It’s not the regulation, it’s the execution

June 3, 2009 by Bruce Landsberg

If you’ve been following the NTSB’s deliberations regarding Continental 3407, the Q-400 (Dash 8 derivative) that crashed in Buffalo this winter in what appears to have been a crew mishandling accident, you’ll know that this is going to be a landmark case. I’ve blogged on it twice; Time in Type and Travel? Buffalo Q-400, and Tail Stall?, but will use the mishap as a stepping off point to a broader topic.

The U.S. Congress has called for a comprehensive review of all commercial airline pilot training and certification programs. On the face of it, that might seem like a reasonable response but I have a hunch that the rules are probably adequate. The problem more often lies is in the adminstration of the regulations. The flash points here are an apparent disregard for airspeed, apparent unfamiliarity with stick pushers, a botched stall recovery, a lack of experience in icing conditions, and disregard of the sterile cockpit rule. There’s probably more but this is enough to chew on.

Rather than the regulations themselves, it might be more telling to explore how FAA is providing guidance to its inspector force, how the inspectors are interpreting that guidance, how new pilots are hired by the carriers, how training is actually being administered to new pilots by the airline and how sterile cockpit is enforced.

It’s clear that the intent, and I suspect the letter, of the regs are that pilots be competent in managing their aircraft in the conditions they are likely to encounter. The airline is on shaky ground in my view, when they say they weren’t required to teach the pilots about the stick pusher. Pilots need to know these things! How the aircraft got so slow that the pusher activated is perhaps another discussion entirely.

That the captain’s record wasn’t exactly the best, will be thoroughly reviewed in the report and it’s inappropriate for me to prejudge here but, again, airlines should know that if someone has a bad rap sheet, it’s a bad idea to entrust them with a multimillion dollar aircraft and 50 passengers. There will be more on this, I’m sure.

Lastly, it’s really unfortunate to give up more privacy to have FAA and airline management routinely scrutinizing cockpit voice recorders but if this is shown to be a critical distraction then maybe that’s less unfortunate than having innocents losing their lives. I’m betting that 90 plus percent of crews are diligent on sterile cockpit but the “bad apple” metaphor balls it up for the rest.

For those of us flying light GA aircraft, there’s lot to learn from this accident in general terms. If you make every attempt to be proficient with your aircraft, understand the nature of the weather in which you’re flying and stay focused on the task at hand, the outcome is likely to be much better.

My take is that there are enough regs, so let’s just use them regularly and efficiently with maybe a dab of common sense as well.

Bruce Landsberg
President, AOPA Foundation

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35 Responses to “It’s not the regulation, it’s the execution”

  1. UmTut Sut (Sure, why not?) Says:

    “The airline is on shaky ground in my view, when they say they weren’t required to teach the pilots about the stick pusher. ”

    Required? No. But testimony in the NTSB hearing revealed the captain had experience with stick pusher in the SAAB 340 simulator and, as a 340 captain, was responsible for a functional check of the stick pusher on the first flight of the day. If these statements are correct, he certainly was NOT unfamiliar with the workings of the stick pusher.

  2. David Tuuri Says:

    Exactly right, UmTut Sut. Besides, looking at the FDR traces in the NTSB docket, by the time the pusher activated the plane was rolling off to the left in a stall. The only question that needs to be asked is “Why did the stick go ‘aft’ after the shaker went off?” Was it bad training by the pilot’s original CFI that never was picked up during advanced training because of the emphasis on setting up stall scenarios rather than the essential recovery step? Or did his seat slide back? I doubt the latter, since the FDR shows he still managed to get full rudder.

  3. Jonathan Freidin Says:

    I also reviewed the FDR traces and it looked to me like an effective stall recovery was in progress at the time of impact. FO said she put the flaps up. Captain grunted. Plane crashed. The flaps were retracting for quite a few seconds, right up to the end of the trace. As a former Arrow pilot/owner, I can’t help but wonder what would have happened if FO had put the gear up and perhaps raised the flaps just 5-10 degrees. Add to the list: complete CRM breakdown during a critical emergency. I still wonder about the accuracy of the airspeed information displayed on the crew instruments.

  4. Avi Weiss Says:

    Chuck Yeager is fond of saying that “rules are made for people who can’t make any for themselves”, and that certainly seems applicable here.

