Final NTSB report on Colgan/CO 3407

[TUCKnTRUCK]

The final actions were the pilots, yes, but the training, policy, and other factors left them I'll prepared to deal with the situation. Blaming it on pilot error without exposing what led to the error does little to change safety related issues, which is alpas goal. The important question is why was the mistake made, not who made the mistake?... By stating that It was other than pilot error it gave them reason to explore the other issues. I would have done the same thing if I were trying to push policy change in the name of safety.

 

[fo4ever]

That assumed they had competent pilots up front...

Sad

Pretty sad way to say that...

 

[Avalon781ML]

That assumed they had competent pilots up front...

Sad

Pretty pathetic on your part.... epic FAIL if you ask me.... respect those who cannot defend themselves or their actions.

 

[ppragman]

Wow, just wow.

Wow, your post is Sad!

Stay Classy.

Not surprised though.

Pretty sad way to say that...

Pretty pathetic on your part.... epic FAIL if you ask me.... respect those who cannot defend themselves or their actions.

Just to play the devil's advocate, are we really able to say they were all that competent based on training and time in the saddle? I don't know, what were the times of the crew members again? What was their level of experience when they got on at Colgan... There are more factors here than just fatigue. While I will agree that the post in question was somewhat inflammatory, how far off the mark is it really. And I say this with no knowledge of the crewmembers outside of media reports, and knowing noone who even knew them to my knowledge, so take this with a grain of salt.

 

[TXaviator]

seems fairly accurate... the crew failed in flying the plane, and failed in their response to the aircraft warnings.

in other words, they were not competent in flying the aircraft.

 

[ChasenSFO]

You can argue either way. One way to look at it is sure, they screwed up. Another way to look at it is does one mistake define a person? Their mistake had horrific consequences, however, this month AOPA did a story about 3 well known high time pilots, including Steve Fosset, who after thousands of safe flights put themselves in one situation they couldn't get out of and met their end. It is assumed by investigators that Steve Fosset unknowingly flew into a downdraft that his plane didn't have the power to recover from, but have you heard anyone call him a bad pilot in the media?

Just food for thought.

 

[MikeD]

The final actions were the pilots, yes, but the training, policy, and other factors left them I'll prepared to deal with the situation. Blaming it on pilot error without exposing what led to the error does little to change safety related issues, which is alpas goal. The important question is why was the mistake made, not who made the mistake?... By stating that It was other than pilot error it gave them reason to explore the other issues. I would have done the same thing if I were trying to push policy change in the name of safety.

A ruling of pilot error doesn't instantly close the doors to looking at what led to that pilot error.

The accident was pilot error, primary cause. The airplane didn't fly itself into the ground. Management didn't fly it into the ground. Training didn't fly it into the ground. The pilot (crew) flew a perfectly good airplane into the ground following getting themselves into a square corner they couldn't get out of. Thats where the pilot error ruling as the primary cause of the accident comes from.

Now, as we delve into the realm of secondary and tertiary causal factors.....ie things that led to or contributed to the primary cause of the accident, thats where we get into WX conditions, training, etc.

But for those to say pilot error wasn't the cause of this accident is obsfucation at best, ignornace at worst.

 

[WestIndian425]

A ruling of pilot error doesn't instantly close the doors to looking at what led to that pilot error.

The accident was pilot error, primary cause. The airplane didn't fly itself into the ground. Management didn't fly it into the ground. Training didn't fly it into the ground. The pilot (crew) flew a perfectly good airplane into the ground following getting themselves into a square corner they couldn't get out of. Thats where the pilot error ruling as the primary cause of the accident comes from.

Now, as we delve into the realm of secondary and tertiary causal factors.....ie things that led to or contributed to the primary cause of the accident, thats where we get into WX conditions, training, etc.

But for those to say pilot error wasn't the cause of this accident is obsfucation at best, ignornace at worst.

Obsfucation? SAT word!!!

Why is it I keep thinking it was IMC that night, and the report is constantly saying night VMC?

 

[Avalon781ML]

Just to play the devil's advocate, are we really able to say they were all that competent based on training and time in the saddle? I don't know, what were the times of the crew members again? What was their level of experience when they got on at Colgan... There are more factors here than just fatigue. While I will agree that the post in question was somewhat inflammatory, how far off the mark is it really. And I say this with no knowledge of the crewmembers outside of media reports, and knowing noone who even knew them to my knowledge, so take this with a grain of salt.

seems fairly accurate... the crew failed in flying the plane, and failed in their response to the aircraft warnings.

in other words, they were not competent in flying the aircraft.

