Thursday, June 4, 2009

As you can see below, early on I pinpointed low airspeed as the crucial event in the Colgan 3407 tragedy which preceded all others. And before that, my first thought was how fatigued and imprecise F/O Shaw sounded on the ATC tapes. [Been there, done that!]

So from day one I was asking reporters to get the crew’s duty times for the prior 72 hours. When they were not readily available, I knew there was a reason. I also commented at the outset that checking out a relatively inexperienced and mediocre pilot as Captain

  • on an aircraft
  • in an area [high density Northeast]
  • and in weather [winter]
he had never flown before made an accident all but inevitable. [Captain Renslow’s previous experience as an airline Captain was on the smaller Saab 340 in Florida and Texas.]

The recent NTSB hearings on Colgan 3407 have now vindicated my position. Here’s an unsolicited note Captain Bud wrote me right after the hearings.

"DT....

It looks like the NTSB is now 4 months behind you, and coming to the same conclusions you reached watching the burning wreckage. It will be another 8 months before they verify your findings with their report. Actually, they are using your report to figure the thing out. All they really have to do is just take your blog and, and put in a few more words and governmentese and they are done. They could have saved a ton of money and will not reach any different conclusions. You better copywrite it and then sue them for plagiarism. Congratulations again on a job well done.............

Capt. Bud"

Thank you, Bud.

But now – determining what happened is not enough. We must also understand why it happened. Yes – Colgan 3407’s airspeed was too low – but why: Why did it get that low? And why did two current and qualified pilots seemingly forget what all pilots learn in their earliest days of flight training?

Or did they...........?

The NTSB's final report will not be issued until a year or more after the crash. Can we afford to wait until then to understand this crash and its causes? What if the NTSB doesn’t consider all available evidence? And once they conclude what they do, what if it’s too late to proffer a differing point of view? Is the NTSB investigation truly objective? Could there be a political angle to their report? What group is not represented on the NTSB panels which should be? And what if the NTSB's conclusions, once formalized and adopted, foreclose legal strategies and positions which could benefit the victims and those who survived them?

Moreover, what if some of the basic assumptions about this accident are wrong?

["But they’re. common sense!" I can hear you say. Right – and common sense tells us the world is flat! And to pull back if our aircraft is sinking! We know learning to fly involves learning to override common sense at times – and stall recovery requires pointing the nose at the ground when we least want to!]

So in the next several weeks, I'll be questioning all these "common sense" assumptions that the NTSB and its blind followers [including most reporters] are making. And as usual, I'll be questioning the most fondly held assumptions about the crew.

Yes, I always seem to be arguing the other side. My first post below questioned the notion that Captain Sullivan [US Airways 1549] was quite as perfect as portrayed. Yes, his splash-landing came out well – but what about all that went before it? [Read my first post at the bottom for more.]

And now I'm going to question if the Colgan 3407 crew could have been quite as bad as portrayed.

Yes... they were fatigued and inexperienced, but were they suicidal or that incompetent? Ask anyone who flies – or has ever ridden a bicycle. We all know – speed is life! I cannot imagine any pilot – let alone an ATP [Airline Transport Pilot] and /or a CFI [Certified Flight Instructor] forgetting that lesson – or ignoring it – without a damn good reason! I cannot imagine an ATP [Captain Renslow] pulling back on the yoke without a good reason. And I cannot imagine a CFI [F/O Shaw] retracting initial flaps in a stall situation – especially without first obtaining the concurrence of the Captain and /or PF [pilot flying].

Initial flaps give mostly lift – final flaps mostly drag. As a CFI, Becky knew that and must have demo-ed and taught it hundreds of times – as did I [Been there, done that!]. So again, she must have had a good reason!

That’s why proper analysis of this accident must question the cherished notion that these 2 pilots suddenly became totally incompetent and suicidal. We’ll have to find the reasons they did what they did.