    While rules are helpful in setting helpful boundaries and limitations, NO amount of rulemaking will ensure basic airmanship skills are current, and that common sense is being used. It will simply make adhering to rules that more onerous.

    Seems that time and effort would be better spent improving training, and increasing situation-based regimes, where pilots can encounter uncommon scenarios such as what what the Buffalo crew ran up against, so at least they have a fighting chance to detect the situation, and hopefully engage remedial action to correct.

  5. David Tuuri Says:

    Better take another look, Jonathan. At impact there was about 140 pounds of back pressure.

    dtuuri

  6. Travis Christensen Says:

    As a Q400 Captain I can say that lack of an appropriate level of pay for the equipment being operated is the real issue.

  7. Travis Christensen Says:

    Also note under the Safety and Proficiency section the article “Death Grip: Spin Training Turns Tragic”, it may reveal some stark similarities.

  8. sam ferguson Says:

    For a somewhat lowtime pilot, reading the cockpit recorder reminded me of my flight school: mostly kids looking for a good time; building time but not really really paying attention to teaching someone how to fly. Granted there was one young man that had a very professional attitude and he was quickly taken by the airlines, but there were others taken that showed the same maturity that buffalo cockpit showed. I can only imagine, with my limited expertise, that in the process of stalling, raising the flaps and pulling back on the yoke would seem to be the exact opposite of what one needed to do but exackly what would happen to the frightened inexperience youngsters at the wheel. As Travis related, I am sure they were a bargain, well at least in the short run.

  9. robert Says:

    The CEO’s say their high salary is needed so only the most qualified are running the companys. Unfortunetly the same doesn’t apply for people responsible for lives. I hope the trial lawyers give them a lesson in economics.

  10. Mike Finkle Says:

    There are many quotations and words of wisdom from which we can summarize important aspects of flight. One of the very first I ever heard, spoken somewhat lightheartedly, was “Let not thy airspeed fall too low, lest the Earth rise up and smite thee!” My very favorite such quotation, more serious and philosophical, goes something like this… “Flying is not, in and of itself, inherently dangerous. However, to an even greater extent than the sea, it is extremely unforgiving of any carelessness, incapacity, or neglect.”

    As a former regional airline captain with thousand of hours flying the Dash-8 (-200, not -Q400), I have followed the NTSB investigation into the Colgan Air accident with great interest… and sadness. Most of that sadness comes from my thoughts of the senseless and needless loss of life for the crew and their passengers, as well as the tragic consequences for their families and friends. Another part is the result of the personal sense of loss I always feel, due to the “camaraderie” among pilots, whenever we lose one of our own. Along with that, it is also always so disappointing when pilots’ failures to realize they have committed the most basic of errors, and disregarded and/or been distracted from following the most basic of operating procedures, combine to result in an accident. I always feel that any failure of any pilot which results in an accident reflects negatively upon us all, and that we all have an obligation and duty to always attempt to study and learn from the mistakes of others lest we repeat those mistakes ourselves. If we happen to also be in the position of flight instructor and/or check airman we have an even greater responsibility, and that is to be our brothers’ (and sisters’) keepers as well.

    If I may, I would like to make a few points regarding the accident, Bruce’s article, the NTSB report thus far, and some of the comments I’ve seen posted here and elsewhere. It seems from the beginning of the NTSB animation video (the last 2-3 minutes of the flight is “reconstructed” at http://www.ntsb.gov/Events/2009/Buffalo-NY/AnimationDescription.htm) that the captain might have had some issues with airspeed control, and airspeed control should have been very easy in the beginning since they were clean, level, on a vector to the final, and on autopilot. The video starts with the airspeed at 189 KIAS, but it then bleeds down to about 167 KIAS in 20 seconds before he adds in a bit of power to get it back up to around 180 KIAS. At 167 KIAS, they are just 14 knots above the minimum approach speed in icing conditions of 153 KIAS with Flaps 5 (per the Q400 AFM), and they weren’t at Flaps 5… the flaps were still up. Perhaps the autopilot had just finished leveling off from a descent to 2300 MSL, slowing the aircraft in the process, but if the desired speed during vectoring to the final was 180 KIAS then he was late on the power application during the level-off. Anyway, their minimum approach speed at their weight in icing conditions should have been 153 KIAS at Flaps 5, 144 KIAS at Flaps 10 (where they were later incorrectly set by the FO), and 138 KIAS at Flaps 15 (which is where the captain asked for them to be set). These speeds all include a 20-knot increase above the normal speeds as a safety cushion because of the icing conditions (see the NTSB’s Factual Report on this accident).

