Time in Type & Travel? Buffalo Q-400
May 13, 2009 by Bruce Landsberg
The NTSB held its public hearing this week on Continental flight 3407 that crashed in Buffalo this winter. There has been much speculation about icing, tail stalls, autopilot weirdness, crew coordination, crew qualification, training – pretty much everything has been open for discussion.
The revelations this week noted that the captain had consistently failed flight checks, that the company (Colgan Air) failed to provide adequate training since the captain had not been trained in stall recovery using the stick pusher that is part of the Dash 8′s stall safety system. The pusher apparently activated as the crew allowed airspeed to decay. Colgan responded that the crew had been properly trained. There was speculation that the crew may have been fatigued at the end of a long day. The first officer (FO) had flown in from Seattle the day before after a skiing vacation and had said she wasn’t feeling well.
The FO also was heard on the cockpit voice recorder voicing concern about icing. The captain responded that it wasn’t a problem and he had experience with ice – but it wasn’t in the Q-400.
I’ll offer two observations: A significant portion of this may come down to experience in type. The captain had just over 100 hours in the Q-400. This is something that the Air Safety Foundation sees constantly regardless of the size of aircraft. There is a noticeable drop off in accident involvement after the first 200 hours in make and model. This happens for two reasons – In GA, not that many pilots accumulate high time in any one model so the exposure may be less and the pilot has started to learn how he/she and the machine interact.
There is more mental margin when one knows the aircraft well. You know its limits and strengths and generally have learned to compensate accordingly. That leaves more time for managing other distractions, such as icing. As an aside, being on guard to adverse developments and mentally running contingency plans is the mark of a pro. Amateurs dismiss such things as unimportant or an over-reaction.
Secondly, it seems logical that the first officer might be fatigued since she had acclimated to a different time zone. In the hearing it was brought out that she lived on the west coast and routinely commuted cross country. The captain was reported to have lived in Florida but both crew members flew out of Newark, NJ.
Two thoughts that will likely generate contrarian views and they are cheerfully accepted:
1. Airlines should leave pilots in make and model routinely so that when an FO upgrades to captain he/she already knows the aircraft well – it’s just a seat and mindset change. Some carriers do this and pay is based strictly on seniority, not the size of the hardware. It’s smart from a human factors and cost perspective. There should be some flexibility to allow equipment change but it really shouldn’t be the norm.
2. The time and distance allowed for commuting pilots should be limited. Long duty days become much longer when it’s a 3 -10 hour commute home and you’re subject to all the “variability” of airline schedules. This is one of the sacred cows of airline jobs that gets into pay/lifestyle issues but it collides directly with fatigue and readiness for flight.
These same factors apply to GA flight ops. We need to know the equipment and be ready to fly. Your thoughts?
Bruce Landsberg
President, AOPA Foundation
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Bruce Landsberg, President of the AOPA Foundation
May 13th, 2009 at 4:17 pm
What does not make sense to me is the fact that an airline will bring a pilot 3,000 miles or more to fly short hops on an opposite coast, the fatigue factor is there before the flight begins. There had to be a type pilot to fill the position locally thus eliminating the fatigue factor in one or more pilot.
Who makes the decision a commercial pilot can fly, the pilot! Another bad safety decision there should be a qualified entity to screen all persons in charge of strict liability issues. In other words if johnny or sally pilot has a sinus cold, is fatigued or stressed that entity screens for such issues. In strict liability issues it is still cost efficient
May 15th, 2009 at 4:42 am
It’s really shocking the tragedy itself. One of the things my instructor as a young pilot always told me is , “never be afraid to ask for help if you even think you’re in trouble”. Have our Commercial/ATP Rated friends forgotten they have help out there if needed. I started very early learning to fly,(14 yrs old, Private at 18, IFR at 20), and entered the Navy as an Air Traffic Controller. During my first duty station one of the things I noticed dealing with “some” of the military pilots is that it ran from one extreme to the other. Some would ask for assistance and priority handling if they were in “trouble”, some would just shrug it off until they were in an actual emergency. My experience in different types of aircraft runs the gamut, but the constant is once again wise words from my two primary flight instructors, “fly the airplane first!” If the FO had a concern about the icing she was right to voice it and having more time in type should have been a little more assertive. The Captain, yes, is in charge and should be able to take that info onboard and make the necessary risk decisions to safely execute flight. I’ve flown T-tailed Arrows and Conventional Arrows and they are both light aircraft, but performance is totally different in certain configs. When dealing with the T-talied designs you are always aware of a tail stall and should constantly contingency plan for it. I agree that the airlines who try to keep a pilot with a particular type, vice bouncing around between aircraft is a smart move. It allows them to become seasoned professionals and cuts down on the operational risk involved in passenger flight. Procedure wise if there is an icing concern the pilots should be able to accept each other’s input and work an immediate solution that is beneficial to completing the flight safely. Temperature inversions are dangerous and not always known, they can occur anywhere and I know this fact from an almost deadly Cessna flight. If that occurred, the aircraft would have surely ckaed on the ice quicker that the system could handle and may be a factor, but nonetheless the pilots should have gotten out of it if rapid formation is seen. Lack of experience and aggressive risk management is a factor in this incident, but is not the primary fault in my opinion.
