Aftermath: The Mystery of Colgan Air 3407

Firebird2XC

Well-Known Member
From Flying Magazine:

http://www.flyingmag.com/safety/accident-investigations/aftermath-mystery-colgan-3407

June 2010 THE CRASH OF A COLGAN Air regional twin turboprop at Buffalo, New York, in February 2009, in which 50 people died, received an unusual amount of media scrutiny, in part because of what the National Transportation Safety Board’s report revealed about the captain’s history of failed flight checks and about the seemingly bizarre lifestyle of the first officer, who lived in Seattle, commuted across the country for work, slept when and where she could and was paid a bit more than $15,000 a year for her pains. But news reports and even an hourlong Frontline documentary aired by PBS on Feb. 9 did nothing to explain how a professional pilot could have made the amateurish mistake that caused the crash.

....
 
I remember reading they think the pilot thought he was iced up and it was a tail stall. Perhaps he over thought what was going on in the panic, and didn't look at the airspeed. I don't mean to armchair general the situation I wasn't there, but it seems like a reasonable possibility.
 
I read one report where the FO put the wrong weight and speed data into the computer, which further confused the issue of when the stall protection system would activate.

I might just be confusing my understanding of how the system works with corrections for anti-icing, but it would seem that a tired, uncoordinated, crew allowed a loss of overall situational awareness create a situation they were unprepared to deal with.
 
I remember reading they think the pilot thought he was iced up and it was a tail stall. Perhaps he over thought what was going on in the panic, and didn't look at the airspeed. I don't mean to armchair general the situation I wasn't there, but it seems like a reasonable possibility.

None of us were there...so we'll never know for certain. Your assessment is plausible; however, IMO I seriously doubt this is what happened.

Instead, (again simply my opinion from my experience) it was more a variety of factors ranging from fatigue, corporate culture, poor training, night IMC, incorrect stall recovery procedures and basic inattention to airmanship (to name a few) is where I think things went wrong. Lot's of problems....and it most certainly can not be blamed solely on pilot error. That's a cop out and 'simple' solution.....but there is much, much more than that.
 
I read one report where the FO put the wrong weight and speed data into the computer, which further confused the issue of when the stall protection system would activate.

I don't know about the Q's systems, but I would venture a guess they are similar to the CRJs. The stall protection system on the RJ only takes data from the AOA vanes, AHRS, Flap settings, weight on wheel sensors, and ADCs. So unless the Q is vastly different I don't see what putting a weight in would have anything to do with the SPS. Can one of the Q drivers add any input?
 
I don't know about the Q's systems, but I would venture a guess they are similar to the CRJs. The stall protection system on the RJ only takes data from the AOA vanes, AHRS, Flap settings, weight on wheel sensors, and ADCs. So unless the Q is vastly different I don't see what putting a weight in would have anything to do with the SPS. Can one of the Q drivers add any input?


The Embraer 145 is similar. There's not real outside input from the pilots unless you select a manual override of the anti-ice system- and that doesn't necessarily change the SPS, just the fact that surfaces get heated.

That's where my confusion sets in- I know beans about the boots on the Q400.
 
More speculation but I feel like he could have just been trying to avoid letting the people in the back know he messed up and just tried to hold altitude and get it back under control without having to push the nose over and go full power. And once he lost control he never was able to regain it. I just don't see that it was purely a lack of knowledge of how to handle/recover from a stall.
 
This article missed quite a few things such as how fatigue played its part in the accident, how the First Officer was sick, and the training of a tail plane stall.

Factor those three things together alone (as Cruise said there is A LOT more) set up a receipt for disaster.
 
This article missed quite a few things such as how fatigue played its part in the accident, how the First Officer was sick, and the training of a tail plane stall.

Factor those three things together alone (as Cruise said there is A LOT more) set up a receipt for disaster.


Agreed. I'm not entirely sure why the article spins it as a 'Mystery'.

The causal factors of fatigue in human error aren't new concepts.
 
The weights imputed to acars have nothing to do with the sps.

The only problem, if you input a weight that is way too light, you may get a shaker at speeds above ref.

I've said it before, the training and support was lacking. Sadly, we've not learned anything from this. Corporate culture still sucks, training has not gotten any better.

Rather than training weak areas found in pilots, we are starting to prohibit anything that could lead to certain situations. Rather than training pilots how to fly an approach on speed, they would rather just force us to use full flap landings. In their minds, if we are flying ref+20 as allowed in the profile, they will just slow down the actual gs by slowing the ref speed.

We are adding features to reduce noise and increase passenger comfort, then forcing a flap setting that buffets like a stall, floats like a boat in winds, and requires significantly more power on a longer approach, increasing ... Noise.

We keeping making changes to checklists, some which make no sense. We still have flows that look like a 5 yr old drew them. We have people makng these changes who have never flown 121 outside of Colgan, so they have no idea how it's normally done.

