3407 public hearing

[MikeD]

That's fair and is your opinion. Maybe it was training at some other level. Maybe they shouldn't have made it through. I don't see how he got his ATP and passes a type ride if the training is on par.. I'd like to know the first time pass rate for upgrade at colgan an compare that with the rest of em.

Primary causal factors: Those factors that directly caused a plane to go into the dirt. Oftentimes pilot error......ie- something the pilot/crew did or didn't do in the cockpit that resulted in the plane going down. Other times, the primary causal factors can be other items.

Training is never a primary factor. It can be secondary, but is usually tertiary. Training, or lack thereof, doesn't cause an accident. It's at best a contributing factor. Plane goes down....what physically made the plane go down? Crew error? Ok, if crew error, what error did they make? How/why did that error happen? It's nearly 3-4 questions down that training even comes into play.

Same as having a road somewhere that has alot of accidents on it. People will decry "that road is unsafe!". No. The road is merely a piece of asphalt with striping that sits there and does nothing (pending in satisfactory condition). People driving on the road are what is safe or not, depending on how they drive. The road could have secondary/tertiary factors such as obstructions, curves, etc. But those don't cause accidents, at best they contribute.

 

[MikeD]

Any time a 121 captain let's a plane slow and stall and then pulls back on the pusher it is a lack of training somewhere.

Caution on this way of thinking.....coming to direct conclusions like this. There are such things as distractions, etc, that can come into play. A + B doesn't instantly equal C in this case, 100% of the time.

 

[kellwolf]

Any time a 121 captain let's a plane slow and stall and then pulls back on the pusher it is a lack of training somewhere.

Eh, I don't agree. Survival instinct is telling you to pull back b/c the ground is coming up at you. I had a few students that I had to smack in the back of the head to get them to push the nose forward b/c it goes against what your brain is telling you.

I do agree with what Bob said in the other thread. There's no way you can be trained for EVERY possibility. However, you have to evaluate what's going on and realize when something isn't working. If pulling back isn't working and you're still losing airspeed, push forward to get the nose over. I highly doubt any airline is TRAINING their pilots to keep pulling back when they get the pusher.

 

[L-16B]

That's fair and is your opinion. Maybe it was training at some other level. Maybe they shouldn't have made it through. I don't see how he got his ATP and passes a type ride if the training is on par.. I'd like to know the first time pass rate for upgrade at colgan an compare that with the rest of em.

Your right, I didn't mean to criticize you, I should have been more clear. What I was referring to was their critical and fatal flaw was something that was taught from day one in private pilot, and at the 121 level you shouldn't have to be trained in airspeed on an approach.

 

[LineUpAndWait]

A pretty good summary of today's proceedings:

http://boardingarea.com/blogs/joesh...ad-tired-pilots-for-colgan-air-buffalo-crash/

 

[SteveC]

Eh, I don't agree. Survival instinct is telling you to pull back b/c the ground is coming up at you.

I've hinted at this in the past, but for everyone's consideration I'll throw this idea out there again:

What if a pilot had some rudimentary knowledge and understood that ice forms much more readily on a sharper edged airfoil than on a blunter one (for example a horizontal tail surface compared to a wing leading edge)? What if this pilot had watched a popular video training segment on icing and tail stalls and knew that "in a full tail stall the nose and yoke pitch forward simultaneously and may require a large amount of pull force to recover." What if this pilot were fatigued and not thinking real clearly nor paying real close attention to something that had become routine - flying an approach in icing conditions? What if this pilot's inattention allowed the airspeed to slow unnoticed until the stick shaker activated? What if the fatigue contributed to the pilot being unable to quickly interpret this sound and feeling that he only experiences twice a year, and never in a real aircraft? What if this pilot knew that putting in additional flaps, if the tail is close to stalling, can cause the stall to happen? What if his disbelief sends his mind racing, and in its confusion he grabs onto the thought that the scary devil called a "tail stall" might be what is causing all of this bewildering noise and pandemonium? Just as his befuddled mind is grasping at straws, including this wild idea of a tail stall, the aircraft enters a full (wing) stall, the nose pitches forward and the yoke is practically pulled out of his hands (stick pusher!)!

Let me finish this little scenario by quoting from an AOPA article:

A full tail stall is more dramatic and much harder to recover from than the wing stalls practiced in training.

