Colgan: No Experience, No Judgment

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As I was reading over the cockpit voice recorder from the Colgan 3407 crash in Buffalo, I had a sudden queasy feeling, as did my colleague Mary Grady in her blog last week. I don't know enough about the state of airline training and pilot experience to have much of an opinion on whether both are in decline. Frankly, I've been hearing that about journalism schools for years, and I can't reasonably say j-school kids are worse now than they were 30 years ago. I'm also ignoring the pay versus skill versus experience argument. I think it's mostly noise.

What caught my eye is this statement made by the first officer: "I've never seen icing conditions. I've never deiced. I've never seen any—I've never experienced any of that. I don't want to have to experience that… and make those kinds of calls. You know, I'dve freaked out. I'dve have like seen this much ice and thought, 'oh my gosh we were going to crash.'"

What disturbs me is this: The F/O, as so many airline new hires are, was a CFI, trained in the sunny Southwest where there's little in the way of serious weather, much less icing. But even at flightschools located in areas where there is weather and icing, CFIs come out of the program with no weather and no icing experience because the schools prohibit them from flying in such conditions.

This reminds me of a note my friend Walter Atkinson forwarded to me a couple of weeks ago about growing up in the 1950s. We rode around in cars without seatbelts, had fat-pill hamburgers and fries for lunch and even ate dirt. Now, Mom straps Junior into a car seat like the ejection capsule in an F-111 and stuffs a gross of sterile wipes into his back pocket.

So, have we gone so far in mitigating risk that we avoid it entirely by refusing to let neophyte CFIs learn their lessons in real weather? I think this has always been true for some number of pilots coming out of the major pilot mills in the sunbelt and elsewhere. But I wonder if it's getting worse. If it is getting worse, we in the aviation press have a hand in it.

Every year, like clockwork, come cooler weather in the fall, we trot out the same boilerplate articles about the perils of icing. We wring our hands over the legalities, gin up the fear factor and basically conclude that you're a fool if you even think about flying an unprotected airplane in icing. These articles generally assume that readers are too stupid to understand that icing risk, like everything else in the known universe, exists in degree. It's never black and white and the way you discern black from white is by exercising judgment. And judgment comes from experience. No experience equals little or no judgment.

To me, this is not an indictment of Colgan 3407's F/O so much as it a broken advanced training system at the GA level. Earning a CFI is graduate-level work, the ultimate point of which is to teach flying skills to others. How can you teach what you do not know? How can you explain to the budding instrument pilot that a layer of light rime won't kill him if you haven't seen it yourself?

These aren't just rhetorical questions, but practical considerations. My view of it is that irrespective of what the airline pays a new hire or how it trains that pilot, no pilot should ever be in the pointy end of an airliner who hasn't seen enough weather to be capable of basic sound judgments.

Message to flightschools: Stop worrying about liability and get busy equipping your students with real world, useful experience. To do otherwise is a disservice to the entire industry.

Comments (116)

The military spends over 1 million training a new pilot in the first year alone, after which the pilot goes on to advanced training. Compare that to the commercial side where they openly boast about putting pilots on airline flight decks with the absolute minimum hours and cost.

http://www2.atpflightschool.com/AirlinePlacements

A “Sully” vs a “Marvin”; No comparison at all.

A professional minded person will do his or her best at their job. However "Who" you get, their "Experience" level, their "Training credentials" are not going to be identical for low pay vs high pay. If you want the cheapest pilot money can buy don't expect an ex-military fighter pilot who had over 5 million dollars worth of training and 20+ years experience. This concept should not escape anyone as it applies to almost any vocation. You get what you pay for. You don't get a "Sully" for a "Marvin" price. Marvin will do "his" best for you but when the chips are down if it isn't good enough don't complain. You got the cheap ticket. You got the cheap pilot.

The only surprise about this accident is that it did not happen sooner.

The only question remaining is what flight will be next?

The explanation on why is clearly explained here: http://forums.jetcareers.com/general-topics/53768-expectations-how-save-5-airline-ticket.html

Posted by: m adams | May 26, 2009 11:06 AM    Report this comment

I have found it interesting that lack of experience is easy to find fault with, but it is more than that. They were not even practicing situation awareness. The aircraft went below approach speed, stalled. I don't know if there is an auto throttle on the aircraft but for sure the autopilot was flying this aircraft in ICE! There are also recent accidents with the 737 that has had auto throttle break lock and the crew was unaware. The one in Denmark killed everyone on board. The 737 in the UK last week was an autothrottle break lock and they went 20 Kts slow before a stall recovery saved them. This seems to have been brushed off. I think it merits grounding the flight crew and a fine! It was an accident due to lack of attention, not flying the aircraft! Too much of no Man-in-the-Loop!

Posted by: Jim Bruchas | May 26, 2009 12:47 PM    Report this comment

A fellow pilot who I knew working at a part 135 operator was telling about a colleague who went to work for (name withheld) regional airline. The captain didn't know how to negotiate a serious line of weather, however the F.O., with a couple thousand hours flying cancelled checks in a Baron was able to explain to the captain how to use and properly interpret his radar and the flight arrived safely. Our problem today - why do I want to work as a CFI and build up 1200 hours to fly for a 135 operator, fly in the 135 op for a year, then when I'm finally making a good wage flying charters go to a regional airline and drop back to flight instructing pay? I guess in life we get what we pay for - including airline tickets! As for the situational awareness - honestly I didn't have much when I was a newbie. The Colgan crew evidently didn't have much either. I passed my checkrides, but those were a license to learn. Flying IFR is not difficult - one of my instructors once told me a monkey could fly instruments - but flying in weather is an art, and it is refined by experience, not a college degree! I'd prefer that these guys learn it by themselves flying freight for a while, as opposed to doing it with 60 people on board! By the way, who came up with the idea that you can get an instrument, commercial, and CFII ticket without ever logging any actual?!!

Posted by: Josh Johnson | May 26, 2009 4:32 PM    Report this comment

Gentlemen -- A CFI is not more than a fundamental skills instructor. The aircraft he teaches on are not certified for flight in know icing. Though the threat is a ground school exercise practical experience is gained by doing.

The pairing of junior and senior officers should be a mentoring where the skills of the senior is passed on to the junior.

Noting can prepare you for an encounter with sever freezing rain. Here ice is not the culprit it is the simple lack of stall awareness creating an incipient spin which at that altitude is not recoverable.

Posted by: Christopher Basham | May 27, 2009 1:27 AM    Report this comment

Christopher, I am not advocating a CFI in a 172 go looking for ice to show his student. What I am saying is that anyone who has logged a couple hundred hours of actual has probably seen it. Hopefully his instructor taught him to allow an effective back up plan. Ground school should teach a person to always allow for an escape route should their plans fall apart, however in the professional pilot world this crew would have had a tough argument with the airline about why they didn't want to take a flight to Buffalo in cold weather - a professional flight crew is expected to be able to handle this level of difficulty. My concern is that instead of allowing a person to build experience through instructing, then freight charters, then people charters, then the airlines, we are allowing them to get their first real IFR experience flying these airliners. The problem is that qualified pilots cost more. Good luck retaining talented experienced pilots on 15,000 per year to start, with no job security and awful working conditions. I think that short of government regulation, we as consumers have to start insisting that these RJ crews are paid a living wage - or find another way to our destination.

Posted by: Josh Johnson | May 27, 2009 7:04 AM    Report this comment

Agree with Christopher B, above - the answer isn't to start sacrificing hour-building CFIs in ones and twos by flying in ice so that they can learn about ice.

Better situational awareness - or rather, training that reinforces the need for better situational awareness - seems to be required. Perhaps also some further developments in CRM for low-hours crews. There's also something about the 'experienced male'/'inexperienced female' aspect of this accident that bothers me. When they should both have been on their mettle, the captain seemed to be trying to be 'cool' to impress the first officer (who was half his age - maybe only middle-aged men can fully understand the implications...); perhaps she had fallen back into the 'pupil' mode that she'd been in for a substantial portion of her flying career. Also, it seems that there should be videos/photos of wing/tail icing for each aircraft type to give crews some point of reference.

Posted by: Ceri Reid | May 27, 2009 7:16 AM    Report this comment

A few years ago I flew for one of the most notorious regional airlines, and it was not uncommon for a newly minted FO to look at you from the right seat and say "Cool, my first actual." These pilots mostly came from the flight school mills and it was also not uncommon for them to have less than 500 flight hours. I always thought it was funny because they couldn't walk down to a local airport and rent a Cessna 172 (a common rental aircraft) until they had more than 500 flight hours to be insurable, yet here they were hauling around paying passengers.

I remember being asked by a young FO if I thought they were ready to upgrade to Captain on more than one occassion. My response was always the same. "If you feel you can operate the aircraft as a single-pilot while being distracted by an FO who has no experience, then you're ready." More than a few waited a little longer to upgrade, and are now Captains there or elsewhere on yet larger equipment.

The low pay also creates an financial need for an FO to upgrade prematurely, with a minimum of experience so they can make a liveable wage (not great, just liveable) as a new Captain. The safety issue within the system is now you have a minimumally qualified Captain with a completely inexperience FO.

The public is truly unaware, and unfortunately doesn't care when they're buying that cheap ticket. It's only when blood is in the street that anyone makes any noise, and then that subsides and it's back to business as usual.

Posted by: Ben Peltzer | May 27, 2009 7:18 AM    Report this comment

It is easy to blame lack of training in icing conditions for this crash. This case shows (and I am being very kind here)a complete disregard for situational awareness on the part of the captain. He should have been on high alert the moment that icing was seen, and taken the opportunity to show the FO how to handle it. NOT continue to be distracted by outside non sterile cockpit discussion. Frankly, when I read the transcript, I was surprised by the large amount of chit chat going on during the whole flight instead of keeping track of what the airplane was doing. Perhaps if the airlines would listen to their own cockpit recorders once in a while and discipline the crews for lack of regard for situational awareness in flight, these incidents would not have happened. CFI's should NEVER take students into icing conditions in aircraft not designed or certified for it.

Posted by: Art Ahrens | May 27, 2009 7:27 AM    Report this comment

If you value money more than your life then it is just a matter of natural selection. It's very unfortunate if you take others with you.

Posted by: Stuart Baxter | May 27, 2009 7:29 AM    Report this comment

Pilots go to work at Colgan for the promised upgrade time. I don't think anyone works at Colgan with the intention of staying there for more than a few years. Most have been told/sold (by Colgan) that they can upgrade from FO to CA in 2 years. This is definitely an issue. You have pilots with no experience going to work somewhere so they can upgrade to CA in 2 years with minimal experience. That's only two winters and two summers sitting in the right seat. It takes a very mature individual to say, "I don't have enough experience to be captain yet. I'm not ready."