It's not an issue of whether the crew made a mistake... we know they did. The remark shows total lack of respect for the dead. It paints a pretty good picture of the posters character or lack thereof..... classless and petty to take a swing at the crew like that.

 

[ILSstud]

"The report states that, when the stick shaker activated to
warn the flight crew of an impending aerodynamic stall, the
captain should have responded correctly to the situation by
pushing forward on the control column. However, the
captain inappropriately pulled aft on the control column and
placed the airplane into an accelerated aerodynamic stall.

Contributing to the cause of the accident were the
Crewmembers’ failure to recognize the position of the
low-speed cue on their flight displays, which indicated that
the stick shaker was about to activate, and their failure to
adhere to sterile cockpit procedures. Other contributing
factors were the captain’s failure to effectively manage the
flight and Colgan Air’s inadequate procedures for airspeed
selection and management during approaches in icing
conditions."

RIP to all, including the flight crew, but those seem like fairly egregious errors. It certainly doesn't warrant a low blow jab towards deceased aviators, or anyone for that matter....

 

[cmill]

It's not an issue of whether the crew made a mistake... we know they did. The remark shows total lack of respect for the dead. It paints a pretty good picture of the posters character or lack thereof..... classless and petty to take a swing at the crew like that.

It IS an issue that the crew made a mistake. What are we supposed to do ignore it?


Nobody is taking a swing at anybody. How is it classless to state a fact? The crew crashed a plane that did everything it could to save itself, and as a result, everyone died. Sorry, but the truth is tough.

 

[SBI]

:yeahthat:

I agree with every word you said. Enough with politically correctness, especially because people died.<O></O>

 

[kellwolf]

RIP to all, including the flight crew, but those seem like fairly egregious errors. It certainly doesn't warrant a low blow jab towards deceased aviators, or anyone for that matter....

I'll agree those were huge errors. Now, neither crew member made huge errors like that on a regular basis. They wouldn't have lived long enough to get where they were. The MAJOR question should be "Why did they commit errors that catastrophic at that moment in time?" 3701 here at Pinnacle was pilot error, but it also had elements of unprofessionalism attached. As soon as the NTSB said the words "pilot error," management was all about trying to go forward business as usual like they had no culpability in the situation. TECHNICALLY, they DID fly the profiles they were trained with. Thanks to that accident (and the NTSB's pushing for better high altitude training at least at 9E), I've get a better grip myself on when I can and shouldn't be flying an airplane of X weight at X altitude. We can use climb charts, low speed buffet charts, etc to determine just because we're LEGAL to fly at a certain altitude (in 3701's case FL410), SHOULD we? I don't even know if they had those charts prior to the accident. The TVC overrun netted better contaminated landing training for us all. The object of the game isn't to assign blame and move on to the next shareholder's meeting. It's to determine not only what went wrong, but WHY it went wrong so it can be avoided next time. If we keep pushing pilots to fly in a manner that the Colgan crew did (and I'm relating to the fatigue/commuting/training here), this is gonna repeat itself per the law of averages. Scary thing is, we've got crews flying fatigued as badly or worse than those guys were on a daily basis, despite any "non punitive and non intimidating" fatigue policies.

 

[ILSstud]

This might seem like a stupid question because I am not in the "industry" like some of you guys. Suppose you are flying a trip and you are so tired that you can barely keep your eyes open. You grab a drink at starbucks after a small nap in the crew lounge or whatever, what are your options as a pilot? Would you be penalized for calling your crew chief and saying you don't think it is safe for YOU to continue your duties? I mean what are the alternatives to flying under extreme fatigue?

 

[kellwolf]

This might seem like a stupid question because I am not in the "industry" like some of you guys. Suppose you are flying a trip and you are so tired that you can barely keep your eyes open. You grab a drink at starbucks after a small nap in the crew lounge or whatever, what are your options as a pilot? Would you be penalized for calling your crew chief and saying you don't think it is safe for YOU to continue your duties? I mean what are the alternatives to flying under extreme fatigue?

Technically, if you DID fly in that situation, you'd be illegal. Any management will agree with you simply because if they didn't, they could be in serious trouble. The question comes in with how they handle it. Our policy here is, you call crew scheduling, tell them you're fatigued, and you're done for 10 hours. You need to fill out a report to document the event, which is no biggie. That covers the not flying part. NOW comes the shady part. You have to meet with base management to "discuss" why you called in fatigued, and they reduce your pay by 3.75. Yes, you lose out on money if the company schedules you in a fatiguing way or due to WX/MX or any other delay, you work so long you're too tired to continue. THIS is something I disagree with. You should fill out the report, and that should be the end of it.