May 15th, 2009 at 8:44 am
First of all when you fly for an airline the schedulers could care less where you live as that is your choice. You are either on reserve or you are able to hold a “hard” line. In the event you hold a hard line you bid for the trips that you would like to hold for the month. If you are on a resrve schedule you get the left overs and fly what trips that need to be covered. For the F/O living on the West coast she would have been more rested as she would have been three hours ahead of her sleep cycle, of course depending what time she started commutting to EWR. The Captain would have most likely been on a reserve schedule as that usually happens when you transition to new equipment only having 100 hrs in type, Dash 8/400. Icing in my opinion did not cause the crash as did losing situational awareness of what going on about “flying” the aircraft. Who was watching the AIRSPEED? They were talking alot about icing and the build up on the aircraft. If you take a look at a picture of the Dash 8/400 they most likely were unable to see the wings as they are so far back on the fuselage, so I am assuming it was accumulating on the windshield as their reference point. Even so folks FLY THE AIRPLANE FIRST! Airpseed is your friend. When the stick shaker activates it is telling you that you are a few knots above the stall. If you don’t add power at that point then you will get the stick pusher forcing the nose down as the aircraft is trying to gain speed on its own. I don’t recall either pilot saying anything about airspeed was slowing or about adding power. You know it doesn’t matter how much time you have in an aircraft you still have to fly the plane. The autopilot was on, so it would be holding your altitude, also you would have the approach mode armed waiting to capture the localizier and glideslope. So the only thing that would be left is to watch the airspeed. Also just because you have four stripes doesn’t mean that you have the most experience. In this case the F/O had more experience in type than the Captain. Cause poor situational awareness, in my opinion.
May 15th, 2009 at 9:47 am
It seems to me there is too much discussion about pilot fatigue etc. It is often said that in aircraft accidents, it is usually a “chain” of errors any of which, if broken, avoids the accident. There are 3 obvious links in my opinion. First, the in-flight deicing equipment was not sufficient in that it allowed enough ice to accumulate on various parts of the aircraft which either 1) added weight and/or 2) destroyed lift thereby increasing the aircraft’s stall speed to a speed not anticipated by the crew. Second, the FO dropped the flaps on final thereby adding drag (and lift), however, without asking, raised the flaps when things started getting squirrely. I assume the FO mistakenly assumed that the flaps were part of the problem. After all, the aircraft was fine seconds before. While raising the flaps decreased the drag, it caused an immediate loss of lift at a time when they were dangerously close to the stall speed. And third, the Captain’s decision to pull back on the yoke.
The crew should have 1) Kept the yoke in the neutral or nose down (slightly) during the event 2) firewalled the throttles, 3) immediately (simultaneously) raised the gear, and 4) AFTER some period of time (after gaining speed), ONLY THEN raised the flaps.
One could argue it was a training issue. The responses (above) should have been automatic on the part of the crew. There is just too much BS coverage on this crash.
May 15th, 2009 at 9:58 am
As an eight year veteran of the regional airline industry I’ve been watching the reports on the NTSB hearings with interest. What I have seen mentioned elsewhere is that F/O Shaw was living in Seattle out of necessity. The cost of housing or even a night in a hotel in the northeast is prohibitive for a regional pilot. Although Colgan disputed it, reports have also listed F/O Shaw’s pay at $16,000 for the 12 months previous to the accident.
