Continental TurboProp crash inbound for Buffalo
I just wonder how if this "condition levers means add power" is so well known and so critical how it can be that each of the two pilots flubbed this task. Neither did it and neither said anything about it. One of them making a mistake would be strange, two of them seems even more unlikely.
It seems that the "PF must increase power" part is similarly critical and should be an Announce and Confirm task.
In my opinion the critical things here are
1/ Fatigue
2/ Sterile Cockpit
3/ Basic flying skills
Things that need a closer look
1/ Blended Command
2/ Whether or not the Captains actions were influenced by viewing the tail stall video.
1/ Fatigue
2/ Sterile Cockpit
3/ Basic flying skills
Things that need a closer look
1/ Blended Command
2/ Whether or not the Captains actions were influenced by viewing the tail stall video.
Person Of Interest
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RE: To much talking
Flashback to 1987...B-727...landing ATL CAT IIIA...The only words spoken below 500' were by the F/E, and then and only then if the "flare" light didn't turn from amber to green...and those 2 words were "NO FLARE"...and that was at R/A 50' + or - 5'....
The A/C would still touchdown, but was all ready in the go-around phase...The crew was trained for this, and nothing needed to be said...
And that was with 800' Touchdown RVR...
And yes, the old 727 could do autolands back in the 80's...believe it or not...
The A/C would still touchdown, but was all ready in the go-around phase...The crew was trained for this, and nothing needed to be said...
And that was with 800' Touchdown RVR...
And yes, the old 727 could do autolands back in the 80's...believe it or not...
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Realistic ???
>When the crap has hit the fan, the last line of defence is ones basic flying skills!
Well, which is the more realistic scenario:
An exhausted pilot with insufficient Hours in Type suddenly recalled an NTSB video about tail stalls and therefore held the nose up because he thought he was in this rather esoteric condition but did not recall the much more commonly encountered situation that Condition Levers to the Max requires Increased Power.
OR
An exhausted pilot simply did not have basic flying skills as a last line of defense so that when the ad-hoc blended PF/NFP system failed there was nothing left.
Well, which is the more realistic scenario:
An exhausted pilot with insufficient Hours in Type suddenly recalled an NTSB video about tail stalls and therefore held the nose up because he thought he was in this rather esoteric condition but did not recall the much more commonly encountered situation that Condition Levers to the Max requires Increased Power.
OR
An exhausted pilot simply did not have basic flying skills as a last line of defense so that when the ad-hoc blended PF/NFP system failed there was nothing left.
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Wheel flies off Canuck plane
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I just wonder if being totally 'maxed out' due to whatever reason PF actually thought this is what he was doing.
Absolutely no part of the aircraft envelope where this would be normal.
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An exhausted pilot with insufficient Hours in Type suddenly recalled an NTSB video about tail stalls and therefore held the nose up because he thought he was in this rather esoteric condition but did not recall the much more commonly encountered situation that Condition Levers to the Max requires Increased Power.
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Thunderstorms kept me awake tonight babysitting the dog, so you all now have to suffer my in depth analysis of the NTSB video/transcript:
Aircraft in level flight at 2300' on an ATC vector for the BUF ILS 23 APPR.
15:06 170kts PF calls for F5 and makes small increase in power
FO replies "what?"
