Spring has well and truly sprung in Canada and I've been off camping, paying no attention at all to my blog account mail. I peeked at it recently and it's full of unread mail from you guys and news alerts on the Colgan accident investigation. (I originally blogged about the Colgan 3407 crashthe night it happened).
The cockpit voice recorder transcript was released last week, and a lot of information about the pilots' lifestyle was released at the hearing. If you're reading about a fatal airplane crash, the only thing you can read that can really be said to be a relief is that the crash was misreported, and everyone is alright. That's obviously not the case here. It's still a little bit of a relief to find out some of what happened, because it collapses the network of all the possible bad things that could happened into the few that actually did.
The first thing that hits me reading this transcript is the stunning inexperience of the crew in comparison with Canadian aviation. The captain says he was hired with 625 hours. That would have been as first officer, but you'd be lucky to get a job on a Navajo or a King Air in Canada with that time. The first officer had sixteen hundred hours at the time of the accident, but much of that was as a flight instructor in Phoenix. There she would rarely have seen a cloud, nor below freezing temperatures. In her own words, in the recording made not quite five minutes before she died ...
"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 experience that and make those kind of calls. You know I'd have freaked out. I'd have like seen this much ice and thought oh my gosh we were going to crash."
So she has no basis beyond company training on which to judge the severity of icing. She's never flown northern routes in the spring to places where the most distinctive landmarks are the crashed remains of airplanes that didn't make it. She is depending on the captains she is flying her now to teach her how to make those judgements. And that's part of being a first officer. She's smart enough to know that, too. When talking about the people hired at the same time as her, she notes that many are agitating for an upgrade but that she "really wouldn't mind going through a winter in the northeast before I have to upgrade to captain."
It sounds as if upgrades happen pretty quickly there, and as if not everyone thinks of their period of time as a first officer as an apprenticeship. I originally looked at the fact that Rebecca Shaw had been with the company through a winter and assumed that meant she had experienced icing conditions in that airplane. But I wasn't thinking about the short routes that Colgan uses the Dash-8 on, and that with a southern base, it's possible to go through a US winter without meeting ice.
The captain you would think had more experience, but he accepted the autopilot setting "I've got you in pitch hold," in icing conditions. Regardless of your experience, one of the things that icing training teaches you so you don't have to find out for yourself is that an ice accumulation that looks exactly like the one the airplane handled fine last week may result in completely different handling today. Very subtle changes can have a huge affect on aircraft stbility and handling. Hand flying allows you to notice how the ice is affecting you, if the airplane is needing more trim or more power to hold the same parameters. You don't want an airplane on pitch hold, holding its own nose up without you realizing what it's having to do to achieve that. In ice, that can lead to a stall. And this airplane stalled fifteen seconds after a cheerfully unconcerned radio exchange with air traffic control.
Not only are they talking to ATC, but they are talking to each other. We're getting a complete career analysis from both pilots right through the flight, interspersed with their clearances and checklists. A reader asked me if he thought that women,stereotypically more chatty, were more likely to disregard the sterile cockpit than men. Anyone who reads my blog can tell that I have a lot of verbiage to dispense. But I know what a sterile cockpit is and what it is for and I STFU when required to. I want to be a professional pilot and it's about more than having your hat on straight. Act like one, sound like one. I don't think this is a male-female issue. The captain is keeping up his end of the conversation. It's company culture. The FO says she's been flying with a lot of captains, some of whom can't finesse the rudder, but none of whom have apparently instructed her or demonstrated to her that one shuts up about ones career below ten thousand feet. It's not a difficult culture to instill because how many times would an FO have to have a a captain point at the altimeter or say, "sterile cockpit please" before she never opens her mouth for non-essential communication below ten thousand?
Other evidence from the hearing shows that pilots paid far too little to live at their bases were living far from their bases were commuting across the country and then sleeping on crew room couches before their duty periods. Ever flown a redeye and then had a nap on a couch in a room where people were coming in and out, having discussions and watching TV? Ready to handle any emergency right? And ready to handle three back to back 16-hour shifts? Yeah, right.