    Approach mode for the autopilot had been armed while on the last vector, and the captain calls for gear down at the same time he says that the localizer is “alive”. It is a pretty standard procedure throughout the industry when on an ILS approach to not lower the gear until beginning to intercept the glideslope (when it’s about a dot above the aircraft’s vertical position) as this helps start the aircraft’s descent to follow it without slowing much. Since at this position the glideslope was still well above them, one might wonder why he chose to put the gear down here. It may be that he simply wanted to slow down and configure the aircraft a bit early so as to be “stabilized” once they were on the localizer centerline and before starting their descent on glideslope. It is quite common for pilots with minimal time in a particular aircraft type to do this so as to stay ahead of things and not feel “rushed”, and he only had about 110 total hours in the Dash-8. Shortly thereafter either he (or the FO) pushed the condition levers full forward to Max, which flattens out the prop pitch on the Dash-8’s huge propeller blades taking them to maximum RPM for the remainder of the approach, so as to be prepared for either a potential max power missed approach climb or maximum drag deceleration (including reverse thrust if desired) on the rollout after landing. He then calls for Flaps 15, but the FO only sets them to Flaps 10.

    Making all of these configuration changes without adding power is like throwing out a huge anchor with a short chain. The net result of maintaining altitude while extending the Dash-8’s enormous landing gear, setting the condition levers to max, and extending flaps to 10, all without adding ANY power, is that the airspeed decreased from about 180 KIAS to less than 130 KIAS in 20 seconds and kept on decreasing to as low as 78 KIAS during the stall sequence. Remember, the minimum approach speed at Flaps 10 in icing conditions was supposed to be 144 KIAS, and in normal conditions it would still be 124 KIAS. Contrary to what others have suggested, I don’t believe that the aircraft automatically pitched itself up when the autopilot disconnected in response to the stick-shaker activation OR when the captain subsequently added power during his attempted recovery. While it is true that the autopilot would have been trimming nose up to maintain altitude during the deceleration, the trim would not have automatically somehow increased pitch even more during the autopilot disconnect which automatically occurred due to stickshaker/stickpusher activation. Further, while it is true that many aircraft do pitch up when power is significantly increased, the Dash-8 has a very high “T-Tail” with the horizontal stabilizer and elevator in a position where pitch is affected very little by increased thrust airflow with power increases. Again, I am only speaking from my experience in the Dash-8-200, having no experience in the Q400, but they both have that tall “T-Tail” and I’m pretty sure the aircraft are similar in this aerodynamic trait. I also don’t believe this captain responded improperly because he thought he had a tailplane stall. There is absolutely no evidence whatsoever that this was the case, including his never having received any training from Colgan Air about this other than it being mentioned in a video, and his actions didn’t follow the correct procedure for that situation either. I believe the captain DID pull back on the yoke, and kept it back, in response to the stick shaker and stick pusher… actions which would seem intuitively correct to a non-pilot… instead of properly recovering as every fixed-wing pilot has been trained to do. Was he simply “surprised” and/or “panicked”, responding in a manner contrary to everything he had been taught? We’ll probably never know for sure, but it certainly seems so.

    Yes, we can talk about more regulations. We can discuss ad infinitum what other training might have been helpful in preventing this accident, like recovery from stalls while on autopilot or recovery from full, “deep” stalls, and more training certainly never hurts. However, the basic stall recovery procedure is the same for every fixed wing aircraft in the situation in which the crew of Flight 3407 found themselves and EVERY pilot should know it… decrease the angle of attack and increase the power. The fact is that any pilot certification beyond Private only requires recovery from “imminent” stalls… and for good reason. Professional pilots, whether they are Commercial pilots in single-engine Cessnas or 20,000-hour ATPs with a B747 Type Rating, are supposed to be proficient in their knowledge, understanding, planning, and execution of their flight duties. They, their employers, and their fellow crewmembers (by at least reporting problems observed to a training pilot) are supposed to see to it that they ARE proficient. If they are proficient, they should never get the aircraft to the point where an imminent stall, much less a full and/or unrecoverable stall, is even a possibility. Colgan’s flight training syllabus and standard operating procedures, which are by extension legally part of the FARs for that airline, already required actions quite different than those exhibited by the crew… does anyone really believe more regulation would have prevented this accident?