(FO asleep? not expecting an out of sequence request? - no distracting conversation/transmission in the previous 33 secs, from transcript)
15:14 174kts ATC gives final intercept HDG and APPR clearance
15:44 182kts Established on LOC intercept HDG
15:47 185kts Small power reduction
15:50 188kts Aircraft reaches its highest speed during the APPR
16:00 185kts Another small power reduction
16:04 180kts PF calls "Gear down, LOC alive"
16:10 169kts CL's are moved forward - no call from either pilot - as aircraft turns to intercept LOC
16:23 140kts PF calls "F15, before landing check"
16:27 130kts Flaps reach 10, shaker activates and PF reacts by pulling back on the yoke then increasing torque
16:32 100kts Pusher fires while in nose high attitude
16:36 97kts Flaps are fully retracted - no call from either pilot - while in a nose high wing over
(The pusher switches off briefly for about 5 secs when the right wing over reaches its furthest point as the nose falls to the horizon and the aircraft is recovered to wings level. But then fires again and stays on as the yoke is held back and the aircraft enters another right wing over from which this time it stalls fully and spins out of control. The aircraft reaches its highest point 2500', as the nose reaches the horizon and the pusher switches off during the 1st wing over. Before returning to 2200' as the wings are briefly leveled, then 1900' as it enters the final wing over from which it enters the terminal stall/spin. The gear goes up as the nose breaks through the horizon for the 1st time in the whole sequence as it transitions from the 2nd wing over to a stall/spin.)
Speed control.
After selection of F5 the aircraft gains 5kts over a period of 50 secs. Following selection of the gear the aircraft now slows by 10kts over a period of 6 secs, then as the CL's are pushed forward the aircraft loses 29kts over a period of 13 secs.
There's something to be said for always doing things in the same order and at the same point on the approach. I'm not familiar with the regular configuration sequence under Colgan's SOP's or any other operator of the type, but the sequencing here of initial flap and then gear on the LOC intercept seems a little odd. Was he too fast and deploying drag to slow the aircraft, then simply forgot about pushing the power back up? My company SOP's on an ILS approach for a similar type and for light business jets is, initial flap at LOC intercept, gear down & before landing check at 1 dot and final flap passing the FAF/FAP established on the GS. Anything other than that would require a brief from the FP as to what he was doing and why to clue the NFP in. Another point to note is that the aircraft gained 200' in the initial stick shaker 'recovery', before losing 300' in recovering from the ensuing wing over and a further 300' as it began the final wing over. So by holding the yoke back throughout the pilot 1st gained 300' then lost 600' for an agregate loss of 300' below assigned altitude before entering the final stall/spin. Even a loss of 600' below assigned altitude in a conventional recovery from an imminent stall would not have significantly imperiled the aircraft and such a loss of altitude would represent a truly woeful attempt at a conventional recovery.
Any thoughts?
Aircraft in level flight at 2300' on an ATC vector for the BUF ILS 23 APPR.
15:06 170kts PF calls for F5 and makes small increase in power
FO replies "what?"
(FO asleep? not expecting an out of sequence request? - no distracting conversation/transmission in the previous 33 secs, from transcript)
15:14 174kts ATC gives final intercept HDG and APPR clearance
15:44 182kts Established on LOC intercept HDG
15:47 185kts Small power reduction
15:50 188kts Aircraft reaches its highest speed during the APPR
16:00 185kts Another small power reduction
16:04 180kts PF calls "Gear down, LOC alive"
16:10 169kts CL's are moved forward - no call from either pilot - as aircraft turns to intercept LOC
16:23 140kts PF calls "F15, before landing check"
16:27 130kts Flaps reach 10, shaker activates and PF reacts by pulling back on the yoke then increasing torque
16:32 100kts Pusher fires while in nose high attitude
16:36 97kts Flaps are fully retracted - no call from either pilot - while in a nose high wing over
(The pusher switches off briefly for about 5 secs when the right wing over reaches its furthest point as the nose falls to the horizon and the aircraft is recovered to wings level. But then fires again and stays on as the yoke is held back and the aircraft enters another right wing over from which this time it stalls fully and spins out of control. The aircraft reaches its highest point 2500', as the nose reaches the horizon and the pusher switches off during the 1st wing over. Before returning to 2200' as the wings are briefly leveled, then 1900' as it enters the final wing over from which it enters the terminal stall/spin. The gear goes up as the nose breaks through the horizon for the 1st time in the whole sequence as it transitions from the 2nd wing over to a stall/spin.)
Speed control.
