Continental TurboProp crash inbound for Buffalo

[Brian Abraham]

Tried a search of the thread without joy to see if this had been referenced. AIRBORNE EXPRESS, DOUGLAS DC-8-63, N827AX, NARROWS, VIRGINIA, DECEMBER 22, 1996. Fatal high level stall/crash.

null

The DC-8 accident report is here

http://www.ntsb.gov/Publictn/1997/aar9705.pdf

Exerpts
Probable Cause
The National Transportation Safety Board determines that the probable causes of this accident were the inappropriate control inputs applied by the flying pilot during a stall recovery attempt, the failure of the nonflying pilot-in-command to recognize, address, and correct these inappropriate control inputs, and the failure of ABX to establish a formal functional evaluation flight program that included adequate program guidelines, requirements and pilot training for performance of these flights. Contributing to the causes of the accident were the inoperative stick shaker stall warning system and the ABX DC-8 flight training simulator’s inadequate fidelity in reproducing the airplane’s stall characteristics.

Recommendations

Evaluate the data available on the stall characteristics of airplanes used in
air carrier service and, if appropriate, require the manufacturers and
operators of flight simulators used in air carrier pilot training to improve
the fidelity of these simulators in reproducing the stall characteristics of
the airplanes they represent to the maximum extent that is practical; then
add training in recovery from stalls with pitch attitudes at or below the
horizon to the special events training programs of air carriers.

Require that all transport-category aircraft present pilots with angle of
attack information in a visual format, and that all air carriers train their
pilots to use the information to obtain maximum possible climb
performance.

Seems some parallels may be hinted at with the Coglan.

[skol]

I haven't read all the replies but $16000 is not just outrageous, it's a scandal that needs to be urgently addressed.
Do these pilots have a union?
There's no doubt this one was going to happen, all the holes in the cheese were neatly lined up.

[TWN PPL]

$

20 year ago; 49 seat prop f/o in Asia. Were paying equivalent to US$4,500 per month. But in the USA !!! Big Variation

Airline Pilot Pay Rates

[speedrestriction]

If my memory serves me correctly, if the Reduced Np option is fitted and armed for a given approach and torque increases above 50% then the props will accelerate from 850rpm to 1020rpm.

[AerocatS2A]

Originally Posted by protectthehornet

OK,HOLD IT...somebody just said stick pushers were usually disabled below 1000'

I"ve flown stick pusher equipped planes and that is not the case.

There was a higher likelyhood of someone surviving this crash if the pilot had just let go of the stick than what he did (pull back) and what the copilot did (retractflaps and distract the captain with gear up)

You may have flown aircraft that had pushers that were not disabled at low level, however, the Dash 8 pusher is disabled at low level. It is not to done so that it won't push if you stall, it is done so it won't dive you into the ground if it malfunctions (i.e., a false stall warning.) On the 300, there is a stick pusher "push off" switch that allows you to disable the pusher if it has fired in error, if you are at low level, e.g., below 1000 feet, you may not have time to do this.

[DozyWannabe]

Shades of BEA 548 as well - pilots either not at their peak, inexperienced or both, poorly trimmed aircraft, both seemingly inexplicably dumped the stick push...

I do wonder how strong the instinct to "pull up" is and how much training/experience is required to overcome it. Speaking for myself, I'd definitely be instinctively reluctant to push the nose down in a stall situation that close to the ground, even though logically I'd know it was the right thing to do.

[Tarq57]

Shades of BEA 548 as well - pilots either not at their peak, inexperienced or both, poorly trimmed aircraft, both seemingly inexplicably dumped the stick push...

I've read that accident report. Admittedly some time ago.
The aircraft in BEA service had a reputation for false stall warnings amongst crews. The stick pusher activated pretty much immediately the LE flaps were retracted; the "who" or "why" they were retracted was not ascertained.(But was the first direct causative accident action.) The stick pusher was deliberately overridden/disabled on the third push following an airspeed check; it was evidently not considered by the captain that the flaps could be in an incorrect position, or at least, didn't enter his thinking at the time.
No similar check appears to have taken place in this accident at Buffalo. The crew appear to have been taken totally unawares by events.

