Final NTSB report on Colgan/CO 3407

My last recurrent for the beechjet we took the sim to full stall and held it there. With the thrust at idle and full aft pressure on the column, the airplane (sim) only came down at about 700 fpm but would "falling leaf", gain airspeed, climb a little, fall a little. To get out of it, I just ran the power levers to max and held what I had and the airplane powered out of it. The whole thing from start to finish (about 30 seconds worth of "deep stall") we only lost 1500 feet or so.

Saab sim isn't a whole lot different.
 
He did add power, actually almost immediately. Start at about 2:00 into the video. The entire sequence leading up to the upset looks to me like a textbook approach to stall in the sim.

Yes, but watch the artificial horizon. At the same time power is applied, the stick is held back until a 30 degree nose up attitude, with airspeed continuing to decay.
 
Also full power was never applied. If I remember right both engines were at about 80% throughout the whole thing after "power was applied". I also would not call a 1.5 G pullup, a "maintain altitude maneuver"
 
Yes, but watch the artificial horizon. At the same time power is applied, the stick is held back until a 30 degree nose up attitude, with airspeed continuing to decay.

Which is what I'm saying. The sim requires you to put a significant amount of backpressure into the control column to maintain the required pitch attitude when power is applied.
 
Also, if some of you guys haven't had a chance to do an approach to stall in IMC or simulated IMC (and no peeking!), it's an enlightening experience. I did one on a recent recurrent ride in the real airplane up at altitude. It can be very very disorienting.
 
I have a few questions/comments about the NTSB Findings.

11. The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.
12. The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.

...unless he was trying to power out of the stall and hold altitude. The power out was from an immanent stall (horn/shaker, right?) I never did full stalls in the turboprop or jet in the sim. Heck, for one drill we had to recover and gain 200 ft, not lose ANY. In the jet, I seem to recall that if you got the pusher, that was a bust (and the only REAL exposure we got to it). If you did everything right, you never really got to experience it. So now look at #35 and specifically the last part.

From a handy FAA publication:

"The principle of recency states that things most
recently learned are best remembered.
Conversely, the further a student is removed
time-wise from a new fact or understanding, the
more difficult it is to remember."

Aside from what people think about his primary training, if the 121 training for the 1900, 340, and the Q were "hold the nose up, apply power" which do you think would stick?

13. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.


...which is to also apply back pressure and raise flaps to the last position if they were just expended.

14. No evidence indicated that the Q400 was susceptible to a tailplane stall.

--...because....? Was this taught in the Colgan training? If it was, why run the NASA video (#38)?
--I'm sure the ATR operators thought it was ok up north prior to Roselawn, too?

15. Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.

...see #13. Ice was at the forefront of their minds.

35. The current air carrier approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall.

How does this jive with #11? Was the PF not performing the "not fully prepared" stall recovery procedure?

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.

...but might shed light on #13 and #15.


This may seem like a biased post, but that is not my intent. I am a little ticked at the NTSB for glossing over these issues and summarily dismissing the rest. Of course errors were made. That is not in question.

"8 runs and a check in the box -- get 'em on the line!"
How many FO's heard "You don't need to know that..." during indoc or systems? How can the FOs be a check for the CAs if they don;t know what they need to look out for?
 
I remember that night on 2-12-2009 I was at work at the line office under B20 at Dulles International (Now A20) And one of my coworkers comes up and said hey Colgan had a plane crash up in up in Buffalo I thought at first it was nothing serious (I was thinking it may had a runway skid at BUF) until I saw the news later that night Very sad night. :(
 
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.


True, but how many legs had he flown OUTSIDE of the sim? Either it wasn't a normal occurrence in regular line flying, or Colgan's Q400 FOs are afraid to speak up and get a dangerous CA off the line.

I'm not defending the CA's training record busts or the fact that he DID, in fact, fail to control the aircraft properly at a critical phase of flight. However, I know guys at my own airline that are good pilots but turn into gibbering goo in the sim.
 
Also, if some of you guys haven't had a chance to do an approach to stall in IMC or simulated IMC (and no peeking!), it's an enlightening experience. I did one on a recent recurrent ride in the real airplane up at altitude. It can be very very disorienting.

I can't imagine anyone doing stalls in actual IMC, never heard of that. You could get yourself into a bad situation very quickly. Now in Navy flight training, we put studs under the hood and put them in unusual attitude's IMC simulated. Of course the T-34 and T-6 are fully aerobatic, OCF, spin capable aircraft. I used to that in the T-2C as well. Of course in every FAM flight, the students did stall after stall. As IP's, we would stall the aircraft and let the aircraft depart and flip upside down to demonstrate would happen. But that's military flight training and done only in VMC conditions.
 
True, but how many legs had he flown OUTSIDE of the sim? Either it wasn't a normal occurrence in regular line flying, or Colgan's Q400 FOs are afraid to speak up and get a dangerous CA off the line.

I have no idea, and I know notihng about colgan politics either.

At least in the flying I do, it isn't a very common occurance for me to fly an ILS to minimums. And let's be honest, at 100 hours in type, flying half the legs, works out maybe 40 landings. So maybe 5 of those were in actual. And how much of that time was on AP?

No one is ever going to call someone else dangerous in this business. But I didn't see in any of the interviews glowing praise of stick and rudder skills either.

This isn't a personal dig at anyone, but it seems like a big training problem that needs to be adressed.
 
Didn't read the accident report; Don't really wish too.

That said, I can't help but wonder if the crew thought that it was a tailplane stall. Wasn't it snow and ice conditions that night? Food for thought.