When the wing stalls you feel the buffet, then the break, and the airplane settles and loses lift. The pilot must lower the nose to recover. In a tail stall, however, the nose will pitch forward, and the yoke snatches forward in an aircraft where the elevator is operated by cables or pushrods as the airflow over the horizontal tail completely separates -- a scenario that could have occurred if the pilot used full flaps.

...

So what should you do if the airplane is not responding properly to elevator inputs or you feel buffet in the controls? Immediately raise the flaps, says Blankenship. "If the yoke is snatched forward, pull back to recover, and retract the flaps. Pulling back on the yoke is opposite to the recovery technique for a wing stall. [Because the tail develops lift in a downward direction, the yoke must be pulled and not pushed.] In icing experiments in our de Havilland Twin Otter, the pilots needed 180 pounds of force to recover from a full tail stall, and they lost over 600 feet." These were experienced test pilots who expected a tail stall caused by ice.

...with...added airspeed on approach, a tail stall is more likely than a wing stall. If there is any ice on the wing, there may be far more on the horizontal stabilizer -- and the pilot may not know ice is building until the airplane's configuration is changed. On approach, with flaps extended and the airplane close to the ground and close to its performance limits, recovery is very difficult.

Even a small amount of ice on the leading edges can cause flow separation and a sudden change in attitude when different inputs are applied, says Rieke. It's critically important to remember that what works for wing stall may intensify a tail stall. In a wing stall recovery, the pilot relaxes back-pressure or pushes the yoke forward to reduce the angle of attack and increase airspeed and regain control.

Responses associated with tail stall recovery are counterintuitive to what ...pilots are taught. The stall symptoms are similar, but the recovery is absolutely different: Pull the yoke back (which might take great force); raise the flaps, if lowered; and reduce or be judicious with the power. The NASA pilots say a tail stall talks to you through the yoke; a wing stall you feel in the seat of your pants.

Tail stalls almost always occur with flap extension or at the high speed limit for flap extension.

What did the pilots of 3407 do? Raised the flaps, hesitated to add full power, and pulled back strongly on the yoke.



Just another thought to ponder.

 

[400A]

Steve

That is a great interp of what may have happened. I have to disagree a little though. If the Capt and/or the FO had that knowledge, as soon as the nose was more than 10 degrees nose up, they should have know it wasn't a tail stall and recovered accordingly. The other thing to consider, did the Captain know it was a regular stall, know he was close to the ground (relatively) and instinctively, via training, do everything he could to keep "the nose up"?

The way we train stalls, for the most part, in the 121/135 world is wrong. A stall isn't a performance event it is an emergency and every available avenue should be used and trained for to get out of the stall. Sitting idle, hands at the ready to "mash" that power and raise the flaps at the first sign of the shaker is not stall training.

This accident, as tragic as it is, has the potential to help the rest of us turn our profession around a little bit, if we can keep from tearing each other apart over semantics and egos.

 

[Seggy]

I talked with our MEC about my sick call in January. Puking in the cockpit suddenly, captain calling me out sick only to have scheduling tell him that i have to personally call them, and scheduling telling me i need a sick note or its a missed trip.

Colgan had a fatigue policy? I've never heard of such a thing. All I heard was from the Beech/Saab guys at a maintenance day tell me how lucky I was that I wasn't at a maintenance base. Apparently they would fly 121 all day long, then at the end of the day Colgan would have them ferry a part 91 flight to go past duty regs. F that.

From our fast read today...



The NTSB Board of Inquiry picked up where the hearing left off yesterday with testimony from Colgan Air management representatives on pilot hiring and training as well as company safety culture and programs. The technical panel, representatives from the parties to the investigation, and the NTSB members focused their questions on Colgan’s sick, fatigue, and commuting policies, pilot pay scales, and scheduling practices. Specifically, they addressed several inconsistencies and set the record straight on testimony from Tuesday regarding Colgan’s sick and fatigue policies, use of company and manufacturer manuals, and pending company initiatives.

The hearing continued in the afternoon with more testimony on those issues and concluded with a thorough discussion of the causes and effects of fatigue, ways to mitigate those effects, and fatigue risk management.

The team officially representing ALPA at the hearing includes Colgan pilots joined by pilot safety volunteers from Delta, Continental, and Pinnacle, as well as ALPA Engineering & Air Safety Department staff.

In addition, ALPA First Vice President Capt. Paul Rice and CJC MEC Chairman Capt. Mark Segaloff have been serving as spokesmen for the Association. They have granted interviews to a number of print, wire, and broadcast reporters covering the proceedings.

