Continental TurboProp crash inbound for Buffalo
I think it went to hell the moment he pulled back against the stick pusher, that showed that he didn't understand what was happening or how to correct it. The stuff leading up to it is important but really, not being confident in your command, or not being sterile below 10,000, none of that makes you forget basic stall recovery. He either didn't truly understand how to recover from a stall, or he genuinely believed it was something other than a stall.
I've actually been in the sim with a captain who was flying and let us get too slow so the stick shaker came on. We'd also left the anti-ice on which artificially increases the speed at which the stall warnings activate, much like the increase ref switch does on the Q400. The stick shaker went on the base turn on a single engine, hand flown, raw data, circling approach and he said "oops correcting". He added power and the situation was immediately fixed. We were at about 600' at the time. No height lost, just a big debrief point and some lessons learned all around.
I've actually been in the sim with a captain who was flying and let us get too slow so the stick shaker came on. We'd also left the anti-ice on which artificially increases the speed at which the stall warnings activate, much like the increase ref switch does on the Q400. The stick shaker went on the base turn on a single engine, hand flown, raw data, circling approach and he said "oops correcting". He added power and the situation was immediately fixed. We were at about 600' at the time. No height lost, just a big debrief point and some lessons learned all around.
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Unwinding an accident establishes a path of errors. The pieces are falling in to place, and it's important to paint a complete picture. I think the investigation starts with gross data and interested people want the glaring evidence, to establish a "cause" immediately. To gain knowledge is to want to see all of it and squeeze out as much experience and ways to improve as is possible. Pulling the Pusher is the beginning.
To lose one scintilla of gain from this horrible crash would be a crime.
To lose one scintilla of gain from this horrible crash would be a crime.
That is true, and a noble goal in discussing an accident, however it is important that the information available is interpreted accurately. It is understandable that speculation happens, particularly when information is scarce. You always start out with a lot of "what if"s. As more information becomes available though, it is not good to interpret it in a way that is not supported by the evidence. Recent examples from this thread, that the FO selected Pitch Mode, no she probably didn't, it was probably automatically selected due to a quirk of the Dash 8 AFCS. And that the FO expressed unease about their ice build up and that they might crash. That didn't happen either (well yeah, they crashed, but she didn't say she thought they might crash.)
By all means, speculate to fill in the gaps, what else can you do? But try and read the data that IS available carefully and with understanding of the context it is in. By doing that, the speculation will be better directed and have a higher level of accuracy.
By all means, speculate to fill in the gaps, what else can you do? But try and read the data that IS available carefully and with understanding of the context it is in. By doing that, the speculation will be better directed and have a higher level of accuracy.
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before you spin, you stall...push foward on stick and you are unstalled (tailplane stall aside).
maybe the fo and cp both thought they tailplane stalled...pulling up and bringing flaps up
better make the PUSHER light bigger and of course do more training.
I was never more careful of a plane I hadn't flown than in the first 100 hours or so...weren't you all?
maybe the fo and cp both thought they tailplane stalled...pulling up and bringing flaps up
better make the PUSHER light bigger and of course do more training.
I was never more careful of a plane I hadn't flown than in the first 100 hours or so...weren't you all?
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AerocatS2A:
I would say it was earlier, when he pulled back on the yoke increasing pitch to a high nose attitude in response to the initial stick shaker. See my post #1253. The pilot holds the yoke back with the shaker active for all but 2 secs and against the pusher for all but 5 secs, of the 18 sec sequence starting with the initial stick shaker until final entry into the spin. Consequently the nose doesn't break the horizon during the whole sequence until the aircraft falls off the final wing over into the spin.
I think it went to hell the moment he pulled back against the stick pusher, that showed that he didn't understand what was happening or how to correct it.