After selection of F5 the aircraft gains 5kts over a period of 50 secs. Following selection of the gear the aircraft now slows by 10kts over a period of 6 secs, then as the CL's are pushed forward the aircraft loses 29kts over a period of 13 secs.
There's something to be said for always doing things in the same order and at the same point on the approach. I'm not familiar with the regular configuration sequence under Colgan's SOP's or any other operator of the type, but the sequencing here of initial flap and then gear on the LOC intercept seems a little odd. Was he too fast and deploying drag to slow the aircraft, then simply forgot about pushing the power back up? My company SOP's on an ILS approach for a similar type and for light business jets is, initial flap at LOC intercept, gear down & before landing check at 1 dot and final flap passing the FAF/FAP established on the GS. Anything other than that would require a brief from the FP as to what he was doing and why to clue the NFP in. Another point to note is that the aircraft gained 200' in the initial stick shaker 'recovery', before losing 300' in recovering from the ensuing wing over and a further 300' as it began the final wing over. So by holding the yoke back throughout the pilot 1st gained 300' then lost 600' for an agregate loss of 300' below assigned altitude before entering the final stall/spin. Even a loss of 600' below assigned altitude in a conventional recovery from an imminent stall would not have significantly imperiled the aircraft and such a loss of altitude would represent a truly woeful attempt at a conventional recovery.
Any thoughts?
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Ice had built quickly, and PF probably felt it would continue to build. FO had shared how the accumulation caused her to consider "we might crash". Though she related that thought seemingly in relief at not being in Renslow's shoes, it couldn't have helped the confidence level on the FD.
The airport's elevation is 728 feet, leaving 1572 AGL. Big load of ice, lack of confidence, still 5nm from threshold. An acute case of "Land Now".
I wouldn't say for obvious reasons either pilot was panicky at this point, but the events suggest it. I think the crew both got ahead of the a/c too far, and way ahead of themselves. Moving quickly without a rock solid plan and crumbling CRM didn't help. Without a solid anchor of experience both mental and muscular, the crew probably wanted to hurry things along, amplifying each hurried blunder into more intense pressure to do the next one.
Pulling the Yoke back with 70 lbs. of force with your feet planted on balanced rudder pedals created the Stall and the Spin. Had the pilot not been pumping the pedals trying to gain purchase to pull the pusher, they may have stalled straight ahead, and perhaps recovered. At night, loaded with ice, in a Stall and without confidence or solutions, who could have recovered that a/c. IMO.
The airport's elevation is 728 feet, leaving 1572 AGL. Big load of ice, lack of confidence, still 5nm from threshold. An acute case of "Land Now".
I wouldn't say for obvious reasons either pilot was panicky at this point, but the events suggest it. I think the crew both got ahead of the a/c too far, and way ahead of themselves. Moving quickly without a rock solid plan and crumbling CRM didn't help. Without a solid anchor of experience both mental and muscular, the crew probably wanted to hurry things along, amplifying each hurried blunder into more intense pressure to do the next one.
Pulling the Yoke back with 70 lbs. of force with your feet planted on balanced rudder pedals created the Stall and the Spin. Had the pilot not been pumping the pedals trying to gain purchase to pull the pusher, they may have stalled straight ahead, and perhaps recovered. At night, loaded with ice, in a Stall and without confidence or solutions, who could have recovered that a/c. IMO.
Originally Posted by Will Fraser
Ice had built quickly, and PF probably felt it would continue to build. FO had shared how the accumulation caused her to consider "we might crash". Though she related that thought seemingly in relief at not being in Renslow's shoes, it couldn't have helped the confidence level on the FD.
Pulling the Yoke back with 70 lbs. of force with your feet planted on balanced rudder pedals created the Stall and the Spin. Had the pilot not been pumping the pedals trying to gain purchase to pull the pusher, they may have stalled straight ahead, and perhaps recovered. At night, loaded with ice, in a Stall and without confidence or solutions, who could have recovered that a/c. IMO.
