercises?

What do the experienced pilots think? Will this be a wake-up call for training departments, or will airlines continue to train to basic levels of proficiency?
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Old 14th May 2009, 18:57
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cause of the crash: the peter principle

the peter principle says you will rise to the level of your incompetence in an organization.




Someone asked why the FAA didn't include the pusher in the curriculum...MONEY

The airlines said: why train someone on the pusher if they are to recover at the shaker?

Why spend 5 minutes in the sim?

I encourage all thinking training departments to resume upset recovery from being disoriented...IE...put your head down, close your eyes, instructor puts you in a bad spot and then you look up...first thing check airspeed...increasing? power back and level wings

decreasing, powerup and level wings...and push forward if you are hanging on the edge of stall.

we did this stuff in pipers. when things went to hell in this plane, if the pilot had read his airspeed and reacted...we wouldn't have a 58 page thread.

OF COURSE it is proper to stay way ahead of things and know how your lift is going...and the closer to the ground, the more often you should be checking airspeed (indirectly lift). In cruise at FL350....you probably don't check airspeed that often (unless you are trying to get home on time~!)
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Old 14th May 2009, 19:02
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Numbers I've used are from NTSB press advisory, dated march 25th. For those too lazy to click, here's the relevant quote:

Originally Posted by National Transportation Safety Board
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.
And yet, nearly two months later there are still expert PPRuNers posting about ice, ice, ice...
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Old 14th May 2009, 19:10
  #1133 (permalink)  
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I like that thought about the goal being to not crash the planes rather than fill file cabinets with well-checked boxes on FAA training requirement forms. Unfortunately, the FAA bureaucrats and the company-equivalents undoubtedly hold contrary views.

I'd like to focus on the 'fly the airplane safely' aspects of this incident.

We all know that there is a bit of slack in many systems. The untied shoelace does't cause the crash but it may indicate a certain lack of attention to detail.

So can those who know cockpit procedures in general and this plane's equipment and the approach that was being made comment on the following questions.

Just how serious a breach was the lack of sterile cockpit? I believe the CVR is a 30 minute loop, so how much chatter are we talking about? Perhaps non-pertinent conversation is a safety violation but it may also have been a coping mechanism to keep awake and to indicate wakefulness?

Is there a point in time where a certain speed bug was set or should have been set? If so, should that speed have been adjusted either mentally or electronically to take into account the perceived and much-discussed icing situation?

When did the speed begin to decay? If it was immediately after leveling off was this decay excessive for some reason? Should there have been particular attention to airspeed at this point in time in normal operations? In severe icing?

Quite apart from any alarms, chimes, or whatever, there certainly should be an instrument scan and I would assume that while attention to a localizer or glide slope would be in order the primary attention is to airspeed at all times. Just how long should it have taken for even a tired and perhaps distracted pilot to notice the airspeed was decaying and decaying rapidly?

The co-pilot seems to have raised the flaps and then announced her action. Was this really wrong? The pilot was a bit busy and cleaning up the aircraft by raising the gear and re-tracting the flaps seems sensible though I admit I'm unsure on these two points. Should there have been an inquiry of the pilot first "Do you want Flaps Retracted" or should the action have been taken without inquiry? Workload must have been rather high at that point in time.

If the stall took place an an altitude where recovery would have been expected had it been perceived and properly dealt with, just what appears to have gone wrong: slow to characterize the problem as a stall? They were just discussing icing, they had added power... it wasn't as if the chatter had been about the in-flight entertainment system. They were worried about excessive ice and the aerodynamic consequences of it. They never actually discussed a stall but that is what the icing conversation was really about.

I think the sequence is stick pusher, stick shaker, wailing of stall warning.
Under what circumstances would a stick pusher suddenly activate but be resisted by the pilot? Once it started the shaking, I understand its really a rather massive force to be dealt with? Would a pilot ever be likely to resist the Stick Shaker's efforts or be unaware of what was happening and why?

Isn't a stick pusher part of simulator time? Even if the simulator is not pogrammed to go thru the entire sequence of a stall surely there is some training in the beginning aspects? After all, a student in a Cessna Trainer would be practicing stalls somewhere around the 3rd or 4th lesson. Complex electronics in the cockpit change the nature of the tasks but not the aerodynamics involved.
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Old 14th May 2009, 19:15
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Shaker at 130kts, pusher at around 100kts during the accelerated stall induced by the 'recovery'. Ice not a factor except to the extent that the INCR speed switch led to a stall warning at higher than expected speeds, which spooked the crew into performing an inappropriate recovery. Sounds about right.
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Old 14th May 2009, 19:19
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I think this "ice, ice, ice" discussion is not an assertion that icing caused the stall. The discussion in the cockpit of the severe ice accumulation re-affirms a degree of situational awareness and concern about the consequences. They were concerned about an icing induced stall and instead suffered a stall that was unrelated to icing.

Query: How does one get spooked if he is a professional pilot? A man who is a dentist and who flies only a few hours a month might get spooked but a professional pilot shouldn't get spooked.
And even if "spooked"... why an inappropriate maneuver? What could the thought processes have been? Increase the Angle of Attack is pretty much at the bottom of the list!
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Old 14th May 2009, 19:22
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Regardless of the technical issues, perceived lack of training, apptitude of the pilots concerened, the most notable factor from what I have heard reported, and assuming to be true, is the "fitness" of the pilots to report for duty.

Allegedly, the poor F/O had not slept for some 36 hours and indicated that she was suffering possibly from a cold and congestion. The Captain would appear, from reports to have slept in a crew room, presumably in an armchair.