    In my experience, the Dash-8 is an unbelievably great performing airplane in every way except perhaps top speed on earlier models. It’s not the very fastest turboprop around, but it loves to fly… and the -200 model I flew was difficult to stall even when you tried to make it stall. This particular -Q400 aircraft seems to have performed no differently. I have watched that video animation over and over again, looking for any problem that might not have been related to improper handling by the crew, and I just can’t find anything at all. The aircraft actually climbs 200 feet during the stall sequence before it starts really descending, recovers from a knife-edge 90-degree right bank, and then keeps only “mushing” even after the FO inexplicably retracts the 10 degrees of flaps that are probably helping the aircraft to stay in the air at that point. Had they simply reduced the angle of attack by getting the yoke forward and then recovered from whatever altitude loss they had allowed in the stall recovery (the ground elevation was less than 700 MSL so they had plenty of altitude to give up), their passengers would have had a wild, scary ride to talk about but everyone would have survived. Better still, had they followed proper procedures, including the FO calling out and insisting on correction of any airspeed deviations of plus or minus 10 knots from normal, perhaps the captain would have realized his error and added power before the airspeed decay from dirtying-up the airplane would ever have gotten to the danger point. As a response to Mr. Freidin, there was definitely NOT an effective stall recovery in progress, and the FO should definitely NOT have retracted the flaps. First, the flaps were only set at Flaps 10 at the time, and in the Dash-8 (and most aircraft) that first 10 degrees of flaps creates far more lift than drag. Further, the FO was not the pilot flying and should never have retracted the flaps without confirming the captain wanted them up. This was a serious error on her part which made things worse. Raising the gear sooner might have helped the situation, but the action was too little too late by the time it was accomplished.

    I respectfully submit that the bottom line appears to be that the reason this accident occurred was solely because this crew seems to have done just about everything wrong (except adding power, and perhaps retracting the gear too late to do any good) once the aircraft had slowed into the airspeed “danger zone” related to the stall. Although the captain had about 50% more total flight time than the FO, the FO had seven times the captain’s time in this aircraft type. It truly appears to have been a CREW failure and, as usual, there were multiple links in the accident chain of events. Had they either not allowed or broken any of those links, it would probably not have occurred. They were certainly both trained and experienced enough that this crew should have avoided this accident.

    Although it is absolutely true that even the very best pilot can fail a checkride for any one of a myriad of reasons on any particular day (they say there are only those who have and those who will), the captain having “failed” six of them in less than 3400 total flight hours is definitely an unhealthy and dangerous pattern. According to the NTSB, he failed his initial instrument airplane checkride in 1991, failed his initial commercial single engine land checkride in 2002, failed his initial commercial multiengine land checkride in 2004, required training to proficiency on his initial proficiency check in the Saab 340 as a FO with Colgan in 2005, failed proficiency training requiring a re-qualification ride in the Saab 340 as a FO with Colgan in 2006 (after over a year of experience as a FO on this aircraft, unsatisfactory tasks included rejected takeoffs, general judgment, landings from a circling approach, oral exam, and non-precision approach… that’s a lot of unsatisfactory areas), and failed his initial ATP and Captain checkride in the Saab 340 with Colgan in 2007. Perhaps the instructors, check airmen, and fellow crewmembers who played a role in the captain’s flying career just weren’t effective enough, or perhaps he was simply not dedicated enough to his own proficiency despite their diligent best efforts. Unfortunately, his life ended sadly and tragically, along with the lives of his crew, his passengers, and an occupant of the home the aircraft hit on the ground, when he failed to successfully handle his final test as an airman.

    We pilots are all human and, as living beings, we all make mistakes. While the luck of the draw certainly plays at least a small part, in my experience and belief the best course to avoid accidents is to unwaveringly dedicate oneself to trying to always pay attention to all of the details and adhere to proper operating procedures. Know your aircraft and its systems well, and be highly suspicious of anything that doesn’t seem right… and seek out the answer as soon as it doesn’t seem right. You’ll still make mistakes, but hopefully you won’t make enough at any one time to complete that chain of events that results in an incident or accident… especially one wherein lives are lost. Again, “Flying is not, in and of itself, inherently dangerous. However, to an even greater extent than the sea, it is extremely unforgiving of any carelessness, incapacity, or neglect.”

