Colgan 3407 afterthoughts

rockman2343@aol.com said:
There won't be another accident like this one because the cause was so elementary.
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I would argue that there are essentially no "new" causes for accidents in aviation...only repeats of mistakes and failures that have all ready occurred.

Never underestimate the ability of humans to react wrong under pressure or to the element of surprise. Since there is a constantly-renewing cadre of pilots, these same "new" experiences will be recycled until humans are no longer performing these roles.

We try and learn from past mistakes, and are largely successful, but...
 
Seggy said:
Ever hear of Air France 447 and Asiana 214?

Now, why don't you rethink what you typed...
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No.
Air France started with a pitot issue,at high altitude. Asiana from what I understand was due to a lack of understanding of the automation. Neither of which is excusable but there was much more to it.
3407 was simply we got to slow and applied the wrong recovery procedure. Yeah they were tired, but maybe it's me but I can't imagine being so tired that you don't know to reduce angle of attack in a stall.
 
rockman2343@aol.com said:
I can't imagine being so tired that you don't know to reduce angle of attack in a stall.
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More than once, highly experienced aviators, when faced with a face-full of earth in a stall, have pulled the stick/yoke well past the point of maximum performance of the wing.

It is a very natural reaction when terra firma is coming up at you, even if it isn't academically the correct thing.
 
Hacker15e said:
I would argue that there are essentially no "new" causes for accidents in aviation...only repeats of mistakes and failures that have all ready occurred.

Never underestimate the ability of humans to react wrong under pressure or to the element of surprise. Since there is a constantly-renewing cadre of pilots, these same "new" experiences will be recycled until humans are no longer performing these roles.

We try and learn from past mistakes, and are largely successful, but...
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That's one good aspect of the ATP-CTP course that I sat through not to long ago. We review a lot of those accidents. Of course, many mistakes are not made today because they were made by somebody in the past and became lessons learned for us.
 
Hacker15e said:
More than once, highly experienced aviators, when faced with a face-full of earth in a stall, have pulled the stick/yoke well past the point of maximum performance of the wing.

It is a very natural reaction when terra firma is coming up at you, even if it isn't academically the correct thing.
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Yes you are correct. This aircraft however was straight and level when he first pulled back on the yoke. A face full of earth may have caused the final two pulls, but not the first one that caused the initial stall. In my opinion.
 
USMCmech said:
So far, the one CA I've flown with that actually had me worried about his disregard for SOP and procedure was in his late 50s, seniority #9 in the company and had been at Mesa since the early 90s. Taxing through the ramp like a bat out of hell, and checking your cell phone while taking the runway is not cool*.

Meanwhile, most of the recent upgrade guys are very safety conscious and have shown remarkable discipline for following SOP.


* Yes, I said something to him personally and also to pro standards. I was covering the brakes the whole trip because I was legitimately worried we might hit something.
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(Some) Regional lifers are a wet fart waiting to happen.
 
JetDoc said:
Come on guys, give it a rest already. We get it. 99% of us are gonna fold like a house of cards when something goes wrong. We get it, move along. Find another dead horse to beat.
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Not at all.
The truth is that errors occur on almost every flight, usually they are minor. The concept behind TEM or Threat Error Management is to recognize this and implement procedures to hopefully catch the errors or, worst case, if the error leads to a UAS (Undesired Aircraft State), give the pilots training to recognize and recover from the UAS. As an example, this lead to changes to procedures at some airlines with stabilized approaches- requiring stabilized approaches by a certain altitude and not just implementing the standards for them but requiring the pilots to state "stable" at 1000' and 500'. As a poor example the Colgan pilots were given minimal stall recovery training and made some poor choices when they encountered that scenario.
The problem becomes what happens when pilots don't know what they don't known or get into that phase where they think they are indestructible. I guess my back ground as a RW and aerobatic pilot gives me the paranoid outlook where I wonder before every flight, "What can go wrong?" Probably helps that several classmates made smoking holes in the ground when we were still LTs. That tends to make you evaluate your infallibility.
So do hours alone matter? No. What matters is what you learned from those hours. Do you have 8000 hours or 1 hour 8000 times?
Do I have the answers? No. Am I above mistakes? I wish. My hope, and even my prayer before every trip is, "God, don't leg me f- up. If I do, don't let me cost anyone but me their life."
 
rockman2343@aol.com said:
Yes you are correct. This aircraft however was straight and level when he first pulled back on the yoke. A face full of earth may have caused the final two pulls, but not the first one that caused the initial stall. In my opinion.
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Last November, B&CA has this article on the subject, and the month before had this one on decision making.

"Of course this method only works when the decision-maker has the necessary background and experience."