And if we find the crew, though fatigued and inexperienced, was neither suicidal nor incompetent?

Then we’ll have to ask "what if?"

  • What if the crew’s actions were not incorrect for the true situation they were in – or at least thought they were in?
  • What if the aircraft, though slow, was not stalled?
  • What if in fact, none of the flight data we have arose from the crew’s control inputs? Could this crash have occurred without the crew’s even touching the controls?
  • What if seemingly trivial items have been overlooked which are not trivial at all? For example, no one seems to have noted certain items on the CVR and ATC transcripts which could have contributed significantly to this crash and in the past caused other crashes which were seemingly inexplicable at the time
  • What if there are other accidents eerily similar to this one which we can learn from?
  • What if this aircraft type had documented design deficiencies, performance anomalies, and / or uncorrected malfunctions which could have caused of the accident?
  • And what if there were other weather factors at play besides icing?
Most importantly, what if the root cause of this crash – the one without which this crash may not have occurred – was one that no pilot could have overcome without specific training in its identification and avoidance?

I believe there are answers to all these "what ifs" – and in the weeks ahead I'll be discussing them in detail.

No -- I do not have the technical resources of the NTSB and other agencies. But like "Deep Throat" of Watergate scandal fame [hence my "nom de plume" – Captain DT], I know where to look and can guide others through the often overwhelming world of aviation. My personal qualifications and experience to perform this task include:

  • over 5,000 hours as a professional pilot
  • Airline Transport Pilot’s license with all Flight and Ground Instructor ratings
  • flying in both regional and major airline operations, including flying the Boeing 727 and the DHC-6 – predecessor to the "Dash 8-400" [a.k.a. the Q400] and the aircraft NASA used in their in-flight icing research and videos.
  • MBA, Harvard, and MA, Psychology
  • senior management positions at United Airlines, as well as at one of the early post-deregulation carriers.
  • consulting to top management at Eastern, Evergreen, and Altair Airlines
  • expertise in Total Quality Management [including training under and assisting W. Edwards Deming at his Senior Management seminars], statistical methods, problem solving, process improvement, Failure Mode & Effect Analysis methodology [FMEA], and quality systems auditing [including ISO 9000]
In addition, I visited the crash site in Clarence Center within three days of the accident. And as you can see from the website, I have access to and work closely with others whose experience and expertise are second to none.

Hopefully, it’s obvious that I am not reluctant to go against current thinking and employ the time tested tools of logic, experience [been there, done that], expertise, statistical analysis, and information learned from past tragedies. Indeed, in this case there are a plethora of accidents and incidents eerily similar to this one.

And now – with the news of AF447 just in – I believe we have another crash surprisingly similar to the Colgan tragedy....

So stay tuned!

Monday, February 23, 2009

Colgan 3407 Update 2/23/09

(c) 2009, airline-crash-analysis.com


I HAVE ADDED A VERY IMPORTANT UPDATE AT THE BOTTOM OF THIS!


If you have not previously read this post, please read it as is, then continue to the update which follows it.

If you have previously read this post, feel free to skip to the bottom to read the update.



The NTSB usually makes their initial report within a week of a crash. Their final follows a year later.

We posted our preliminary last week, and here’s our latest. Our first post’s focus was on chain of events issues based on my CRM [crew resource management] training and philosophy. CRM teaches us that accidents generally are caused by multiple interrelated factors forming a chain that leads to disaster. No one ”link” by itself would have caused such a crash, but joined together they make the crash almost inevitable.

Even where we find pilot error, we avoid assessing pilot blame. Although we must “calls ‘em as we sees ‘em,” we have to ask why? – endlessly why? – if we want to prevent a repetition. In quality improvement, we call this process root cause analysis – with the approach that you can’t eliminate the symptoms without eliminating the disease and/or the conditions that bred it. In other words, the root cause is the cause you can fix which will eliminate a recurrence of a similar accident.