I commute across the continent that, but only once a month, and the company ensures I've had eight hours in a hotel bed before I'm expected to work. Three back-to-back 16 hour duty days is criminal. I'll work three fourteens and I'm beat. There's no way I'd be safe with another two hours on each of those days. I worked back-to-back sixteens like that back when I was seventeen years old. After a few days of that routine, I slept right through my alarm and was late for work. But I didn't get in trouble. The doughnut shop *manager* got in trouble for scheduling me that way. Yes, I was working in a doughnut shop, not flying an airplane. It seems that Canadian doughnuts and coffee are deemed by company upper management to deserve more alert supervision than the controls of a Colgan commuter airline. The FO also seems to have had a cold--she sneezes more than once during the flight and the captain is inquiring about her ability to clear her ears as they descend, even planning the descent profile for her comfort.
A manager at Colgan suggested random audits of the CVR for compliance with sterile cockpit procedures. That's not where professional flying comes from. Train and examine people to the standards you expect. Spot checks? What is this, summer camp? If you have to do spot checks of basic safety proedures, you're hiring the wrong people or training them incorrectly.
Interesting to hear your views on this one ... and on professionalism in general. As an amateur pilot I'm not qualified to say much on some specific technical tasks, but with more than 50 years in avaiation I can tell you, for sure, there will be more crashes like this until someone at the top takes these word to heart and makes them part of their company culture:
"I want to be a professional pilot and it's about more than having your hat on straight. Act like one, sound like one."
The sad litany of CVR transcripts from literally hundreds of accidents I have reviewed are littered with concrete examples of a 'care-less' attitude, even as bad as a major air carrier captain attempting to hit on a jumpseating FA and commenting on what his wife would think if she heard the tape, 60 seconds before unsuccessfully trying to take off without flaps.
"Remember who you are, then act accordingly" might be a useful creed ... the money you are paid is not a good indicator of the level of trust expected.
An interesting idea for a study which I have not yet made ... (I think Canadian pilots have a slightly better set of hours of service regulations than the US, but my point will still hold) ...
Altough we the US public and government bleat continually about our support of air safety, our actions speak as if we really don't. Take a situation where a pilot works for an air carrier who also operates commercial trucks. The pilot, still within FAA mandated duty limitations, may be way beyond the limits to drive a truck ... many pilots in passenger for-hire aircraft would not be leagal to trade modes and drive the trip they are flying in a motor coach ... Aa bus driver is required by law to have more rest than an airline pilot.
Food for thought?
I don´t think that the autopilot had anything to do with this crash. Have you read the thoughts Sam has about this? His analysis is about the best out there...!!!
Yes, hand flying would probably have made a difference, but the reality is that these airplanes are very automated and one is expected to fly them that way. The hydraulics usually mask most of the subtle changes that icing can provide in these circumstances. I think it boils down to Pitch+Power=Performance...
Love your blog,
I've always thought it interesting that pilots and doctors routinely work such long, circadian shifting days. You'd think a well rested surgeon might be at least as important as say an alert librarian. :-)
WHOA WHOA WHOA!!!! Slow way down, here, PLEASE!
I'm a Q400 CA, and there is NOTHING wrong with running the airplane in pitch hold during icing conditions. This is done routinely, and APPROPRIATELY, thousands of times per day, every day, all over the world. Only in SEVERE icing is the A/P required to be disconnected. 'Pitch Hold' in the Q400 is a mode commonly used for setting a pitch for descent or climb, and is even used during single-engine climb after a V1 cut (even during icing).
This accident was not caused by icing. Failure to maintain adequate airspeed and a spectacularly inappropriate reaction to a low-speed cue (shaker) were the causes of this accident.
Oh, and the airplane didn't stall at the beginning of the incident. The 'ref speeds' switch was in 'incr' which means the shaker activated about 30kts above aerodynamic stall. The airplane then pulled more than 2Gs when maneuvered (try that with a stalled wing sometime).
This whole post reads like it was written by somebody else. So careless and plainly inaccurate.
So, how do you establish a company culture that abides by things like the sterile cockpit rule? Not suggesting the CVR should be reviewed, In the US at least it is not allowed to be used for any purpose except accident investigation. That aside, you've just been appointed DO of an airline where the sterile cockpit rule is routinely ignored. How do you change that?
For SEQU and Buzzoff...
While it may be technically correct to fly Q400s on AP in icing conditions TODAY, I await the TSBs recommendations with GREAT interest... as to whether THEY will think it is STILL appropriate in low-speed, "dirty" configurations.
No the autopilot is not the cause of the accident, but the issue is:...
Do you not have to be listening to what your aircraft is telling you, especially in conditions which are less than ideal? Especially at times of major configuration changes?
