Continental TurboProp crash inbound for Buffalo

[22/04]

Having looked at the transcript the FO here seemed to be quite subservient = may have found it difficult to ever be assertive.

[fauxpaw]

Having looked at the transcript the FO here seemed to be quite subservient = may have found it difficult to ever be assertive.

Seemed assertive enough to raise the flaps without being asked......

[protectthehornet]

22/04 makes a fine point.

if I may; a plane with two engines has equal power from both engines to work correctly.

so too the pilots, the idea of one very experienced pilot (high power) and one inexperienced pilot (Low power) forming a balance in the cockpit is a backward way of thinking.

two high powered pilots (with one legally in command) offers a better safety factor than one pro and one shmo.

especially when the higher powered pilot is broken and the lower powered pilot isn't capable of coming up to snuf.

[SDFlyer]

Protectthehornet:

"captain, you are getting slow

captain, you are getting slow

captain you are getting slow

I"VE GOT THE PLANE (reduce angle of attack, add power)

and that is the way training works at my airline...it is called the three communication rule."
------------

Thank you for that. It's the sort of thing I was looking for and I find it profoundly reassuring.

In my own line of work, if I'm about to make a serious technical blunder with major consequences (e.g. federal regulatory) down the line, I tell people to please tell me right away and make no bones about it. Might come as a momentary shock but I'll be thanking you for it shortly.

[p51guy]

Being a strong FO vs a PITA requires careful but positive thought about what is required to do your job vs over doing your job as SIC. Any good captain will apreciate your help, the others may try to fire you. Choose your battles with the captain with care because you will no longer be heard if every flight is a battle. I had a couple times when I either took control of the aircraft or convinced the captain he was not making the right choice. I knew when I took the 4 engine jet and went around when he was trying to land in a thunderstorm very high, at night, on a short runway I was fired. I was quite surprised when he thanked me for doing it.

Both pilots are responsible for the safety of the flight, not just the captain. Always stay totally in the loop on what is happening.

[PLovett]

From another web site this comment on the crash of an aircraft in India in 2000:

The crew had not followed the correct approach procedure which resulted in the aircraft being high on approach. They had kept the engines at idle thrust and allowed the airspeed to reduce to a lower than normally permissible value on approach. They then manoeuvred the aircraft with high pitch attitude and executed rapid roll reversals. This resulted in actuation of the stick shaker warning indicating an approach to stall. At this stage the crew initiated a go-around procedure instead of an approach to stall recovery procedure resulting in an actual stall of the aircraft, loss of control and subsequent impact with the ground.

Improper technique has caused crashes before and will continue to do so until all airlines take training seriously. The Indian crash was lack of proper training which I still maintain is at the core of the Buffalo crash.

[goldfish85]

Protectthehornet,

I think it should read


Captain, you're getting slow.
Captain, you;re getting slow.
Captain, you're too slow.
I've got the ***** airplane.

One more comment, in my previous life with a large regulator agency, I observed a reverse hierarchy on occasion. One case comes to mind. A very junior Captain, still holding a reserve line and a senior F/O (who was upgrading in a couple of weeks). The Captain kept saying things like :"Do you think we ought to ...." and the F/O said lots of things like "We have to do ...." Made me very uncomfortable.


Goldfish

[John Farley]

I was on the jump seat recently from a local UK airport to overseas via a major UK hub.

The mature captain had very little time on type, did not feel he knew as much about the glass stuff as his young F/O and made no secret of how he looked to his F/O for guidance and cross checking of his selections and actions on all these aspects. However there was never any doubt about who was the captain or how the F/O accepted his captain's background and experience. It was a joy to watch them operate as a crew.

No matter the rules or SOPs in the end it is the quality of the individuals in the cockpit (not only their piloting skills) that is so important for a safe flight.

[fireflybob]

Psychologists have established that when we become "maxed out" the first sense the brain deletes is that of hearing. Hence incidents when the flying pilot doesn't act on repeated challenges in high workload situations.

You may have to create a "pattern interrupt". This could include, for example, shaking the flying pilot on the shoulder to fully get his attention!