In this approach, usually – not always – pilot error results from management error. Even if we find the crew were sleazy, drunk, incompetent, etc.,. – which in this case they were NOT – we’d have to ask how were they hired, trained, scheduled, evaluated, and coached? Those are all under management’s control, not the crew’s. Therefore, fixing human performance issues entails examining any management error which contributed to the pilot’s error and modifying it appropriately.

This accident’s “chain of events,” updated a week later, includes: [Note: This section is still being revised.]

  • overscheduling [12 hr plus hour duty day (not confirmed) + 2 hour delay = 14 hour duty day] = pilot fatigue
  • minimally experienced captain [less than 100 hrs tt in type and limited previous flying experience in the N.E. in winter]
  • icing
  • deicing system turned on 10 minutes after takeoff – never turned off
  • autopilot use in icing up to stall onset
  • airspeed 45 K below recommended for that phase of flight [no gear or flaps, outside outer marker]
  • incomplete readbacks to ATC and “fuzzy” rushed radio transmissions
  • jumpseat captain on board [seat location unknown]
  • radar vectors by ATC to turn final close in to marker
  • previously reported glideslope anomalies
  • localizer anomaly [suspected by ATC immediately after crash and confirmed by DL 1998, the aircraft following 3407]
We’ll refine and detail this more later this week, but for now, it’s not very different than what was posted last week
.
But meanwhile, based on Jerry Zremski’s Buffalo News article on 2/20/09, there may be machine [design, maintenance, or performance] issues that could be root causes of this accident. Therefore, we’ve decided to give the benefit of the doubt to the crew, and added 2 Machine theories to the huMan error theory. No doubt they overlap in some areas.

Let’s start with 4 assumptions:

1. Weather-related items like “icing” cannot be given as a root cause per ICAO standards. "Failure to handle the weather" by huMan or Machine can be, but weather items like icing, for example, are considered a given in commercial aviation; you shouldn’t be out in it if the huMan or Machine is not certified / trained / designed to be capable of handling it. If “caught” in such a situation, you should have exited it as quickly as possible. Thunderstorms provide a clearer example. During World War II, the US military tried to find a way to safely penetrate and fly through significant thunderstorms. They were unable to, and to this day pilots are forbidden to attempt it. Therefore weather radar systems aboard airliners are for thunderstorm avoidance, not penetration.

2. A stall in this type aircraft under the conditions 3407 was experiencing:
  • less than 1500’ AGL
  • night
  • IMC
  • turbulence [forecast]
  • icing
  • and 49 souls aboard

is unrecoverable; therefore we’re not considering events after stall onset to be relevant. Stall avoidance is what would have counted here; failure to do that doomed the flight. [See the email from my colleague Captain Bud (below) for more information.]

3. The most significant pre-stall event per the FDR information releases so far is airspeed readout of 134K – just prior to flap and landing gear extension. Based on information from the FAA type certificate DHC-8-400 series, PW150A:

Airspeed limits:

VFE (Flaps extended)

Flap 5 - 200 kts
Flap 10 - 181 kts
Flap 15 - 172 kts
Flap 35 - 158 kts

[posted by 'little alex" on www.jetphotos.net]

as well as other Colgan Q400 captains and my own experience flying props in a high density regional airline operation, the appropriate airspeed for that phase of flight [no flaps or gear; outside the marker] is 180 K [give or take 15 – it really doesn’t matter]. The readout speed is about 45 K too low, making the subsequent events virtually inevitable. We reject out of hand the reasoning that somehow the crew wanted to be at 134 instead of 180 – no matter how fatigued or marginally experienced, there's no way professional pilots fly 45 K below where they should be, if only because they, too, want to get to home as quickly as possible and do it in one piece. When you're doing props in the soup on a 14-16 hour day -- and I have, lots -- you may miss small things and/or your decision making may not be the greatest. But you don't forget to keep the plane flying.