Did you watch the animation and see how how the airspeed indicator dives after the major gear and flap adjustment??... and nobody adjusted the power!!!
Would not "feeling" the airplane have "told" the PF that it is time to adjust power....well before the stick-shaker finally told him???
But not only that. Would not "Feeling" the airplane have focussed his attention on FLYING, which is what PFs do? This aircraft was not being "flown" in the seconds before the stick-shaker. And judging by the way the airspeed dropped with no power input, it is even debatable whether it was being "monitored".
Having been not listening, when he finally DID hear the aircraft, he seems to have heard it wrong..
Thank you for the corrections Buzzoff. I haven't flown anything with an autopilot that can be trusted in abnormal situations. I tried to phrase it as a question about that choice, but then added too much and it got lost.
I agree that the cause of the accident was poor airspeed monitoring and an inappropriate response to the stick shaker, but I understood that the loss of airspeed was a consequence of airframe icing. Was it just poor descent profile planning?
And yep, you caught me posting something with inadequate research, just back from the bush and trying to catch up with news. I guess fatigue is a factor for bloggers, too.
If you want to e-mail me a more informed analysis, I would love to post that.
The aircraft stalled because it leveled off and power was not applied. Furthermore, the configuration changes allowed for a quick loss of airspeed. Those blades are mighty speedbrakes!!!
No icing involved there. Bombardier knows a lot about icing, and I´m sure the aircraft carries ice very, very well, Buzzoff must be a better reference there.
As to the autopilot, again, if the NTSB goes on to suggest that when in icing, one must fly manually, I think it will be a step in the wrong direction. The PF must fly the aircraft, autopilot or no autopilot. Makes no difference.
Aviatrix, take the time to read Sam´s analysis of this whole thing. For those of you that don´t know Sam it´s fl250.blogspot.com .
Thanks for your post on this.I'm not a pilot and I can't comment on the choices these two pilots made but in regards to the "fatigue" issue, at my airline a lot of people commute. Pilots and Flight Attendants alike. I can't tell you a percentage but it's high, especially to our Newark base. I often fly with pilots who just commuted in from the west coast,on a JS and don't have any time to rest...even in the crew room...they head straight off a red eye to their work day. Very common!! Always bothered me.So it's not just a $$ issue, these people at my airline make well over six figures.They can afford to live where they want or chose to get a hotel room. I also don't feel it is safe for pilots to work red eye flights in most cases. Most people are not at their best that late, just my opinion: )I avoid red eyes for this reason.
As far as experience gos...a few years back before the economic downturn, we hired a lot of pilots fast. I couldn't believe we were upgrading FOs to Captains within a couple years. They were in their mid twenties. I know just because they were young doesn't mean they didn't have experience but as a FA you get to know pilots at least those you work with and I don't think a lot of these pilots had the maturity or experience to be a Captain at a major airline. Again just my opinion from the front lines. That was one thing I was happy about when the economy turned...these young, inexperienced pilots were back to being FOs.There is a lot to be said for learning from our older more experienced captains.
Almost every media report lately mentioning the crew of the Colgan flight contrasts them with the heroic experienced pilots of the Hudson ditching. Many of them bemoan the obvious dangers of commuting...while not mentioning that Capt. Sully commutes from California to Charlotte, and FO Skiles from Wisconsin to Charlotte. Most reports mention that the pilots commuted in on long flights and then went to work....while failing to mention that Capt. Renslow had arrived in Newark the day before. FO Shaw had commuted in on Fedex, arriving in Newark a legal eight hours before her report time and then went to her crashpad. Even if their commutes had been official working hours, both pilots were legal to fly the flight. Legal, but perhaps not safe. Everyone agrees that these pilots were dangerously fatigued, but they had received legal rest. This would be an appropriate time to examine pilots' max duty time and rest requirements, which the NTSB ruled inadequate decades ago. Again, remember that even factoring in the commutes as duty time, these pilots were legal to fly. As an aside, research shows that fatigue is one of the top factors in what many call "unprofessional" behaviors such as poor checklist discipline and breaking sterile cockpit.