Because of deficiencies in training, lack of experience in type and that environment, "they didn't know what they didn't know."
 
rockman2343@aol.com said:
There won't be another accident like this one because the cause was so elementary. A pilot pulled back on the yoke at the first sign of the stick shaker, and then did it again three times. Who does that? Yes there were contributing factors, fatigue, chatter below ten etc. For all the analysis, and attention that this accident got, it comes down to one of the most fundamental aspects of flying, something we are exposed to in lesson one two or three, and have to be able to handle by our first solo.

The best thing that came out of this is now airlines take a closer look at failures, as this guy had multiple issues with aircraft handling throughout his flying career.
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You clearly don't understand anything about what happened with 3407, and true be told because of the lack of talking in the cockpit during the upset we really don't know what he was thinking. Was he a weak pilot? Yea, and I don't think any one would say he wasn't, but let's not let Colgan and the FAA off the hook that easily. There were gaps in the systems training, and sim training that the FAA signed off on. That kind of crash was going to happen, it wasn't a question of if but of when. 3407's number just came up.
 
rockman2343@aol.com said:
There won't be another accident like this one because the cause was so elementary. A pilot pulled back on the yoke at the first sign of the stick shaker, and then did it again three times. Who does that? Yes there were contributing factors, fatigue, chatter below ten etc. For all the analysis, and attention that this accident got, it comes down to one of the most fundamental aspects of flying, something we are exposed to in lesson one two or three, and have to be able to handle by our first solo.

The best thing that came out of this is now airlines take a closer look at failures, as this guy had multiple issues with aircraft handling throughout his flying career.
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https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701

http://forums.jetcareers.com/threads/psa-crj-incident.168568/ (this one didn't result in a crash, but certainly looked a lot like the Pinnacle set up)

http://abcnews.go.com/Travel/plan-stalls-mid-flight-faa-slaps-skywest-altitude/story?id=32452209 (again, not an accident, but same setup)

I'd be very reluctant to say it can't happen again. This was what I could pull from memory. Two of the three are AFTER the Colgan crash.
 
msmspilot said:
https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701

http://forums.jetcareers.com/threads/psa-crj-incident.168568/ (this one didn't result in a crash, but certainly looked a lot like the Pinnacle set up)

http://abcnews.go.com/Travel/plan-stalls-mid-flight-faa-slaps-skywest-altitude/story?id=32452209 (again, not an accident, but same setup)

I'd be very reluctant to say it can't happen again. This was what I could pull from memory. Two of the three are AFTER the Colgan crash.
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This is what I find most disturbing about this thread. The "it can't happen to me" "it's so easy a caveman can do it" attitude about 121 flying. I'm not in training, yet I've seen enough FOQA results to make my hair stand on end. The only thing that saved the crews in every case was the recognition that they screwed up and an immediate focus on getting out of the UAS. It is an easy job... until it isn't.
 
Gonzo said:
You clearly don't understand anything about what happened with 3407, and true be told because of the lack of talking in the cockpit during the upset we really don't know what he was thinking. Was he a weak pilot? Yea, and I don't think any one would say he wasn't, but let's not let Colgan and the FAA off the hook that easily. There were gaps in the systems training, and sim training that the FAA signed off on. That kind of crash was going to happen, it wasn't a question of if but of when. 3407's number just came up.
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Alright you win. Having flown the Dash, read the report several times, recently, I don't know anything about what happened. Because of poor training, lack of sleep, it's perfectly understandable that an airline pilot, induced a stall and couldn't recover. Come on.

No one is letting Colgan or the FAA of the hook, and an accident was probably bound to happen. But an airline pilot pulling in response to a stick shaker? Im willing to bet you put most new commercial pilots in there, show them where the yoke and the power lever is, keep them up for 24 hours, and they'd still recover. This was that basic.
 
msmspilot said:
https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701

http://forums.jetcareers.com/threads/psa-crj-incident.168568/ (this one didn't result in a crash, but certainly looked a lot like the Pinnacle set up)

http://abcnews.go.com/Travel/plan-stalls-mid-flight-faa-slaps-skywest-altitude/story?id=32452209 (again, not an accident, but same setup)

I'd be very reluctant to say it can't happen again. This was what I could pull from memory. Two of the three are AFTER the Colgan crash.
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You are citing one accident in which the pilot's were fooling around, an incident where the plane stalled, but the crew RECOVERED. There's no report on the PSA one so I don' t know what happened there, but apparently they must've recovered from the stall, which at high altitude, which is not 100% the same as low altitude.

