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Continental TurboProp crash inbound for Buffalo

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Continental TurboProp crash inbound for Buffalo

Old 21st Feb 2010, 10:17
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Icing - on tail plane video - recovery, anybody care to make a comment regarding this vs Buffalo crash.

YouTube - 3 of 3, Aircraft icing loss of control
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Old 21st Feb 2010, 11:58
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Yes, no conection at all, please read my previous post {page 81 I belive}
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Old 21st Feb 2010, 13:03
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The tail-plane stall NASA video may be relevant in this respect: It was mentioned in a couple of newspaper articles (sorry, can't offer proper citations) that according to Colgan pilots, they were shown this film at training sessions, where it made a strong impression. Was the pilot of the Buffalo flight one on whom it made a great impression? We don't know, but if he had it in mind it could go some way to explaining his mis-handling of the situation.

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Old 21st Feb 2010, 13:19
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This video, and the concept you suggest, was all discussed in great detail way back near the beginning of this thread. I have no idea which post numbers, but it's one of those things where it helps if one has followed the thread from the beginning (as opposed to trying to read all 90 pages in one sitting, or, worse, just jumping in...).
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Old 21st Feb 2010, 13:22
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Yes would appreciate to find those old posts, did some search without any luck. However, Clunkdriver, why would there not be any relevance or connection? Just out of interest, look P 80 without any luck. Sorry.

And if was irrelevant, could this still have been in the back of the mind of the pilots when the situation occured! As a normal stall recovery should have been second nature of most pilot!
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Old 21st Feb 2010, 13:38
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Okay, start at the very beginning of the thread and begin reading, you'll come across them pretty quickly. It was an early theorization that was pretty quickly put to bed.
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Old 21st Feb 2010, 13:39
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Originally Posted by tigermagicjohn
Icing - on tail plane video - recovery, anybody care to make a comment regarding this vs Buffalo crash.
The NTSB made a comment:

38. The inclusion of the National Aeronautics and Space Administration icing video in Colgan Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training.
The article I copied that from is a good summary of the crash:

Crash: Colgan DH8D at Buffalo on Feb 12th 2009, impacted home while on approach
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Old 21st Feb 2010, 13:48
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Tiger, the post is on page 81. The point is that the Q400 does not display the pitch down when it has a bit of ice on the airframe, unlike the aircraft I fly these days which does, in fact with any contamination we use very limited flap when landing the aircraft, in my hangar I have two wrecks of like models {spare parts} which tried to land with full flap loaded with ice, tail stalled in the flare, scratch one nose gear.The point is one MUST understand the nature of the aircraft one is flying:example, we had two marks of a certain fighter on strenght at a unit I flew on, one mark spin recovery needed in spin aileron to recover , one didnt, one had better know which one was flying ! The previous aircraft flown by the captain Im told does display a pitch down when iced up, to apply a previous type recovery to this aircraft shows a total lack of correct handling of this aircraft. It should be noted that Jazz, Porter, Air Inuit, CAF in Canada have thousands of hours on all Dash Eight models in what is one of the worst ice conditions in the world, all done with no ice related acidents ,this crash should not have taken place, along with most of the US commuter prangs of late.
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Old 21st Feb 2010, 21:57
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PJ2: "When I (and many here) joined an airline (nearly fourty years ago now), checkride comments were blunt, clear and business-like which left no doubt in the candidate's mind as to what went wrong and what was done correctly. It was a pretty honest assessment of how one was doing; check pilots "knew" and weren't shy about letting the candidate know.

Today, that is quite different. Eventually such records became evidence in prosecutions after investigations were complete. Airlines naturally began requiring "less detail" of such ride reports. That left less information and fewer meaningful comments for future check pilots on how a pilot was actually doing. Such information was sometimes verbally communicated but in a large organization that process is not assured.

In other words, as described above, liability issues would slowly begin to drive meaningful comments either off the record entirely, or underground. That is the reason why sometimes we will see very strong reactions from pilots on using information which rightly belongs to safety processes, for prosecutions or enforcement of discipline against pilots and why safety reporting policies are so important in maintaining open, honest communications. Unfortunately, our society is not built upon these principles and a legal blame-culture is preferenced over "finding out" what really occured in order to prevent another occurrence."