Another common statement in response to the accident is "Why did the captain pull back instead of push to break the stall? It's the first thing you learn as a student pilot!" This is true, but 121 pilots are taught a specific stall recovery that is a bit different. The minimum altitude loss is emphasized to a large degree, and the aircraft never stalls. The assumption of the checkride is that this is happening at low altitude and the imminent stall should be approached and recovered with essentially no altitude loss. This means basically once you get the shaker you do not let the aircraft descend (it will a bit anyway, and that's about all that's allowed). There is no release of pressure to break the stall, because in this scenario you never let the aircraft stall. You go max thrust and ride the shaker out at that altitude, then recovering the small amount of altitude lost. The point is that this manuever requires a fair amount of back pressure. In the sim, under basically perfect conditions (calm air, pilots aware that they're approaching a stall, alert and intensely focused crew) approaches to stalls ride a small margin of back pressure between perfect recovery and the stick pusher (automatic unsat). Procedures obviously will vary somewhat, but to my knowledge the constant factor is that you do not push to break the stall (because the aircraft never stalls), and recovery involves a pretty good amount of back pressure. So, now you have a tired crew at the end of a long day...a flying pilot who is surprised by the stick shaker...and a sudden rush of adrenaline. While we will never know what Capt. Renslow was thinking, I posit that it was highly probable he was attempting to perform the stall recovery he was taught in the sim and overdid the back pressure to the extent that the investigating agencies say he "pulled up".
The summary of my long statement is that I am not that quick to jump on the "simply incompetent pilots" bandwagon. I feel that many of the factors involved have to do with inadequate industry regulations and perhaps inappropriate training procedures. In my opinion, those media reports that write off the accident as "regional airlines are bad and these pilots were incompetent" are missing a chance to examine and perhaps mend real issues in the industry.
There's no question that in this instance, at least, the a/p took the pilots too far 'out of the loop.' BUT, do you blame the a/p? Of course not. For whatever reason, the CREW failed, in this case, to properly monitor their aircraft (of which the autopilot is a system). Flying around without the a/p whenever in icing conditions would not be an enhancement to safety. I frequently fly up to 7 legs per 12 hr. day, all of which occur almost entirely within icing conditions. If you haven't flown that many legs during a day, WITH an a/p, and noted your fatigue level even halfway through, you'll have to trust me that taking away automation would be a real 'killer'.
The a/p is a very valuable tool, which requires management. Not unlike the landing gear. When somebody lands gear-up, we don't suggest everyone leave their wheels down permanently from then on, do we?
If I had to ascribe a single cause to almost every bit of goofy behavior I've seen or committed in this career to date it would be:
F A T I G U E.
Aviatrix, I've never seen the aircraft's performance noticeably degraded in the least during even severe icing. The thing has over 5000HP (3700kw) on each wing, with 13'6" props; Ice has less impact on this airplane than any other I've flown, including jets.
Sorry for getting a little hot-headed, and thanks for your graceful response.
Always happy to answer any questions about the airplane and/or the way my outfit runs ours.
I need to say that I do enjoy the controversial yet respectful discussion in this blog. Very interesting, once again, for a person like me who's not a pilot but just an aviation nerd (with some technical background).
There's one minor- yet entirely important- detail regarding the quote about icing from the FO.
She was going through her thoughts as a newhire. She had been online for a year, and I guarantee you she had seen icing conditions on the Dash 8 prior to the accident.
Colan exclusively uses the Dash in the northeast, where icing is literally a way of life.
I wouldnn't for a minute, expect the NTSB to recommend against use of the auto-pilot "in icing conditions".
MY interest is about their opinion on its use "in icing conditions while in landing configuration at speeds well below cruise".
I await the report.
ALL flight in landing configuration is well below cruise speed, so it amounts to the notion that we shouldn't use the a/p on approach in icing.
I repeat: this accident wasn't caused by, nor related to, icing, except in the sense that the ref speeds switch being in the 'increase' position brought about an earlier stick shaker.
I'm only a Q400 CA in the NW US. You may well know more about this airplane and this airplane in icing.
But I kind of doubt it.
The AP is mandatory on some approaches, and recommended on others (CAT III, or a 1800RVR CAT I, HUD/FD/AP to DA). It doesn't matter if it is FZFG, BLSN, MIFG, etc causing the low vis.
Just for giggles- what would the handflown Q400 "tell" the PF?
What kind of feedback would you expect, and why? Better yet, how?
It's a workload management tool, and is as much a part of the airplane as TCAS, the Nh guages, and the fire bottles.
I don't know a whole lot about the Q400, but I do know a little bit about ice.