ALPA is saying that the crew wasn't trained for such-and such a scenario My response is: If pilots were trained for every possible scenario, they'd never be out of training. Airlines hire experienced pilots because they have seen and done enough that they have the judgement to handle a situation that wasn't covered in training.

Al Haynes wasn't trained on a triple hydraulic failure. Neil Armstrong wasn't trained for a stuck thruster. These situations turned out a lot better than they could have because of their experience and judgment.
 
An error is an error. Assaulting the character or personality of the victims would be wrong - but questioning their actions, and criticising their actions if warranted are neccesary as part of the process.

I would state that the real tragedy, and the true insult to the crew, would be to not learn anything from this - including their mistakes. And I imagine that they would probably agree with that statement if they were here.

Just a bit late to this portion of the discussion, but I would PERSONALLY want people in the aviation community to discuss any error I may have made to expedite my demise in regards to operating an airplane. I would hope that SOMEONE would learn from my mistake and perhaps keep from making the same mistake. No one here is "disrespecting" the memory of the "person" and who they were...instead, it is a discussion about the "crew members" and the actions that they took or didn't take that night.

So for the record...if I put one down and don't live to tell about it...please discuss amongst yourself...it's all good...even if it's bad!
 
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.

I don't think a blanket policy for check ride busts is a good idea. I have taken two check rides and busted both of them on the first try. The first one was because I had never been trained on something(VOR tracking under the hood) but it was partially my fault because it was in the PTS. My second checkride(multi add on and FAA ride along) was because I didn't check the fuel cross feed which isn't part off my school's procedure. How do you account for exceptions? I have seen many people fail check rides on very small things.
 
#34. Colgan Air’s procedures and training at the time of the accident did not specifically require flight crews to cross-check the approach speed bug settings in relation to the reference speeds switch position; such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning.
My favorite of the bunch. Why the hell would you want guys trained or checking on that, you'll just "learn it on the line", right Ed Yarig? My favorite and often lamented catch phrase at the Colgan training/hair care/ballet/chinese/and tire center. Obviously when Colgan put out the memo describing it's use and that someone should be responsible for the switch position in the cockpit that fixed everything. No one had any trouble with that afterwards.

Edit: I forgot to put "all righty" at the beginning and end of every sentence.
 
At least in the flying I do, it isn't a very common occurance for me to fly an ILS to minimums. And let's be honest, at 100 hours in type, flying half the legs, works out maybe 40 landings. So maybe 5 of those were in actual. And how much of that time was on AP?

I've done more than 5 approaches in actual in one trip before. It's not unheard of.

No one is ever going to call someone else dangerous in this business. But I didn't see in any of the interviews glowing praise of stick and rudder skills either.

Why not? I've called pro stands on a CA that I thought was gonna get me killed before.
 
http://www.youtube.com/watch?v=lxywEE1kK6I

He did add power, actually almost immediately. Start at about 2:00 into the video. The entire sequence leading up to the upset looks to me like a textbook approach to stall in the sim.

Maybe I am missing it but I dont see any trim indications in the video. I would imagine the autopilot had trimmed quite a bit nose up in order to hold altitude at such low speeds, so as soon as the captain would have put the power levers forward wouldn't the grossly over powered engines have aided in that 30 degree nose up attitude. I am not denying the fact that he pulled back, i am just thinking it looks a lot like a trim stall or what ever that was called from private days
 
Maybe I am missing it but I dont see any trim indications in the video. I would imagine the autopilot had trimmed quite a bit nose up in order to hold altitude at such low speeds, so as soon as the captain would have put the power levers forward wouldn't the grossly over powered engines have aided in that 30 degree nose up attitude. I am not denying the fact that he pulled back, i am just thinking it looks a lot like a trim stall or what ever that was called from private days

Perhaps, but I don't see that considering the engines are mounted above the CG. If anything, a trim setting too far aft would have helped the natural pitch-down tendency of the airplane under power.

Disclaimer: I don't fly a Q400; I'm just going off of basic physics here.
 
No one is ever going to call someone else dangerous in this business.


My old man had a list of NWA colleagues back in the day. If they were driving, we didn't get on that airplane.

I've called Captains to task on more than one occasion. I'm as unoffensive as I can be about it- there's a thin line between the duty of the FO to correct the CA and mutiny. I am, however assertive when I have to be.

That being said, the phrase, "I really don't feel comfortable about this," is usually all it takes.


I have had to 'talk it out' with a few CAs in level cruise, or politely demand a pause before we pushed off the gate, but those were exceptions.

It's really that simple. It's not some Top Gun-esque shouting match in the shower yelling "You're DANGEROUS!" It's just a matter of noting that the CDI on the 'Safety Meter' is a little too far off center to be cool with you.

Address it, discuss it, and move on. I've yet to see a Captain that wouldn't reign it in if I had a legitimate objection, and I don't really tend to go around objecting to random things.

I've seen it personally in the military and in two different airline cultures.

The most dangerous thing a cockpit crewmember with a lax or cavalier attitude can bring with them is another crewmember that doesn't speak up.
 
I will never keep my mouth shut in the cockpit if I feel my CA us doing something unsafe. Hell I've had to play instructor(I'm not a CFI) and literally walk through an approach or soemthing like that. It happens. Just because the guy is in the left seat doesn't mean a damn thing. I had worse luck than the poster above the CA was always "right" no matter what which made it difficult but I think when you have 2 different pilots in the cockpit you're gonna have some things you don't agree on safety wise.
 
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