9l's safety drive consisted of safety audits, line checks, on site trainng etc. I personally have faced 16 jepoardy training events in the last 2 years. 2 recurrents ground schools, 5 pc's, 4 "observations", 5 line checks, 2 fed rides, losa audit. Not to mention emergency ice protection training, online Fom, winter ops, additional training, 1/2 crm class etc. Of course while this was going on, we were placed under a punative sick and fatigue policy, abusive scheduling dept, lots of new "sched" rules which do not help us.

None of this new "training" has taught me anything new about flying this airplane. It's just the same old stuff, more frequently now.

Maybe when all of our check airmen actually know what all the limitations and profiles are, it will get better... But guess what, we have another completely new set of profiles coming out soon... This will be the third set in less than 3 years. Untill then, I'll stick to my current vor/ rnav profile that has me overspeeding the flaps for 2 miles leading up to the final app. Fix.
 
I'm really dissappointed that fatigue wasn't a bigger part of the NTSB report. Those two pilots may not have been the top of the heap, but they both demonstrated many times to highly experienced evaluators, an understanding of stalls and demonstrated how to get out of them. It is clear in my mind that they were disoriented due in large part to fatigue. I believe that is why the entire sequence of events seems a mystery, fatigue can make you behave as if you were drunk.

It's time regulators got real about what causes fatigue. Low pay, high work load, little rest and bad company culture. At the time of the accident, almost every memo we got had the tag line "...up to and including termination". Tell me it isn't stress/fatigue inducing when day in and day you you are afraid for your job for the smallest of honest mistakes.

What forces someone to stay in crewrooms instead of a crashpad? (remember, this is a man trying to feed his family not a young single guy like me) what forces someone to commute from Seattle overnight and work sick just so she could recover in a hotel room? Now tell me pay had nothing to do with that!
 
Maybe when all of our check airmen actually know what all the limitations and profiles are, it will get better... But guess what, we have another completely new set of profiles coming out soon... This will be the third set in less than 3 years. Untill then, I'll stick to my current vor/ rnav profile that has me overspeeding the flaps for 2 miles leading up to the final app. Fix.

This is a prime example of why it is so hard to listen to these buffoons talk about professinalism. It is like being yelled at by a clown.
 
Same corporate culture lead to a new profile that had us stowing the reversers by 75 kts. The call out the PM makes is "80 knots." People, by the time he or she finishes the CALL you've busted the new speed. Nevermind the fact that a profile like that would DIRECTLY lead to people slamming the reversers closed as soon as they heard someone start talking. It would only be a matter of time before someone landed on a contaminated runway, head "80 kts," slammed the reversers closed and took the thing off-roading....again. Luckily, they changed the profile back after we made a stink about it.
 
Do people in your training department actually fly the plane at all, or what?

No. Our director of standards just started his O. E, fleet manager is typed and flew the line for a bit though.

Some did proving runs and stuff , but haven't touched one since. Mx controll pretty much has never actually seen one.

It's a joke. And then these people tell us how we are supposed to do it. I guess it also helps that we have RCPs that have never been a 121 pic before... And ground school instructors too for that matter.
 
The weights imputed to acars have nothing to do with the sps.

The only problem, if you input a weight that is way too light, you may get a shaker at speeds above

I think I'm missing something. I don't quite understand how both your statements could be correct. Is it because the V speeds would be set incorrectly?
 
With the low weights your 'ref' could be well below your real ref speed. So you fly at 'ref' but the shaker comes on at 'ref' plus a little, but had you flown at your real ref, no shaker.

Put the ref in the second one in air quotes and it should make sense.
 
With the low weights your 'ref' could be well below your real ref speed. So you fly at 'ref' but the shaker comes on at 'ref' plus a little, but had you flown at your real ref, no shaker.

Put the ref in the second one in air quotes and it should make sense.

that's what I thought, but then in my opinion the problem isn't the shaker going off above ref, but having your ref set incorrectly. The sps would be doing what it's designed for. I guess my brain just works a lil differently.
 
Interesting concepts at work here- the company scapegoats the crews and processes inane policies directed at snowing the Feds.


Are things getting any better in recent days for Colgan pilots? ie, are they still hammering you?
 
*uninformed perspective alert*

From watching the NTSB animation of the FDR, the events leading up to the stall look exactly like what I'd expect from a crew where the FO was worn out and sick and the captain was ready to be done with a long day. Power comes back, drag comes out, nobody pays enough attention to the airspeed... I've seen that before with myself flying fatigued and with students who were out of it. Same thing with the botched stall recovery-It looked like an attempt to follow the procedure from Q training but hampered by being behind the airplane and surprised that a stall could occur in that situation.
 
Back
Top