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Continental TurboProp crash inbound for Buffalo

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Continental TurboProp crash inbound for Buffalo

Old 20th May 2009, 10:24
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maxrpm

No misunderstanding. Several posts in the thread already making your point. No matter how clear the low speed indicators were on the speed tape the crew cannot have registered them or they would not have set and later confirmed the wrong bug speeds. Please read the CVR transcript.

Last edited by xyze; 20th May 2009 at 10:41.
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Old 20th May 2009, 10:29
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Max rpm,

You're right, except of course that if you have switched the "increase ref speeds" switch on in the cruise the bottom end of the speed tape scale isn't visible to you when you bug the speeds.

It would be nice to think that as the aircraft slowed down the fact that the tape became visible would immediately remind you of the problem - as I admitted in an earlier post I have been caught out by it in broadly similar circumstances - end of a long day, night IMC, distracted - when we got the stick shake, as I said I did the "wrong" thing and turned off the switch - but the difference was that we were no longer in icing conditions, and I understood what the system waas doing and why. And I wasn't an inexperienced captain with 100 hours on type.

Hopefully there will be some recommendations about training as a result of this hearing, along with some about flight time limitations and crew rest. It would perhaps be nice if there was a recommendation that the "increase ref speeds" switch should be linked to the GPWS flap selector switch and the software be modified so that the speed bugs were automatically reset by whatever amount was required for the selected flap setting, or at least were moved so they could never be set lower than the top of the low speed cue.
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Old 20th May 2009, 11:13
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xyze

With the wrong setting their speedbugs must have been in the red zone of the speed tape when the stick shaker came on.

Seems like they did not whatch their speed at all. The proposal of excrab would not have helped here. Even when a change in software puts the speed bugs automatically in the right position when selcting "speed increase" you still will have to scan for airspeed speed during approach.
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Old 20th May 2009, 12:46
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It would perhaps be nice if there was a recommendation that the "increase ref speeds" switch should be linked to the GPWS flap selector switch and the software be modified so that the speed bugs were automatically reset by whatever amount was required for the selected flap setting, or at least were moved so they could never be set lower than the top of the low speed cue.
The problem with this proposal is that the calculated landing distance needs to be linked to the bugged Vref. If the bugged speeds are increased, there needs to be a new landing performance calculation, which considers any runway contamination, and a new comparison against available runway length.

The fixes needed, in my opinion, are much better stall recovery training and better rested crews.
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Old 20th May 2009, 12:50
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Members of Congress said they were stunned by the salaries of the pilots of Continental Connection Flight 3407, employees of the smaller commuter airline Colgan Air Inc.
Are these people delusional or just plain stupid?!

When the general public think it is acceptable to only pay bus fare to travel by air something has to give & two of the first things to suffer are pilot salaries & training.

I think part of the problem is that the low-cost PR people are busy reinforcing the myth that you can travel by plane for the same price as travelling by bus, all in the name of competition & 'the big boys have been fleecing the fare paying passenger for years & we are here right that wrong' crap that they dole out all the time.

Also, modern management don't seem to get the whole 'experience' thing. "He/she meets the minimum regulatory requirements & is happy to accept the position & pay we are offering, so what's the problem?" Couple this with the fact that in a lot of airlines, if not all, training has been cut to the bone to save costs & you have a problem.

As for the management mindset, a very senior flight ops manager at a large ME airline recently told a group of his pilots that he believes that there is NO link between low morale & safety. Sounds as though he comes from the same school of delusional management as this guy -

“Compensation has nothing to do with safety,” Cohen said.
This exact same statement was also made at the ME airline mentioned above & while I believe that this particular statement is technically correct, it shows a lack of understanding of the subtle links between human performance & the various emotions & stresses people deal with in their lives. It also shows a lack of understanding of the effects on employees of the environment that management creates in the workplace.

Flight Ops management these days seem to be of the opinion that strong SOP's, coupled with absolute adherance to them, means that they can put any pilot in the seat, treat them anyway they like & still expect to have a perfectly safe operation. This may work OK for a while as long as everything is going according to plan during a flight, but when the wheels start to come off & SOP's are forgotten in the heat of the moment, or perhaps don't cover the situation, then the outcome may not be quite what everyone wants.