4. Lest there be doubt about this last assertion, although the captain’s experience in type and in Northeast winter flying was marginal at best, he had already flown as a captain on a smaller Houston-based jet prop for a year. While he may not have been a great pilot, there’s nothing to indicate he was irresponsible or incompetent in any way. According to the Buffalo News, Captain Renslow had worked his way up, was a dedicated husband and employee, passed his checkride, had never flown intoxicated, and was not a member of a weird death-seeking cult. So he at least knew that flying 45 K below the appropriate speed is not good, for all the reasons I explained. We’d have no problem adding "dumb, poorly selected and trained idiot" to the huMan category [1] above, if we thought it fit, but we don't.

We’ve discussed the first major cause types possible – huMan. The only other possible major cause is Machine.

In other words, what Machine causes[s] would have put this aircraft 45 K below where it should have been?

We only see 2 possibilities here, both related to machine system design flaw or malfunction, as follows:

2A. Instrumentation failed to inform the crew how slow they were.

The crew could have been unaware of how slow they were due to incorrect information from the airspeed indicator[s]. There is a history of prior problems with this system, as evidenced from the airworthiness directive [A/D] note the FAA issued regarding it in 2006.

[Thank you to “AA7772ER,” who posted it on www.jetphotos.net].

http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/34c4557f2807655c862572450052f0ba/$FILE/2006-25-17.pdf

Even if this problem has now been corrected, it’s possible that where’s there smoke there’s fire – another design flaw has presented itself, or the previous fix was not effective, the A/D not accomplished timely, or – if accomplished –not accomplished properly. Have you ever had the mechanic not fix your car correctly on the first try? Thus, obviously, the crew would only realize how slow they were when the stick shaker and nose pusher activated – and by then the die was cast.

and/or

2B. The machine itself could not be prevented from slowing rapidly to an inappropriate / hazardous speed, and it could not regain a safe speed rapidly enough to forestall this accident.

On a normal descent into an airport like BUF, an aircraft like the Q400 would slow to 250 K below 10,000’ to comply with the speed limit mandated in the FAR’s. On a high performance jet prop transport like the Q400 the crew would likely reduce power to idle or perhaps a little above. [The Colgan Q400’s are not equipped with auto throttles, which adjust thrust to maintain a pre selected airspeed.]. The crew would want the airspeed to be under 200 K [the maximum speed for flap extension] once they leveled off close to the marker at 2300’ MSL like 3407 was doing so they could begin their approach with initial flap extension. Normally an aircraft descending at 250 K with low or no power is going to slow below 200 K pretty rapidly once it levels off. Therefore, the crew may choose to feed some power in slightly before level off, but they may not want to if they’re being vectored to intercept their final approach course close in to the outer marker. Either way, once the flaps start down at 180 –190, say, – followed by landing gear extension – the Q400 would slow down in a hurry, as long as it’s level outside the marker. Therefore its pilots would be ready to feed in power as required to hold altitude and at least 160 K until passing the marker inbound. [160 is desirable because it provides a margin of safety and stability, especially if there may be ice and/or turbulence possible. And it also is about the slowest speed the larger turbojets fly to the marker; slowing below their slowest speed means delaying them, risking inadequate spacing, or being taken off the approach by ATC and sent to the back of the line. [I've been there / done that – only once thank you – that was quite enough!]

Given that the crew knew all this, what could have slowed them down to 134 K so quickly they had no time to recognize, react, and recover from it? I emphasize that at 134 if you’re still slowing rapidly, you could be to stall speed in a heartbeat – and then it’s over. Again, the crew had to know this.

But what if something was acting like a big speed brake slowing 3407 down much more rapidly than normal, and when they leveled off -- especially if they hadn't led the level off with power [intentionally or not] – it really brought them to a halt.

What could this have been?