Pay is definitely a motivating factor. The pilots get paid too little for the responsibility they have, and as Ben Peltzer mentioned, they upgrade for the money. I'm not suggesting that new hire, low-time FOs make $100k/year, but they should earn more than the teenage kid working at the drive-thru.

The public is truly unaware of a lot of things. Of course they are going to shop for the cheapest ticket. People shop for the cheapest anything. This doesn't mean that fares could not be raised.

Posted by: David Brown | May 27, 2009 7:44 AM    Report this comment

Stirring discussion always educational:

“Sully” vs a “Marvin” – Sully made a mistake but not a fatal mistake he did not or the first officer failed to hit the ditch switch causing the aircraft to sink faster than it otherwise should have.

In the Dash 8 accident both the first officer and the captain failed to monitor airspeed, failed to increase power on gear and flap extension. The autopilot was probably in altitude hold mode. In my opinion, regardless of pay scales the crew failed to maintain airspeed. They are not the only ones Turkish airlines with their top pilot and crew aboard failed to maintain airspeed causing the 737 to land short of runway and stalled. Blaming the radio altimeter and auto-throttles is a poor excuse for failure to override the autopilot and hand fly the aircraft to a landing. Pilots are becoming too complacent with automation.

This is an area that all instructors (CFI) should emphasize airspeed and cross check attitude and vertical speed. This is a fundamental of flight.

Posted by: Christopher Basham | May 27, 2009 7:49 AM    Report this comment

I clearly remember the day I decided to depart the regionals, even as a Captain...

I had made great time and arrived at Phoenix-Sky Harbor early to find there was no gate available. We taxied to the holding pen at the far end of the ramp to wait. Our contract paid block time only, not block or better, so while I sat in the holding pen for nearly an hour, I was compensated by per diem only, and back then domestic PD was something like $1.30/hour.

I realized that the kid who's first day at McDonald's was today was making more than me per hour right now and they didn't have a fraction of the responsibility.

That's when my job search went full-time, and within a month or so I was out the door...

Sad commentary!

Posted by: Ben Peltzer | May 27, 2009 7:56 AM    Report this comment

Please folks, I know you airline types are a frugal lot and fixated about pay levels, but this discussion is supposed to be about experience and icing and not about pay envelopes.

Posted by: Stuart Baxter | May 27, 2009 8:27 AM    Report this comment

Yes Stuart, you are right. Once implanted into the seat of a FAR Part 121/135 seat, attention is quickly diverted to pay. Pay wasn't an issue in a pilot trying to get that first job, nor was it a consideration in obtaining a suffcient amount of flight experience in the real world before they were considered for that seat in the first place. I have found the cheaper an airline is with it's pay and benefits, the cheaper they are in their quality of instruction and the the higher the turnover, hence, the less experience you have coming in the door. It becomes quite a hampster wheel right up until that crunching sound of impact.

Posted by: Kim Barnes | May 27, 2009 8:45 AM    Report this comment

I read the CVR transcript. During the flight this crew was doing the aviation equivalent of texting while driving. Niether crew's heads were in the learning or coping or high situational awareness modes. Because of where the FO's head was, that icing experience would have had no effect on future behavior anyway. FAR 91.3(a): The pilot in command of an aircraft is directly responsible for, and is the final authority as to the operation of that aircraft. Every pilot should seriously consider and remind himself of this reg. often. Does wonders for situational awareness. Personal responsibility is a product of culture and character. While authority can be delegated, responsibility cannot.

Posted by: Steve Hooley | May 27, 2009 9:00 AM    Report this comment

I thought the investigation had long moved beyond icing being a factor? I realise that the FO admitted that she was not familiar with icing, and that perhaps raises the question of what else she was not familiar with, but it wasn't ice that caused the crash - it was a simple stall. The Captain moved the props to fine pitch, didn't add power, the airplane slowed down, and when the stall warning fired the resulting incorrect recovery actions sealed their fate. Given such a basic error, I wonder if the Captain was so tired that he actually fell asleep for 4 or 5 seconds - a "micro-sleep" - and the shock of waking up to the stick shaker was never correctly handled.

Posted by: ANDY DAVIS | May 27, 2009 9:01 AM    Report this comment

Stuart, unfortunately the items are linked whether we like it or not... It is also unfortunate that companies, aviation companies, Part 91, 135 and 121 each have some operators who choose to operate to the bare minimum of regulations, sometimes below those regulations.

Hidden in my comments is the point that usually low pay indicates a company that maintains a culture of cutting corners. It's the culture that permeats safety as well, and that includes minimum hiring standards, minimum training, minimum upgrade times, etc.

Nothing will change until you change the culture, and some of that needs to be regulatory, and some of it is driven by pay which allows one to hire someone more experienced and keep them in the right seat.

With that said, anyone would struggle with severe icing, but most wouldn't abandon basic rules of airmanship in the process...

Posted by: Ben Peltzer | May 27, 2009 9:09 AM    Report this comment

Most CFI's do not have an opportunity to gain any experience in ice because the flight schools typically don't offer flight into known icing (FIKI) aircraft for rent. I used to know of a Piper Malibu for rent, but the insurance requirements to rent it were more than the FO hiring requirements for the regional airlines. The 20 hour minimum check out made the cost way to much for the typical CFI/student to afford. Until the insurance requirements and prices on FIKI aircraft reach a reasonable level (I don't see this happening any time soon), there are not many options to gain meaningful icing experience unless you are flying 135 or corporate.

Posted by: Chris Handevidt | May 27, 2009 9:20 AM    Report this comment

Unless new commercial pilots come out of the military it is almost a sure thing that they have no icing experience. The only real solution I see to that is to make sure fledgling pilots are ALWAYS paired with an experienced captain who has demonstrated his/her ability to cope with these situations, until such a time that they too have demonstrated this proficiency.

I know there must be hundreds of reasons floating around out there to argue that this is not a feasable policy, but to a non-pilot it seems to be a solution worth considering.

Posted by: Dennis McNish | May 27, 2009 10:12 AM    Report this comment

>>no opportunity to gain reasonable icing experience...FIKI>>

Hmmm. Guess I didn't get through here. And without being too inflammatory, old school CFIs--and I am one--flew often in winter in unprotected airplanes. Many still do. We didn't cower in the pilot lounge because the forecast contained icing or because we didn't have a flight into known icing airplane. We learned to make judgments about weather and to develop exit plans when we did encounter icing. We learned to recognize those days when we couldn't fly. We learned by doing.

Sounds wild eyed, eh? It isn't. I'd rather have an FO or Captain who had this kind of experience than not. Nothing calms the mind and encourages continuing good judgment like having seen the mountain once or twice.

Posted by: Paul Bertorelli | May 27, 2009 10:21 AM    Report this comment

It would be good to require the bozos who are in the top management positions at these regional carriers to purchase tickets and be seated as ordinary passengers with luggage on their airlines flights at night and into IFR weather (thunderstorms and icing conditions), preferably on flights at the end of a crew's daily schedule. Perhaps then they'd realize that the quality of their product is in need of repair. So long as these regional carriers are operated so as to maintain the bonus and high salaries of managers to the detriment of their pilots and support staff, they'll continue to offer crummy transportation services, putting the public in jeopardy.

Posted by: Keith Bumsted | May 27, 2009 10:31 AM    Report this comment

While I agree that experience is the best teacher, I would never advocate for someone to break FAR's in regards to icing conditions to gain experience. If you fly in the north long enough you will eventually pick up unforecasted and unreported ice in an aircraft not certified for icing conditions, but I would not take off in a non FIKI airplane with the intent of finding some ice on purpose to gain experience.

Posted by: Chris Handevidt | May 27, 2009 10:37 AM    Report this comment

The icing comment did not bother me quite as much as the one about the "chip light" coming on and the FO not having a clue about what that was. As important as basic flying skills are, so are systems skills. If you have to very quickly diagnose a system and make a decision on either emergency landing, ditching, crash landing, etc. you'd better know what all those "switches and stuff" mean up there.

Posted by: Craig Simpson | May 27, 2009 11:00 AM    Report this comment

I came from the "no seat belts" era of flight instructing, in a figurative sense. I put a little ice on most of the training aircraft as a CFI in Minnesota. I knew enough to keep it to a minimum in a non-deiced aircraft. As I moved into night freight and charter, I got to play in the ice with aircraft that were deiced. I learned something about flying in the ice.

When it became clear that I needed to make more money that what I could garner flying light aircraft, it was also clear that the only way to the majors was through the regionals. I worked the numbers and decided that grad school was cheaper and offered better opportunities than the airlines. This was in 1997. I guessed right. With 50% more total time, and vastly more weather experience than the entire Colgan 3407 crew, I packed it all away. I now pay more in taxes than the entire Colgan 3407 crew made. Juxtaposed with the oft repeated comments of the current crop of major airline pilots, it is clear that the race to cheap, is being felt in the quality of the crews. In the end, one does generally get what you pay for.

Posted by: KRISTIN WINTER | May 27, 2009 11:01 AM    Report this comment

While we might mess with the rules and regs, we can't screw with the laws - as in the laws of aerodynamics. It wasn't really an icing issue - regardless of how they got there, the crew unknowingly let their airspeed bleed to just above stall. Where in hell did the captain get a single neuron embedded in his brain that dictated the proper response to a stick shacker was to plant the stick in his lap?

Posted by: Paul Valovich | May 27, 2009 11:05 AM    Report this comment

(continued from above)

That's bullshit, and the FAA ought to be embarrassed for ever thinking it was safe. The only instrument flying a CFII with no actual is qualified to teach is to someone who is going to use their instrument ticket entirely in VFR conditions. And to the people who would say, "well, I'll just go get some actual before I teach," I commend your maturity, but why shouldn't the FAA simply require that before giving you your CFII ticket to begin with? Yes, it would make it inconvenient for these CFI mills in the desert Southwest to churn out more CFIIs. Boo fucking hoo. Your students deserve better than that, and so does anyone you take up as a passenger in actual IMC.

cl

Posted by: Chris Lawson | May 27, 2009 11:19 AM    Report this comment

Paul, while I understand this rhetorical question, the reality is that when you are in these situations, you must overcome your biological, natural instinct. That instinct is a contraction of your muscles. As a pilot with your hands on the stick/yoke/side-stick, that's usually the worst possible response. Only training, and experience in a training environment will teach you to overcome your physical response. No coursework in theory replaces practical experience. Military pilots get it, some specialty civilian pilots get it as well, but generally, not. That's the theory behind Red Flag and Top Gun. I'm not arguing for military only pilots, just that type of hands-on training...