The hearing will conclude tomorrow, May 14, with testimony from ALPA Executive Air Safety Chairman Capt. Rory Kay (UAL), among others.

 

[ready2fly]

Here at the Beagle, we have neat concepts like:

Calling a Reserve pilot at home, on a late-day reserve availability period, for a one leg to overnight. To the East coast. Then give him a showtime that requires a 4 AM wakeup. So now, as he likely slept until 9 or 10 am on his late-day RAP to start, he's now expected to drop immediately to deep sleep at 8 PM local time, 7 PM body-clock time, in order to wake up rested at 4 AM local time, 3 AM body clock time.

What are the odds his body will actually accommodate that kind of sleep demand? Now that you've ruined his chances of a solid night's rest, repeat this cycle over 10 to 12 hour duty days for the next 3.

As for reserve utilization, we're furloughing, and we're already JMing and tacking on extentions to reserve pilots as much as possible.

Last time staffing was like this, I flew every day I was on Reserve, and as much as scheduling could legally demand of me. Every time.

One month, I had a 91 hour composite line, and they tried to insert a RSV day mid-month on me. They thought they could just sneak it by me.

To add insult to injury, this was after six days of work. Because there was 24 hours rest in between the two day trip and the four day trip, it was legal per the FARs. It was not, however, contractually legal.

.... and this is at one of the so-called 'better' regionals.

I shudder to think how it really is some days at some of the less congenial operations.

1. Re-
2. Write
3. The
4. FARs!!!

 

[CAPIP1998]

Are the hearings being televised today and if so, on what channel?

I'd like to be able to watch while I'm working.

Sorry to backtrack a bit, but if anybody wants to watch the FULL hearings they're here. Personally, I'm keeping them for posterity.

http://www.ntsb.gov/Events/2009/Buffalo-NY/Default.html

 

[Qgar]

Thanks for the link. I missed Tuesday afternoon's proceedings and will definitely watch it as soon as I can.

BTW, hope you're doing well, N.

 

[SoCalAprch]

Eh, I don't agree. Survival instinct is telling you to pull back b/c the ground is coming up at you. I had a few students that I had to smack in the back of the head to get them to push the nose forward b/c it goes against what your brain is telling you.

I do agree with what Bob said in the other thread. There's no way you can be trained for EVERY possibility. However, you have to evaluate what's going on and realize when something isn't working. If pulling back isn't working and you're still losing airspeed, push forward to get the nose over. I highly doubt any airline is TRAINING their pilots to keep pulling back when they get the pusher.

You guys are right, yesterday I was a few cold ones deep and was just sick of listening to the company and media chastise these guys for being inexperienced and bad pilots.

 

[wheelsup]

Why did she pull the flaps up in the stall

 

[SpiraMirabilis]

Why did she pull the flaps up in the stall

There are no callouts being done but on all Dash models (including the 400) you retract the flaps one notch. I think they were on their way to 15'? She I think did a little more than that (15 to 0'?)

 

[wheelsup]

You retract them when you are still in the stall? Or with positive performance climbing out of it?

 

[727to7400]

Folks, I hate to state the obvious, but this crash was not caused by an innappropriate response to the stick shaker. It was caused by a crew that was lulled into a false sense of security by letting the airplane fly on the magic.

The autopilot will do exactly what you tell it to do until it can do it no more and then it say's "I'm outta here, you figure it out." American Airlines in Lima...punched in the wrong identifier, engaged the a/p and it flew them into the ground. What were they doing? Non standard stuff and not watching the magic. It happens all the time. FMC's and A/P's are wonderful work load relievers. They do not relieve us of the responsibility of flying the airplane and watching the instruments, period.

Having the magic is fun. It's easy. The tough part is realizing that the magic and the glass make you a lazy pilot. Why hand fly the plane and really get to know it when you can hit the switch and sit back? Why hand fly an ILS to the mins when the box can do it?

Because it teaches you something. You learn skills and judgement that you don't get by hitting the switch. Watch a pilot who grew up on steam guages in a glass cockpit. He is more likely to use the magic as an adjunct accessory rather than a primary tool. Put a glass guy on steam and he's got a steep learning curve.

My point is this. I have no doubt these were two fine folks. Their loss, and the loss of everyone else was a tragedy. The only thing more gut wrenching than reading the full transcript is watching a graphic display and seeing what was on the guages...declining airspeed. And knowing that not two feet from saving this aircraft and everyone on board were two people who were not looking at the airspeed indicator. A "flying pilot" and a "non flying pilot" who was supposed to be there to back up the FP.