Posted by jehm on www.flightaware.com

The attached picture shows ice accumulated on the wing of a DHC-6 Twin Otter [which I flew] which preceded the Dash 8 - Q400. This picture raises the obvious question: What about the dictum that you can’t fly with that much ice? This aircraft seems to be flying just fine. But the DHC-6 is a STOL aircraft with fixed gear and a short stubby wing – made to produce a lot of lift, fly slow, and carry a lot. What if that wing were replaced with a long, thin high performance wing built for speed – like the Q400 wing? And what if the de-icing boots on the wing’s leading edge were working fine – so the aircraft was flying fine, since the essential aerodynamic surfaces were clear? And what if, while the leading edge were clear and the sensors were reassuring the crew that all was well, ice remained further back on the wing?

There’d be no way to know it was there in a high wing aircraft like the Q400 -- but there it be, acting like a huge speed brake. And when the Q400 leveled off, with power reduced or at idle to enable that tight turn in, what if this “speed brake” really kicked in and brought everything to a crashing halt – aggravated, of course, as flaps and gear were extended? Extending flaps and gear, chasing an errant localizer and/or glideslope, autopilot continuing to trim nose up [see below] would only enhance an already unredeemingly fatal situation. It's possible that had the crew known that such was the situation, they would have kept power and speed up to descend a few hundred feet lower on the glideslope – and once below the freezing level [which was just about at 2300’ MSL], all their ice would have melted prior to landing, as it did for US Airways 1452 15 minutes later [See ATC transcript.] On the other hand, it may have been too late, no matter how much power were added. Only wind tunnel tests and more information from the FDR and CVR can confirm or deny this theory. Again, Captain Renslow could not have known about this “speed brake” by looking or via the sensors – he could only have suspected it by experience. And while experience like I had as an understudy for some of the best pilots in the business certainly would have helped, it may not have been enough in this case.

So – putting the huMan and Machine chain links together, we can construct a scenario of the final moments of Colgan flight 4307:

The aircraft was had slowed to 134 K prematurely, either because the crew was unaware of it or was unable to prevent it or recover from it.

Thus, the following events ensured – per the FDR information released so far:

Initial flap extension – perhaps to add lift to compensate for the low airspeed. This could cause the nose to pitch up if only a bit. And given the aircraft’s predicament – low airspeed, possible wing contamination – the flaps may have caused the aircraft’s angle of attack to increase a little – perhaps not enough for the crew to notice immediately, given that they were still in the clouds without outside visual cues.

But next, gear extension, combined with the slight pitch up further slowed the 4307.

[Normally flaps and landing gear extension are done by the non flying pilot, hopefully not until commanded by the p/f. But what if in this case that convention was not observed, further surprising the p/f? We cannot confirm or deny this possibility without obtaining the CVR data.]

Meanwhile, we know the crew had previously advanced stall response speed [stick shaker and nose pusher] to occur 20 K above normal. If stall speed on the Q400 is around 105, and by then they had slowed another 9 K below the 134 last reported, they’d be right at 125 K – and 105 + 20 = 125.

Bingo!

As stick shaker and nose pusher engage, the autopilot clicks off. There are several theories that as the wing loading had increased due to icing and as the aircraft had just leveled off – possibly without a major power increase, the auto pilot would have gradually increased nose up trim, trying to maintain altitude. It’s possible that while the autopilot was banking ever more sharply to intercept / make the tight turn required for close in localizer interception or to chase an unreliable, unstable localizer, it further increased nose up trim – to an extreme degree. And thus, when the autopilot clicked off due to stick shaker activation, the nose pitched up to 30 degrees [with or without crew control input], resulting in an accelerated stall. Initial bank may increase [45 degrees left per FDR] on the side the aircraft is turning toward [in this case – left, perhaps to finish joining the localizer,] followed by sharp wing drop off to the opposite side [100 degree bank right reported.]