Some of the accidents & incidents over the last few years, particularly in recent months seem to indicate that the shortsightedness of this philosophy is coming home to roost.

Last edited by Oakape; 20th May 2009 at 13:15.
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Old 20th May 2009, 13:01
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Are these people delusional or just plain stupid?!
Yes. They are politicians, after all.
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Old 20th May 2009, 14:08
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they are not PLAIN stupid

but they are PLANE stupid! ;-)
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Old 20th May 2009, 14:24
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After 71 pages some points:
How come so many professional pilots are so intolerant when they come on to this site? CRM what CRM? Or possibly could it be that they are not pilots at all?
Experts who know exactly how systems work on a plane they have never flown, never read the manuals for and have only ever seen from the outside or on flightsim.
Rants over - and relax.

Back to the thread.
From the CVR transcript and the video presentation It is clear that the capt was situationaly aware (up to a point).He is listning out on the radio and corrects the Fo a couple of times, he knows where he is geographicaly and aware of loc alive etc.
As the aircraft levels and is on the intercept heading he maintains the speed around 180. after flap 5 is selected again power adjustments are made and speed is maintained.
The aircraft is aproaching GS intercept and the 4dme point. Presumably he would have liked the aircraft to be stabalised by then or at the least configured and aproaching vref. Max v for flap 5 is 200, gear down 200 and flap 10 172.
He therefore allows the gear down and condition levers max to to decelarate the aircraft alowing flap 15 - we cannot mind read but presumably he would have adjusted power to aprox 15% to maintain vref once on the glide flap 15.
If this Aircraft had not had the incr ref on the plan would probably have worked. Not exactly like I would have done it but it would have worked.
The big questions are why did he ignore the red bricks and why did he react as he did to the stick shaker?
First a couple of points - on the presentation there is no torque value or indication where the flight idle or rated detents are. My suspicion is that the graphic represents the full power lever angle allowed. It would therefore include the proportion above the detent which allows for emergency power selection. If this is the case max power (to the rating detent) was aplied during the 'recovery'.
Second on his previous aircraft the saab 340 there is no inc ref switch. the stall protection system works in the same way and has stick shake and stick push but there is no acoutnt taken of icing however. To account for this you add an increment of 20kts. You can do mental arithmatic and calculate minimum manouver speeds for each weight and flap setting or follow conservative manouver speeds which asumes max weight.
There are no red bricks just plastic bugs for the ref speeds (if they have not fallen off)
Only the very early saabs had aleged problems with tail stall but I belive all production models had overcome this certainly I was not made aware of it as an issue.
If the aircraft is clear of ice ie the airframe is clean then the inc ref can be switched off during the aproach even if there is moisture outside. that would make the calculated v values correct.
We therefore have a pilot who has relatively little experiance of the inc ref switch, who is used to mentally adding corections for ice, who is relativly unused to seing red bricks, who is intentially decreasing speed towards his desired vref.
You see what you want sometimes and the red bricks should not have been there in his mental model It is possible that he simply ignored it or did not register it.
The onset of the stick shake must have come as an extreme shock, combined with the noise of the ap disconect disorentation would be very easy.
The recovery:
Some posts above there is a statement that most Colgan pilots would pull against stick push presumably to avoid height loss. If we presume that this was a typical pilot then the problem lies completely with the training that they recieved. It is possibly that his reaction was to maintain altitude - links above refere to problems with stall recovery training undar faa rules.
At this level training needs to be aircraft specific and not include spurious information relevant to other types. And Training is where I think the fault lies.
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Old 20th May 2009, 14:57
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good post PT6D
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Old 20th May 2009, 17:58
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Khorton,

You rather selectively quoted from my post - you will notice that I also suggested there should be improvements in training and crew rest requirements.

However, I stand by my suggestion. The information provided for pilots by the company for which I operated the Q400 indicated that with an increase of Vref of 20kts the landing field length had to be increased by 25% - this may seem a lot until it is remembered that for a Q400 a flap 15 landing on one engine at max landing weight only requires 1360 metres on a dry runway, or 1700 metres with the "increase ref speeds" switch on.