Posted by: Ben Peltzer | May 27, 2009 11:20 AM    Report this comment

Somewhere along the line, neither of these pilots learned to concentrate on flying the airplane. Perhaps they became enamored with the autopilots in their previous flight experience--too many high performance singles are "better" equipped than the airliners of my instructional era--even the ubiquitous 172 now comes with glass and a full autopilot. I've watched pilots flip on "Otto" before they've hardly departed the pattern. Yet "Otto" can fail, or be mis-programmed, or left on during situations that should be hand-flown. When someone else or a mechanical thing is flying the airplane, it’s too easy to become an educated passenger, distracted from the main task.

I only fly for pleasure now (except for the occasional Angel Flight), but because of my CFII and SE charter experience, there is not much chit-chat with my passengers, except in the least stressful parts of a long cross country. When I fly with another pilot who “assists”, we practice good CRM. When I fly with a non-pilot, I concentrate on flying the airplane. In all cases, I insist on a sterile cockpit within a 10 mile radius of the departure and arrival airports and in approach areas. Too bad that didn’t happen with this Colgan flight.

Posted by: Cary Alburn | May 27, 2009 11:44 AM    Report this comment

Amen Chris! I had about 500 hours TT when I went for my CFI, and about 100 actual when I went for my CFII exam (neither exam was as bad as all my buddies from the college programs said it would be) (How did I get my time, I bought a piece of junk 172, saved every dime I could to upgrade it, and flew the wings off it) Like I said before, a monkey can fly an approach, but flying weather can only really be understood by experience. There is a big difference between actual IMC and simulated - you don't get those subtle cues from the corner of your foggles and there's certainly a sense of needing to do this right because it's for real. I still remember my first approach to published minimums on an ILS - I felt in control, but definitely a little more uptight than usual. I was very fortunate at the 135 op I worked at for about a year to have flown with some very experienced people who could show me in the real world how to get out of ice (in a known ice airplane) and how to use weather radar (and when not to trust the radar) Anyhow, my conclusion to the aviation experience is to fly in connection with my non-aviation-related business. Can I fly a complex airplane in ice and weather - you bet! Will I do it for peanuts - not a chance! As for the ice, I agree with Paul B. There is a big difference between going through a cloud layer in the winter when it's 2500agl overcast with good VFR beneath, and going through clouds in the winter when it's 200 and 1/2 out.

Posted by: Josh Johnson | May 27, 2009 12:56 PM    Report this comment

Also, I think the post about sacrificing CFI's in ones and twos illustrates some of the problem we have. Contrary to what some might say, you will not surely die if you should ever get caught in icing or IMC. I've always felt icing and thunderstorms are much like a snake - when handled correctly you can be safe with acceptable risk, however act carelessly and it can and will kill you. In the right aircraft, with a skilled pilot, icing can be handled in MOST situations. Take one of these out of the equation, and the risks go up substantially. My point is that allowing a person to gain primary instrument experience working for an airline is akin to giving 16 year olds with a fresh drivers license a school bus full of children in which to learn. No amount of groundschool and ADM will fully prepare a person to handle their aircraft, this needs done with several years field experience which is not happening for reasons mentioned above. I'd prefer that experience to be gained when I am not in seat 16a behind this "student pilot"

Posted by: Josh Johnson | May 27, 2009 1:16 PM    Report this comment

I would like to put my two cents in., and I am sure that's all my opinion is worth. I read the CVR transcript, I thought the FO was using good judgement in her discussion on how little icing experience she had. She was making a point how she was glad that she was flying in the east coast wx and gaining valuable experience. Also that she thought it was ludicrous to be promoted to captain with out that experience. I somehow always thought that one of the purposes for having an First Officer is so they can learn from the captain how to make good judgment calls. As far as Sully versus Marvin, I am guessing that when Sully was promoted to captain that he did not have the hours and experience he had when he made his remarkable landing. The question begs to be asked is when do you have enough experience to become captain. I have always heard and taught that flying is a life long learning experience. It appears from the CVR transcript that things went awfully wrong right after flap deployment. Could it be that the captain might have had the thought that conditions were ripe for tail plane icing? That he knew that lowering flaps can trigger a tailplane stall? If so, then his response was correct for stall recovery. Food for thought.

/

Posted by: JERRY ALLEN | May 27, 2009 1:39 PM    Report this comment

The Colgan and Turkish accidents are a combination of 1. Autopilot dependent pilots who are unwilling, unable or without sufficient confidence in their ability to control the aircraft, to disengage the autopilot and hand fly the airplane when they should be hand flying the airplane.

2. Autopilot dependent habit patterns that allow them to ignore the airspeed and power combination, and in the Colgan accident as influenced by whatever ice they were carrying. If the airplane had been off the autopilot and hand flown, would not a properly qualified pilot spent enough time on the airspeed to prevent this accident?

Both of these crews ignored their basic responsibility to the industry and the flying public to maintain control of the airspeed and flight path of their aircraft, in spite of what is inoperative or dealing with airframe ice.

I used to see it a lot. When the autopilot starts not reacting properly, and makes "mistakes", the pilot in control of the aircraft, when he lacks confidence in his ability to hand fly the aircraft, will not disengage the autopilot, and take over manually, unless horns blow and red warning lights illuminate.

If a copilot made those same "mistakes" would he be allowed to contiue to hold altitude to the stall?

The current approach misses a lot if needed information to overcome the lack of experience. Almost all of the training is "teach them what they need to know to pass the tests and a check". Is that enough?

Posted by: THOMAS OLSEN | May 27, 2009 1:56 PM    Report this comment

Tailplane stalls are classically encountered when the landing flap position is set in the aircraft. Tailplane stall at about 10 flaps, were the flaps were when the airplane stalled, is not in the training information we used to use. Also, the correction for the tailplane stall, is to retract the flaps to the previous position, which the FO over did and put all the way up, which did not help the situation.

Again, this goes to a lack of training. Spring loaded to handle a tailplane stall and not a stick shaker stall warning?

By the way, one of the ways to prevent the problem in the first place is to not use full flaps (landing flap) position for the landing. Why was there no discussion of that material and that option? A lack of training perhaps?

Posted by: THOMAS OLSEN | May 27, 2009 2:04 PM    Report this comment

So who, or what is to blame for this accident? The crew resources concept failed. They let the airplane slow to the stalling speed. Were they watching? Did they know what the stalling speed was? I was consisdered a low time new-hire in '83 when I was hired at a regional airline. I had 3,600 hours of mostly scheduled Eastcoast cargo flying under my belt, and I considered myself fortunate to be hired to sit right seat in a Metroliner. I think we'll see a new mandate from the NTSB and action from the FAA on this one guys.

Posted by: Dave Sandidge | May 27, 2009 10:00 PM    Report this comment

Thomas: As far as I can tell from the CVR transcript, they intended to use only flaps 15 for landing, which is definitely not full flaps in a Q400. I'd suggest you take a look at the transcript; it's on the NTSB site.

cl

Posted by: Chris Lawson | May 27, 2009 11:02 PM    Report this comment

Experience in icing conditions is more often a matter of chance than long experience. In a career that included 38 years military and airline worldwide flying I have not carried enough ice, in total, to "chill a highball", as Ernie Gann once put it.

So don't blame the training process for the lack of experience -- collecting ice in flight is a matter of chance more than anything else. And the number of General Aviation training airplanes that are certificated for flight into known icing conditions (the ONLY way to get real icing experience legally) is vanishingly small and breathtakingly expensive, and therefore unlikely to be found in an FBO fleet. Our CFI's are doing their jobs well if they inculcate into each student a true respect for the possibility of ice accumulation, a realistic appraisal of its effects, and a stern discipline to stay out of conditions remotely conducive to encountering it. Period. Once a pilot graduates to flying airplanes equipped to legally handle icing conditions, it becomes a matter of knowing the procedures for operating the deicing and anti-icing systems. But the actual experience will always be a matter of being in the air at the time and place where icing actually exists. As I said - you can fly a lot of miles and never find it!

Posted by: Anthony Vallillo | May 28, 2009 5:51 AM    Report this comment

Many responses here imply that pay levels in the airlines today have nothing to do with accident rates. Nuts. Why is it that while we all realize that you get what you pay for in any walk of life, but when it comes to airline flying we seem to make an exception? Thirty years ago when I began my airline career, the pay and working conditions were good, and everyone wanted the job. There were 500+ applicants for every opening, and managements could be very choosy. Does anyone think that is the case today?

The commuters are a training ground, the farm team for what is today a very sick major league system. Frankly, I think anyone still thinking of persuing an airline career has rocks in their head, and given the imminent demand as us Vietnam era types mercifully retire, really very few are in the pipeline. If pay and working conditions were to revert to where they were, the quality would follow. Supply and demand, you get what you pay for.

On top of that, in the commuter field you have inexperienced crews flying aircraft that spend most or all of the enroute phase down in the ice levels, in all wx, in aircraft less well-equipped to deal with accumulations. The set up is like Russian Roulette. This is why I do not put my daughter on the commuter-only flights available from her college town, and instead have her take the bus to the jet airport two hours away.

I say it again: You Get What You Pay For.

Posted by: BILL MCCLURE | May 28, 2009 6:50 AM    Report this comment

>>Experience in icing conditions is more often a matter of chance than long experience. In a career that included 38 years military and airline worldwide flying I have not carried enough ice, in total, to "chill a highball", as Ernie Gann once put it.<<

We have had very different career experiences. In 4500 hours of *GA* flying and instructing in the northeast and midwest, I have had many icing encounters, the vast majority in airplanes not approved for icing. Some were in forecast icing conditions, some not. In every single instance, I had a solid gold plan to exit the icing and in those circumstances where that wasn't possible, I cancelled. I cancelled a lot, but I didn't always cancel for forecast ice. I diverted once because of ice.

I was fortunate to have had an old school instrument instructor--retired military--who encouraged flight in actual at every opportunity. And we encountered some ice. He taught me early on not to panic, but to rationally deal with the situation and resolve it. So I always did. My point here is that the GA training environment now fails its students by not encouraging learning instrument flying in actual weather. We hide behind regulations, stated policies and prodcedures that all but legislate against learning what it's like to deal with real weather. So we end up with young FOs flying airliners who haven't had much--if any--real weather experience. That had no bearing on this accident, I'd guess, but it is a curiosity.

Posted by: Paul Bertorelli | May 28, 2009 7:58 AM    Report this comment

Training in actual has fallen by the wayside as has spin training. Theory sounds good, but training in an actual environemnt is critical as you can never replicate your adrenaline, decision-making under actual circumstances, and the fact that rarely are two situations the same... It's always obvious when you have someone who learned to fly in all the pretty new glass panel aircraft, as many lack basic flying skills. Sorry, it's true. It's more than a computer game up there, especially when you have external factors such as weather, mechanical issues, whatever...