This last scenario may or may not accurately describe what kind of stall 3407 was in at this point – it may have been a combined wing and tail stall; it may not have been an accelerated stall, it may have been a mild stall aggravated by or not by ice. It doesn’t matter – the stall rapidly became a spin, likely a flat spin. We know this because we know at this point the aircraft had a very high descent rate [-10.000 fpm] and a very low airspeed [100 K, less than its stall speed]. Thus, it was no longer flying, it was dropping.

There is no recovery from such a drop, beginning no more than 1500’ above the ground [1500’ / 10,000 fpm = .15 minute = 9 seconds maximum recognition and recovery time.]

So, we reach journey’s end. Barring substantial new NTSB disclosures, we have constructed the most likely scenario combining the huMan chain links and the Machine possibilities about 1 week after the crash. NTSB will take a year to develop theirs.

And they should. Hopefully, theories like ours will be tested and confirmed or denied. We can't go any further without more FDR information, the CVR raw information, a wind tunnel, the wreckage, access to other pilots, management, and ATC people, the aircraft’s A/D and maintenance logs, the pilots’ schedules and training records, etc., etc.

Obviously, the NTSB has all these items and more. That's why we’re done now, and their work is just beginning. Hopefully they'll view ours as a good start.

Captain DT
(c) 2009, airline-crash-analysis.com

IMPORTANT UPDATE, POSTED ON 2/24/09

This is a summary; I hope to expand this in the next few days.


As I reflect upon the post I made yesterday, I am troubled by one question: How could Captain Renslow not have realized he was dangerously slow for that phase of flight and not have acted accordingly by increasing power rapidly? Why would he have lowered flaps and extended gear, thus compounding the airspeed problem, if he had thought he was close to a stall?

A malfunctioning ASI – as I explained yesterday – does not explain this. For if it were indeed malfunctioning, the ASI would likely read low, not high, alerting Captain Renslow to the problem more vividly instead of masking it.[Thanks to Falconer's comment at jetphotos.net for reminding me of this.] Moreover, as the conscientious and well trained pilot he was, Captain Renslow likely was aware of the A/D note and the problems the Q400’s airspeed systems had had in the past, so he was likely all the more on the lookout for them.

Therein lies the explanation: The ASI was functioning properly, and the perilously low airspeed was staring Capt. Renslow in the face! But because he was aware that that ASI system had had problems, he chose to ignore it! Quite possibly, he thought that just as his windscreen had iced over, moisture had contaminated or ice had blocked the pitot-static system -- which provides raw data for the ASI.

Thus, it’s not that the ASI failed to warn him. It’s that because ice on the wing’s surface [where there is no deicing system or sensor] is not visible from the cabin, and the leading edge and its deicing boots – which he could see – looked free of ice, the de-ice system appeared to be operating properly [which it was]. Thus, based on his knowledge and his perception, there was no reason for the ASI to indicate such a low airspeed -- unless it was malfunctioning once again. And if it had been, his best course of action may well have been to continue the approach another minute or 2 until the moisture cleared and the ASI returned to normal. {Been there / done that -- see below.]

Unfortunately, somewhat like the deicing system on the ATR-42 [American Eagle, Roselawn, In], the Q400’s de-icing system’s design did not allow it to clear as much ice off the wing as necessary. Capt. Renslow may have compounded this design flaw by remaining in the ice for almost an hour, but again, there was no way he could have seen evidence of that.

This is not the first time a pilot has chosen to ignore what his instruments are telling him and compounded an already perilous situation. Indeed, often -- ignoring seemingly inaccurate instrument indications is advisable. [See my personal note, below].

Unfortunately, without assessing blame, we have to at least admit the possibility that -– possibly for the best of reasons –- Captain Renslow ignored the low airspeed reading he was getting [134 K] and chose to assume that his Q400 was still flying at the appropriate and safe airspeed [180 K] for that phase of the flight.

There is no other good explanation for his actions.