If all of the above is true, regardless of what their training had been, they were clearly incapable of performing to the required standard they were capable of, no matter how good or bad that standard was. They might just have well been supping pints of beer down their local to achieve the degredation of performance that we pilots rightfully complain of due to inhuman rostering! This however appears to be self-inflicted in the case of the crew concerned. I've already read one report suggesting that the F/O was paid sucha a paltry salary ($16,000 pa) that she had no alternative but to live with her parents, necessitating a whole nights travel on 2 airplane jumpseats to reach her reporting place of duty. Not acceptable under any circumstances.

If they were incapable to report for duty, they should have called sick. That is expected of them as professional licence holders. End of story, if all reported is true.

The above also debases the legitimate concerns of crew who claim of fatigue through inhumane rostering practices.
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Old 14th May 2009, 19:33
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I have just read the section in the Bombardier AOM regarding stall recovery -this is the latest version available electronically, not the one I got nine years ago when I first did the conversion course.

Interestingly, the section on stall recovery, which runs to a grand total of one page, describes the training exercise in the words "recovery will take place at the operation of the stick shaker". There is still no mention of the full stall, ie holding the aircraft in the stick shake mode until the pusher activates. And to be fair, when we used to demonstrate this in the simulator, a lot of the time the only way we could get a stick push to actually happen was to instruct the PF to give a fairly hefty pull on the yoke, or the pusher wouldn't push (having done it for real in the aircraft on air tests that obviously isn't what really happens, but was the way the sims were modelled when I operated them, albeit a few years ago now). But teaching someone to pull back on the control column isn't very good as it instills exactly what you don't want. However, the Q400 is massively over powered at low level, like a jet - and to maintain 180kts level at 2300ft they would have about 30% torque set - so they should have been able to just firewall the power levers and pitch down a couple of degreees to recover when the shaker went off, and it would have just been a worrying incident.

As for the issue which was raised earlier about the F/O raising the gear without being asked - this is a stall recovery not a wind shear recovery, and possibly getting rid of the drag from the gear could have helped - so maybe she was actually doing something sensible - remember they were in uncharted territory as far as their training and the AOM was concerned.

The "pitch to the stick shaker" thing has been mentioned, but that actually isn't what is normally taught in the Q400, or emphatically wasn't when I used to instruct on it, and that wasn't something I made up. It works in a jet, because if you are unlucky enough to have a flame out at that high angle of attack the loss of lift isn't instant as the speed has to decay, so you can lower the nose a bit to hopefully keep control of the aircraft. However in the case of a turboprop if an engine fails the prop wash is providing a large amount of lift, and at the stick shake you are almost certainly below VMCA so if an engine flames out you have a more serious problem. It is interesting to demo in the simulator, but best done with the motion off. The wind shear recovery in the Q400 used to be "pitch to V2/Vga" and the checklist stated quite definitely not to pitch to the shaker, unless you were obviously going to
hit the terrain in which case you would do whatever you could, and take the chance that you didn't get windshear and a flame out at the same time. But holding it in the shaker for a stall recovery isn't the idea, you are supposed to be increasing the IAS by lowering the nose a bit.

Sadly it would appear that this wasn't practised by or demonstrated to these pilots in the simulator. However you cannot blame them for that. It isn't their fault that they were in the positions they were in when they were relatively inexperienced - that is the fault of the airline management, it's accountants, and to some extent the travelling public. I have flown with Captains with less experience than the captain here had, and with F/Os with far less experience than here, and have known of crews operating together with less total time than here. The big difference is total time on type - but having said that, my first flight as a captain on a dash 8 after line training was with an F/O who had been on the same sim course as I had, and we had less than a hundred hours on type between us, and when we did the conversion to the Q400 less than 50 hours between us - but considerably more total time. Maybe we were just lucky...
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Old 14th May 2009, 19:36
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>the F/O was paid sucha a paltry salary ($16,000 pa) that she had no alternative but a whole nights travel on 2 jumpseats to reach her reporting place of duty. Not acceptable under any circumstances."

Okay. Lets continue the comparison with the burger flipper. Many of those employees are faced with similar lifestyle and driving tasks and some litigation has resulted from auto accidents as exhausted burger flippers traverse dark windy roads to get from Place of Cheap Rent to Place of Employment. True, a whole planeload of passengers don't die but a carload of passengers might.

Do we place a burden on the burger flipper to say "No, you've shifted my schedule around too much and my peonage wages impose an unsafe driving condition on myself and the other vehicles". No, we impose liability on the burger flipper's employer. A professional license might make the pilot obligated to take extreme action, but it doesn't make him any more financially able to do so.

Whether its fatigue or utter exhaustion, I don't know, but its clear that the problem goes back further than that 30 minute loop on the CVR. Had either of the pilots refused duty and stated the reason was Company Induced Exhaustion, do you really think they would have kept their jobs?
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Old 14th May 2009, 19:41
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Excrab...I'm sorry, but I cannot agree with you that the blame lies entirely at the door of the airline due to poor training. Maybe you didn't read my post, but clearly you must agree that any pilot who reports for duty when his/her capacity is seriously dgraded due to fatigue is not fit to fly an airplane and especially one with passengers!

36 hours lack of sleep, inmho, renders a person unsafe operating a lawnmower or other powered equipment, let alone an airplane.

We pilots cannot change the argument to fit the circumstances. Take a look at the long thread about EK and the issues there concerning fatigue at its contributory effects on human performance related incidents. That argument I have a lot of sympathy with; the other (reporting for flight duty whilst incapacitated, whether it be due to alchohol or fatigue) I have none.

Time to choose which argument you wish to endorese!
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Old 14th May 2009, 19:46
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Fine, but there is a distinction between working "flipping burgers" and taking command of an airplane, just in the same way as driving on the road if you are incapable of doing so, even if you flip burgers. Dereliction of either responsibility now in many places results in a mandatory jail sentence and so it should be!
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