-------------------------------

Powerful, disturbing and highly plausible testimony. If we take this as all true for the sake of argument: 1) any change that regulators could make to address?; 2) how else to do it?

Can we reconcile society's need to assign blame (as appropriate) to the requirements of a robust safety culture?

btw, I agree with whoever said that the whole training/safety culture of professional aviation is superior to that of any other profession - the ne plus ultra. I speak as a professional in the "medical industry" shall we call it.
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Old 21st Feb 2010, 23:31
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SDFlyer;
Can we reconcile society's need to assign blame (as appropriate) to the requirements of a robust safety culture?
I re-read the comment I made and realized that I left out an important piece of information or perhaps even misled by leaving the possible impression that it is airlines who actually do the checking, with no involvement of the regulator. Quite the contrary but here is the arrangement:

Airlines designate check pilots who are trained, checked and if successful, granted check authority to conduct check rides and recurrent IFR/PPC (Pilot Proficiency Checks) simulator rides on behalf of the regulator. In short, they have licencing authority. So while it is the regulator that is responsible for the checking, most of it is done by the regulator's designated representatives who are almost always airline staff. This staff is not automatically the most senior or the most experienced but nor can just anyone who applies for the position do it or do it well.

Such staffing is almost uniformly very good and where necessary and/or mandated, failures do occur. The relationship is not "incestuous" as some outside the industry might perhaps think but is instead highly professional.

All this stated, the comments have gone from detailed and anectdotal to "pass/fail" usually with an intermediate quality which passes the candidate but indicates a repeat exercise or an otherwise marginal execution of the procedure. Too many "marginals" will result in a failure. This will not have developed without the regulator's authority and concurrence.

This applies both in Canada and the US. I do not know how it is arranged in Europe or Australia but I strongly suspect it is the same. There simply aren't enough inspectors otherwise, and, under SMS, certainly not in Canada with the introduction of SMS and the consequential reduction in TC staffing where it counts.

So the reduction in commentary is a process with an intertwined history and not merely associated with the airlines; the regulator has the final say because it is the regulator, not the airline, that licences pilots. Just to clear that up.

btw, I agree with whoever said that the whole training/safety culture of professional aviation is superior to that of any other profession - the ne plus ultra. I speak as a professional in the "medical industry" shall we call it.
I think any one of the professional airline pilots here could have said it. The industry's safety record and fatality rate speaks to this very approach. That observed, I think it would be very challenging for medicine to achieve the same level of safety - I believe the processes are much more complex, the diagnostic process far less rigid and much more complex in terms of SOPs and the outcomes often take much longer. I think intuition plays a greater role and by definition that wonderful human quality does not lend itself well to standardization. I know there are other differences and authors/medical people like Guattari have written wonderfully about these issues.

PJ2

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Old 22nd Feb 2010, 00:35
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do you perhaps mean Gawande rather than Guattari--Atul Gawande?
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Old 22nd Feb 2010, 00:43
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Tail plane stall didn't seem involved in this crash. It was a wing stall that was not handled properly. Letting the airspeed to deteriorate to stall speed because of inattention was the probable cause. The final report will come out some day so we will wait and see.
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Old 22nd Feb 2010, 00:50
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At about page 150, tailplane stall will re-re-re-rear its ugly head. After all, Clive Irving, the aviation expert at Tina Brown's The Daily Beast, a year ago identified it as the cause.
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Old 22nd Feb 2010, 01:16
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stepwilk;
Gawande, yes, thanks! Guattari is a different author. Distracted by the Canada-US hockey game!
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Old 22nd Feb 2010, 01:17
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Originally Posted by p51guy
Letting the airspeed to deteriorate to stall speed because of inattention was the probable cause.
This doesn't seem exactly right. According to the article I linked to above:

Upon stick shaker activation, which also deactivated the autopilot so far engaged, the captain pulled on the control column and applied power however did not advance the throttle levers to the maximum power detent. The airplane had only minimal ice accretion and was way above actual stall speed. The pull of the control column to pull about 1.4G, nearly 1.5G - inappropriate response to the stall warning and not consistent with any pilot training - increased the pitch and angle of attack and brought the airplane into an accelerated stall from which the crew failed to recover.
The pilot actually put the plane into a stall by his actions. It did not stall because he flew too slow. The stick shaker activated at a higher point than normal because the SPEED REFS switch was set to INCR, but as noted, the plane was not actually near to stall speed.
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Old 22nd Feb 2010, 01:44
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ZFT I cannot tell you how much I appreciate your honest and cogent remarks! You are 100% on target as far as I am concerned. Simulation is something I do know about and you are absolutely correct. While “seat cueing” can be effective, that methodology is no match for well a well-tuned 6DOF system – and there have been studies that have proven this conclusion. I agree with those pilots who have voiced their concerns at conferences … and the only correction I would offer is that they probably do not actually need more “vigorous motion cues” anywhere near as much as they are in need of more “on-set motion” cues –otherwise known as acceleration cues. As long as the motion system is anchored firmly in the ground, you will never get sustained “g-force” cueing in simulation that is available in today’s technology – unless you use a centrifuge-based system … and then that is only partially effective and it loses as much as it gains in that you have something like 1.5 g’s sitting at the gate. Which is not very realistic at all.

The system you reference by a “European Turboprop manufacturer in conjunction with the French DGAC," is actually a seat shaker system. It’s great for vibration cueing, but it does little for the subtitle “acceleration cues” that most pilots use to fly their airplane. Unfortunately, line pilots are not very good sources of information when it comes to critiquing simulators. And it’s not their fault. Pilots generally do not (because they cannot) tell you what cue they use initially, secondarily, and so forth … in fact I have personally witnessed pilots who where critiquing specific aspects of simulation when the “culprit” that was causing all of their problems was a cue that they had not even considered – sound. It is this specific reason that I am so high on the simulator/flight INSTRUCTOR as being THE agent of necessity in getting pilots trained correctly. They have to know the limitations of simualtion and use simualtion to it's extent, but not beyond its extent.

Don’t get me wrong, I think the lesser levels of simulation have their place in pilot training – but that place is systems understanding, and systems application. When it comes to systems integration, the only way to “integrate” systems understanding is to have it “integrated” with other systems. Eventually, at least in my book, that means putting it all together, several times, but certainly at least once, before you march off to be checked on what you’ve learned. That means the device in which you do that last training session, and the device in which you demonstrate your proficiency, should, heck, it MUST, provide you with all the cues that would be available to you in the airplane in order to be sure that you have put everything together where it belongs, when it belongs, to the satisfactory outcome of the flight. Anything less, is just that – LESS. At that is something we cannot afford.

PJ2 – I wish it were not so … but, trust me, the vultures are circling. Blood is smelled. For some inexplicable reason, the FAA is seriously considering allowing recurrent training to be completed in devices that don’t have motion cueing … at least, a portion of the recurrent training/checking would be allowed in a device that doesn’t move. Also, the same thing would hold true for the Line Oriented Flight Training – the "powers that be" are lobbying for that to also be allowed in Non-motion devices. And to show you how serious they are, the coveted AQP program in the FAA, already allows the LOE (which is the equivalent of the check ride – it’s the session that is used to issue the license or the type rating) is allowed to be done in what the US describes as a Level 6 FTD. That, in case you were wondering, is a non-motion, non-visual, open cockpit device (heck you can get on the FAA National Simulator Program website and see what it entails). For me, the bottom line is this is the first, very large step, down that very slippery slope toward requiring sophisticated simulation consisting of a "dining room chair and a plumber's helper" as the only necessary simulation device that will ultimately be required to demonstrate recurrent proficiency for airline operations (ah... that was my tongue in my cheek - I HOPE).