[DozyWannabe]

it was evidently not considered by the captain that the flaps could be in an incorrect position, or at least, didn't enter his thinking at the time.

The evidence for BEA 548 suggests the captain was experiencing a major coronary episode at the time, and from that point onwards without a CVR we'll never know exactly what happened. All we have is that the leading-edge droops were raised while the aircraft was travelling some 60-odd knots slower that the airspeed they were supposed to be raised at and at that point the cockpit warnings would have been somewhat overwhelming, and that's without taking into account the fact that the PF would in all likelihood have been completely incapacitated.

So many accidents have been caused because a basic mistake made while pilots were distracted, fatigued or even incapacitated snowballed into an unrecoverable situation within seconds. I guess this is the reason for "sterile cockpit" rules for certain phases of flight.

[FoolsGold]

the PNF put the condition levers to max

>"...When the PF ordered gear down and flaps 15 the PNF also put the condition levers to max - this means the prop blades are flat and turning at max rpm. This acts like a giant brake creating a lot of drag as opposed to the reduced rpm setting prior to gear down. ..."

Okay. It seems that whereas there were several factors at work throughout the flight such as exhaustion, concern about icing, failure to adhere to sterile cockpit rules, the one critical point seems to have been this "also put the condition levers to max".

When the PF calls for Gear Down and Flaps 15, is it a standard response to do ANYthing with the condition lever? If so, what would you expect the PNF to have done with the condition levers at that time. Apparently, "levers to max" is a woefully inappropriate choice at that time. Once made and trouble develops, should there have been a thought of "oops, whatever I just did may have caused this I should think about hitting that "undo" button"?

[Relic01]

Sad event. Looking at the animation, it looks like he was going to recover but another link in this deadly chain was the FO putting the flaps up during recovery. I got chills down my spine when I saw that. TL never went to full power and why the rodeo on recovery? Reading through the NTSB interviews with folks at colgan is also very troubling. The company training, procedures, and hiring practice leaves a lot to be desired.

CD List Of Contents

[protectthehornet]

how to fix things

1. allow changes in the law to enable every pilot in the country to go on strike for better pay across the spectrum.

DOZY...reading the book "stick and rudder'' until the first reaction is automatically push forward, has saved my life and my students. every pilot should read this book a dozen times until it is your new instinct...even below 1000'.

FOOLSGOLD...in one plane I flew, we called flaps up/slats retract. while flying with someone new to the plane, I called flaps up (and didn't say slats retract)...he retracted the slats and I yelled at him. Our speed was ok, no stall danger, but people do make mistakes and it is DUE TO POOR TRAINING and evaluation. I can imagine a bad habit pattern of putting condition levers forward with gear wasn't spotted during evaluation or by the PF.

The planes that I flew with pushers (english planes plus the san antonio sewer pipe) all had gadgets to turn off the pusher if you had to. Does the Q400 have a clutch relese or some similiar gadget to turn off the pusher????????????

[khorton]

I (for what it is worth) believe he thought he was in a tail stall situation.

I wonder if Colgan's DHC-8-400 ground training included watching one of the NASA ice contaminated tail plane stall videos.

NASA has done some stellar ice contaminated tailplane stall research, and produced several great tail plane stall videos, but some operators with aircraft that are not prone to tail plane stall use these videos in their training, without also stressing that their aircraft type has no known susceptibility to tailplane stall. I currently fly two aircraft types that are not prone to tailplane stall (many hundred of each type in service, with no tailplane stall accidents or reported incidents), yet each year in recurrent training for each type I watch a NASA tailplane stall video.

Yes, pilots should know about ice contaminated tailplane stall, but training should cover the specific risks for each aircraft type. If a type has no history of tailplane stall, then the cold weather portion of recurrent training should focus on other, more relevant, aspects.

