NTSB - Colgan 3407 Follow-Up
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Center_Mid
Well-Known Member
Until I watched the NTSB animation, one thing I never understood was how airspeed could deteriorate so quickly without pilot reaction until it was too late. I'd always sort of assumed that there was a safety margin built in to approach speeds, especially with icing. Something like Vref plus 15 or 20. It wasn't until I saw the animation that I understood just how fast the airspeed bled off after the flaps were lowered to 15. Holy crap. There seemed to be little margin for error. It seems like either you have to be right on top of the airspeed or you're in major trouble fast.
Also, at 2,300 MSL, did they have much room to push the nose over for a recovery? It's certainly enough for a C172, but a Q400? I know nothing of these things. I thought that maybe the CA's reaction was due to the low altitude AGL. Maybe he was worried about terrain or obstacle clearance. Sure, stall recovery in a 172 involves pushing the nose over, but at 2300 in a transport category a/c, I suspect that stall recovery is a bit more complicated. Could he have reasoned that overriding the pusher was important because the pusher didn't have enough altitude to recover airspeed? Again, I have no 121 or Q400 experience. Just thinking out loud.
Also, at 2,300 MSL, did they have much room to push the nose over for a recovery? It's certainly enough for a C172, but a Q400? I know nothing of these things. I thought that maybe the CA's reaction was due to the low altitude AGL. Maybe he was worried about terrain or obstacle clearance. Sure, stall recovery in a 172 involves pushing the nose over, but at 2300 in a transport category a/c, I suspect that stall recovery is a bit more complicated. Could he have reasoned that overriding the pusher was important because the pusher didn't have enough altitude to recover airspeed? Again, I have no 121 or Q400 experience. Just thinking out loud.
Bumblebee
Commodore
Great way to analyze and think about things.
I know that if I ask for flaps, unless I want to slow and have planned for the natural reduction of airspeed, I am adding power as the flaps go down. It really is something how on a level off on step downs, you will drain off a/s very quickly.
SurferLucas
Southern Gentleman
The Q400 has plenty of power to get itself out of a stall. If you stalled at Flaps 15/Gear Down...going to the Rating Detent and getting 90% trq would be plenty to get it out of the stall. (Just from my experience stalling the airplane in the simulator)
ctab5060X
Well-Known Member
Your posts have been very insightful in helping understand the Q400.
Would you mind adding something about the way the airplane (and instrument indications if possible) reacts (speed, pitch, etc.) to configuration changes on a normal ILS approach?
SurferLucas
Southern Gentleman
The Q400 is fairly easy to slow down...say on a downwind for SEA at 10,000, we'll get a descent to 7000. You can go Flight Idle and use about 1800-2100 fpm down to maintain 245 KIAS (Redline at 8,800ft or so).
Level off and about 28/30% trq will give you a 190-200 KIAS speed for Flaps 5 and Gear Down (both 200 KIAS). When we call for "Gear Down, Landing Checklist" this is where we set the condition levers for Max. We can do Reduced NP (RNP) or Normal NP. Difference is that with RNP, you can still have the props at 850RPM's and the condition levers at max...in the event of a go around, as soon as you press the TOGA button it goes to Normal NP. It's all computer controlled. Normal NP is 1020RPM and the airplane will slow if you simply push the condition levers to max without using RNP.
Flaps 10 is 181 KIAS
Flaps 15 is 172 KIAS
Flaps 35 is 158 KIAS
The biggest pitch change comes with Flaps 35. If you've ever flown a 182RG with Flaps 40...when you go from Flaps 20 to Flaps 40...and it feels like you've put barndoors out...same type feeling in the Q4.
The plane autotrims for this, but I find it's easier just to use the electric trim and reduce trq to 8/10%.
Level off and about 28/30% trq will give you a 190-200 KIAS speed for Flaps 5 and Gear Down (both 200 KIAS). When we call for "Gear Down, Landing Checklist" this is where we set the condition levers for Max. We can do Reduced NP (RNP) or Normal NP. Difference is that with RNP, you can still have the props at 850RPM's and the condition levers at max...in the event of a go around, as soon as you press the TOGA button it goes to Normal NP. It's all computer controlled. Normal NP is 1020RPM and the airplane will slow if you simply push the condition levers to max without using RNP.
Flaps 10 is 181 KIAS
Flaps 15 is 172 KIAS
Flaps 35 is 158 KIAS
The biggest pitch change comes with Flaps 35. If you've ever flown a 182RG with Flaps 40...when you go from Flaps 20 to Flaps 40...and it feels like you've put barndoors out...same type feeling in the Q4.