Bracing his feet against the pedals didn't cause a problem, it was the fact he tried to fight the stick pusher at all. If he'd just lowered the nose at some point they would've been fine.
At night, loaded with ice, in a Stall and without confidence or solutions, who could have recovered that a/c. IMO.
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What are you reading into my post? She said what she said as a FO, not as a Captain, but that means what? It's an admission of fear either way.
Saying that to an inexperienced Captain puts him at ease?
Seventy pounds is substantial. Whether you want to diminish it or not, and his feet were on the pedals to, you know, do some ruddering if needs be. Check the Rudder index on the display, watch it deflect. This was, in my opinion, not flying related, but pulling related. In a stalled a/c to guarantee a spin, one uses rudder. IMO means just that, I stand to be corrected, and if wrong I'll listen, certainly.
It is certainly a supposition that I make, but I extrapolate based on my conclusion that an attempt to defeat the Pusher was a blunder. A BIG blunder, and perhaps indicative of other blunder related evidence, such as Spin, ignoring the need for power to counter flat pitch, Gear down before Loc., ignorance of his ruddering at Stall, etc.
"Letting Go" may have helped, but the a/c is still spinning.
Rgds. Aero,
Will
Saying that to an inexperienced Captain puts him at ease?
Seventy pounds is substantial. Whether you want to diminish it or not, and his feet were on the pedals to, you know, do some ruddering if needs be. Check the Rudder index on the display, watch it deflect. This was, in my opinion, not flying related, but pulling related. In a stalled a/c to guarantee a spin, one uses rudder. IMO means just that, I stand to be corrected, and if wrong I'll listen, certainly.
It is certainly a supposition that I make, but I extrapolate based on my conclusion that an attempt to defeat the Pusher was a blunder. A BIG blunder, and perhaps indicative of other blunder related evidence, such as Spin, ignoring the need for power to counter flat pitch, Gear down before Loc., ignorance of his ruddering at Stall, etc.
"Letting Go" may have helped, but the a/c is still spinning.
Rgds. Aero,
Will
What are you reading into my post? She said what she said as a FO, not as a Captain, but that means what? It's an admission of fear either way.
Saying that to an inexperienced Captain puts him at ease?
Saying that to an inexperienced Captain puts him at ease?
I have watched the video. The rudder input is in time with aileron input in the same direction. That suggests to me that he was using rudder instinctively to help raise each wing in turn. Like I said, 70 lbs might sound like a lot, but with two hands on the column it's not a big deal for an average bloke (like me) to over-ride it. I definitely didn't need to brace my feet on the rudder such that I couldn't use the rudder appropriately.
yeah that's another thing. all the guys— @ came in to our when we
interviewed and he said oh yeah you'll all be upgraded in six months into
the Saab and blah ba blah ba blah and I'm thinking you know what. flying
in the northeast I've sixteen hundred hours. all of that in Phoenix how
much time do you think actual I had or any in in ice. I had more actual
time on my first day of IOE than I did in the sixteen hundred hours I had
when I came here.
no but all these guys are complaining they're saying you know how we
were supposed to upgrade by now and they're complaining I'm thinking
you know what? I really wouldn't mind going through a a winter in the
northeast before I have to upgrade to captain.
I've never seen icing conditions. I've never deiced. 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 calls. you know I'dve freaked out. I'dve have like
seen this much ice and thought oh my gosh we were going to crash.
interviewed and he said oh yeah you'll all be upgraded in six months into
the Saab and blah ba blah ba blah and I'm thinking you know what. flying
in the northeast I've sixteen hundred hours. all of that in Phoenix how
much time do you think actual I had or any in in ice. I had more actual
time on my first day of IOE than I did in the sixteen hundred hours I had
when I came here.
no but all these guys are complaining they're saying you know how we
were supposed to upgrade by now and they're complaining I'm thinking
you know what? I really wouldn't mind going through a a winter in the
northeast before I have to upgrade to captain.