This has to be taken into account whenever the switch is on, be the re-bugging of speeds be done manually or automatically.

Obviously if the runway is contaminated or the braking action not good that must be taken into account, but I would suggest that most (not all) destinations being served by Q400s would not produce any problems.

I see from your profile that you are an engineering test pilot. If you work for Bombardier, could you guess at how difficult the software changes I suggested would actually be?
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Old 20th May 2009, 23:04
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I see from your profile that you are an engineering test pilot. If you work for Bombardier, could you guess at how difficult the software changes I suggested would actually be?
I work for Transport Canada, but much of my work is on various Bombardier aircraft. I've only got three flights on the Q400 though. Any posts I make here are my personal opinion, and don't represent the views of my employer.

Software changes sound easy in theory, but they are never simple in the real world. The first big question is whether the physical interfaces that you need for the new function exist. I.e., look at which box drives the speed bugs, and see whether that box has knowledge of the SPEED REFS switch position. If not, then you need to find a way to get that info into the box. If you need to add new physical interfaces (i.e. new wires), then the cost and complexity go through the roof. But even if you don't need new wires, if the box that drives the speed bug does not already have knowledge of the SPEED REFS switch position, then you need to look at which other boxes you can pass the info through, and you might need to change the software in each of these boxes to pass the SPEED REFS switch position onwards, to eventually get the info where it needs to be.

Then, you need to fully define exactly how the new software will work, and there are always a multitude of corner cases to consider. Then the vendor has to write all the code that does the work, and it must be extensively tested. Usually there are bugs, which means more code writing and more testing.

To further complicate things, all the new code must be developed in accordance with a very formal software development process, that attempts to ensure the final software does exactly what it is designed to do. This is a laudable goal, but the required process is very expensive to implement.

But we still have my original comment to resolve - if the bugged Vref could end up higher than originally set by the crew, then they need to have calculated landing performance that accommodates that possibility. If I understand your proposal correctly, you want the bugged Vref to automatically be increased to cover flap angles lower than planned, and/or SPEED REFS switch in INCR, when the crew's intention was flap 35 and SPEED REFS to OFF. I don't have Q400 landing performance at hand, but there must be quite a large difference in Vref between Flap 35 + SPEED REFS to OFF, and Flap 15 and SPEED REFS to INCR. As a first order approximation, for every 10% increase in speed you can figure on a 20% increase in required field length.

Maybe operators on long runways could live with always using a landing field length that assumed minimal flap + SPEED REFS to INCR, but there are operators who actually go into shorter strips. Consider Porter Airlines, who fly into Toronto City Centre (CYTZ), with a 4000 ft long runway (1219 m).
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Old 20th May 2009, 23:47
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And if I may interject a more fundamental concern - the bugs are intended to be set by the crew to the speeds THEY desire - not to specific speeds drawn from the AFM or other docs. Say you want to 'bug' Vref+5 - because it's SOP, because you have a failure that requires +5, because you like that number. Go ahead, do so. You may in such a case be very unhappy to find your (perhaps carefully chosen) bug shifting around as a result of the INC REF switch. It may also be invalid for it to move.

Suppose (and I'm not directly involved with the Q series, so the exact scenario may not apply, but the concept should) that you have a failure which requires landing with an increased speed. Perhaps a control restriction. In that case the extra speed isn't there for stall margin, it's there to give more control power.

Now I flip the INCR REF switch. Fine, I already have my bug set high. So I quite reasonably leave it alone - the extra speed now does double duty for both control power and stall margin. If I instead double added, I may be over gear speed limits, or tyre limits, or at an unusually nose-low attitude (with risk of nosewheel strike on touchdown, or ...)

My point being, the bugs are to be set by the crew, as an aid to the crew in monitoring speed, with the speed chosen based on all kinds of factors, including simple airmanship.