This wasn't about ice. It wasn't about a tail stall or a wing stall. It wasn't about a stick shaker or pusher.

It was about two people who were not paying attention to their airspeed and expecting the magic to do the job. Everything that followed was a consequence of that.

Pay attention and fly the airplane. Rule one.

 

[SpiraMirabilis]

You retract them when you are still in the stall? Or with positive performance climbing out of it?

With stall, the callouts are on the 200 at YV (I know the 400 has similar callouts, speeds might be different):

Shaker goes off
PF: Set max power, flaps 5 (or whatever 1 notch above would be)
PNF: Positive rate (although this call is actually made at 100kts, not a positive rate of climb)
PF: Gear up
PNF: Through VFR
PF: Flaps up
PNF: 130 kts
PF: Set low cruise (or climb power, or whatever)

At Mesa we're trained not to lose too much altitude and just power out of the stall basically, although obviously you'd fail the maneuver if you let the shaker go off again while in the recovery.

I asked a Q400 guy and he said the recovery was similar, you retract 1 notch flaps immediately then when youre through VFR retract the rest.

 

[jynxyjoe]

Folks, I hate to state the obvious, but this crash was not caused by an innappropriate response to the stick shaker. It was caused by a crew that was lulled into a false sense of security by letting the airplane fly on the magic.

The autopilot will do exactly what you tell it to do until it can do it no more and then it say's "I'm outta here, you figure it out." American Airlines in Lima...punched in the wrong identifier, engaged the a/p and it flew them into the ground. What were they doing? Non standard stuff and not watching the magic. It happens all the time. FMC's and A/P's are wonderful work load relievers. They do not relieve us of the responsibility of flying the airplane and watching the instruments, period.

Having the magic is fun. It's easy. The tough part is realizing that the magic and the glass make you a lazy pilot. Why hand fly the plane and really get to know it when you can hit the switch and sit back? Why hand fly an ILS to the mins when the box can do it?

Because it teaches you something. You learn skills and judgement that you don't get by hitting the switch. Watch a pilot who grew up on steam guages in a glass cockpit. He is more likely to use the magic as an adjunct accessory rather than a primary tool. Put a glass guy on steam and he's got a steep learning curve.

My point is this. I have no doubt these were two fine folks. Their loss, and the loss of everyone else was a tragedy. The only thing more gut wrenching than reading the full transcript is watching a graphic display and seeing what was on the guages...declining airspeed. And knowing that not two feet from saving this aircraft and everyone on board were two people who were not looking at the airspeed indicator. A "flying pilot" and a "non flying pilot" who was supposed to be there to back up the FP.

This wasn't about ice. It wasn't about a tail stall or a wing stall. It wasn't about a stick shaker or pusher.

It was about two people who were not paying attention to their airspeed and expecting the magic to do the job. Everything that followed was a consequence of that.

Pay attention and fly the airplane. Rule one.

Yeah man, it's almost like they were drunk or absent minded or something.
http://cf.alpa.org/internet/projects/ftdt/backgr/fatigue_performance_impairment_1997.html
Poor-quality sleep and inadequate recovery leads to increased fatigue, decreased alertness and impaired performance in a variety of cognitive psychomotor tests.

Anyway, thanks for stopping in and telling us all this great stuff, we are all pretty dumb here.

 

[jtrain609]

You retract them when you are still in the stall? Or with positive performance climbing out of it?

You retracted them during the stall in the ERJ, if I remember. I believe the call was. "Go around, flaps 9."

You'd go from 45 to 9 while ramming the thrust levers through the EICAS and mashing the togo buttons.

But don't quote me on that, because I'm beyond uncurrent in the plane. As far as I remember, that was the procedure.

 

[derg]

I talked with our MEC about my sick call in January. Puking in the cockpit suddenly, captain calling me out sick only to have scheduling tell him that i have to personally call them, and scheduling telling me i need a sick note or its a missed trip.

What the hell? I called in sick for an FO in a foreign freaking country four months ago because he was too busy vomiting and pooping himself after a food poisoning situation...

Stop putting up with crap like this and demand to be treated as a responsible adult. The company has to realize that if they won't trust a pilot making the call that he's unable to fly because of health, they probably shouldn't be trusting them to fly a multi-million dollar aircraft.

That totally blows me away.