If it happens, it’s a sad – very sad – commentary on where we’re going in the name of safety! And, what is more, is that it is likely going to take a concerted effort of the industry to thwart such a Head-in-the-Sand approach to airline training requirements! I recognize the necessity of the regulator ... but when the regulator decides that it is their responsibility to look out for the financial viability of the individual airlines, they immediately run into a conflict of interst; and that is safety vs. cost. One is diametraically opposite the other in almost every situation. Who are they kidding? They shouldn't be looking to be the "nice guy," they should be looking to be the "right guy!"
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Old 22nd Feb 2010, 02:52
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Air Rabbit;
but when the regulator decides that it is their responsibility to look out for the financial viability of the individual airlines, they immediately run into a conflict of interst; and that is safety vs. cost.
Well, we've heard of and, in places, seen this kind of coziness before in the U.S. Nor is it unknown in Canada.

If such downgrading of simulation requirements is to take place, the certification regulations will have to be re-written such that Level D simulators are no longer required for type endorsements. Removing the "training", (exposure to) learned kinisthetics and psychomotor responses forces the interpretation of instrumentation purely into the cognitive realm where "imagination" plays a greater role and the muscles of the body are left untrained until the candidate is in an airplane.

I hope the designers and engineers of such changes are doing their philosophical, psychological, biological, cognitive and kinisthetic homework and that some people in the regulatory side smart enough in all these areas, are checking their work.

Interestingly, such a downgrading of requirements fits right in with the MPL philosophy, does it not? You should take a look at the program and qualifications that gets an ab-initio pilot off the street into the right seat of an airliner here.
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Old 22nd Feb 2010, 05:25
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Protect writes:

my company has more than 5000 pilots. Saying: no more cowboy flying and you would still have a few cowboys out there.

Saying: we fired a guy for flying cowboy like without a good reason...is it worth it? Now that gets someone's attention.

All the research in the world only looks good in books. Dealing with real people with real emotions, problems and pride...that is what flying is all about.
Deadly true.

You can have qualified employees with top skills, and still have a crappy workforce if the culture is wrong.

Qualifications and skills are a "bottom up" sort of thing, while culture tends to be a "top down" sort of thing.

Someone saying "good enough" has different results, depending upon who the person is. "Good enough" from a worker-bee type has a whole different impact than "good enough" from a management joe.

I've worked for good managers and bad. The bad ones were the ones who used phrases like "good enough," or "that will do for the moment."

Some of the best managers I've worked for were at Motorola (pre 1989 while the Galvins were still in control) and RadioShack (while it was under control of the Tandy family, pre 2002).

I now work for myself. A phrase I never use is "good enough."

My customers don't accept "good enough."


I don't work in the industry. There is more that I don't know about it than I do know about it.

But looking at it from an interested but uninformed perspective, I see a great many "liability shields" in place, especially when speaking of regionals.

"X" carrier uses "aX" company for regional transit, and pays them nn number of dollars per occupied seat.

"X" carrier forms relationships based upon lowest cost, to maximize their profit.

If something goes terribly wrong, it is primarily a problem for "aX" and not "X".

"X" carrier is free to seek the lowest bids, and shrug off most responsibility.


No idea how to fix this, other than to slap 1960s-style regulation back in place.

Might not be a bad idea, after thinking about it a moment.

Higher prices would certainly clear a lot of the dross out of airports.


Cheers,
RR
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Old 22nd Feb 2010, 05:52
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AirRabbit/PJ2

Gentlemen

…and yet both the FAA and TC were members of the IWG whose regulatory harmonization activities during 2006-2009 were adopted by ICAO into ICAO 9625 Edition 3 last year. I understood the FAA was going to incorporate these new standards into their draft update to Part 60 currently in progress (which should be completed in 2010?)

These new standards or at least my interpretation of them was that for Training to Proficiency tasks (for non MPL activities), a Type VII devise had to be used.

Again if my interpretation is correct, this is a vast improvement over current regulations whether they are JAA or FAA. As you are aware, at present it is possible to perform all recurrency checking on a Level B device (and this was the market that I believe the FFT was initially targeted at) which just doesn’t make sense.

Likewise current Level D FFSs with 180° X 40° visuals are certified for circling approaches – this is in reality an impossibility. The Type VII recognizes this and mandates a minimum of 200° X 40°, a significant improvement.

Now add in the Type VIIs other refinement that of a dynamic and fully integrated ATC environment requirement and what was once a Level D FFS has (almost) entered the 21st century.