A personal note: I recall landing a single engine Cessna 172 on a dark, short runway in a strong gusty wind at night after a long trip home from my grandmother’s funeral in Buffalo. As I turned from base leg to final, I heard a thump, and my ASI stopped working. It was the old mechanical type, and the dial read 0. Initiate stall recovery or go around? Heck no! - I knew that a certain pitch attitude at a certain power setting would give a certain airspeed. I may have lowered my nose a little and/or added some power to increase my margin [sound familiar?], but I knew I would be fine and kept up with the landing. I was ignoring my airspeed indicator, wasn't I, because I knew better? In that case, it was the right thing to do - especially because unlike 3407's it was totally inoperative and I was in visual contact with the ground and runway. Also I had felt that thump on the wing when this had all begun. So I had lots of good reasons to ignore the defunct ASI -- what choice did I have? ;-]

As I was tying down, the reason for the ASI’s malfunction became apparent - I had speared a bird with the pitot tube [ASI probe].

Captain DT
(c) 2009, airline-crash-analysis.com

Tuesday, February 17, 2009

COLGAN 3407 -- INITIAL ANALYSIS

I've added some personal comments at the bottom of this [after the ATC transcript.]

Also -- just added an email from Capt. Bud, a highly experienced international 747 driver and instructor re. serious stall and upset recovery in transport aircraft. It's at the bottom after my comments.



This analysis assumes:


Overall, thorough and useful analysis must go beyond making a simple conclusion and ask – if that is so, why did it happen? For example – it seems apparent at this point that icing had a role in the crash – but that doesn’t tell us anything unless we ask, "Ok – if so, why didn’t other aircraft crash from the icing? Why did the crew not successfully manage the icing?"

As taught in CRM training, airline crashes are almost always caused by a chain or combination of causes, none of which by itself would have led to a fatal outcome. Therefore, we always ask, “What was the chain of factors [human, organizational, and physical] which led to the crash?” instead of seeking a single cause.

The pilot’s primary job is aviate, navigate, communicate [in that order!]. That means command decision – assertiveness, if you will – is #1. CRM [Cockpit / Crew Resource Management Training] -- basically assertiveness training for airline pilots -- is arguably the most important training they get. [After all, pilots already know how to fly.] CRM emphasizes that accidents are invariably caused by many things going wrong – never just one thing – and the crew’s responsibility is to assert themselves to break this fatal chain.

However, pilot experience, pairing, training, schedules, and assertiveness are controlled by management; if any of these lead to pilot error, the root cause is management error.

Although pilots are taught stalls from the beginning, they are taught mostly stall recognition and recovery. But in the real world a stall close to the ground will become an unrecoverable [flat] spin – and thus stall training should emphasize avoidance over all, since there will be no recovery.

Icing in a prop plane with boots is a different animal than in a jet with heated surfaces. The boots only provide time to escape the ice – lingering in it will not lead to a good outcome. The mantra: “go up, go down, turn back, go around!” is the only way to deal with icing classified as more than “light.” Even modern aircraft like the Dash 8 – supposedly certified for flight into known icing should be flown out of it ASAP. Their deicing capability is still certified under regulations dating from the 1940’s. These do not take into account the effects ice have on a high performance wing like that Dash 8’s, which is much less forgiving than older, slower airfoils.

Although we are not in a position to assess the mechanical issues [if any] associated with the accident aircraft, most of the other issues are readily apparent from listening to the conversations between BUF ATC [approach, tower, departure, and ground] and aircraft in the area.

Our transcript of those 30 minutes [excerpted for clarity] with the crucial items highlighted is attached. Our overall analysis, based on the transcript as well as NTSB and media reported facts, follows:

Given the short time since the crash, please understand that

  • The transcript is not perfect – we will be refining it over time and updating it as required. However, modifying what we have here to improve accuracy will not change any of the conclusions we have drawn from it so far.
  • Many of our points are speculative and may not stand the test of careful examination or further information gathering – rather, they are given to be treated as hypothesis – to be considered as part of the crash investigation and cause determination.
Thus, from the recording of ATC [BUF approach , tower, ground, and departure controls] between 0300 and 0331:50Z on 2/13/2009 [10:00 – 10:31:50 PM EST on 2/12/2009] and other sources we note the following:

Re. Colgan 3407

1. pilot fatigue / lax cockpit discipline – demonstrated by the f/o’s failure to repeat ATC clearances as given, as well as reporting in with information romeo rather than sierra, which was current at the time.