Posted by: Ben Peltzer | May 28, 2009 8:05 AM    Report this comment

As one of the other posters has mentioned, the Captain of Colgan 3407 had most of his flight expedrience in the Saab 340, an aircraft that apparently is more prone to tailplane icing than most. Stall recovery for a tailplane stall in that aircraft is to pull the stick back, which is just what he did. Unfortunately, we will never know for sure if he pulled back on the yoke because he thought it was a tailplane stall, or he just panicked. Either way, several things come to mind. FIrst, from the moment they realized they were picking up ice, he should have disengaged the autopilot and started hand flying the aircraft.

Posted by: George True | May 28, 2009 8:10 AM    Report this comment

Secondly,this particular pilot had a lot of flight experience - something like 3500 hours, and most of it flying for the regionals. Even with little experience with icing, he should have been able to handle this. But when things sudenly went bad, he was simply not mentally prepared for it. The video simulation that the NTSB put together from the flight data recorder shows an aircraft in the throes of a classic wing stall. This was a recoverable stall, even at their relatively low altitude. He should have been able to handle it, but his mind was not in the game.

Here is where the regionals could make things a lot safer. They need to develop a curriculum of intensive additional training for their newer pilots specifically in the areas of weather flying and flying in ice. This should ideally involve a sufficient number of harrowing zero viz weather flights in the simulator, that routinely include engine outs, icing, wingstalls, tailplane stalls, and hand flying approaches in really turbulent conditions. Second, the regionals must conduct in-depth classroom training for the aircraft the pilot is going to be flying that specifically covers flight characteristics in icing, and specifically icing stall recovery procedures. Had Colgan done this, the captain of flight 3407 might have known that the Dash 8-400 was not particularly prone to tailplane stalls in icing conditions. He might have also had the confidence to hand fly the approach at the first sign of icing.

Posted by: George True | May 28, 2009 8:56 AM    Report this comment

I took my first flight in several years on a RJ back in March (based in Detroit). I was quite surprised to see how it looked like an old 310 or Aztec check hauler, much of the paint was peeling and flaking off (due to the ice picked up in the low altitude flights this airplane was making) To me, it is impossible to comprehend how a captain with 3500 hours TT. going into Buffalo would not be prepared to deal with ice. (I've flown IFR all over the Midwest in winter, you WILL get to deal with ice sooner rather than later when flying IMC in the winter in Michigan, and near the Great Lakes.) Notwithstanding his lack of experience, fatigue just had to be a factor in this.

Posted by: Josh Johnson | May 28, 2009 9:19 AM    Report this comment

I took the FO to be speaking about the past, at the beginning of her IOE, when she said she hadn't seen icing, etc. Her next comment or two about being so much comfortable with it all "now", seems to fit with that interpretation. The ice she was seeing at that point didn't seem to bother her too much, or that captain for that matter, as they continued with the infected cockpit concept.

Complacency (captain), deferrence to greater experience (FO), and especially a lack of serious professionalism (both) evidently precluded the need to worry about monitoring airspeed and such, in the critical ice-laden approach phase of the flight. These things more than anything else IMO, caused this accident, and prevented the FO from gaining more of the experience she needed. She already had enough to know how to recover from an imminent stall (the captain's reaction to it notwithstanding), but it was allowed to sneak up on them, and coupled with the pilot-flying captain's response, was too much too low to fix.

The "mandate" that likely would have prevented this accident was already there - no extraneous conversation below 10,000ft. No amount of procedural training or rules is going to make a pilot a mature individual, who is very aware of the deadly serious nature of operating a piece of machinery suspended in nothing but thin air, that the earth is constantly trying to violently reclaim. That's got to come from within the person.

Posted by: Mike Holshouser | May 28, 2009 9:30 AM    Report this comment

What I'd really like to know is why the Colgan management kept the captain for this flight on the payroll after he had failed his flight test each year for the preceeding five years? This person was having trouble all along. Why was he given the responsibilities of captain? The problems leading to this crash started long before the flight crew ever entered the cockpit.

Posted by: SCOTT W. WILLIAMS | May 28, 2009 11:21 AM    Report this comment

This is a one word mishap report "NAFOD" In Naval Aviation "NAFOD" stands for "No Apparent Fear Of Death" They had it and it killed them and those around them.

Posted by: Brian Todd | May 28, 2009 3:26 PM    Report this comment

Scott - of the checkrides I've had, they are very subjective to the check airman or designated examiner, or inspector giving the flight check. I've been fortunate and passed on first attempt every time, however I know a pilot who is more qualified than me that failed every other 6 month test at the FSDO (He said the inspector didn't like him, but who knows?) I'd want to see the captain's training records and know a little about his check airman before passing judgment on his experience from the number of flight checks he passed or failed (he might have gotten Santa Claus or Atilla the Hun for an examiner - I've seen both personally!) Anyone who flies enough is going to fail a checkride sooner or later. I think there are other factors involved here.

Posted by: Josh Johnson | May 28, 2009 5:08 PM    Report this comment

The FO was having what might be considered irrelevant conversation by some....(frankly I thought discussing ICE was pretty RELEVANT.) It was the CAPTAIN who has the final authority, the perceived experience, and the ULTIMATE RESPONSIBILITY for that accident. Yes, autopilot, inattention, ice, flaps, low altitude....it's HIS FAULT! and his salary has NOTHING to do with it. Did the FO also share the blame? Yes, for failing to point out the deteriorating airspeed. The crew was discussing matters not directly related to that flight at a critical time, which may have been a contributing factor. But the ultimate error, I've already stated my opinion. Lack of professionalism includes inattention to DUTY. It matters not what the salaries and other irrelevant issues might be.

Posted by: George Horn | May 28, 2009 6:00 PM    Report this comment

It is all about pay. Anyone is a fool to think otherwise. With higher pay great pilots like me with THOUSANDS of hours of real weather flying, in jets and turboprops would apply. Instead I fly a Malibu for a corporation and make a LOT more money.

Posted by: Matt George | May 28, 2009 7:47 PM    Report this comment

The starting pay does determine who's in the field. And the price of the initial training is cost prohibitive (military route excluded). You've basically got to start young and be financed by a well-off Mom and Dad or take a huge loan. If you're a little older, with a need to support a family, you can pretty much forget it, unless you have access to other funds.

Also, there may be those who'd make great FOs, but not do so hot as captains, or have no desire to attain that position. That leaves the majors as the only place to make any appreciable money. How do you get there in the current system? Probably not by staying a FO in the commuter/regional scene. Correct me if I'm wrong.

Posted by: Mike Holshouser | May 28, 2009 8:45 PM    Report this comment

How about a different thread - the issue of whether, during initial flight training, enough emphasis is placed on maintaining control of the aircraft? If you maintain control, you at least have options; lose control you're along for the ride. As a navy carrier and adversary pilot, I spent a lot of time maneuvering in deep buffet, with the angle of attack an RCH below departure. Flying AOA as your primary instrument near the stall works. A possible recovery scenario at the onset of stall warning - assuming proper training - would have been full throttles, wings level, primary scan to the AOA gauge, and manipulation of the pitch axis to keep the needle below or slightly above 3 o'clock. Why don't GA and the airlines include AOA procedures in their training? Hell, I'm building an RV-8A homebuilt and for less than $1500 have a very capable AOA system and display in my panel.

Posted by: Paul Valovich | May 29, 2009 9:42 AM    Report this comment

What I'd like to contribute to this discussion is not so much a comment on the qualifications of the crew of that unfortunate plane, but a question:

Is it possible to simulate severe icing on a flight simulator, so that an instructor who's operating said simulator can throw icing at student pilots?

A problem with ice-training pilots is this: A flight instructor, when instructing a student pilot in an actual aircraft, can simulate engine failure very easily: Just retard the throttle. I went through that when I took flight lessons in a Piper PA-28-140. But icing is another matter. So, I have another question:

After a student pilot has been subjected to icing on a flight simulator (and has passed that part of his or her training), could a method be devised to make an actual aircraft behave as though its wings or tail were iced up, without actually flying into said conditions?

Icing is another of numerous emergencies for which pilots ought to be trained, in addition to loss of all engines (due to bird strikes, for example), engine nacelle fires, instrument failures, and so on.

Posted by: Alex Kovnat | May 29, 2009 2:02 PM    Report this comment

Matt George, you ...and others ...MISS the point. It matters not what the guy in the left seat is making on his paystub when it comes to paying ATTENTION to DUTY. YOUR claim that because YOU (Great Pilot that you claim to be) weren't in the left seat is why that crash occured. Wrong. It occured because whoever was there, despite their salary, wasn't doing what they were supposed to be doing. Marvin (or whomever) has something FAR MORE VALUABLE than a paycheck invested in each and every flight. I'm not arguing that pilots aren't underpaid in most commuter positions. But that had little to do with the captain of that Colgan flight's leisurely, condescending acquiescense to his FO's admiration and BOTH their failures to do what they were doubtlessly paid so little to do. Their SALARIES HAD NOTHING TO DO with their failures as pilots.

Alex, yes, I am a simulator instructor and examiner for a major training facility, and we can simulate ice accretion on the airframe. I frequently kill experience, well-paid corporate pilots like Matt using that capability when they DON'T PAY ATTENTION.

Posted by: George Horn | May 29, 2009 2:25 PM    Report this comment

George,

A more icing experienced pilot is likely to have been paying more attention and handflying the aircraft. I have always hand-flown the aircraft in any significant icing conditions and always while on the approach. Experience can teach a pilot when it is important to pay attention. On approach with an iced up aircraft is one of those times.

Posted by: KRISTIN WINTER | May 29, 2009 2:54 PM    Report this comment

Why would a MORE experienced pilot be more inclined to pay attention when ice is present than a less-experienced pilot? That's not what I've witnessed. Have you ever heard the phrase "Familiarity breeds contempt"? I don't believe previous success at living thru icing makes one "more attentive". I believe it makes one "more complacent". A pilot who is scared of ice.... is a safer pilot than one who "has seen this before" and does nothing about it.

Posted by: George Horn | May 29, 2009 3:32 PM    Report this comment

Maybe the experience lacked was the kind that throws a little scare into you; the captain recounted how a previous airplane would take on a bunch and "keep on truckin'", and the FO said she was so much more omfortable with it all now (actual, etc.). Maybe neither one had ever gotten that scare related to the conditions they were in. False sense of security kind of stuff.

Posted by: Mike Holshouser | May 30, 2009 12:32 AM    Report this comment

A more icing experienced pilot is more likely to know that she/he is a test pilot, every time you put ice on an airplane. Granted, an inexperienced pilot might be more afraid of ice, but not know what to do with that fear. Experience makes you respect it, even if you don't fear it.