  11. Mike Finkle Says:

    Another bit of information I forgot to include is that although it is not prohibited to use the Q400 autopilot in icing conditions unless it is “severe” icing, Colgan’s operations manual apparently recommends (as does the NTSB since the they came out with their recommendations after the American Eagle ATR-42 crash in 1994) NOT using the autopilot in any icing conditions. Had the crew been following this recommendation by having the autopilot off, the captain might have noticed the decaying airspeed a lot sooner… another way in which the crew was perhaps not following accepted procedures.

  12. Mike Finkle Says:

    Another bit of information I forgot to include is another way in which the crew was perhaps not following accepted procedures. Although use of the Q400 autopilot in icing conditions is not prohibited unless it is “severe” icing, Colgan’s operations manual apparently recommends (as does the NTSB since the they came out with their recommendations after the American Eagle ATR-42 crash in 1994) NOT using the autopilot in ANY icing conditions. Had the crew been following this recommendation by having the autopilot off, the captain might have noticed the decaying airspeed a lot sooner.

  13. David Heberling Says:

    One thing that has not been mentioned here at all is fatigue. Both crewmembers were quite sleep deprived by the time they needed to be fully alert. As a pilot for 37 years, with the last 22 at a major airline, I have personally seen the affects of fatigue. Riding on the jumpseat to commute home, I have seen the affects of fatigue on the crew flying the airplane. When fatigued, you can actually fall asleep with your eyes wide open. You also experience micro-sleep events without even knowing it. If you want to ask why this crew so disregarded company procedures, sterile cockpit requirements, and CRM, you have to look at the fatigue issue. Being fatigued is just like being drunk. Your reaction times are longer, your thought processes are slower and you become easily confused.

    We can chase our tails over training issues, regulations, etc. However, the real issue is fatigue. Until we recognize that fatigue is the major contributor to this crash, we will be no closer to keeping this type of accident from happening again.

  14. Mike Finkle Says:

    While I agree with Mr. Heberling that fatigue MAY have been a factor in this accident, I sincerely doubt that it was “the major contributor”. Further, even if it was the major cause, it should not have been and would not have been if the crewmembers had lived up to their responsibility to meet all of the requirements of their medical certificates, and good common sense, regarding their fitness for flight.

    Anyone in the industry knows that most airline pilots don’t live at their domicile city, a condition which consequently usually requires them to commute to work using the privilege of jumpseating to get to their domicile. Many commute from one coast to the other for work, as the FO had done in this case. However, living away from their domicile is still their choice. While I agree that low pay may make it more difficult to live on one’s own or to be able to afford a “crash pad” at the domicile away from home, every crewmember nevertheless has an absolute moral and legal obligation to either be healthy and well-rested for their assigned flight duties or call in “fatigued” or “sick” so that a reserve pilot who IS well-rested handles the flight in their place.

    Fatigue happens, and flight and duty time allowances under the FARs could certainly be tightened up to help minimize it. However, no matter how much the allowable times are shortened, it still won’t prevent pilots from making bad decisions concerning flying tired or sick. It will always be the individual PILOT who has the ultimate responsibilty for making certain it doesn’t significantly adversely affect their own individual perfomance. If you’re an airline pilot and you can’t make your life situation work for you in a way that allows you to report for duty fully able to execute all of your duties in a competent, proficient, and professional manner, then you shouldn’t be flying for that carrier… PERIOD! Being tired can NEVER be an acceptable reason for killing 50 people and doing millions of dollars of property damage.

  15. Travis Christensen Says:

    Very good summation, Mr. Finkle. A tragic and avoidable loss indeed. We have recreated the scenario in the simulator as accurately as possible and have found that one has to literally fight the natural tendencies of the aircraft, including the automated stall protection of the aircraft, (as well as instinct that should be instilled from earliest flight training) to get the aircraft into this type of stall situation. It took roughly 2500 feet to recover once we had relaxed the back pressure on the control column. Had no action been taken by the crew at the onset of the stick shaker the aircraft would have iniated saving itself. Simply selecting power to the rating detent of the throttle quadrant with minimal flight control input could have prevented the situation. The tremendous amount of power available was nowhere near fully utilized. (over 10,000 horsepower is available with both engines operating at Maximum Take Off Power)

  16. sam ferguson Says:

    As a relative newcomer to flying (260 hrs with instr rating working on Comm) I want to thank Mike Finkle and AOPA with its forums for its excellent education into flying. Its that type of input that will probably save my butt one day. Flying for me, though limited at this time, is a true passion of mine. My normal brain shoots from the hip, my flying brain cannot go there. I am learning a whole different way of thinking and a mixture of the two, intuitively shooting from the hip and thoughtful detailed analysis will help me intensely in the future. It is refreshing to have someone like Mike Finkle bring his years and years of experience forward in a very non-judgmental way.