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make the PUSHER light bigger
- Reference Notes: as of Sunday 5/17/09
- Low Speed Cue
- Displays speed (*)margin to stick shaker and VMCon the airspeed tape
Last edited by E.Z. Flyer; 18th May 2009 at 00:08. Reason: Added Slide presentation, as of Sunday 5/17
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Commuter Pilot’s Life Defies Glamorous Stereotype
NY Times does an exposé on commuter pilots:
http://www.nytimes.com/2009/05/17/nyregion/17pilot.html
Capt. Paul Nietz, 58, who recently retired from a regional airline, said his schedule wore him down and cost him three marriages. His workweek typically began with a 2:30 a.m. wake-up in northern Michigan and a 6 a.m. flight to his Chicago home bases. There, he would wait for his first assignment, a noon departure.
By the time he parked his aircraft at the last gate of the night, he was exhausted. But he would be due back at work eight hours and 15 minutes later. “At the very most, if you’re the kind of person that could walk into a hotel room, strip and lay down, you might get four and a half hours of sleep,” he said. “And I was very senior. I was one of the fortunate guys.”
http://www.nytimes.com/2009/05/17/nyregion/17pilot.html
Capt. Paul Nietz, 58, who recently retired from a regional airline, said his schedule wore him down and cost him three marriages. His workweek typically began with a 2:30 a.m. wake-up in northern Michigan and a 6 a.m. flight to his Chicago home bases. There, he would wait for his first assignment, a noon departure.
By the time he parked his aircraft at the last gate of the night, he was exhausted. But he would be due back at work eight hours and 15 minutes later. “At the very most, if you’re the kind of person that could walk into a hotel room, strip and lay down, you might get four and a half hours of sleep,” he said. “And I was very senior. I was one of the fortunate guys.”
I would say it was earlier, when he pulled back on the yoke increasing pitch to a high nose attitude in response to the initial stick shaker.
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....and now for something completely different
The airplane suffered a tail stall as soon as the flaps 15 setting was selected and the crew did what they were taught – they reversed the procedure and retracted the flaps.
It is a pitch up when the tail loses its ability to provide required down force due to ice contamination. The airspeed bleeds off rapidly and the stick shaker and pusher react. The crew knows that the standard recovery of lowering the nose won’t work so they pull back like they were taught. Lateral control is then lost, followed by pitch control as well.
It is a pitch up when the tail loses its ability to provide required down force due to ice contamination. The airspeed bleeds off rapidly and the stick shaker and pusher react. The crew knows that the standard recovery of lowering the nose won’t work so they pull back like they were taught. Lateral control is then lost, followed by pitch control as well.
So there you have it! I'd almost be inclined to consider what this man has to say if he provided any rationale or sources of information to back up his statements.
Originally Posted by MU3001A
I think, everyone who has experience flying turboprops required by type certification to have two pilots, is assuming that no company SOP could be that poor. I could be wrong and Colgan's SOP's may well leave this important aspect of speed control on final approach to the discretion of the NFP, but I don't think so. Doesn't make any sense whatsoever. I doubt the manufacturer would recommend such a procedure either, which would make it difficult for the airline to have their regulatory authority sign off on it.
Condition levers max is part of the gear down flow. The PF calls gear down the the FO puts the gear down, aux, ptu, stby pumps on, bleeds min, condition levers max and chimes the FAs. What she did in that aspect was standard.
E.Z.Flyer,
I'm sorry, because I always get a little bit annoyed when people on these forums get into a discussion about it being a "professional" pilots rumour network.
I apologise if you once held a licence for single engine piston, but are now a bombardier flight test engineer, but otherwise...
At the top of each pilots PFD (that means primary flight display) and is a huge great big screen in front of them, there is an area called the FMA (flight modes annunciator) which tells them what the aeroplane systems are doing or about to do.
On every EFIS aircraft I have flown (6 types with as many different operators) it has been company SOP that one or other of the pilots calls what they see on this screen as it changes, and the other confirms it. That includes the Q400 but not with Colgan apparently, or if it was SOP they ignored it for the whole flight.