The plane autotrims for this, but I find it's easier just to use the electric trim and reduce trq to 8/10%.
AngelFuree
Well-Known Member
Having read the transcript of the CVR and seeing the NTSB's video of the FDR, I can agree with those who believe the cause of the accident to be pilot error.
I do find some posts interesting in this thread, however.
It almost seemed as if one of the factors involved was possible distraction in part by both pilots whether fatigue or lack of a sterile cockpit caused such distractions.
At no point in time does it appear that either CA or FO make mention of the decreasing trend in airspeed (regardless of what caused such decrease in IAS). I'm sure it's happened to you before when you've flown and either your FO or CA has called you out on any abnormal trends. It appears both were not monitoring the aircraft attentively, otherwise one would have called out the abnormal trend especially in this instance where no increase in power was ever made with consecutive config changes (gear down and flaps down).
There have been instances before where I'll call out, "speed," while the captain was PF and quickly approaching an overspeed in cruise. The same can be said when I've been flying (e.g. requesting for flaps when too fast, etc.) It can happen to any of us where we'll doze off and not pay attention to the instruments. It's the whole reason for having a two-crew environment. We watch each other's backs.
However, when fatigue comes into play or even basic conversation, one can "forget" to continously monitor the instruments and it almost seemed like this was the case with this flight as it approached a stall.
Something else I found interesting was someone's post earlier regarding the possibility of the captain's judgement in the type of stall occurring. It almost seems as if this may have been the case where the captain misinterpreted the stall to be a tailstall.
One thing to note, however, is the the conversation about icing between the CA and FO may have put the captain into a different mode of thinking....almost as if it set him up for an expectation that icing = tailstall = reactionary recovery by pulling as hard as you can on the yoke. (indicative of the extreme high pitch attitude as seen on the NTSB video) Too bad we will never know exactly what was going through his mind at that time...
Maybe he never considered the approaching stall and decreasing airspeed to be caused by the lack of power and instead concluded immediately it was icing that caused it.
I'm obviously speculating, but that's the feeling I've gotten so far.
It really gave me chills when I watched the NTSB video. There's a lot to be learned from this accident.
I do find some posts interesting in this thread, however.
It almost seemed as if one of the factors involved was possible distraction in part by both pilots whether fatigue or lack of a sterile cockpit caused such distractions.
At no point in time does it appear that either CA or FO make mention of the decreasing trend in airspeed (regardless of what caused such decrease in IAS). I'm sure it's happened to you before when you've flown and either your FO or CA has called you out on any abnormal trends. It appears both were not monitoring the aircraft attentively, otherwise one would have called out the abnormal trend especially in this instance where no increase in power was ever made with consecutive config changes (gear down and flaps down).
There have been instances before where I'll call out, "speed," while the captain was PF and quickly approaching an overspeed in cruise. The same can be said when I've been flying (e.g. requesting for flaps when too fast, etc.) It can happen to any of us where we'll doze off and not pay attention to the instruments. It's the whole reason for having a two-crew environment. We watch each other's backs.
However, when fatigue comes into play or even basic conversation, one can "forget" to continously monitor the instruments and it almost seemed like this was the case with this flight as it approached a stall.
Something else I found interesting was someone's post earlier regarding the possibility of the captain's judgement in the type of stall occurring. It almost seems as if this may have been the case where the captain misinterpreted the stall to be a tailstall.
One thing to note, however, is the the conversation about icing between the CA and FO may have put the captain into a different mode of thinking....almost as if it set him up for an expectation that icing = tailstall = reactionary recovery by pulling as hard as you can on the yoke. (indicative of the extreme high pitch attitude as seen on the NTSB video) Too bad we will never know exactly what was going through his mind at that time...
Maybe he never considered the approaching stall and decreasing airspeed to be caused by the lack of power and instead concluded immediately it was icing that caused it.
I'm obviously speculating, but that's the feeling I've gotten so far.
It really gave me chills when I watched the NTSB video. There's a lot to be learned from this accident.
jtrain609
Antisocial Monster
Re: Pilots' low pay, long commutes probed in air crash
I ain't passed the bar but I know a little bit, enough that I've seen a little bit more of the pie than you.