If you are flying DHC-6s, Jetstream 31s, etc you need to be very aware of tailplane stall, what limitations and procedures must be followed to avoid it, how to recognize it, how to recover from it, etc. If you are flying types with more recent type certification dates, there should be no susceptibility to tailplane stall, if AFM limitations and procedures are respected.

[Lost in Saigon]

Originally Posted by khorton

I wonder if Colgan's DHC-8-400 ground training included watching one of the NASA ice contaminated tail plane stall videos.

I saw part of the NTSB inquiry video, and yes, Colgan uses that video in it's training.

This may be a contributing cause of this accident. Due to overall inexperience, the crew may have had too much pre-occupation with ice and tail icing. It may even have been subconscious on their part.

The Captain may have also felt some need to demonstrate his superior icing knowledge given that the FO expressed so much inexperience and fear of icing conditions.

[Will Fraser]

On three distinct occasions, the First Officer performed PF tasks without asking. Pitch mode, Flap retraction, and condition levers. She had a great deal more time in type, (Didn't everybody?), was there a tacit arrangement whereby she would assist in the flying? I sense that with the Captain's inexperience, the Command duties may have been "shared" in some makeshift, "intuitive" fashion. He didn't correct her, were they flying as a "committee"?

At Stick Pusher "Pull" was she helping? Or was she wondering what he was doing? With a "blended" command, things can get real dicey.

[AerocatS2A]

When the PF calls for Gear Down and Flaps 15, is it a standard response to do ANYthing with the condition lever? If so, what would you expect the PNF to have done with the condition levers at that time. Apparently, "levers to max" is a woefully inappropriate choice at that time. Once made and trouble develops, should there have been a thought of "oops, whatever I just did may have caused this I should think about hitting that "undo" button"?

Condition levers to max is quite normal at that stage.

The 400 is obviously a little different in how the condition levers work compared to the smaller Dashes, but the procedure in the smaller aircraft is pretty much how it happened in the accident (without the accident part of course.) Gear is selected down, flaps to 15, and condition levers to max. As the condition levers go to max the torque drops right off and the pilot flying will need to compensate with an increase in power.

Power changes when leveling off, rudder trim changes with airspeed and power changes, power changes with configuration changes, even with all automatics engaged, the Dash 8 must be flown at all times.

[AerocatS2A]

Originally Posted by Will Fraser

On three distinct occasions, the First Officer performed PF tasks without asking. Pitch mode, Flap retraction, and condition levers. She had a great deal more time in type, (Didn't everybody?), was there a tacit arrangement whereby she would assist in the flying? I sense that with the Captain's inexperience, the Command duties may have been "shared" in some makeshift, "intuitive" fashion. He didn't correct her, were they flying as a "committee"?

She didn't select pitch mode, she advised him that they were in pitch mode. I'm pretty sure I know how they got into pitch mode. They got an alert for four thousand, they then conversed for a while, they were then given further descent to two thousand three hundred. He would then have rest the altitude selector to two thousand three hundred, if you do that while the previous altitude is being captured, the autopilot will default to pitch mode. They've then descended in pitch mode and she has subsequently noticed and advised him.

The flap's were raised in a misguided effort to fix the problem.

I'm not sure about the condition levers. It is possible that the condition levers to max is an automatic action from the PNF in response to a cue from the PF such as "landing checklist." Does it say somewhere that the PNF selected the condition levers to max? Maybe he did it himself. Certainly in our company the PF calls for condition levers to max, the PNF moves the levers and the PF follows through with power as required.

[Hot 'n' High]

Just been catching up with this sorry tale. Not much to add to what has been said. One thing caught my eye from DozyWannabe:-

I do wonder how strong the instinct to "pull up" is and how much training/experience is required to overcome it. Speaking for myself, I'd definitely be instinctively reluctant to push the nose down in a stall situation that close to the ground, even though logically I'd know it was the right thing to do.