So, in a realistic scenario, you've got an FO that makes $24/hr (we don't have any first year FOs here anymore, and I did say realistic). He's exhausted and staring at another 3-4 legs for the day. He really SHOULD call in fatigued, but he knows he's gonna have to do the carpet dance with the base manager, and he's gonna be out $90. Granted, after the meeting with the base manager, if they decide it was a valid fatigue call, he CAN get that back out of his sick bank. Once again, realistically, you're talking 1-2 MONTHS before he gets the money back. In the meantime, he's gotta figure out which bill he's gonna skip in order to NOT fly exhausted. I'm still waiting for the MEETING for a fatigue call I had back in December. So, I'm out $226 for that one that I haven't gotten back, yet. However, our management has declared our policy "non-intimidating" and "non-punitive." I disagree with them.

Now, other airlines have a VERY different policy. They play the "Call crew scheduling, tell them your fatigued and fill out a report" model. Then you're done.

Edit: Forgot to mention. If you're on reserve, they'll release you for 10 hours after your fatigue call. If you still have part of your reserve period after that 10 hours.....it's still there. I've called in fatigued before, got 10 hours and still had to do a HSV overnight before.....

 

[MikeD]

RIP to all, including the flight crew, but those seem like fairly egregious errors. It certainly doesn't warrant a low blow jab towards deceased aviators, or anyone for that matter....

It IS an issue that the crew made a mistake. What are we supposed to do ignore it?

Nobody is taking a swing at anybody. How is it classless to state a fact? The crew crashed a plane that did everything it could to save itself, and as a result, everyone died. Sorry, but the truth is tough.

I agree with every word you said. Enough with politically correctness, especially because people died.

Maybe it'd be good for everyone to read the last paragraph that appears at the bottom of all the MikeD Accident Analysis reports that I author for this site.

 

[drunkenbeagle]

I'll agree those were huge errors. Now, neither crew member made huge errors like that on a regular basis. They wouldn't have lived long enough to get where they were.

Well, from the vast amount of information gathered by the NTSB, I would have to disagree. There have been past accidents where captains had fundamental issues with basic aircraft control, and this appears to be one of them.

The phrase "behind the airplane" appeared far too often for my comfort in the training records the NTSB gathered. And on a regular basis? Kind of, as the captain didn't pass sim rides for exactly this problem - being way slow and unstabilized on approach.

I think it is highly relevant that the pilot didn't just fail, but bombed the Instrument, C-ASEL, C-MEL, and ATP rides, plus some others. In many areas of operation. The NTSB correctly pointed out that there is a very strong correlation between multiple checkride busts and fatal mishaps.

I honestly do think it is a major problem. That given enough money, you will eventually get every rating in aviation. I'm not placing blame on anyone in particular, but systemically it is an issue. It probably starts with the CFI, who really needs to be the one to say "Look, you really don't belong in a job flying paying customers with the skill level you are demonstrating." Most CFIs I know worry more about getting their students to pass a checkride.

For those that remember Tom Wolfe's book, aviation used to be about getting to the top of the pyramid. That necessarily meant washing out most, those who weren't the best. When you care more about paying as little as possible, and hiring those with minimum qualifications to do so, who is that going to attract long term?

A lifetime cap on checkride busts for part 121 would be a good thing in my opinion. Fair? Maybe not. But doctors here have a 3 strikes rule on malpractice, fair or not.

 

[drunkenbeagle]

Maybe it'd be good for everyone to read the last paragraph that appears at the bottom of all the MikeD Accident Analysis reports that I author for this site.

Have you ever thought off collecting them and writing a book? You would probably get to be on TV every time a Cessna lands on a golf course

 

[Cav]

I mean what are the alternatives to flying under extreme fatigue?

Not a stupid question at all. I can only speak for my company but it's really not a big deal. You call crew scheduling, tell them you are fatigued and you are removed from the trip. Once you've done that, company and union policy dictates that you fill out a report which will ask questions that pretain to the causes of fatigue (i.e. Schedule, sleep cycles, etc). This is non punitive (some will argue this point) and done for research reasons. I truly believe our system is excellent. If you are truthful, using the policy for the right reasons (not trying to get out of work), and show that you have made every attempt in your power to show up rested for work, you will never hear a word about it.

 

[MikeD]

Have you ever thought off collecting them and writing a book? You would probably get to be on TV every time a Cessna lands on a golf course

I'd be "that guy" they go to for the "so can you tell us exactly what happened??"; to where they'd get "you're seeing what I'm seeing, Bob".