I've never seen icing conditions. I've never deiced. 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 calls. you know I'dve freaked out. I'dve have like
seen this much ice and thought oh my gosh we were going to crash.
I've had FOs express similar sentiments to me about needing more time as an FO and in no way has that come across as a lack of confidence or somehow made me feel uneasy.
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As I read it, didn't she make her statement after looking at the ice on her wing? Doesn't that relate it to their flight? What she said inferred that she needn't worry about that much ice, since she wasn't a commander.
What does Marvin Renslow do with that? She has several hundred more hours than he in type, probably a better pilot in type, and she just shifted all her concern about their current load of ice onto him. Now he gets to carry ALL the stress, SWELL. I am not imputing any motive to either pilot, but below 10,000 feet her comment is prohibited. Wouldn't her speech better serve the Flight if it pertained to faster bug speeds, De-ice status, etc.? If any talk at all?
Again, this is opinion, hoping to learn from a discussion about an unfortunate accident. I try not to be accusatory or defensive, it doesn't help the format.
G'day (Stoof, round and loud)
Will
Question? With both your hands on the Pusher, pulling, who's caressing the throttles?
What does Marvin Renslow do with that? She has several hundred more hours than he in type, probably a better pilot in type, and she just shifted all her concern about their current load of ice onto him. Now he gets to carry ALL the stress, SWELL. I am not imputing any motive to either pilot, but below 10,000 feet her comment is prohibited. Wouldn't her speech better serve the Flight if it pertained to faster bug speeds, De-ice status, etc.? If any talk at all?
Again, this is opinion, hoping to learn from a discussion about an unfortunate accident. I try not to be accusatory or defensive, it doesn't help the format.
G'day (Stoof, round and loud)
Will
Question? With both your hands on the Pusher, pulling, who's caressing the throttles?
Originally Posted by Will Fraser
This was, in my opinion, not flying related, but pulling related. In a stalled a/c to guarantee a spin, one uses rudder. IMO means just that, I stand to be corrected, and if wrong I'll listen, certainly.
As I read it, didn't she make her statement after looking at the ice on her wing? Doesn't that relate it to their flight? What she said inferred that she needn't worry about that much ice, since she wasn't a commander.
What does Marvin Renslow do with that? She has several hundred more hours than he in type, probably a better pilot in type, and she just shifted all her concern about their current load of ice onto him. Now he gets to carry ALL the stress, SWELL. I am not imputing any motive to either pilot, but below 10,000 feet her comment is prohibited. Wouldn't her speech better serve the Flight if it pertained to faster bug speeds, De-ice status, etc.? If any talk at all?
What does Marvin Renslow do with that? She has several hundred more hours than he in type, probably a better pilot in type, and she just shifted all her concern about their current load of ice onto him. Now he gets to carry ALL the stress, SWELL. I am not imputing any motive to either pilot, but below 10,000 feet her comment is prohibited. Wouldn't her speech better serve the Flight if it pertained to faster bug speeds, De-ice status, etc.? If any talk at all?
As for Renslow, everything is already on his shoulders, he's the captain! Everything is his responsibility, it always is, on every flight he does. I'm sure having an FO express satisfaction that she didn't get an early upgrade didn't burden him any more.
I think events went down almost the opposite of how you see it. You seem to see them nervous and anxious about the ice build up and trying to get down and land quickly. I see them being overly casual, talking too much about unrelated crap and forgetting they are getting to the busy part of the flight where they actually have to fly the aeroplane.
Last edited by AerocatS2A; 16th May 2009 at 15:27. Reason: Corrected the captain's name.
Abagnale,
I understand what you are trying to say but I do think you take a pop at the wrong target. I never knew Marvin Renslow so this is a generic response. True, for various reasons, people want to get on in life and some people are quite capable – notwithstanding the wise words earlier in this Thread regarding the difference between “capability” and “experience”. Others not so. A strong motivation for moving seats may be $$$, given what the FO was earning. When there are bills to pay, people need to earn a wage which at least keeps them. Again, who knows what was Marvins’ motivation to get a Command asap – if, indeed, that is what he did.