[Mansfield]

One of the best captains that I ever flew with in my early years was a Swede who held dual citizenship. After many years flying in Europe, including a stint with the UN flying C-46s in the Congo during the early sixties, he ended up flying CV-240s with my little freight company in the States. He didn't have much time on the Convair, but a lot of time on the DC-6, 727, etc.

Years later, when teaching CRM and new captain ground school courses, I would use this gentleman as an example. I explained that somehow, he never once made me, the first officer, feel that he could do my job better than I could. At the same time, he never once let me feel that I could do his job better than he could.

I never have been certain of how he did that, but it has always been a worthwhile goal.

[AirRabbit]

Originally Posted by PLovett

Improper technique has caused crashes before and will continue to do so until all airlines take training seriously.

I’ve said before and I’ll say again, it’s not that any airline takes training less seriously than they should. I believe the problem comes from the fact that many pilots apparently believe that they can take a “short-cut” from what they learned in training. When someone trains and trains, getting all the nuances of every issue just about as perfect as they can get them, then go out to the airplane and fly it without paying any attention to what they learned in training – all bets are off. In the US military they have a saying: “Train like you fly and fly like you train.” There is a lot to that saying – particularly if it is practiced! In fact, this is the “action version” of what quality management systems have been advocating for decades. In their vernacular, to begin to construct a Quality Management System, the employees of a company must 1) “say what they do” (i.e., write down what they do – how they do it – when they do it – what tools they use – etc.) and then [and here’s the tough part] actually 2) “do what they said.” The mundane part is 3) “now keep records of all that.” It’s essentially a formulated plan and a plan followed – carefully and deliberately. Translating that into physical practice regarding training and doing, it becomes “train the way you are expected to perform and then perform the way you were trained.” Put the aviation variation to it and it becomes “Train like you fly and fly like you train.” The bottom line is that when we see this mind-set permeate the aviation world, when pilots are trained just the way they are intended to fly, and then fly just like they’ve been trained, we’ll see a better safety record than we have at the moment.

[protectthehornet]

air rabbit makes a fine point...indeed our airline has the same saying.

but...I recall one training captain, landing to the south at DCA (washington national airport with an unusual approach along the potomac river) blatantly violating the 1000' configuration rule.

fully configured for landing at 1000'.

So, showing off to the new copilot, the training captain delays till the final turn (about 300' or so) and configures full flaps then.

All human endevour is full of failure. BUT if I were head of the airline, I would have investigated this and then fired the training captain.

AND that is the difference...the management doesn't back up the saying with action.

and colgan didn't back up anything

[Razoray]

“Train like you fly and fly like you train.”

I agree with this motto, but whats in question with the Colgan crash is the lack of training in specific type, and a lack of discipline in the cockpit. I know it's been said and made fun of, but these two pilots were blabbing away while oblivious that they were headed for a fatal crash...... I would doubt that many airlines would stand for this kind of conduct from there pilots, and it shows an endemic problem with Colgan in general.

When you are trained correctly for a situation, that situation becomes normal....not the case here.....

[PJ2]

Air Rabbit;

When someone trains and trains, getting all the nuances of every issue just about as perfect as they can get them, then go out to the airplane and fly it without paying any attention to what they learned in training – all bets are off.

I agree: Indeed, all bets are off if one chooses to disregard any safety processes and their training.

Just the propensity for such disregard, even for a moment, is both a broader matter of organizational culture, and a matter of individual cockpit discipline which is informed by both the knowledge and experience of what happens when such discipline is not practised by all crew, or, most importantly, that tone set and enforced by the captain. We can all cite examples of where this failure provided the seeds of an accident.

PTH;

All human endevour is full of failure. BUT if I were head of the airline, I would have investigated this and then fired the training captain

Statement 1 might be an working assumption in flight safety work so let's see how it works with statement two. Statement 2 (fire the captain) is a curious one. Likely your organization's response, should they see such an event in the FOQA data, isn't to "fire the captain", so other than expressing an emotional response what's the purpose in making the statement or indeed why even investigate if that's what you'd do? Does your program have a set process and agreement by which serious events in the data may be brought to the crew's attention and dealt with in terms of learning or, where resistance is met, dealt with such that "firing the captain" is not the first alternative but offering training might be?