Idk, maybe I shouldn't say can't happen, but I think is unlikely. Every other accident cited here had some other factor leading up to the stall (messing around, the flaps, pitot tubes icing up). Especially with all the attention and the increase in stall training, I don't think we'll see it again, a pilot inducing a stall while in straight and level flight, at low altitude.
 
rockman2343@aol.com said:
You are citing one accident in which the pilot's were fooling around, an incident where the plane stalled, but the crew RECOVERED. There's no report on the PSA one so I don' t know what happened there, but apparently they must've recovered from the stall, which at high altitude, which is not 100% the same as low altitude.

Idk, maybe I shouldn't say can't happen, but I think is unlikely. Every other accident cited here had some other factor leading up to the stall (messing around, the flaps, pitot tubes icing up). Especially with all the attention and the increase in stall training, I don't think we'll see it again, a pilot inducing a stall while in straight and level flight, at low altitude.
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In the Pinnacle accident and the PSA incident, the pilots pulled against a pusher. 121 level, airline pilots not recognizing and avoiding a stall, and then doing the exact opposite of what was required to recover. The difference between Pinnacle and PSA was that the Pinnacle crew lost both engines and the PSA crew only lost one. While you're correct that a high altitude stall and a low altitude stall are different, you still have shakers, pushers, and other alerting devices that should let the crew know they're approaching a situation where pulling is not the answer.

As far as "some other factor," yeah, every accident has some other factor. Show me one accident ever where you can't say, "Yeah, X is technically the cause of the crash, but if Y didn't happen, they never would have been there."

It is the height of arrogance to think that it can't ever happen again and to think it can't happen to you. On your "normal" days, you're right. We're probably all better pilots than that. But did you really get good sleep last night at that hotel by the interstate/where the local high school soccer tournament was staying? How stressful was the day? Now you're delayed, taking an extension, and frustrated with the day. Are you still 100% sure you're above all these petty, human mistakes? I'm not.

@Hacker15e has posted in this thread and in others about the human factors he saw in the military. When stuff hits the fan, the best pilots with the best training can still be human. That's why we train over and over.
 
rockman2343@aol.com said:
Alright you win. Having flown the Dash, read the report several times, recently, I don't know anything about what happened. Because of poor training, lack of sleep, it's perfectly understandable that an airline pilot, induced a stall and couldn't recover. Come on.

No one is letting Colgan or the FAA of the hook, and an accident was probably bound to happen. But an airline pilot pulling in response to a stick shaker? Im willing to bet you put most new commercial pilots in there, show them where the yoke and the power lever is, keep them up for 24 hours, and they'd still recover. This was that basic.
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First the 100/200/300 is nothing like the 400. I guess a few things you missed in all your reading was the Colgan stall profile was to power out of a stall, and I guess you also missed the part about a few of the CA busted rides were because altitude loss on his stall recovers. Add in the law of primacy and you have a recipe for disaster. You must have also missed the fact that crews didnt train on the use of the ice switch and most didn't understand how it changed some systems. Maybe you also missed the fact that they bugged non-ice speeds and had the ice switch on. I willing to bet you also missed that Fed that signed off the books was friends with the senator.
 
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rockman2343@aol.com said:
You are citing one accident in which the pilot's were fooling around, an incident where the plane stalled, but the crew RECOVERED. There's no report on the PSA one so I don' t know what happened there, but apparently they must've recovered from the stall, which at high altitude, which is not 100% the same as low altitude.

Idk, maybe I shouldn't say can't happen, but I think is unlikely. Every other accident cited here had some other factor leading up to the stall (messing around, the flaps, pitot tubes icing up). Especially with all the attention and the increase in stall training, I don't think we'll see it again, a pilot inducing a stall while in straight and level flight, at low altitude.
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https://en.m.wikipedia.org/wiki/West_Caribbean_Airways_Flight_708

Stalled while climbing on autopilot, Captain held the nose up all the way in to the ground.

And it will happen again.
 
Gonzo said:
First the 100/200/300 is nothing like the 400. I guess a few things you missed in all your reading was the Colgan stall profile was to power out of a stall, and I guess you also missed the part about a few of the CA busted rides were because altitude loss on his stall recovers. Add in the law of primacy and you have a recipe for disaster. You must have also missed the fact that crews didnt train on the use of the ice switch and most didn't understand how it changed some systems. Maybe you also missed the fact that they bugged non-ice speeds and had the ice switch on. I willing to bet you also missed that Fed that signed off the books was friends with the senator.
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Nothing like a 400? Ok. I didn't miss any of that. Infact if he had powered out of it, he would have likely been ok, especially since the ice switch was on. The plane was not stalled and even with the stall recovery procedures of the time, it was a completely recoverable situation. But he pulled back on the yoke. Was Colgan teaching him that?

As for his training failures I guess you missed that there was more going on with him then just altitude loss on a stall.
 
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