If you know Marvin, perhaps this was true – but I would suggest unlikely. However, if you didn’t know him, I would suggest that this is not only unfair on the guy, but actually detracts from the core issue which, again, has been widely voiced here. The REAL issue is why, given the immense responsibilities that any Commercial Pilot has, does the system not weed out the “weak candidates” or trap the “gotchyas” like excessive travel before a Duty? To say that Company Regs forbid/advise against this and that is not enough. A Company has a responsibility to ensure that such Regs are followed. It’s known as QA. Any Management system has a responsibility to ensure the Employee is up to the task and that its Regs are being followed.
I am quite sure Marvin did not deliberately set himself up for this. Who would? Was this, in part, a culturally-driven issue? Given the large %age of staff who appear to travel considerable distances, sleeping in the lounge may have been the “norm”. However, the whole issue of why the system permits people to get out of their depth (ie having low levels of “capability”, “experience” and other attributes for a given role) is key. Since Daedalus and Icarus, some aviators have pushed their own boundaries and have come a cropper! The Bankers spring to mind here too. In both cases, a lack of EFFECTIVE “enforced regulation” created a culture where lower standards get through the net.
The early part of your Post about Colgan is rightly where the focus should be. To have a pop at Marvin is a waste. If, hypothetically, he should have been weeded out much earlier …. well, that is the real worry. If Marvin was as incompetent as depicted, why was he permitted to get to that point – for his own safety let alone the safety of those in his care? Looks like a range of people need to reflect on what part their actions played here – managers, examiners, regulators etc.
Says it all really! Sadly!
Unfortunately this is the real face of aviation world today and mother****ers, like Marvin Renslow just want to jump to that left seat as soon as possible,
…. disregarding any safety considerations, …
I am quite sure Marvin did not deliberately set himself up for this. Who would? Was this, in part, a culturally-driven issue? Given the large %age of staff who appear to travel considerable distances, sleeping in the lounge may have been the “norm”. However, the whole issue of why the system permits people to get out of their depth (ie having low levels of “capability”, “experience” and other attributes for a given role) is key. Since Daedalus and Icarus, some aviators have pushed their own boundaries and have come a cropper! The Bankers spring to mind here too. In both cases, a lack of EFFECTIVE “enforced regulation” created a culture where lower standards get through the net.
The early part of your Post about Colgan is rightly where the focus should be. To have a pop at Marvin is a waste. If, hypothetically, he should have been weeded out much earlier …. well, that is the real worry. If Marvin was as incompetent as depicted, why was he permitted to get to that point – for his own safety let alone the safety of those in his care? Looks like a range of people need to reflect on what part their actions played here – managers, examiners, regulators etc.
Unfortunately this is the real face of aviation world today
Spin recovery
wings level, opposite rudder, break the Stall.
wings level, opposite rudder, break the Stall.
.P.S., my interpretation of the power lever scale on the video is that flight idle is at the very bottom of the movement range. If that's the case, then the power levers were never at flight idle, just at a setting too low to maintain speed in lever flight. I know that flight idle isn't the bottom of the range in the real aeroplane, but "MIN" is not the bottom of the condition lever range in the real aeroplane either.
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I think you are quite correct about their chatty banter. My point is most definitely that at some point, things went to Hell. Of course Renslow is Captain. A commander with 109 hours in the a/c total. By his actions and lack of experience, I may be assuming a certain lack of confidence on his part, all the ingredients are there. I could be wrong, but there is a reason for the sterile cockpit, and I don't think Renslow's lack of discipline came from his comfort with his authority or his confidence in his flying. The reverse, actually, it showed a lack of command authority. Either that or he didn't understand his role.