Bit of a worry if that were the case here – basic airmanship at PPL levels is what we are talking about. As we all know, the most basic of training for everyone hammers home that reducing the AoA is key to recovering from a conventional stall. It also teaches that the pitch down required does not necessarily need to be that great – just sufficient to break the stall and, generally, it will not lead to too great a loss of height – not sure what a Dash 8 would lose – I’m sure some Dash 8 jock could enlighten me! Furthermore, I would assume adding power on the Dash would assist in pitching the nose down. Again, I don’t fly the Type so am resorting to basic aerodynamic theory here.

I’d definitely be reluctant not to lower the nose as what follows the other action in a conventional stall (pulling back) is just as we saw here, the aircraft eventually breaking into an incipient spin or worse. Now, that will guarantee you considerable height loss! That is why the discussion of the crew potentially “misidentifying” the upset as contaminated tailplane stall may hold some water. At least that provides a logical explanation to the actions that took place in terms of pitch. In reality, I guess we will never really know the answer to the “why” question.

When I do have time for some PPL Instructing, I do come across some trainees who, at low level, do not like to lower the nose when speed is starting to rapidly decay (ie if they start to get a bit out of shape on Final approach during early circuit training). The illustration I use to back up the Standard Stall Recovery Action, and which is applicable to them, is “I can fly at 50ft and 100 kts but I can’t fly at 100ft and 50kts”! The point is that sacrificing a little height will save the day. In this case, numbers different, concept the same – if they'd ID'd the stall correctly.

Perhaps my comfort in this sort of manoeuvre harks back to my gliding days. You get a winch cable break at 75 ft just as you are pulling hard into the 45 deg climb in a launch (and which is the most likely time for the cable to let go on you - or a kind Instructor to spring it on you!!!), you really do have to get that nose right down quick or else! You have absolutely no choice, particularly as you are already tending to hold a whole load of backpressure against the cable. But even that significant pitch down is controlled as you don't want to throw away what little height you have - it gives you time to decide exactly where you are going to land! Had to play that game more times than I care to remember!

[MU3001A]

Condition levers

From what I remember from my Jetstream days, speed levers high (same thing) is an item on the before landing checklist. But there was an understanding amongst crews that the NFP would call "Speed levers" and await an affirmative "Speeds high" from the FP before moving them. This is because of the significant braking effect that results from selecting fine pitch, essentially you now have a pair of spinning metal disks out there which would normally require the FP to set a corresponding increase in torque to maintain airspeed. The FP also had the option to call for "speeds high" at any point during the approach outside the usual checklist sequence, especially if a little fast, in effect using the props as an air brake.

For a NFP to move the speeds to high without a request or confirmation from the FP would be a definate no no and I would be mightily pissed with anyone who did that of their own volition.

[MU3001A]

Reluctance to pushing the nose down in a stall situation

IMHO every commercial pilot should be required to have some basic aerobatic training and some stick time in an aircraft designed to be landed power off. Basic stick and rudder skills should be the foundation of every commercial pilot's armory. Regular power on landings, imminent stall recoveries and unusual attitude training just doesn't cut the mustard.

I always enjoy the opportunity to do unusual attitude training in the sim. My sim partners, most of whom have no aerobatic training, are often unreasonably fearful of the maneuvers.

[FoolsGold]

So it wasn't "condition levers to the max"...

So it was not "conditions levers to the max" per se that was the critical step. It was the "condition levers to the max" unaccompanied by a prompt increase in power.

So "condition levers to the max" was proper or atleast acceptable for that time and place, it was simply that somehow the "condition levers to the max" did not trigger the usual and necessary accompanying action of "PF increases power".

Perhaps the shared duties were confusing since it appears the designations of PF and NFP are not really proper for this particular flight. If there would usually be a sharp line of demarcation but this crew had blurred that line due to a recognition of PF having inadequate Time In Type then perhaps the "mentally associated" Prompt-Increase-In-Power was somewhat muted.

So it would be Exhaustion coupled with an adoption of an Ad-hoc Cockpit Resources Management blending of the PF and NFP roles?