Part of the issue may be that pilots seem to be much more autopilot dependant than in the past. If it does nothing else, handflying the aircraft connects the pilot to the plane, and forces the pilot to be in the loop.

Posted by: KRISTIN WINTER | May 30, 2009 10:00 AM    Report this comment

I disagree Kristin. Anytime a dicey situation is encountered and escaped...doesn't matter whether thru skill, or plain dumb luck.... that person is more likely to presume that "I'm so much more comfortable with it now..." (does that sound familiar? NO? Did you read the cockpit transcript of the Cogan flight?)

Posted by: George Horn | May 30, 2009 11:42 PM    Report this comment

I did! We disagree. Fair enough.

Posted by: KRISTIN WINTER | May 31, 2009 9:33 AM    Report this comment

I did! We apparently disagree. Fair enough!

Posted by: KRISTIN WINTER | May 31, 2009 9:34 AM    Report this comment

George,

I have to agree with you. The old adage of familiarity breeds contempt may have been a factor. I have read some comments from Rod Machado about what he calls fear extinguishing.

When I was working on my instrument rating, my instructor had a very causal attitude toward icing. He would take me up in a Cessna 172 and we would pick up ice all the time. One time the windshield was so iced up, that I had to crab all the way down final so I could see out. I was not at the time uncomfortable with flying in ice, because I trusted my instructor. As I gained more experience and knowledge, I realized how wrong and dangerous the situation was.

I am interested in knowing if the Q400 has a speed bug or alert annunciator? How was it that the flight crew let it slow up to critical AOA?

Posted by: JERRY ALLEN | May 31, 2009 10:41 AM    Report this comment

Jerry the stick shaker/stick pusher substitutes for the stall horn and triggers before an actual stall. In this case, as deice is on the stick shaker triggers at a higher airspeed than it normally would.

Posted by: Christopher Basham | May 31, 2009 11:43 PM    Report this comment

It would be expected that the aircraft should have an airspeed bug that the crews should move as each phase of flight is changed. Yet, in the last two critical minutes, neither pilot mentions the airspeed even once.

Being on the autopilot in icing conditions, even light icing conditions, within the terminal environment, is just not smart. The use of the autopilot masks the subtle and occasionally the not-so-subtle clues that the flight in icing conditions may (or may not) be having its way with the airflow over the wing and horizontal tail. Unless the aircraft is hand flown, the clues needed to safely operate the aircraft in icing conditions are masked by the use of the autopilot. This crew, probably true to long established habit patterns, either did not wish to (in spite of all the reasons why icing conditions and the autopilot don’t mix), or didn’t have the confidence, to hand fly the aircraft in such a situation.

Unfortunately, unless the red lights flash and horns blow, the policies of most air carriers flying this and similar equipment encourage their pilots to “let George do it”. That means that the pilots don’t get the requisite practice to acquire the skill to fly the airplane without the autopilot when it shouldn’t. In this case, that policy and the fact that the autopilot was allowed to fly the airplane until it was disengaged by the stall warning, is probably a significant causal factor in this accident.

Posted by: THOMAS OLSEN | June 1, 2009 12:49 AM    Report this comment

Yes, when considering whether or not to use the autopilot in a particular circumstance, the workload is a consideration. It is important that the workload be kept to a rational level, but the workload in this cockpit was certainly not overwhelming, considering the crews improper conversational priorities, until the aircraft was allowed to slow to the stall warning (stick shaker). At which point the pilot had no choice, he had to hand fly the airplane and he should have been able to recover, but this crew didn’t.

Notice that I wrote “stall warning”, which in this case means the stick shaker. The stick shaker is supposed to activate so that a properly trained and experienced crew has the ability to recover from the impending stall, before the “actual” (the nose falls and there isn’t anything the pilot can do about it) stall.

Being “comfortable” about any amount of ice that can impact the flight characteristics of the airplane, and “significant” ice certainly qualifies as ice that probably impacts the flight characteristics of the airplane, is a bad idea. Certainly, in a properly equipped aircraft, there is no emergency, but there are steps that must be taken to assure safety. Unfortunately, this pilot was not knowledgeable enough, to understand the reason you don’t continue to operate the aircraft on the autopilot in icing conditions, is to prevent the autopilot from masking undesirable control characteristics that can accrue in icing conditions.

Posted by: THOMAS OLSEN | June 1, 2009 12:50 AM    Report this comment

It would be expected that the aircraft should have an airspeed bug that the crews should move as each phase of flight is changed. Yet, in the last two critical minutes, neither pilot mentions the airspeed even once.

Being on the autopilot in icing conditions, even light icing conditions, within the terminal environment, is just not smart. The use of the autopilot masks the subtle and occasionally the not-so-subtle clues that the flight in icing conditions may (or may not) be having its way with the airflow over the wing and horizontal tail. Unless the aircraft is hand flown, the clues needed to safely operate the aircraft in icing conditions are masked by the use of the autopilot. This crew, probably true to long established habit patterns, either did not wish to (in spite of all the reasons why icing conditions and the autopilot don’t mix), or didn’t have the confidence, to hand fly the aircraft in such a situation.

Unfortunately, unless the red lights flash and horns blow, the policies of most air carriers flying this and similar equipment encourage their pilots to “let George do it”. That means that the pilots don’t get the requisite practice to acquire the skill to fly the airplane without the autopilot when it shouldn’t. In this case, that policy and the fact that the autopilot was allowed to fly the airplane until it was disengaged by the stall warning, is probably a significant causal factor in this accident.

Posted by: THOMAS OLSEN | June 1, 2009 12:52 AM    Report this comment

Flying the aircraft around in icing conditions, with operational de-icing boots is not an emergency, but it is not “normal” either. Flying in icing conditions does generate some concerns that would not be present in a “normal” non icing environment. Responsible crews should be trained and knowledgeable and able to handle these situations, and when necessary, have a plan of escape.

One of those concerns about flying in icing conditions is how the aircraft will react when the autopilot is disengaged. Many aircraft have a nose down tendency, accompanied by some “lightness” in the controls that can induce pilot induced oscillations upon autopilot disengage. How slight or how drastic depends upon the airplane type, the amount of ice on the aircraft when the autopilot was disengaged, and at what speed the autopilot was disengaged. It is something that is generally handled easily enough, just as an “out-of-trim” condition can almost always be handled when the autopilot is disengaged when an out-of-trim condition is present.

One of the questions in this accident is why did the pilot pull so hard on the yoke when the stick shaker activated and the autopilot disengaged. In a “classic” tailplane stall, it is not the wing (where most stall warning devices are located) that is stalled, or approaching the stall. It is the tail, which does not contain any stall warning device except for the probable elevator control buffet that often precedes a tailplane stall.

Posted by: THOMAS OLSEN | June 1, 2009 12:53 AM    Report this comment

Why the pilot pulled the aircraft up into an actual stall is a question that we cannot answer definitively, but some informed speculation might be useful. Did this pilot feel the possible pitch down and lightness in the controls that probably accompanied the disengagement of the autopilot, and assume that the aircraft was in a tailplane stall, in spite of the stick shaker?

The stick shaker is probably the best evidence that what this crew encountered was NOT a tailplane stall, but just your average, have been trained to recover from, accomplish in the simulator every six months, garden variety stall warning.

The stick pusher did not activate until the aircraft, in a considerable nose up attitude, slowed to approximately 105-106 knots. The pilot’s decision to pull the yoke up at the activation of the stall warning was not influenced by the stick pusher, it did not activate until he had lost an additional 24-26 knots.

The interesting thing about this fact is that when the activation of the stall shaker occurred, at 131 knots, the aircraft was still flying, and flying pretty well. It is only when the pilot applied considerable up elevator that the pilot pulled the aircraft into the actual (where things happen outside of the control of the pilot) stall.

Once the pilot pulled the aircraft up into the actual stall and as long as back pressure was not released, recovery was impossible and they were all just passengers to impact.

Posted by: THOMAS OLSEN | June 1, 2009 12:55 AM    Report this comment

I am told that some versions of the Q400 are equipped with an “ICE SPEED” Switch, which increases the onset speed of the stall warning by 20 knots, and is supposed to be a clue to the need for increased speed while in icing conditions. I was also told that initiating the use of the de-icing boots will increase the speed at which the stall warnings (stick shaker) will activate. The NTSB says that activation of the stick shaker, at 130 knots, is consistent with the proper operation of the stall warning systems with the boots operating. Depending upon the amount of ice being carried by the aircraft, the activation of the stick shaker at 130-131 knots is probably a much larger margin above stall that would be expected without the ice. Especially since the stick pusher did not activate until a much slower speed.

The fact that this aircraft was allowed to slow to stall is probably related to the pilot’s habits as to airspeed cross checks, with the autopilot engaged, slightly positive thrust, and without a load of ice on the aircraft. The pilot never showed a concern for the airspeed during this entire evolution. When a pilot does something often enough, and it works, especially if he is taught to do it that way, unless he is experienced or careful enough to realize that habits that apply to “normal” situations, do not apply to all situations. Unfortunately, the copilot was not monitoring the airspeed either, as was probably part of her habit pattern as well.

Posted by: THOMAS OLSEN | June 1, 2009 12:56 AM    Report this comment

According to the NASA Animation, the power levers are not at flight idle because there is a slight power lever offset from the idle position and from each other, which is fairly typical for a slightly positive thrust position, with one power lever slightly forward of the other to create equal amounts of positive thrust. At the beginning of the NASA animation, the aircraft speed slowed from 189 to 169 and the pilot increased power to recover, maintaining the same slight difference in power lever position. However, the power was reduced to near idle as the flaps and gear extended.

It would be reasonable that the failure of the pilots to monitor the airspeed could be related to his/their perception of the time that it normally takes for the aircraft, from around 185 knots, to slow to a rational approach speed, after the gear and flaps are extended, with the powerplant output slightly positive, when not operating in icing conditions.

It is reasonable to speculate that the pilot habitually allowed the aircraft to slow to approach speed and had done it enough to not be concerned with the airspeed slowing to a stall. However, in this case, his undoing was the icing conditions in which he was flying, and the increased rate at which the speed was lost while flying in icing conditions.

Unfortunately, a pilot’s habits are often more prominent in his operation of the aircraft than current instruction, policy or needed adjustment due to changed circumstances.

Posted by: THOMAS OLSEN | June 1, 2009 12:58 AM    Report this comment

So, what pilot about knowledge, experience and training?

Why didn’t he know that the autopilot in icing conditions can mask unwanted control characteristics induced by the ice?

Why did the pilot react so badly to the stick shaker? Didn’t he know that it is not normally associated with tailplane stalls? At 2,300 feet, he certainly had more than enough altitude to recover from a garden variety stall warning. Why did he assume it was a tailplane stall?