  17. Ber Says:

    Quoting Travis Christensen
    “As a Q400 Captain I can say that lack of an appropriate level of pay for the equipment being operated is the real issue.”

    Although I agree that pay at the Regional level is abysmal. In this context I find this statement to be incredibly self-serving and totally unprofessional.

    Pay is just numbers on a bank ledger, in itself, it does not indicate nor bestow a higher level of skill or professionalism. That my friend, is up to the individual!

  18. Robert Says:

    I wonder if we paid lawyers,doctors, police,teachers,professors,CEO’s,scientists 16,000 a year if we would get the same higher level of skill and professionalism. Just a thought.

  19. Jim McSherry Says:

    While there may be some secondary correlation between the pay level and the caliber of the performance, it is far from direct or causative. I have been a teacher, a professor, a scientist, and a CFII (though not a CEO). None of those activities is especially well paid, and the training investment for each is significant. There are plenty of positions that will get you a bigger paycheck, and many of those do not have the responsibility that every PIC undertakes with every flight.
    Mr. Finkle has hit at least one of the nails squarely on the head: “…flying tired or sick. It will always be the individual PILOT who has the ultimate responsibility for making certain it doesn’t significantly adversely affect their own individual performance.” The PIC is always captain of the ship, with full responsibility for the safety of that flight. If you can’t do it, and do it proficiently on a regular basis, find another line of employment. And too, if you see that another crew member is not performing well enough to keep everyone safe, take action. Perhaps a word of caution is all that is needed; but if not, a bug in the ear of a check pilot or a CFI would get some needed instruction to keep us all safer. Even those of us who do this more for fun than money still have the responsibility to do it safely.

    And as the sarge always admonished on Hill Street Blues, “Let’s be careful out there!”

  20. Jim McSherry Says:

    And back to the beginning, I believe that Bruce has said it correctly; no amount of additional regulation would have had an effect on this event. A more vigorous attention to the existing regs might have been appropriate. But regulation alone will never take the place of attitude enhanced by peer pressure.
    I might make the comparison to those who call for longer jail time for the offense of the day; the length of the sentence is immaterial to those who do not expect to be caught. More prohibitions will not lead to safer attitudes – safer attitudes on our part will avoid more restrictions.
    Programs by Air Safety Foundation that emphasize safe flying are a benefit to us all, when they promote attitudes which lead to fewer off-field landings from fuel exhaustion (“Small airplane crashes in bean field!!! Film at six!!!”) I don’t know what regulation could have helped an ATP who struggled so mightily at every level, and still seems not to have known what my pre-solo students do: “Maintain thy airspeed, lest the ground rise up and smite thee.” But I’d bet my next paycheck (either CFI or professor) that some comments from other pilots about sterile cockpit, or standard procedures, would have had some effect. Alas, we will never know.

  21. Dave Tuuri Says:

    Mike Finkle said: “Although it is absolutely true that even the very best pilot can fail a checkride… the captain having “failed” six of them in less than 3400 total flight hours is definitely an unhealthy and dangerous pattern. According to the NTSB, he failed his initial instrument airplane checkride in 1991, failed his initial commercial single engine land checkride in 2002, failed his initial commercial multiengine land checkride in 2004, required training to proficiency on his initial proficiency check in the Saab 340 as a FO with Colgan in 2005, failed proficiency training requiring a re-qualification ride in the Saab 340 as a FO with Colgan in 2006 (after over a year of experience as a FO on this aircraft, unsatisfactory tasks included rejected takeoffs, general judgment, landings from a circling approach, oral exam, and non-precision approach… that’s a lot of unsatisfactory areas), and failed his initial ATP and Captain checkride in the Saab 340 with Colgan in 2007.”

    Yep. About the only thing he NEVER FAILED was stall recovery. Aparerntly, that’s one area the ‘system’ was perfectly happy with.