Ain't much, but it's enough to know that Justin is 100% correct; there are times when a 400 mile commute IS worse than a 3,000 mile commute, and having done both, I've seen the differences. I've had to go do DTW-EWR for a little while, and while it was *generally* easier, when there were ground stops going into EWR it ruined your day, and your commute. While SLC-EWR generally sucked HARD because of the long distances required, those flights almost never had delays. EWR had no way of knowing how long the flow control was going to last, and they never figured 4.5 hours, so they simply launched the plane and held it if need be. When you're as close as Detroit, they'll hold you on the ground for what seems like days, and a 1.5 hour commute turns into a 12 hour commute real fast.
I ain't passed the bar but I know a little bit, enough that I've seen a little bit more of the pie than you.
Ain't much, but it's enough to know that Justin is 100% correct; there are times when a 400 mile commute IS worse than a 3,000 mile commute, and having done both, I've seen the differences. I've had to go do DTW-EWR for a little while, and while it was *generally* easier, when there were ground stops going into EWR it ruined your day, and your commute. While SLC-EWR generally sucked HARD because of the long distances required, those flights almost never had delays. EWR had no way of knowing how long the flow control was going to last, and they never figured 4.5 hours, so they simply launched the plane and held it if need be. When you're as close as Detroit, they'll hold you on the ground for what seems like days, and a 1.5 hour commute turns into a 12 hour commute real fast.
jtrain609
Antisocial Monster
Re: Pilots' low pay, long commutes probed in air crash
Ok and here's another reason why having even a year at a regional and getting the crap kicked out of you a little bit is good for your perspective.
Until you've been on your second 16 hour day in a 56 or so hour period, you have no idea what kind of horrible decisions and reactions you will make. I've had a few times where I was just fighting to stay awake on that last leg at oh dark thirty, after I'd been up about 18 hours after getting my 5 hours of completely legal sleep, and I'd do something and immediately look at the switch I just threw and say, "WTF? Why did I do that?" Sometimes I wouldn't even realize the mistake.
Until you're in that situation, where you're so seriously fatigued you're probably getting out of the plane based more on good luck of everything going properly than skill of being able to hack any problem that comes your way, you don't know what it's like. Have I seen it year in, year out for decades? No, but it only takes a few times of this happening to realize that fatigue will kill you faster than just about anything.
Cross country commute? Again, some suck, some don't. I knew a guy that was doing a three legger from the west coast to Cleveland; that commute sucked. As just also pointed out, BGR-EWR is one of the hardest commutes in the system, and could well take you longer to do than one from Europe. So to say all long commutes are horrid shows a lack of experience in the arena of commuting and fatigue manamgent. I'm not saying you guys can't have your opinions, but as with most things in life, until you've actually been there and done that, it's hard to understand the nuances of what's involved.
And that's really what we're discussing, because so much of this activity (flying), and career (being an airline pilot) is incredibly nuanced. Having a private pilot attack these guys because they "just didn't do the stall recovery procedure correctly" is no different than the media attacking these pilots for the same reason. Now I'm sitting here saying to myself "Jesus, why DIDN'T they just fly out of the stall, it shouldn't have been a big deal," but then I have to look at what their body clocks were going through and then I start to say to myself, "Oh wow this is just like that one time going into X where I did Y and we were all lucky things worked out, because the captain fell asleep three times on that leg and was just as useless as me."
This crash isn't as simple as "not being trained on a stick pusher," or "they commuted too far," or, "they were both horrible pilots because they lost track of their airspeed." If you're saying that, you're saying YOU have never made a mistake up there, and if you're saying that, to borrow the incredibly cliche line, you're dangerous. If you think you're that invincible so as to never make a very, very, very basic mistake that can (and has, and will continue to) kill you, then you're either incredibly arrogant or incredibly niave, both of which will get you hurt.
These guys screwed up and killed 50 people for it, but don't think for a second that you're beyond the bounds of letting it happen to you, because I've had that theory pulled out from under me time and time again.
Ok and here's another reason why having even a year at a regional and getting the crap kicked out of you a little bit is good for your perspective.
Until you've been on your second 16 hour day in a 56 or so hour period, you have no idea what kind of horrible decisions and reactions you will make. I've had a few times where I was just fighting to stay awake on that last leg at oh dark thirty, after I'd been up about 18 hours after getting my 5 hours of completely legal sleep, and I'd do something and immediately look at the switch I just threw and say, "WTF? Why did I do that?" Sometimes I wouldn't even realize the mistake.
Until you're in that situation, where you're so seriously fatigued you're probably getting out of the plane based more on good luck of everything going properly than skill of being able to hack any problem that comes your way, you don't know what it's like. Have I seen it year in, year out for decades? No, but it only takes a few times of this happening to realize that fatigue will kill you faster than just about anything.