Thus comes out the dirty laundry that the airlines, especially the regionals, don’t want aired. People make great sacrifices to be airline pilots, hoping that they will make it to where the pay is good and the living is easy(ier?) Increasingly, that place is farther away, verging on unobtainable. Because of this the experienced pilots are leaving anyway, but by exiting the industry, not advancing. Can you blame them? When your computer science majoring buddy from college makes multiple times what you do in the cockpit, how long do you stay and try to make it pay?
No, low pay isn’t the probable cause of this accident, not even close. But this accident has brought the slave-like wages and working conditions of the regionals to light. Maybe some good will come of this.
May 15th, 2009 at 10:15 am
In my opinion. airspeed is the critical component in this tragic event. Had the airspeed been increased to accommodate the acummulating ice, I believe the mishap would have been prevented. I was taught in heavy icing conditions, you take the plane off autopilot so you can “feel” what is going on. Also a change in configuration, ie, landing gear, flaps, etc, should not be done in such heavy icing conditions. these items should be left for the final approach fix inbound on the localizer and not use flaps, if you have the runway length to accomodate a no flap landing. These coupled with watching the guages for speed degredation is a must. I Also agree that Pilots should not be allowed to commute coast to coast and then fly any length trip, short hop or other. There are enough good qualified pilots out there. Thanks AOPA for these great services you provide to keep us informed on such critical issues!!
May 15th, 2009 at 11:26 am
A couple of points: changing equipment is not necessarily a bad thing. My company imposes a 39-month seat lock for lateral moves in most cases. So as an FO, I’m stuck in my current fleet for 3 more years, which I feel is a reasonable time to get familiar with the airplane. And when it’s time to change fleets, I’m facing at least a month, and often more, of training for the new fleet. And if it’s an upgrade to Captain at the same time, then there’ll be a lot more training.
One of the things I’m hoping (but not holding my breath) for is for the Public to say “Oh!!!! THAT’S how they keep the ticket prices low! I don’t wanna fly for the cheapest operator any more!”
I hate the airline managers who artificially depress ticket prices and hide operational costs like pilot salaries.
May 15th, 2009 at 12:31 pm
I do not understand the news comments that the PIC did not have training in stall recovery. If so, how did he get a type rating for the aircraft? The ATP and Type Rating PTS clearly calls for demonstration of recovery of three types of stalls, including during approach. I have always had to go through stall recovery, both in initial and recurrent training. How can any pilot NOT have had training in stall recovery?
May 15th, 2009 at 12:46 pm
What is very disturbing to me is the lack of sterile cockpit procedures especially inbound of the outer marker…you can read the cockpit voice recorder transcript here:
http://www.ntsb.gov/dockets/aviation/dca09ma027/418693.pdf
It makes sense to have rules about captains having more than 200 hours time in type. It also makes sense to have rules concerning commuting distances for professional pilots. It would also make sense to have sterile cockpit rules enforced, especially inbound to the outer marker. The flight crew should have been calling out altitude and airspeed, and should have had de-icing procedures memorized. They were confused and behind the airplane at the most critical time of the flight. There is simply no time for confusion or distraction inbound to the outer marker.
May 15th, 2009 at 1:39 pm
Pilots commuting does add to fatigue, but restricting commuting would change the whole way the industry works. If I was to get a job at Best Buy in Atlanta, I know I’m going to work there. When you get a job at an airline, most of the time they don’t even tell you where are are going to be based until half way through training. Additionally, pay is a factor in fatigue. Airlines schedules lead to chronic fatigue which pilots where able to combat by taking time off. But as pay has decreased, their financial responsibilities remain the same (mortgage, groceries, car). It is hard to tell the wife your going to have to sell the house, move back in with your parents, and sell a car because you are tired all the time. And that is after 10 years into your career!
May 15th, 2009 at 2:55 pm
It’s fascinating to have so much information about the last 30 seconds of Continental Connection Flight 3407 splattered all over the newspapers. As a former aircraft owner, 900-something hour pilot, I can’t help but speculate on factors that led this crew to fail. Understanding what happened is the first step towards minimizing the risk of a recurrence. One of three scenarios seems clear.
1) Crew had no idea what the airspeed was.