    Dave Tuuri

  22. Robert Says:

    And my final comment on pay versus caliber of employee: you get what you pay for

  23. Mike Finkle Says:

    Actually, Mr. Tuuri, we don’t know that his performance was satisfactory regarding stall recoveries. I only listed specific problem areas for the one specific proficiency training event in 2006 in which he performed sufficiently poorly that he was required to take a complete “re-qualification” ride. For those of you unfamiliar with airline training operations, this “re-qualification” ride requirement occurs only after a pilot performs so poorly that the check airman conducting the test feels that pilot has not even exhibited that he still deserves to hold the position/certificate/rating he already holds. It is analogous to having a certificate/rating taken away from the pilot by his training department and then being required to take a complete new checkride to “re-earn” the authorization he once held. Check airmen will often not list ALL of the problem areas since the pilot will need to re-take his complete checkride anyway. They may only document enough problem areas to cover their own posterior in taking the position that the “re-qualification” ride was really necessary, because it makes things look as though this pilot has somehow “slipped through” the airline’s training program to obtain a qualification he or she didn’t really deserve. No airline wants to have this sort of thing on their training records, so check airmen always make sure they document the situation sufficiently to justify (to airline management and the FAA) having made their decision.

    Actually, Page 7 of the NTSB document at http://www.ntsb.gov/dockets/aviation/dca09ma027/417441.pdf
    specifically lists failure areas in other flight tests as well. For example, after his initial commercial multiengine land airplane flight test he was notified that the entire flight portion of the practical exam would need to be re-accomplished. Also, during the 2005

  24. Mike Finkle Says:

    (sorry about that) initial proficiency check the unsatisfactory task area identified was “normal/abnormal procedures”, which may have included stalls.

    The bottom line is that all we know for certain seems to be what I previously called “an unhealthy and dangerous pattern” of unsatisfactory performances for this pilot.

  25. David Heberling Says:

    I never meant to say that fatigue absolves the crewmembers involved in this crash from ultimate responsibility. Yes, they were weak in airmanship. What does fatigue do? It accentuates those weaknesses. What else can explain the bizarre behavior that this crew exhibited? You can pontificate all you want about flying tired or sick. It just happens…alot. There are too many financial penalties to calling in sick or fatigued. Every industry has people working who are tired or sick or both. Our industry is very fault intolerant and when people make mistakes, people can die.

    This is not about right or wrong, it is all about human nature. If you are tired, drink a lot of caffeine. If you are sick, load up on cold medication because you do not want to blow your eardrums out. I have seen enough of this in my 37 years of flying to know that it is true.

  26. Dave Tuuri Says:

    Mike Finkle Said:

    June 8th, 2009 at 12:57 pm
    “Actually, Mr. Tuuri, we don’t know that his performance was satisfactory regarding stall recoveries. I only listed specific problem areas for the one specific proficiency training event…”

    Well, I read all the docket’s documents and interviews with check airmen giving the rides. As a former DPE myself, I noted no reference to stalls anywhere in any test the PIC ever failed. I think you are using this accident to further your own agenda–and you have lots of company, unfortunately. Fatigue, sterile cockpit, training, pay, flight hours, etc., have no bearing on the root cause of this crash which was, simply, the stick did not go forward when the shaker went off. Pure and simple. But why didn’t it? The other items are just crusaders’ efforts at ‘not wasting a crisis’.

    Dave Tuuri

  27. Harold Coghlan Says:

    I have been a pilot and instructor for more than 30 years in military/airline/charter/corporate flight environments, and although we hate that regional pilot pay scales are not what they should be, it appears quite clear that this case is not about pay, nor duty rigs, nor fatigue, nor even weather for that matter (contributing factor maybe, but not causal).

    Rather, as several have explained so well in the prior commentaries, this case appears (in very simplified terms) to be all about a) Lack of Situational Awareness (SA), b) Not following standard procedures (like putting the gear down early, putting props high/fwd early, not veryfying that the airplane was configured correctly, etc, etc), c) Improper speed control, and lastly, d) Lack of
    proper stall recovery technique.

    All airplanes stall because the wing’s angle of attack (AOA) exceeds the stall AOA, and the only way to recover is to reduce the AOA (notice I did not say to “level off”) and increase the power. This basic technique works regardless of whether the plane is a Boeing or a Cessna, whether the plane has manual/hydraulic or fly-by-wire flight controls, or whether the plane has or not a stick pusher.