Cross country commute? Again, some suck, some don't. I knew a guy that was doing a three legger from the west coast to Cleveland; that commute sucked. As just also pointed out, BGR-EWR is one of the hardest commutes in the system, and could well take you longer to do than one from Europe. So to say all long commutes are horrid shows a lack of experience in the arena of commuting and fatigue manamgent. I'm not saying you guys can't have your opinions, but as with most things in life, until you've actually been there and done that, it's hard to understand the nuances of what's involved.
And that's really what we're discussing, because so much of this activity (flying), and career (being an airline pilot) is incredibly nuanced. Having a private pilot attack these guys because they "just didn't do the stall recovery procedure correctly" is no different than the media attacking these pilots for the same reason. Now I'm sitting here saying to myself "Jesus, why DIDN'T they just fly out of the stall, it shouldn't have been a big deal," but then I have to look at what their body clocks were going through and then I start to say to myself, "Oh wow this is just like that one time going into X where I did Y and we were all lucky things worked out, because the captain fell asleep three times on that leg and was just as useless as me."
This crash isn't as simple as "not being trained on a stick pusher," or "they commuted too far," or, "they were both horrible pilots because they lost track of their airspeed." If you're saying that, you're saying YOU have never made a mistake up there, and if you're saying that, to borrow the incredibly cliche line, you're dangerous. If you think you're that invincible so as to never make a very, very, very basic mistake that can (and has, and will continue to) kill you, then you're either incredibly arrogant or incredibly niave, both of which will get you hurt.
These guys screwed up and killed 50 people for it, but don't think for a second that you're beyond the bounds of letting it happen to you, because I've had that theory pulled out from under me time and time again.
BajtheJino
I'm looking at you.
Agreed. Until he's bought and paid for his job he knows nothing.
But then again the crash was pilot error.
Arrogant. You bet'cha. Is there anyone on this planet that can stand to be in the same room with you? Or do you reserve the tough guy act for the internet?
Doing a couple of 16 hour days a week if even that many is whats called working in this country. You can talk about how many people you've got on board (flying freight is nothing like flying people?) and how (dramatic) their very lives are in your hands...if you can't hand fly it down let the autopilot. I don't think any of us truly appreciate what a "hard days work" is. But then again, the ones that bitch the most are also the same ones that bragged the loudest when they got the jobs. A gig as a flight instructor and then a few months at a regional hardly qualifies anyone to be the loudest expert on the situation.
Remember boys and girls, you put the gear down with flaps-add power.
Dale, I was thinking similar thoughts yesterday:
http://forums.jetcareers.com/airline-pilots/87816-3407-public-hearing-2.html#post1179483
CoffeeIcePapers
Well-Hung Member
Re: Pilots' low pay, long commutes probed in air crash
Yes, but you are an adult. You made the decision to live out of base and to take the job. It sounds like a pretty crappy QOL to me. Obviously, you didn't enjoy it much, or you wouldn't be going to law school.
I agree with 99% of what you are saying, especially the bolded part. I just took issue with the snide one-liner. I know I have made mistakes, but that is life. Hopefully, I never make mistakes that takes my life and the lives of other people. To remove the responsibility from the pilots and their actions does everyone in the industry a disservice. With the press this is getting, maybe it will put an end to zero to hero outfits and make the QOL better for pilots.
Yes, but you are an adult. You made the decision to live out of base and to take the job. It sounds like a pretty crappy QOL to me. Obviously, you didn't enjoy it much, or you wouldn't be going to law school.
I agree with 99% of what you are saying, especially the bolded part. I just took issue with the snide one-liner. I know I have made mistakes, but that is life. Hopefully, I never make mistakes that takes my life and the lives of other people. To remove the responsibility from the pilots and their actions does everyone in the industry a disservice. With the press this is getting, maybe it will put an end to zero to hero outfits and make the QOL better for pilots.
jtrain609
Antisocial Monster
Re: Pilots' low pay, long commutes probed in air crash
You really think that?
Ask your chief pilot about me going to law school, he actually knows me, unlike you. It has little do to with crappy QOL (we could have moved back to Michigan and had better, which is exactly what we're doing), and lots more to do with me wanting to do something with my life more than fly airplanes.
You really think that?
Ask your chief pilot about me going to law school, he actually knows me, unlike you. It has little do to with crappy QOL (we could have moved back to Michigan and had better, which is exactly what we're doing), and lots more to do with me wanting to do something with my life more than fly airplanes.