Captain Renslow’s actions were appropriate if he thought he was going around and oblivious to airspeed. Shaw’s decision to raise the flaps is also consistent with going around at speed
2) Crew somehow missed all of the stall/spin awareness training drummed into every pilot from day one.
Impossible, right?
3) Captain Marvin Renslow committed mass murder/suicide.
Based on the cockpit voice recorder transcript, Capt. Renslow’s last utterances indicate confusion inconsistent with mal-intent. First Officer Shaw’s apparent decision to raise the flaps (without discussion?) was a contributing factor that seems to have gone unnoticed in the investigation reports. A conspiracy seems unlikely. Captain said, “Oh .”, not, “G*d is Great.”
What kind of airspeed indicator/pitot static system was in this airplane? If pitot heat was off/malfunctioning/overcome in the icing conditions that the crew had just acknowledged, ice may have trapped air in the pitot line. The airspeed indicator could have been “stuck” from around the time the tube became blocked. As the plane descended, if the static port was not blocked, static pressure would increase, registering an apparent slowing of the plane, but still higher than actual airspeed. At the time Renslow pulled up, he could have believed he was flying well above the stall speed.
It is easy to assume that captain and first officer were knuckleheads. And that may be. But Occam’s razor teaches us that this crash was most likely caused by erroneous airspeed indications. This is what the investigation should be focusing on. Fortunately, there are simple solutions to that problem—provide redundancy, link airspeed indication with groundspeed and known wind data.
If the indicated airspeed was correct, but somehow both captain and first officer failed to notice, that is much harder to believe. But it also leads to possible solutions:
1) Audible warnings, “Airspeed is low. Airspeed is low.”
2) Mandatory airspeed callouts by the crew during descent
If ground proximity warning systems have access to wind information or a reliable airspeed indication, they could be reprogrammed to offer audio/visual warnings in these circumstances.
Please do keep us posted on the investigation.
May 15th, 2009 at 9:42 pm
What happened to “I’m Safe” that we all learned in Flying 101? At least four of these items were present in the NTSB investigation. “I”, “S”, “F” and “E”. Are commercial pilots exempt from these factors? The fact that the stick shaker was activated leads me to believe that the airspeed measurement components were operable and pulling back on the yoke was, perhaps, the singular fatal error that brought down this flight.
May 16th, 2009 at 11:39 am
I agree with the comments about possible impairment of crew capabilities. But there is still a missing link in the chain. Why did airspeed drop to near stall without the crew realizing it? From the moment the autopilot switched off they had only seconds to correctly analyze the situation and react properly.
Here’s what I’m wondering–
What was the system of airspeed sensors and interconnections on board? Was the stick shaker activated based on angle of attack or other wing airflow sensor or airspeed? Did the crew instruments display information from the same source or a different source? Did the flight recorder record the airspeed indications that were visible to the crew? What was the book stall speed in that configuration (with and without flaps), and at what speed was lift and control lost?
I’m sure all these possible factors came up during the investigation, but they haven’t been reported in the newspapers. If stall speed was significantly higher due to ice accumulation, that could also explain why the captain pulled up.
June 5th, 2009 at 12:18 pm
The training of the pilots is still a concern. Regardless of other issues. Current pilot training from primary to airline left seats is all designed to “get you through the check”. There is little consideration of such extraneous matters such as why you don’t use the autopilot in the terminal area while in icing conditions, or how to handle an unexpected stall that might be associated with ice build-up.
The pilot (allegedly) pulled the nose up reacting to an alleged tailplane stall. However, the activation of the stall warning (indicating the impending stall of the wing) is not generally associated with a tailplane stall. The only warning of a tailplane stall is the possible flutter on the elevator before the actual forward “jerk” of the yoke.
Also, the stick pusher did not activate until the aircraft was around 106 knots, and he pulled up at the stall warning, into a stall attitude, at 130-131 knots. Therefore the stick pusher did not influence his decision to pull the aircraft up into a stall.
When the stall warning disengaged the autopilot, if there had been some ice buildup, there may have been a forward pitching moment on the elevator controls, and the pilot over-reacted, but the activation of the stall warning is critical to the solution of the problem. It there is a stall warning, you should do what you do every proficiency check, fly it out of the stall, not pull it up.