If you read through the 10quadrillion posts hear you will find out that they didn't need to see it wasn't a tailplane stall, because aircraft with non reversable powered flight controls are not prone to this indication of a tailplane stall. It was not a tailplane stall. Bombardier say it wasn't. Transport Canada say it wasn't, The NTSB say it wasn't.
Whatever happened, they didn't need a warning to tell them it was a tailplane stall because it doesn't happen in a Q400.
I'm sorry, because I always get a little bit annoyed when people on these forums get into a discussion about it being a "professional" pilots rumour network.
I apologise if you once held a licence for single engine piston, but are now a bombardier flight test engineer, but otherwise...
At the top of each pilots PFD (that means primary flight display) and is a huge great big screen in front of them, there is an area called the FMA (flight modes annunciator) which tells them what the aeroplane systems are doing or about to do.
On every EFIS aircraft I have flown (6 types with as many different operators) it has been company SOP that one or other of the pilots calls what they see on this screen as it changes, and the other confirms it. That includes the Q400 but not with Colgan apparently, or if it was SOP they ignored it for the whole flight.
If you read through the 10quadrillion posts hear you will find out that they didn't need to see it wasn't a tailplane stall, because aircraft with non reversable powered flight controls are not prone to this indication of a tailplane stall. It was not a tailplane stall. Bombardier say it wasn't. Transport Canada say it wasn't, The NTSB say it wasn't.
Whatever happened, they didn't need a warning to tell them it was a tailplane stall because it doesn't happen in a Q400.
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In both cases, a lack of EFFECTIVE “enforced regulation” created a culture where lower standards get through the net.
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AerocatS2A:
It was part of the before landing check on the Jetstream aircraft that I flew too. The FP would call "Gear down, Flaps 20, before landing check" and Speeds High was the last item on that check. But there was an understanding that the NFP would not move the SL's without coordinating with the FP ie. "ready for speeds?" or "speeds coming high" in order that the FP could adjust the torque as required. I would certainly be very pissed at any NFP that moved the SL's in rote observance of the checklist without announcing it.
So the condition levers max is an automatic action that happens as part of the gear down flow. In that respect it is not uncommanded, the command just doesn't specifically state "condition levers max". It does seem to be a poor SOP though. With the props being such powerful speed brakes, I'd have thought the PF should know exactly when they're being put to max RPM.
So what are the real holes in the cheese here? If something is to be considered a causal factor (a hole in the cheese) then it has to be of enough significance that if removed, the accident would not have occured.
1/Fatigue...would the accident have happened if the pilots had not been fatigued? No.
2/Training....would the accident have happened if the crew had recieved training in stick shaker/stick pusher events? Probably not.
3/ Sterile Cockpit....would the accident have happened if the crew had observed a sterile cockpit SOP? Probably.
4/Stick pusher light too small...would the accident have happened if there was a bigger stick pusher light. Probably.
5/SOP regarding condition levers....would the accident have occured if the PF had had to ask for props up specifically? Probably.(He had to specifically ask for the gear and that didn't motivate him to increase thrust so why would another drag form?)
Obviously all just my opinion, but it helps me identify what I think are the most important factors. I'm not in any way suggesting that a sterile cockpit isn't important at these phases of flight.
1/Fatigue...would the accident have happened if the pilots had not been fatigued? No.
2/Training....would the accident have happened if the crew had recieved training in stick shaker/stick pusher events? Probably not.
3/ Sterile Cockpit....would the accident have happened if the crew had observed a sterile cockpit SOP? Probably.
4/Stick pusher light too small...would the accident have happened if there was a bigger stick pusher light. Probably.
5/SOP regarding condition levers....would the accident have occured if the PF had had to ask for props up specifically? Probably.(He had to specifically ask for the gear and that didn't motivate him to increase thrust so why would another drag form?)
Obviously all just my opinion, but it helps me identify what I think are the most important factors. I'm not in any way suggesting that a sterile cockpit isn't important at these phases of flight.