The comment that "the aircraft's performance [is not seen to be] noticeably degraded in the least during even severe icing" is kind of interesting. I am a Bombardier fan, and perhaps they have come up with a magic airfoil.... But there is ample research out there, both theoretical and experimental, which suggests that even small amounts of ice affect lift and drag significantly. The papers at the NASA site: http://icebox.grc.nasa.gov/resources/documents.html are a good starting point.
Now the Q400's boot deice systems may be very effective. But in the typical airfoil, at high angles of attack, the underside of the wing gets contaminated back beyond the leading edge. How effective are the boot systems back there?
The "performance" comment tends to support the position that the a/p does, in fact, mask the pilot's perception of what the aircraft is doing.
All icing is not the same. 100 approaches in 100 icing condition will produce 100 subtle differences in the control inputs required to maintain the appropriate approach profile. And it is quite true that the A/P can make them a lot more accurately than the PF.
But when the A/P finally DOES have to be disconnected, whether in the normal course of approach and landing.... or whether because of a surpise event such as the subject incident ... then is there not a sudden discontinuity in the "stabilized-approach" profile???... while the PF becomes acclimatized to the forces required, the responsiveness or sluggishness of the controls???? And could that discontinuity "surprise" the pilot???... possibly to the point of disorientation???...especially in a time of fatigue?....
The NTSB's recomendations in this report:
would suggest that this was a concern to them.... Granted, different aircraft, different circumstances.... which why I am very interested to see whether they feel it applies to THIS aircraft, THIS circumstance.
The Colgan investigation has also produced a few interesting icing quotes from the pilot interviews: (http://www.ntsb.gov/dockets/aviation/dca09ma027/417449.pdf)
1. Icing conditions exist when the temp is less than 5 deg and there’s visible moisture.
2. He defined severe icing as: freezing rain, temperatures minus 20.
3. Severe icing to him it’d be real cold temperatures, freezing rain,
Number 1 is a pretty good rote definition of the requisites for CARB icing in your basic C172, but I doubt that above-freezing temperatures are going to produce much AIRFRAME icing. Sure, maybe it is time to start monitoring the temperature carefully as it is getting close to zero, but I seriously doubt that "icing conditions exist".....
Numbers 2 and 3: "really cold" temperatures, such as minus-20, is where much of the liquid water has already frozen. And as a result, the icing would normally be quite LIGHT, except possibly in the core of a thunderstorm.
"Freezing rain", or course, is the biggie, but the most dangerous temperatures are just below zero to maybe minus-10. That's where your super-cooled liquid content will be the greatest and thus so will be the icing.. As you get colder than minus-10, SOME of the droplets will freeze or the existing moisture will form snow (ice) crystals. Once any ice crystals form, they begin to "steal" moisture, causing the water droplets to get smaller while the snow crystals grow.
Therefore, typically, the rate of ice accretion will be LOWEST below minus 20, somewhat greater between minus 10 and minus 20, but the greatest will be in the range zero to minus 10.
The pilot responses in those interviews bother me. Do we truly understand the factors which affect our aircraft, or are we simply pushing "this" button in response to "this" situation, and expect that all will be well????
I agree with the Q400 drivers here. The only thing this accident had to do with icing was that they forgot to switch off the "Increase Ref Speed" switch.
They briefed their non-icing ref speeds and the captain had his energy management set for those speeds.
When the stick shaker came on 20kts above those "mind set" speeds he was simply in awe and reacted the wrong way. The f/o did so aswell and put up the flaps. Dead.
Giving it a little power and not touching the yoke at all would have been sufficient to "save" the situation.
It's the simple things that get you...remember that.
And off course it is part of the system...too bad people always die before things are changed!
And about flying the q400 manually...sorry its not a Seneca. Nobody flies and Airbus manually in icing. And the Q400 is an Airbus, compared to e.g. a Saab 340.
Aviatrix, all the best for your new job.
I'm with Aviatrix on the autopilot issue. I don't think it 'caused' the accident, but I think if it had been off, the captain wouldn't have been able to decelerate as fast as he did while holding an altitude.
He would have noticed the decaying speed much sooner while hand flying.
I'll admit it. Hand flying keeps me more aware of the airplane, no question about it. Maybe others maintain a super-scan with the autopilot on, but I don't.
As I blogged about last week, I don't think the non-sterile cockpit had much to do with the accident, since they had been quiet for more than two minutes prior to the deceleration (starting with 'gear down') and remained so throughout the event.
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