    I feel sorry for the current state of airline pay vs. job demands, but as others have said, neither pay nor lack of rest was causal to this accident, Pilot Error was. sad, but true.

    Unfortunately, every time an aircraft accident happens, all of us in aviation are affected, and all of us feel the pain.

    Stay safe, and remember “speed is your friend”.

  28. Kevin Collins Says:

    Travis Christensen said in reference to recreating the situation in a simulator, “[i]t took roughly 2500 feet to recover once we had relaxed the back pressure on the control column”. Since you said the airplane would have recovered on its own, I wonder if “2500 feet” was a typo since the accident airplane was at ~1600′ AGL when the problem started. Would you please clarify?

    Thanks, and I also appreciate all of the great info everyone has contributed to this thread.

  29. Mike Finkle Says:

    Dave Tuuri Wrote (in response to one of my posts):

    “I think you are using this accident to further your own agenda–and you have lots of company, unfortunately.” You (Dave) wrote this in response to my statement that “we don’t know that his performance was satisfactory regarding stall recoveries”. You disagreed, you said, because “As a former DPE myself, I noted no reference to stalls anywhere in any test the PIC ever failed “.

    As I pointed out, and as a knowledgeable former DPE I would think you’d agree, check pilots are not required to list every single area of performance in which the pilot was initially less than proficient. All they must really record, in practice, is sufficient information to justify a finding of a disapproval. Further, as long as in the opinion of the check pilot the airman eventually received training in and/or satisfactorily demonstrated proficiency in noted deficient areas, that tested airman may then subsequently “pass”. Especially since he had test events in which it was determined that the entire flight check must be redone, we don’t know all of the specifics. I was, therefore, merely stating that we don’t absolutely KNOW (as I feel you stated when you said “About the only thing he NEVER FAILED – your caps – was stall recovery) that this particular pilot had not had any problems with stalls. We can only KNOW if an area was found to be unsatisfactory if it has been specifically identified as such, not if it has NOT been documented.

    I never said, nor meant, that he had previouslly performed poorly at stall recoveries, nor did I even provide a reason as to why he seems to have done so in this accident. In fact, I asked/stated “Was he simply “surprised” and/or “panicked”, responding in a manner contrary to everything he had been taught? We’ll probably never know for sure, but it certainly seems so.”

    While I can understand how you might (possibly correctly) view some of the comments in some of the posts here as “just crusaders’ efforts at ‘not wasting a crisis’” to further their own personal agenda, what in the world to you think might have been my ulterior motives or “agenda”?

    I believe I have done nothing more than to restate factual information, along with some personal experience and belief, in a logical, rational, and deductive manner to support my view of what I think the NTSB may ultimately find were the probable causes of this accident. I don’t believe I promoted anything but thought, and I attacked nothing and no one. I assure you I have and had no agenda at all, either open or hidden, other than to attempt to bring information to light for consideration by any interested people who read Bruce’s article and our posts here. I do this in the hope that we might all be encouraged to remind ourselves, and others, that we must always be vigilant in our duties, and proficient in our performance, when we fly. The consequences of not doing so are simply too great, and all of us lose at least a little when any of us fail to remember that.

  30. Robert Says:

    I have NO agenda too. I’m an elevator mechanic who makes as much as a 747 captain. If you guys like low wages that’s up to you. I just think you get what you pay for. Forbes just had an article that listed the top ten blue collar paying jobs and elevator mechanics was number one. By the way elevators are the SAFEST mode of transportation. What do I know I’m just a private pilot.

  31. Robert Says:

    The real cause of the accident was insufficeint clearance between plane and terrain. Stalling the plane may have been causal to this accident.

  32. Roger Hanson Says:

    Mr. Turri, rather than dissect this crash further (as others in here have done a splendid job on) I’m sure we can agree there is no denying the base elements have to do with pilot decision making. As a DPE, you know that a pilot’s psychological “programming” is a critical component of good decision-making habits.To state that the training, fatigue, pay scales have no relevance to he “root cause” is a bit narrow in focus.

  33. Travis Christensen Says:

    To clarify for Mr.Collins, we were going through a series of stall maneuvers at 10000 feet when we simulated the accident scenario, so the altitude was not accurate in that respect. The sim. instructor wanted to be able to demostrate the recoverability. Apologies.

  34. Kevin Collins Says:

    Mr. Christensen, thanks for the response!

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