His inability to recover from the actual stall, once he induced it, is a common circumstance among even experienced and knowledgeable pilots and has happened before, most recently several years ago with a new pilot in an Airborne Express DC-8 in an out-of-maintenance test flight.

Since the advent of simulators, most pilots today have never seen a transport category airplane in a full stall. Only manufacturer’s test pilots or company out-of-heavy-maintenance test pilots actually see or practice technique of recovering from an actual stall. Some T-tail aircraft cannot be allowed to full stall, but there are others where it is accomplished on a regular basis. I don’t know if the Q400 is prohibited from full stalls, but if not, it should recover from an actual stall induced by a line pilot, if the proper technique was applied.

All previous training focused on preventing stalls. “Recognize and recover” has always been the mantra. Maybe the simulators need to simulate what really happens in an actual stall?

Posted by: THOMAS OLSEN | June 1, 2009 1:13 AM    Report this comment

In an approach to a stall, the aircraft is still completely within the control of the pilot, unless he screws up. The pilot is instructed to increase the thrust to maximum and control the pitch to quiet the stick shaker, and fly the airplane out of the stall. This generally means that the pitch, in the initial recovery, remains somewhat nose up, until sufficient speed is attained that requires the pilot to release nose up pressure to prevent the aircraft from climbing.

An actual stall is not like that at all. Out of maintenance test flights on the Lockheed Electra, DC-8 and the 747-200 all require full stalls to check flap and control rigging. The full stall is induced by holding back pressure, usually with the yoke almost all the way back, the airplane shaking like a five cylinder diesel engine with a rod out of balance, running at high speed.

When the nose breaks, it breaks over hard, you end up in an attitude that makes you think that you are pointed straight at the ground. The only way to break the stall is to release the back pressure and allow the airplane to recover flying speed and increase the power to minimize the altitude loss. In the DC-8, in a clean stall, altitude loss might vary from 600 to 1,600 feet.

I think these pilots could have recovered if they had just released the back pressure and allow the airplane to fly. Unfortunately, they were never trained to accomplish anything besides approaches to stall.

Posted by: THOMAS OLSEN | June 1, 2009 1:14 AM    Report this comment

Quite a discussion Thomas -- I suggest you see my comments Christopher Basham on May 27, 2009

I am not pleased with what I see -- it is simply failure to maintain airspeed.

Posted by: Christopher Basham | June 1, 2009 2:57 AM    Report this comment

After monitoring this forum and other sources of info, I can understand why the captain yanked back on the stick - if he assumed he was in a tail plane stall. But if there is even a possibility of instantaneously having to decide which it was - tailplane or "regular" - why wasn't such a decision-making process hammered into his skull during training? In the Navy, we called them Instant Action Emergencies - and you had better get them right on every exam - with no crib sheets!

Posted by: Paul Valovich | June 1, 2009 8:23 AM    Report this comment

Yes Chris, if the crew had maintained airspeed (prevention), we would have probably never had a reason to ever know their names. But since they didn't, the situation progressed to the next level, which was in fact stall recognition and recovery (cure). There was still plenty of opportunity to do the right thing even at that point, as further explained by Thomas Olsen.

The surprise nature of the thing however, put a right response in greater question than handling a stall in a training scenario. Had they been primed to expect a stall, they wouldn't have let the airspeed decay. The incorrect and somewhat mysterious response to the stick shaker is where all was lost, not before.

It seems that training would've taken over and allowed the captain to automatically make the right choice in this situation, almost without thinking. But (excluding a pure panic explanation) tailplane stalls were apparently overemphasized in his thinking, possibly due to his training experiences. This seems similar to the New York Airbus crash FO from earlier this decade who had aggressive control inputs impressed on him as the proper response to a wake turbulence encounter (which cost them their horizontal stabilizer).

Posted by: Mike Holshouser | June 1, 2009 8:48 AM    Report this comment

I don't know what really happened, but can I redirect the discussion again:

It wasn't an ice incident - it was a stall-spin. Although they were flying in icing conditions there is nothing to suggest that ice itself was a factor. The only indirect "cause" of the upset was that because the anti-ice was switched on, in the type they were flying the stall warning triggers at a higher speed to give an additional buffer against the chance there is residual ice on the airframe.

In fact, there probably wasn't significant ice on the airframe, since although the stall warning fired at over 130 kts, the aircraft was still trying to fly when the speed fell to 105 kts.

I'd like to repeat what Thomas Olsen said - the stick shaker is just a warning, like the horn on a light single. It's like having your phone set to vibrate. The real aerodynamic stall comes later, and is a different story. When the stick shaker starts - the airplane HAS NOT STALLED - YET. When a transport aircraft stalls, it'll shake your teeth loose.

All this speculation about mysterious tailplane stalls or windshear recovery makes no sense at all. The Captain slowed the aircraft towards the stall, and when the stall warner sounded, he heaved back on the controls. This incident is a mystery because there is no rational explanation for his action. There is certainly no reason at all for him to assume anything other than "classic" incipient stall when the shaker went off. Maybe he just screwed up.

Posted by: ANDY DAVIS | June 1, 2009 8:57 AM    Report this comment

Unfortunately Andy, he did screw up...Stall recovery is one of the very First maneuvers taught to a pilot. You have to effectively recover from a stall before you can even solo. What happened on 3407 was purely pilot error. And more important F/O error. They made 3 very big errors. First off, they did not maintain a sterile cockpit. Secondly, the F/O raised the flaps after the aircraft was clearly in a stall. My 9 year old son knows not to do that. The captain applied 25lbs of back force on the yoke. That is not trying to raise the nose slightly, but rather a freak out maneuver that was made by a pilot that was caught off guard because he was not paying attention to what as going on. Regardless if the aircraft is a 172 or a 747-400; t stall or regular; there is 1 solution to stall recovery: airspeed. This is a very unfortunate tragedy that could have been avoided by using basic airmanship.

Posted by: Matthew LaMay | June 1, 2009 9:14 AM    Report this comment

Coulda Woulda Shoulda . . .Time to start rethinking this whole hiring 250 hour pilots, paying them a non-living wage and upgrading in a year at 1500. Time to start rethinking the financial relationships between the mainline carriers and it's commuter subcontractors. Either you allow the commuter / subcontractors to charge more and keep more money to offset ever increasing seat per mile costs, or you put the whole operation under one roof and make everybody perform to one standard. Operationally AND financially.

When all this shakes out, this may be the accident to do just that!

Posted by: Kim Barnes | June 1, 2009 10:06 AM    Report this comment

Correction to previous post: The New York Airbus lost its Vertical stabilizer, not horizontal.

Posted by: Mike Holshouser | June 1, 2009 10:20 AM    Report this comment

First of all get off the icing. It was a stall/spin. Ice had NOTHING to do with the pilot control inputs that put the aircraft into a full stall/spin. Did you see how low the airspeed went in the animation? Did you watch the animation? Clear on that?

For those who keep saying "Pay has nothing to do with it". You are in serious denial or uninformed about the current situation in the commuter airlines. It's not that Pilot "A" will work harder or try better if he/she is paid more. It's the fact that you don't hire low time/low experience/substandard performing pilot "A" in the first place. You hire the most qualified person for the job not the cheapest. The backgrounds of pilots willing to show up for work WILL vary based on salary level offered. Do you realize Pinnacle put a person in the right seat of a CRJ with a grand total of 240 hours and 12 hours ME? That's right 12 hours ME. If you think that is a highly qualified level of experience to fly part 121 you need serious help and you won't get it on these boards.

Posted by: m adams | June 2, 2009 3:13 AM    Report this comment

Mr. Adams -- I understand that even British Airlines will put a 350 hour commercial pilot into the right seat of a B 737.

Pilot's have to start somewhere. It is not necessary that they go through bush - commuter - majors and have 1000s of hours prior to sitting on the righthand of the Captn.

Furthermore, the "man" who stalled the airplane had a lot more time than 240 hours. Also, if I remember correctly, I sat in the left seat of an airplane with "0" hours.

Posted by: Christopher Basham | June 2, 2009 6:57 AM    Report this comment

Well said Chris. The captain had somewhere close to 2500hrs. Mr Adams, I do my job the same no matter how much money I get paid. The company I work for told me how much they would pay me before I accepted the position. So what gives me the right to bitch about my pay when I knew full well how much they paid before I took the job. And to respond to your "hiring the most qualified person" statement: I'm sorry, but you are just not going to hire some 45-50 year old 757 captain from Delta to come fly your non-autopilot B1900 for 10 legs a day. I don't care if you offer him $150,000. He won't do it. It is people like you that just don't get it. You people need to go cry in your beer with Sully, and let us people who *gasp* actually like flying take it from here. You know what is some funny irony?? People bitching about how much they get paid to fly, while other people are dishing out $150/hr to rent a cessna. Or better yet, emptying the savings account and taking out student loans just for the opportunity to learn how to fly. Shame on you guys for being so narrow sighted.

Posted by: Matthew LaMay | June 2, 2009 7:24 AM    Report this comment

Does anyone know how long the captain and the FO had worked together? I am going in a crazy direction with this idea, but I wonder if the captain could have lost his concentration with having a pretty and young FO.

I know of a young CFI who took off with his Pitot cover on when asked to give an intro ride to a pretty, young lady.

I once tried to takeoff with my airplane tied down when giving a ride to a pretty girl.

It seems that one of the issues here is that the crew was not concentrating on their flight responsibilities.

Also, there has been a lot of speculation about the experience and or lack of training for the flight crew. Is there any evidence of that? Do we know enough about the background of either pilot. Do we know how much previous icing experience the captain had or the sim training he has received?

So what is really the issue? Is it as simple as low paid pilots equals low safety? Is it that we need higher standards/training? Or is it because we have people flying these complex machines, humans with the capability to make mistakes in judgment and decision making, that we will continue to have accidents that defies explanation.

Posted by: JERRY ALLEN | June 2, 2009 10:37 AM    Report this comment

You guys keep fixating on the wrong culprit. Hours alone does not make the pilot. Yes, foreign airlines have been known to put ab-intio pilots in a seat with just several hundred "airline" trained hours. They sit there at FL370 for 12 hours at a time and read the newspaper. Fine. It also takes 20+ years to upgrade to captain in those programs. Apples and Oranges to what we are talking about.

Let me ask you a question. Would you let your family board an airplane you knew was piloted by a pilot ( or crew )who had never experienced ice of any kind fly into an airport that was reporting Low CIGS and widespread DZ near freezing?

If you said yes, you either hate your family or you don't have the experience to know what you don't know. Experience should be sought only after careful consideration and examination of your perceived skill level, equipment flown and the conditions that are believed to exist. NEVER EVER should this "new experience" be attempted at the expense of 50-300 passengers!