Such discussions do not "turn the sights" on organizational matters alone; individual pilots are responsible for maintaining and enhancing personal and professional standards; but the organization has a solid role in creating a culture which is intolerant of high risk maneuvers. The FAA Safety Advisory to Operators has now twice advised airlines to examine their FOQA data for ferry/non-revenue flights simply because 25% of air carrier accidents occur during such operations. The scenario (approach event) to which you refer PTH, is a variation on this, thus my observation and question.

PJ2

[BarbiesBoyfriend]

How true. It's not a girls day out.

Do your work. Have a laugh when you can but never forget what is actually going on.

Or what can happen.

Fly your aircraft.............................Or find another job.

[protectthehornet]

PJ2

point one:

the event I described happened about 12 years before the FOQA program began.

second...a training captain who disobeys the SOP shouldn't be teaching anyone how to fly.

And it wasn't a ferry flight...it was loaded with passengers who should have the right to not be aboard a non routine flight.

Harsh? Emotional? yes...But I would bet money it wouldn't happen again and others would straighten up and fly right.

[Teddy Robinson]

Fauxpaw

I'm glad somebody else noticed that.

It's usually "go around ! - full power-flaps (check speed) airbrake in, positive rate" ... etc.

Removing a high lift device during a low speed/stall/upset recovery is generally not a good idea.

[AirRabbit]

Originally Posted by Razoray

… whats in question with the Colgan crash is the lack of training in specific type, and a lack of discipline in the cockpit. I know it's been said and made fun of, but these two pilots were blabbing away while oblivious that they were headed for a fatal crash...... I would doubt that many airlines would stand for this kind of conduct from there pilots, and it shows an endemic problem with Colgan in general.

I’m not sure than anyone can blindly “fault” the Colgan training program based on what snippets of testimony and pieces of evidence have been highlighted during the investigation. Could it have been a better training program? I’m sure the answer is YES. But, what training program couldn’t be better? The fact that the two pilots on this particular flight didn’t do what you or I would have thought they should have been doing, doesn’t necessarily mean that what they were doing was what they were trained to do. And, that’s my point. At this moment, I tend to give the training program and the training staff at Colgan a bit of reprieve, presuming that the training program was what you or I would like to have seen. IF that is true, then it is the fault of the individuals who did not “fly like they were trained.” I say this because if my presumption is false, and the crew was “flying like they were trained,” then we have a completely ignorant training staff and, significantly, a regulatory body whose local office is just as ignorant, or, at best, non-caring – which may be worse! We can talk about the “culture at the airline,” but what is that, really? It is the outward expression of an internal attitude that is picked up by others and emulated. Reinforcement of the training received, by all facets of the airline is the best, heck, it’s the ONLY, mechanism that can positively influence this “culture.”

[palisadesk]

These two articles suggest there may indeed have been serious problems in Colgan training (at least as far as the Q400 is concerned):

http://www.nytimes.com/2009/06/04/ny.../04colgan.html

FAA aided Colgan’s scheduling after inspector's complaints : City & Region : The Buffalo News

[PJ2]

PTH;

But I would bet money it wouldn't happen again and others would straighten up and fly right.

It may work in very small companies where everyone knows everyone else but does not work in large organizations. So I think you might lose some money, not because firing in and of itself is the wrong approach but because such actions employ as their justification, a high fear factor among employees. Using punishment to force compliance is an approach which demonstrably does not work and will not enhance flight safety. That said PTH, there are specific places in which such a tactical approach can and does work - humans do respond to fear, just not chronic, constant fear.

Safety Reporting Policies at most airlines around the world (I have a basis for stating this - we did extensive research before writing, approving and implementing our safety reporting policy), state that intentional, egregious or negligent acts will not be tolerated and can be grounds for dismissal.

Few would disagree with this approach. It deals with the specific problem individual, (some would say 'rogue'), who may not be (or has not been), amenable to all other approaches including peer discussions. Such serious cases are extremely rare as I'm sure you would agree but the policy must be there for all to be guided by and ultimately for the protection of the passengers and the airline.