Not to adopt all or at least the majority of ICAO 9625 Edition 3 is foolhardy.

I operate under the umbrella of EASA as opposed to the FAA and to date, apart from national regulatory authorities unilaterally ‘dumbing down’ requirements there doesn’t yet appear to be any general EASA moves similar to those that appear to be occurring on your side of the globe, however if this ball ever gets rolling, god help us all.
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Old 22nd Feb 2010, 06:29
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RR;
You can have qualified employees with top skills, and still have a crappy workforce if the culture is wrong.

Qualifications and skills are a "bottom up" sort of thing, while culture tends to be a "top down" sort of thing.
Both statements are true of this industry, (and all others, of course), as is PTH's statement you quote, but only as far as each of these statements go. I respectfully disagreed with PTH's statement in the quote not because it is an incorrect statement of affairs or that such notions are not important to take into consideration in running a large operation, but because making such statements goes only so far but does nothing to fix the situation or provide means by which a fix can be measured and validated.

The issue as we all know is, unless one knows about a problem it cannot be delineated and if it can't be described, it can't be targeted and fixed and then validated as fixed over time. Recidivism is rampant in the industry and that is why firings, punishment and such simply do not work and never will. The key is in knowing, not in forming opinions based upon mere impressions. Data is absolutely necessary and it is cheap and the granularity is very fine with the equipment available today.

Unless an airline knows what its fleet, and its pilots are doing in the fleet on a day-by-day basis, neither trends, nor how the organization's "culture" is really functioning can be accurately measured, even if done anecdotally. One must look at the airplanes and then, with trained, experienced eyes and mind, assess what is occuring, collate it, break it into bite-size reports so management don't have to be experts themselves, then offer educated, experienced thoughts on what is happening on the line. If problems creep up then can be seen, watched, trended, reported on and operations can change SOPs for a trial period and the results can again be trended and reported even over a long period of time.

I could provide dozens and dozens of examples of this process at work, successfully, (and not so successfully, for other reasons). Pilots themselves are their own best/worst critics and always wish to do well and welcome mature, non-judgemental, frank feedback and I can think of nothing better than showing them their own data over a period of time or for a flight they may have had an event on and wish to know more. By conveying information on trends, pilots quietly absorb the data and, along with the usual ways of maintaining competency, put the data to work in their operation. If the data tells the airline that an approach into XXX from the west tends to be hot, high and with reduced power and perhaps long landings, procedures can be examined, SOPs for that airport changed and briefing notes detailed. Mexico City is one such airport, I'm sure any who go there will concur - it's a very tight turn onto final from the west and some "interesting" events are recorded.

The notion of "precursor" is also important and that is another thing that "culture" and neither pilots nor management's opinions can delineate and act upon. Known precursors in flight data can now be highlighted and compared with current industry trends such as loss of control, CFIT, overruns and mid-air collision - There are 28 ways a TCAS response can be done incorrectly and events designed to capture and display these trends is available and is easily read. The key is in using the data, not just having the program.

Qualifications and skills are indeed a bottom-up phenomenon and that is what FOQA measures and can report on. Depending upon the airline's culture, and that does indeed come from the top, more complex issues can also be measured including the effects of fatigue on approaches, the performance of visual and non-precision approaches, time-of-day/ATC issues, fuel usage including single-engine/engine out taxi fuel savings, how long the carrier's aircraft wait at the gate burning fuel, (FOQA can report by airport, by fleet, by month, etc), before ground crews have prepared the gate so the airplane can taxi in.

FOQA is certainly not the end of the process. It is all about knowing "what". Knowing about "why" requires context and that is where other flight safety programs come in.

The capability to take QAR information and replay it in the simulator is also in the wings if not available already and, assuming it was serious enough to warrant such attention, an incident/event can be re-flown and examined for training purposes.

So, I don't disagree with the statements above but only point out why they need to go further if a thorough approach to flight safety is to be achieved. It provides clear ways in which to deal with people, using knowledge of specific operational events.

I agree with PTH that that isn't what flying is all about, but that is what running a safe airline is about.
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