Go out there and fly. Fly Fly! Go drone around in the weather with a gross loaded aircraft of freight in the WX! Do 10 legs a day. Pretty soon you'll be that person I want in the seat of that 121 carrier! NOT the "this is a wing" to "121 job interview" in 9 months!

Posted by: Kim Barnes | June 2, 2009 10:37 AM    Report this comment

The truth of the matter is we will never know why the captain let his airspeed get so low. Or why he yanked on the stick instead of pushing.

Rod Machado has a very good article on why some very good and highly experienced pilots, bend metal.The NTSB reports are full of statistics where highly experienced 20,000 +hr pilots kill themselves in a aircraft. A recent example of this is a highly experience mountain flying instructor who did himself in buzzing elk.

Posted by: JERRY ALLEN | June 2, 2009 10:39 AM    Report this comment

Jerry, With the rotation schedule that commuters have, it wouldn't surprise me if they never flew together. The F/O was clearly a distraction as she didn't even know how to correctly fill her log book out. And by raising the flaps on an already stalled aircraft, she really let her inexperience shine. They both came from Gulfstream. The airport that I am based at is a hub for Gulfstream, and some of the captains that you see don't even look like they have hit puberty. Then they go out to their 1900 with 19 souls on board and zoom off into the wild blue yonder. Experience counts for alot, but with experience comes complacency. At the local airport that I fly my Cessna out of, we had a guy that was a retired F-111 pilot and also flew 737's for a major end up in the water after over-running the runway on a landing attempt. And what is really interesting is he was returning home from doing formation flying and 3 abreast landings over at Sun n Fun. When he was asked why he didn't just execute a go around, he said that he thought he could stop in time. The point is, he got too complacent, and it ended up costing him a 2 year old Cirrus. The younger "kid" would probably still have his Cirrus.

Posted by: Matthew LaMay | June 2, 2009 1:46 PM    Report this comment

So what are you suggesting Matthew? Fire everybody who has over 1,500 hours to combat complacency?

Complacency isn't it, at least not for the reason you cite.

They didn't have the "experience" to become complacent according to your theory. But maybe they were complacent because they didn't know what they didn't know?

Now we're right back to where we started from. Experience AND Judgement . . .

Posted by: Kim Barnes | June 2, 2009 8:54 PM    Report this comment

What I am suggesting Kim is that it is a no win battle. Nor am I saying that all grey haired pilots are complacent. I know many very good pilots of all ages. I also know that when you are in the middle of shooting an ILS approach it is not the time to be talking about your golf swing. This accident did not happen because of complacency. It happened because of 2 people not paying attention to what was happening. I also believe that it would not have happened if the F/O wasn't talking the captains ear off. It ws also the captains fault for not telling her to shut the hell up and for not maintaining a sterile cockpit. It just kicks my ass every time something happens, people have to bring up how much an airline pays (or a lack thereof)their pilots

Posted by: Matthew LaMay | June 2, 2009 10:33 PM    Report this comment

Fair enough Matthew. The reason for why pilots get into these situations are as numerous as the accident count itself. I look back at my 33 years in aviation and cringe at the close calls, the close calls of learning.

Those still among the living at one time or another bit off ALMOST more than we could chew. But I'll bet we all took a close hard look at what almost got us afterward. We learned. We studied. Hopefully that experience taught us to do it differently next time. Judgement.

At some point we must all "jump off" into the wild blue and continue to learn. All I have been trying to say is there is a progression. Good training and education certainly makes this jump off point sooner, but what if we keep making the jump off point earlier and earlier and training continues to get shorter and shorter?

Give me a pilot who has 500 hours and 3 years to absorb it all. Then give me the same 500 hour pilot who rushed through and got it inside a year, and I'll show you 2 entirely different pilots in both skill and judgement!

Posted by: Kim Barnes | June 3, 2009 10:27 AM    Report this comment

We can never train the pilot for the final tragic combination that does him in. I had never seen ice before the first time I flew into it, and I survived (knock on wood) because I had learned and been taught about it. Pilots need to understand their aircraft and the art of flying to be able to extrapolate their knowledge into the future combination of events and inputs that will help them make the right decision at some fateful point in their future. No pilot (or computer) can be trained (or programmed) for every eventuality -- but pilots (unlike computers) can understand the underlying reasons and extrapolate, and perhaps (at that stage we are test pilots) find a safe way out of the problem.

What if you were flying an airplane like the Colgan flight through ice and suddenly the yoke starts to vibrate and then moves itself forward to the panel? It could be the stick-shaker or it could be tail-plane icing. Could the two causes be indistinguishable in a period of high stress? Clearly the incorrect interpretation of the yoke moving forward would exacerbate the real problem and close to the ground, realization and correction might take too long.

Posted by: Kingsley Hill | June 10, 2009 11:23 AM    Report this comment

one more thing???

Was there any indication that the Colgan pilots commanded deice boot inflation? They appear to have noted the ice, but were the boots working? Activated?

Posted by: Kingsley Hill | June 10, 2009 11:29 AM    Report this comment

I remember reading that the deicing system had been activated and was working properly. The problem was that they let the airspeed get too low which can clearly be seen on the NTSB reenactment

Posted by: Matthew LaMay | June 10, 2009 11:57 AM    Report this comment

Did they let the airspeed go down (presumably by climbing), something every pilot is trained to avoid -- or did the stall speed rise (because of ice) above their airspeed. See my prior post about possible confusion between stick-shaker and signs of tail-plane-stall.

Posted by: Kingsley Hill | June 10, 2009 12:11 PM    Report this comment

We are getting off the track on this accident. They should have been hand flying the aircraft in the terminal environment. PERIOD. Not because of legality, but because using the autopilot masks the impact the ice (regardless of boot operation) that might (or might not) be accumulating, on the way the aircraft flies. The crew will never know what that impact is if the don't manage that risk and hand fly the aircraft in the terminal environment in icing conditions.

The question is, why did they ignore the appropriate risk management? Were they ignorant about the fact that flying in ice requires some additional risk management? Starting with not hand flying the airplane in the terminal area in icing conditions. Was this crew so autopilot-dependent that they did not have the confidence in their own skill to hand fly the airplane in these conditions, even though it is more than a good idea? This whole accident arose from their unwillingness or inability to employ the proper risk management under the existing circumstances.

Posted by: THOMAS OLSEN | June 10, 2009 12:21 PM    Report this comment

You seem to be pressing for poor judgement on the part of the crew. I submit that they may have been presented with ambiguous information (either stick-shaker or tail-plane stall). The response to one is exactly opposite to the response to the other. An incorrect interpretation would be catastrophic close to the ground. In either event an airfoil stalled...and the question reverts to why the boots did not remove the ice from that airfoil.

Posted by: Kingsley Hill | June 10, 2009 12:49 PM    Report this comment

There is a long history of boots not removing all the ice, especially when "significant" ice is accumulating. Also, ice can accumulate where there are no boots, and that may impact the flying qualities of the aircraft as well. By not hand flying the aircraft they could not know what that impact was, and they were responsible to know. To know that, hand flying was necessary.

The wing stalled when the Captain pulled it up into a stall upon stick shaker activation. The aircraft was not stalled at stick shaker activation. This stall warning went off an estimated 20 knots [actual ice impact (if any) on stall unknown] because it was reset to a higher speed when the de-ice system was activated.

What caused the accident? I submit that the accident was caused by training and operational policies that make crews autopilot-dependent, without the confidence, ability and willingness to hand fly the airplane when proper risk management demands it. Hand flying would have prevented the accident.

Posted by: THOMAS OLSEN | June 10, 2009 3:57 PM    Report this comment

Consider that perhaps the pilot error was one of OVER-thinking rather than under-thinking. What if the pilot interpreted the onset of the stick-shaker as the onset of a tail-plane stall? Yoke behavior when the stick-shaker fires and when the tail-plane stalls is nearly identical -- it moves decisively forward. If the pilot incorrectly interpreted the forward movement of the yoke as the onset of tail-plane stall and attempted to counter that tail-plane stall (characterized by the aircraft pitching downward) with back-pressure he would have aggravated a main wing stall.

The airplane was descending and level when ice would have accumulated. It is in a climb when ice can often form below and behind the boots. I would like to see a citation from a accident report or research report where correctly used and working boots did not remove sufficient ice (in level or descending flight) to keep the wing flying. Even in freezing rain I have had airplanes accumulate a lot of ice and boots always remove it when used correctly -- of course there are a lot of places that can get ice condemning a flight to failure -- so I would never recommend to fly in freezing rain nor do so myself intentionally.

Posted by: Kingsley Hill | June 10, 2009 5:52 PM    Report this comment

Boots are no guarantee of ice removal from all locations where the boots are located or anywhere else on the airframe. The reason the boots are operating is because ice is accumulating. If you ever land after or during a significant ice encounter, have a look at the airplane before the ice melts. To assume that just because what you can see is clear of ice is an assumption based on facts not in evidence. Even light icing means there are risk management issues that must be addressed.

I do not agree that the activation of the stick shaker is any justification to immediately think tailplane stall. Stick pusher, maybe, but that feature did not activate until 20-26 knots below the activation of the stick shaker, so that is not part of the picture.

What we are all forgetting is that a large part of the picture is this crew's lack of proper airspeed monitoring that allowed the aircraft to slow to the stick shaker in the first place. No stall warning, no bad decision.

Posted by: THOMAS OLSEN | June 10, 2009 6:16 PM    Report this comment

When the stick shaker disconnected the autopilot, this pilot was suddenly forced to hand fly the airplane. The pilot probably(?) misinterpreted the pitch down and "lightness" on the controls that usually accompanies disengagement of the autopilot in icing conditions, along with a possible out-of-trim condition from the autopilot attempting to hold altitude as the speed decreased (55 knots in 27 seconds) as the “stick push” from a tailplane stall.

In icing conditions, if we are to believe there was any justification for his use of the tailplane stall technique then he probably did it to himself by staying on the autopilot until he ignored the airspeed for a sufficient period for the aircraft to slow to the stick shaker.

The stick shaker is not normally associated with a tailplane stall. At that altitude, if he had reacted to the stall warning and pushed the nose over an applied the power, we would not be having this discussion. If it was a tailplane stall, he had altitude to fix it.

Posted by: THOMAS OLSEN | June 10, 2009 6:39 PM    Report this comment

Please review the effects of the onset of tail-plane icing. The yoke will begin to shake as the ice begins to disturb airflow over the elevator. As the problem gets worse the tail plane will stall and cause the yoke to pull itself forward out of the pilot's hands.

I agree there are risk management issues in any icing situation. I am just not ready to condemn a dead crew for poor performance while there is still a reasonable doubt.