To devise an automatic resetting of the bugs which would not get someone inadvertently into trouble might be rather hard. And, perversely, as an OEM it's valid to assume that crews have airmanship - or common sense, if you prefer. Once we take the action out of the crew's hands, though, our hardware doesn't have any sense, common or otherwise; we must design it in. And sadly, common sense is sometimes VERY difficult to specify.
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Old 20th May 2009, 23:48
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Khorton,

Thanks for the information you gave. I don't have a performance manual to hand so I used the figures I had available as an example which were the landing field lengths needed from the abnormal checklist. The single engine flap 15 case was the nearest estimation I had to a "normal landing", most other system failures give greater increases.

The differences in the speeds are an extra 20kts to Vref at flap 15 and an extra 15 knots at flap 35 (or at least were in 2005 - they may have been adjusted since as knowledge changes as fleet operating hours increase). These gave respectively an increase in landing field length of 25% at flap 15 and 20% at flap 30. Those were figures from company documents but I always supposed they would have originated from Bombardier.

The point I am making is that it makes no difference whether the speeds are re-bugged manually or automatically, the calculations still have to be done. I suspect that Porter either have to very carefully limit their landing weights if they anticipate landing in Toronto city centre airport in conditions which require them to have "the increas ref speeds" switch on, or accept that on those days they may be diverting to Pearson. This was similar when Flybe operate into Guernsey in the Channel Islands south west of the uk, except there the microclimate is such that even in winter those conditions are rarely met. In such conditions on a wet runway the max landing weight was reduced from 28 tonnes to 23.7, which with minimum fuel on arrival for the closest alternate restricted the passenger load to about 53.

I totally agree with you - they should have been better trained in stall recovery, or technically incipient stall recovery as that is what the stick shaker event was. And the airline and indeed the FAA should be mandating that pilots must be properly rested - if they chose to commute then they should make suitable local arrangements.

However cost alone should not be a reason not to consider a software/hardware change. I accept what you are saying about the complexity, but possibly in this case my suggestion might have prevented them entering the stick shake regime at all.
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Old 21st May 2009, 00:12
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lots of talk of stall recovery

should have been alot of training about stall avoidance.
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Old 21st May 2009, 00:40
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Not sure if it has been mentioned before(Too many posts). Did anyone notice that straight after the crash the news media and the NTSB only mentioned the copilots hours in detail including hours on type, but did not feel the need to mention the captains specific hours.
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Old 21st May 2009, 03:31
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From the NTSB docket ( CD List Of Contents ) the ref speeds for approach/landing in icing the Colgan checklist calls for,
Flaps 0, Vref +25
Flaps 5, Vref +20
Flaps 10, Vref +20
Flaps 15, Vref +20
Flaps 35, Vref +15
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Old 21st May 2009, 03:42
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Mentalist..."too many posts...you just added andother that has already been covered...read the long thread or don't comment...

Google "Rebecca Shaw" and you will find the info you want there...same for "Capt Renslow"...
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Old 22nd May 2009, 04:35
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Gulfstream International, where captain Renslow trained and worked before joining Colgan, has been fined 1.3 million dollars for falsifying pilot records:
Airline fined $1.3M for faking pilot records - USATODAY.com
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Old 22nd May 2009, 07:11
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DownIin3Green

My humble apologies, I had a late night. Just call me lazy.
I have always liked the Dash-8, to me it's sexy. Sitting behind a Dash-7 the other day made me think there is one with a couple of extra engines, only suitable for certain extremes.
I suppose it comes back to the old saying, situational awarness. Know where the hell you are and what the a/c is doing there, if not get the f**k out of there. Suppose a snow storm above Buffalo isn't the best place to find this out.
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Old 25th May 2009, 02:27
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Mentalist...well said...didn;t mean to bark at you...

Coming into Iceland one evening, on a ferry flt in a 727, with the F/O flying, the wx went tits-up as often happens in Iceland...

All of a sudden the rwy was not servicable, (snow covered), vis went to hell, crosswind was 090/35-40kts, and I told the F/O I had the A/C...

He says "Don't you think I can do this?"

I say "NOW IS NOT THE TIME TO FIND OUT"...end of story...

Gotta love "wasta"....anyone who's been there knows what I mean...
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