That's a fair point, though if additional words are needed to safely accomplish something then they should be incorporated into SOPs. In our company we specifically call for "condition levers max." At any rate, by asking for the gear down, you should know that you are also asking for the condition levers max and so you should be ready to follow through with the power if necessary (sometimes it is not.)
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we really don't know if gear down also meant speeds high/condition levers forward at that airline.
on one plane I flew, we yelled bleeds and speeds on taking the runway for takeoff.
and we yelled book em danno for flaps 50 on landing
you gotta love the way we talk in the cockpit.
and maybe this poor guy, who had busted FIVE checkrides had gotten his act together and had read lots of stuff on the tailplane stall phenomenoa. AND MAYBE COLGAN DIDN"T TELL HIM THE Q400 wouldn't tailplane stall... hell, I didn't even know it was called a Q400, I thought it was a Dash 8-400 till this accident.
and maybe, just maybe, the crew had been talking about tailplane stalls on the part of the CVR that had been erased...or in the crewroom, or while waiting for the delays in Newark to clear
we well never know...but hopefully everyone flying will reevaluate their own flying.
on one plane I flew, we yelled bleeds and speeds on taking the runway for takeoff.
and we yelled book em danno for flaps 50 on landing
you gotta love the way we talk in the cockpit.
and maybe this poor guy, who had busted FIVE checkrides had gotten his act together and had read lots of stuff on the tailplane stall phenomenoa. AND MAYBE COLGAN DIDN"T TELL HIM THE Q400 wouldn't tailplane stall... hell, I didn't even know it was called a Q400, I thought it was a Dash 8-400 till this accident.
and maybe, just maybe, the crew had been talking about tailplane stalls on the part of the CVR that had been erased...or in the crewroom, or while waiting for the delays in Newark to clear
we well never know...but hopefully everyone flying will reevaluate their own flying.
we really don't know if gear down also meant speeds high/condition levers forward at that airline.
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For sure, even if it IS sop to put the condition levers up as the gear goes down, IT MUST BE CALLED OUT.
As those big old props disc up (ie full fine and no power added) the a/c is in serious trouble if the power levers are not advanced absolutely straightaway.
This guy may have been having a bad day (who hasn't). This single ommission (failing to advance the power levers) started the sequence of events that killed them all. (in about 19seconds)
No one single mistake should bring an a/c down.
In this case it simply brought the crew to a new point that they were unfamiliar with and which they mishandled-and who could say that for sure they'd never mishandle an aircraft which was in an unfamiliar situation?
FLY FLY FLY FLY your aircraft!
Never let the automatics do stuff you can't do yourself.
Also: No pilot should move a lever (for gear or flap ) without puting his or paw on the appropriate lever and announcing a version of :
'speed checked- FLAP-flap9'.
To do otherwise is bloody gash.
To slap the fuel condition levers to max while saying sweet nothing is piss poor.
Puting the flap up without being asked smacks of the same lack of discipline.
As those big old props disc up (ie full fine and no power added) the a/c is in serious trouble if the power levers are not advanced absolutely straightaway.
This guy may have been having a bad day (who hasn't). This single ommission (failing to advance the power levers) started the sequence of events that killed them all. (in about 19seconds)
No one single mistake should bring an a/c down.
In this case it simply brought the crew to a new point that they were unfamiliar with and which they mishandled-and who could say that for sure they'd never mishandle an aircraft which was in an unfamiliar situation?
FLY FLY FLY FLY your aircraft!
Never let the automatics do stuff you can't do yourself.
Also: No pilot should move a lever (for gear or flap ) without puting his or paw on the appropriate lever and announcing a version of :
'speed checked- FLAP-flap9'.
To do otherwise is bloody gash.
To slap the fuel condition levers to max while saying sweet nothing is piss poor.
Puting the flap up without being asked smacks of the same lack of discipline.
Last edited by BarbiesBoyfriend; 17th May 2009 at 02:32.