Orange Anchor
New Member
Re: Update on 3407
were that it was so simple. There are so many issues with this crash that are going to come to light that this is going to have EVERYONE running for cover.
Training, checkrides, oversight, FAA, fatigue, scheduling, commuting, sleep requirements, record keeping.
Simple pilot error? Not by a long shot.
were that it was so simple. There are so many issues with this crash that are going to come to light that this is going to have EVERYONE running for cover.
Training, checkrides, oversight, FAA, fatigue, scheduling, commuting, sleep requirements, record keeping.
Simple pilot error? Not by a long shot.
CoffeeIcePapers
Well-Hung Member
Re: Update on 3407
Those are all contributing factors. Like I posted above, maybe some of this gets addressed with the press this is getting. I am sure you and everyone else knows about the "chain of events" that leads to accidents.
Those are all contributing factors. Like I posted above, maybe some of this gets addressed with the press this is getting. I am sure you and everyone else knows about the "chain of events" that leads to accidents.
Re: Update on 3407
As an aside, the only thing I don't like about "error chain....break one link" is that it assumes a single-point failure in the situation; the one link. I like Reason's Swiss Cheese Model (James Reason, 1990) of system safety. Basically, you have slices of swiss cheese which can each represent nearly anything. These slices of cheese constantly rotate, with the holes in teh slices representing weaknesses in the system. These weaknesses can be anything, and will vary both in size and number on each slice...as represented by the individual hole. An accident progression attempts to proceed through a hole in the cheese, but will get stopped by a slice of cheese where no hole is present. Until such time in the rotation that all slices of cheese are aligned, thus allowing the accident sequence to proceed unimpeded, there will always be something that prevents the accident from occurring.
As an aside, the only thing I don't like about "error chain....break one link" is that it assumes a single-point failure in the situation; the one link. I like Reason's Swiss Cheese Model (James Reason, 1990) of system safety. Basically, you have slices of swiss cheese which can each represent nearly anything. These slices of cheese constantly rotate, with the holes in teh slices representing weaknesses in the system. These weaknesses can be anything, and will vary both in size and number on each slice...as represented by the individual hole. An accident progression attempts to proceed through a hole in the cheese, but will get stopped by a slice of cheese where no hole is present. Until such time in the rotation that all slices of cheese are aligned, thus allowing the accident sequence to proceed unimpeded, there will always be something that prevents the accident from occurring.
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zmiller4
Well-Known Member
Re: Update on 3407
Right, but there's plenty of people implying that it was simply pilot error ("some people just shouldn't be flying people in airplanes"). That's the worst attitude we can take now, because like you say there's a *ton* of factors that really could have contributed to this, and to simply blame the pilots would leave a lot of causes unexplored.
Right, but there's plenty of people implying that it was simply pilot error ("some people just shouldn't be flying people in airplanes"). That's the worst attitude we can take now, because like you say there's a *ton* of factors that really could have contributed to this, and to simply blame the pilots would leave a lot of causes unexplored.
Orange Anchor
New Member
Re: Update on 3407
Sorry but when I see 'pilot error' that is just like 'connect the dots' for me. That is a very simplistic, unrealistic and narrow look at what happened and avoids the fact that an accident is a complex series of events. It has to do with more than just one flight and one crew.
Tossed out is the obvious fact that these pilot had successfully completed hundreds if not thousands of legs without an accident. But this combination of factors created a situation they were unprepared to deal with. The environment exceeded their capabilities.
The fact is we train for the center and why? Because there is only so much time and money and were we to try and train for every possible event, no one would ever leave the sim. Does this grant carte blanche to the crews? No. This crew obviously had concerns about the ice however the concern didn't translate into action. So the question becomes WHY? That question may not be asked and indeed, there may be no answer.
Sorry but when I see 'pilot error' that is just like 'connect the dots' for me. That is a very simplistic, unrealistic and narrow look at what happened and avoids the fact that an accident is a complex series of events. It has to do with more than just one flight and one crew.
Tossed out is the obvious fact that these pilot had successfully completed hundreds if not thousands of legs without an accident. But this combination of factors created a situation they were unprepared to deal with. The environment exceeded their capabilities.
The fact is we train for the center and why? Because there is only so much time and money and were we to try and train for every possible event, no one would ever leave the sim. Does this grant carte blanche to the crews? No. This crew obviously had concerns about the ice however the concern didn't translate into action. So the question becomes WHY? That question may not be asked and indeed, there may be no answer.