The most important aspect of the policy is safety reporting, where if mistakes are made or bad things happen and they are reported, one is shielded from a straight disciplinary approach, the policy instead placing learning and change at the top of the list.

Air Rabbit;

Reinforcement of the training received, by all facets of the airline is the best, heck, it’s the ONLY, mechanism that can positively influence this “culture.”

I think such reinforcement is not only done through checkrides and recurrent simulator work nor through the informal organizational culture which, as you say, has strong underlying influence. It is done through a robust reporting and flight data program. It is only through such data programs, especially the daily analysis of flights, that an airline's management and therefore the training department, actually know how their aircraft are being flown on a daily basis.

Everyone is tuned up and on their best behaviour for checkrides and sims but it is a natural human characteristic that when no one is looking, behaviour changes. Most of the time "more relaxed" is what the data might reveal but I can guarantee that anyone who is running such a program will have seen some surprises and even some very disconcerting events, some very close to an accident. Also what will be seen though rarely, are the kinds of events PTH described above in his post.

Such information, interpreted by experienced, knowledgable pilots (and not newbies or hired interns because they are cheap) can provide a very detailed insight into an airline's operation. So with that in mind, I would like to quote again:

At this moment, I tend to give the training program and the training staff at Colgan a bit of reprieve, presuming that the training program was what you or I would like to have seen. IF that is true, then it is the fault of the individuals who did not “fly like they were trained.” I say this because if my presumption is false, and the crew was “flying like they were trained,” then we have a completely ignorant training staff . . .

I agree with your statement here as far as it goes. But I wouldn't be prepared to give any standards and training department "a reprieve" based solely upon presumptions of compliance or non-compliance.

Check rides and sim sessions were intended to provide that feedback but the data from such is highly granular. Also, simulator sessions especially, are largely driven by legal, (licensing and minimum regulatory competency standards), not larger safety concerns. With today's data capabilities and much lower costs to do FOQA, standards and training now have very fine-grained information from which to trend their operation and know about and respond to individual events which may have a "precursor" element to them.

That some managements may prefer not to know thus apparently granting themselves plausible deniability (although not knowing in the face of inexpensive capability is becoming a legal issue itself), is an ongoing issue.

If one sat down with someone who knew FOQA well and had seen just about all there is to see in the data except an accident, one would discover that one's attitudes and understandings of a daily operation and a pilot culture might be quite different after the discussion. The program, when engaged robustly and used as intended, jointly by an airline's management and pilots' representatives, is a remarkable tool for daily as well as historical examination of trends.

The other undeniable element of an active data program is indeed cultural. It is so because it extends the expectation of professionalism to every flight, such that where something doesn't go as the crew or the airline expected, it can be examined and incorporated into training if a trend, or discussed with the crew using pilot, not management, representatives using the data rather than relying upon mere opinion.

The FAA's notice on ferry flights is interesting, read in the light of these comments. When crews know that their flights are routinely analyzed, the trend in serious events decreases. The notion of "Big Brother", created by George Orwell, only applies to a society which is being spied upon for nefarious purposes. Given FOQA's long history in Great Britain, Germany, the U.S., Australia and, increasingly, Canada for some, but not, sadly, in Asia, the program cannot legitimately be compared to that concept.

Airline managements today in all the countries mentioned except Asia know very well what will happen to their data programs should they use safety data against a crew for disciplinary purposes.

Instead, airline managements, investors, employees, fellow pilots, passengers and the regulator have a right to expect that an organization's aircraft will be flown by the book and that where untoward events occur, as they will, they are dealt with under flight safety principles and not industrially as airlines have in the past.

Thus, an examination of Colgan's program and how/if it was used as intended, should be part of the investigation. It was with QANTAS' Bangkok overrun (as I have mentioned numerous times now) and the AAIB determined that that accident "was in their data".

This is not to say that the Colgan accident was in the data of course. Even the captain's history of ride failures may be more distracting to the investigation than material to the cause of the accident. While identified FOQA data is never part of a formal investigation into an accident, the historical record may be in terms of, "have you seen this before and if so, what was done?". Indeed, that kind of organizational response is the very condition upon which FOQA data protection is based in the United States under the FAA's rules on FOQA programs.

PJ2