As to airspeed monitoring...do we know they were flying slow (before the pitch up)? Or did they fly at the right speed but stall speed increase due to the icing?

Posted by: Kingsley Hill | June 10, 2009 6:44 PM    Report this comment

Third question first. They slowed from 186 knots to 131 knots in 27 seconds. There was little or no monitoring of the airspeed in a very critical point along the approach after the gear and flaps were extended. I believe the aircraft, with the existing positive thrust, decelerated quicker than expected by the crew, probably because of the accumulation of ice. (Icing conditions risk management again.)

Second point, the stick shaker is quite a bit different from the vibration in the elevator that precedes the tailplane stall. The stick shaker makes a very specific noise that is discernable on the CVR. The yoke vibration (flutter) that precedes the tailplane stall is almost silent and usually at a different frequency. Plus that vibration is a warning of the stall, not the actual tailplane stall. The elevator vibration is a warning to retract flaps, not pull up.

Posted by: THOMAS OLSEN | June 10, 2009 7:37 PM    Report this comment

The actual tailplane stall is not indicated until the yoke is jerked forward, out of your hands. That forward jerk may not be as violent with hydraulically boosted flight controls, but it will be there. I have my doubts that the stick “push” at autopilot disengagement, in this instance, would have risen to the violence of the stick “push” associated with a tailplane stall.

Remember, this aircraft was pretty far from the actual stall at stick shaker activation, until the pilot pulled up. Had this pilot, which is pretty typical of modern training methods, ever seen an actual stall of his aircraft, so he could not recognize his mistake.

Certainly this crew was a product of their previous and their airlines training, qualification and operational policies that set this crew up to fail, but they and the industry we all serve are part of that failure. This crew may not be totally responsible, but their failings in basic airmanship, before the stall are a tragedy of their own making.

Posted by: THOMAS OLSEN | June 10, 2009 7:57 PM    Report this comment

You points are well made. I am just less ready to condemn a dead crew for poor performance while there is still a reasonable doubt.

Posted by: Kingsley Hill | June 10, 2009 8:14 PM    Report this comment

Kingsley, your statements omit the fact that the crew members didn't appear to have their minds totally on what they were doing up to and at the point of yoke motion (whatever its source). I'm thinkin' that had a little bit of an effect on their performance, in both the leadup and response to the crisis, regardless of whether it was wing or tail related.

Posted by: Mike Holshouser | June 10, 2009 10:02 PM    Report this comment

I agree that they did not show the best cockpit discipline nor maintain a sterile cockpit during the approach. They appeared to take a difficult approach as too routine. I doubt that this is a problem of this crew alone. Airlines, check pilots, and pilot management must express and emphasize discipline and focus. BTW, discussing the ice and one's lack of experience with ice could be considered relevant conversation.

Posted by: Kingsley Hill | June 11, 2009 6:44 AM    Report this comment

There was another point at which this crew could have prevented the accident. That point is just after the pull up by the pilot. The fact that they were able to achieve such a high pitch attitude was very clear evidence that the stall warning was of an impending wing stall and not a tailplane stall.

Had they really been in a tailplane stall, the ability to raise the nose that much above the horizontal would be extremely unlikely.

To get as much pitch up as they induced, if they were properly trained, would have instantly indicated that the stall warning they were getting was an impending wing stall and not a tailplane stall.

Posted by: THOMAS OLSEN | June 11, 2009 2:24 PM    Report this comment

If the pilot firmly believed he was experiencing an uncommanded pitch-over due to tail plane stall he would have pulled back on the yoke with all his might (it takes alot take the yoke back). Anyone in that event would have over-corrected. Once the yoke came back easier than expected it would have take a while for any pilot to discard his first (erroneous) thought as to the cause of the stall and take the correct action. The confusion as that change of mind takes place is extreme and would put incredible stress on the pilot. Imagine second guessing yourself close to the ground, in ugly weather knowing that the wrong action at this moment will kill you. Until you've been there don't be so quick to say how you'd react. Maybe some other pilots would have initially reacted differently and avoided the problem, but once the wrong decision had been made the stress level, proximity of panic, and proximity of death is something that only the most disciplined and well trained pilot could work through calmly.

Posted by: Kingsley Hill | June 11, 2009 4:00 PM    Report this comment

Kingsley, It is quite obvious to me that you have not read the NTSB's report nor watched the recreation video. They both clearly indicate that the stick shaker had been activated and said nothing of a t stall

Posted by: Matthew LaMay | June 11, 2009 4:15 PM    Report this comment

Matthew it is quite clear that you have not read the whole thread. I said that the pilot interpreted (erroneously) the shaking of the yoke and the uncommanded forward motion of the yoke as the onset of tail-plane stall. See earlier posts for details.

Posted by: Kingsley Hill | June 11, 2009 4:24 PM    Report this comment

I actually wrote some of those earlier posts. I do remember what they stated. You can tell very clearly what happened by listening to the CVR. They were chit chatting away at 2300ft and were not paying attention to their airspeed. The stick shaker activated and the pilot did an "oh crap" maneuver while the F/O did a couple of "I really shouldn't be an F/O" things that made the problem all the worse. IMHO, the worst thing that they did was to raise the flaps when the aircraft was on the verge of (if not already) stalling.

Also, keep in mind, they were at 2,300ft. If this were a bigger jet, then yeah they would have not had much time to react, but they were in a Dash-8...certainly no Cessna, but they were going as fast as one and easily had plenty of altitude to recover from a stall

Posted by: Matthew LaMay | June 11, 2009 4:38 PM    Report this comment

Matthew, as I said, put yourself in their shoes. Yes, they were not paying as much attention as they should have for the conditions (some, including I, would say they were not paying enough attention for any conditions. When the stick-pusher fired, he reacted by pulling the yoke back because he thought he had encountered tail-plane stall to which the correct response is pulling the stick back and raising the flaps. This turned out to be wrong, but it was an understandable misinterpretation. Now you have a main wing stalled, being pulled into a deeper stall by the pilot, and the flaps coming up further raising the stall speed of the wing. The pilot has to realize his error, get over the shock, keep himself calm, push stick the back forward, add power, realize where the flaps are and command flaps back down. Each of those things takes time (and some not without reservation and second-guessing) and things were happening quickly.

I am not saying the pilots did not contribute to the accident. I am just saying that contrary to the implications of some of the posts, I am not persuaded that they were complete imbeciles incapable of flying any airplane much less a small airliner in hard IFR. They made some mistakes and they paid with their lives (and those of 48 others). All of those errors have been made by other pilots and some (e.g. the incorrect response) are understandable (but nevertheless wrong).

Posted by: Kingsley Hill | June 11, 2009 5:21 PM    Report this comment

The stick pusher did not operate until the airplane had been slowed to 105-106 knots, or approximately 25-26 knots below the speed at which he pulled up into a stall. He was pretty close to max pitch when the stick pusher activated and then went away at about 98 knots.

We don't know how much push accompanied the disengagement of the autopilot, but as I said, I doubt that it rose to the violence of what would be associated with a tailplane stall.

They were not complete imbeciles. However, Intelligence/skill is not always an indicator of professional and responsible airmanship that must be exercised on every flight.

This accident was caused by their lack of exercise of the responsible basic airmanship, risk management and improper priorities, before the stall warning was activated.

Such circumstances are not what the public has a right to expect from the crew on any air carrier flight. Certainly they paid for that mistake, but so did 46 other people who had a right to expect better.

Posted by: THOMAS OLSEN | June 12, 2009 7:01 AM    Report this comment

"They were not complete imbeciles. However, Intelligence/skill is not always an indicator of professional and responsible airmanship that must be exercised on every flight." - Right.

"Such circumstances are not what the public has a right to expect from the crew on any air carrier flight. Certainly they paid for that mistake, but so did 46 other people who had a right to expect better." - Precisely the important point, not, How correct were the pilots' reactions after they painted themselves into a corner? That's an insult to the passengers and the person on the ground who died, which, (not to minimize the pilots' themsleves and their families' loss) is the real tragedy of the whole thing, because they weren't responsible.

Posted by: Mike Holshouser | June 12, 2009 7:53 AM    Report this comment

you are speculating that the airplane began an descent at the command of the autopilot (which should not have been on), the pilot pulled back on the yoke causing the autopilot to kick off and then the pilot continued to pull back apparently without regard to airspeed into a stall? The stick shaker fired and still the pilot failed to respond? All of this because he was having an irrelevant chat with the co-pilot and he had the autopilot flying the airplane too far into the approach? I am not buying that scenario. Something else had to have happened, or been happening.

Yes, airline passengers expect professionalism from the crew. But the crew deserves the benefit of the doubt in an tragedy like this until it is proven otherwise. Let the pilot who has never made a bone-headed mistake cast the first stone.

Posted by: Kingsley Hill | June 12, 2009 9:05 AM    Report this comment

I made no intention to insult the passengers. I believe that the cockpit crew of this airplane failed in their professional responsibilities to properly fly the aircraft in the circumstances wherein they were operating.

Were they trained and qualified properly? I am sure that Colgan is going to maintain that they were. Then how did this happen?

We all make mistakes, some of them really bone headed, but someone was alert enough or managed the risks of those bonehead mistakes so it didn't end up as a subject for an accident investigation.

I sympathize with the families of the crew and the passengers and the person on the ground who was killed and the family that lost their home. I believe they all had the right to expect better from an air carrier crew.

However, the point of these post-mortems is not to protect anyone, but to prevent similar accidents from happening in the future. The question should be, what have we learned from this? The rest is window dressing.

Posted by: THOMAS OLSEN | June 12, 2009 12:53 PM    Report this comment

Thomas, I was totally agreeing with your statments that I quoted. Especially regarding what the passengers should've been able to expect performance-wise out of the crew that they entrusted their lives with.

Has anyone said what the discrepancy was between the speed the aircraft slowed to before stick shaker, and what the approach speed at that point was supposed to have been?

Posted by: Mike Holshouser | June 12, 2009 2:35 PM    Report this comment

The approach speed is roughly 140kts, and landing speed around 110kts. Of course these vary with wind and weight and etc, but they're good estimates. With that being said, you can easily see where there was absolutely no airspeed management going on

Posted by: Matthew LaMay | June 12, 2009 3:25 PM    Report this comment

Just to be clear. The autopilot is kicked off by the activation of the stall warning. When the autopilot disengaged, with the stall warning (stick shaker) doing its best to warn him away from the stall, the pilot pulled up into a full stall.

If he had been properly monitoring the speed and and properly managing the risk, the accident would not have happened. What happened after the stall warning never would have happened if the crew had been properly monitoring their aircraft to prevent the stall warning.

Posted by: THOMAS OLSEN | June 13, 2009 12:10 PM    Report this comment

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