2. The Dash 8 -- is a boot – equipped jet prop, not a pure jet with heated surfaces. The NTSB reported that de-ice had been turned on 11 minutes after take off. We also understand that the windshield was iced over, making it unlikely the crew saw how much ice they were carrying. [Although the NTSB reported the crew discussed the ice buildup, we assume they did so on the CVR or prior to 10:00; at any rate, they did not mention ice on the recording we reviewed.] On the other hand, if the windshield was iced over, the wings likely had ice as well. And the tail may have had triple whatever the wings had.

Using the autopilot in such circumstances, while neither forbidden nor necessarily hazardous, would reduce the “feel” of the control yoke, further reducing awareness of the ice buildup. We don’t consider autopilot use significant either way; the only true negative to using it is the false sense of security it may give an already over worked and tired crew.

[The crew conversations recorded on the CVR will be vital to determining the level of crew awareness and alertness. Casual [non flight related] conversation is forbidden below 10,000’. We know that that there was another new captain jump seating aboard the aircraft; we don’t know if he was in the cockpit conversing with the pilots or sitting elsewhere, and again we don’t know if whatever conversation ensued enhanced pilot awareness and performance or detracted from it. But we will find out.]

re. ATC:

Most important – and hitherto unnoted – When tower clears Delta 1998 – the first arrival after the crash – for the ILS, he tells him not to autoland, and asks him to report any problems with the localizer. Tower says, “It's reading fine up here [in the tower].” Did tower know something? Why else would he be asking, while stating it looks fine to him? Upon landing, Delta 1998 says, “Yes we had a 1 dot deflection either side on the way in.” Yet ATC does not stop approaches to that runway [23] and divert arrivals to another runway or Niagara Falls [IAG] until the localizer is confirmed to be fully functional.

Moreover, in response to tower’s query, Delta 1998 reports being in the clouds at 2300’ MSL. This indicates to me that tower may have thought conditions were VFR at 2300 over Klump [as they may have been earlier] and thus vectored Colgan 3407 in close to the marker because he thought 3407 would see the runway from there or at least have visual ground contact in that area. Let’s note that tower vectored the flights following 3407 to intercept the localizer farther out – at Trava, the fix preceding Klump – a much more appropriate intercept point for aircraft conducting an ILS in IMC in icing conditions at night.

Not directly pertinent to Colgan 3407 , but still indicating less than optimal ATC performance:

ATC didn't call responders until 5 minutes after they had asked Colgan 3407 to contact Buffalo tower and Colgan 3407 failed to do so. Admittedly, this may be a non issue; ATC cannot declare an emergency every time an arrival is slow to make a frequency change. Moreover, it’s doubtful that any lives could have been saved even if had responders been present immediately.

But ILS 23 approaches were resumed 5 MINUTES after the call for responders – using the same ILS [23], the same marker, and same altitude [2300] as the lost aircraft was last reported at. ATC assumed it had crashed -- but they had no way to know at that point. We can only wonder if ATC considered diverting arrivals to IAG -- 15 miles away with a 10,000' runway -- or at least switching approaches and landings to another ILS at BUF like the ILS 32 [wind 260@10].

Re.: Other aircraft in the area

ATC began soliciting reports concerning rime icing only after 3407 had crashed – only then did Cactus 1452 report “½ inch– make that ¼ – and has been building for 10 minutes.” The 10 PM weather radar shows heavy precipitation off the lake. Given the surface temperature of around 38 F, icing potential was a no-brainer – OAT decreases 3.5 F for every 1000’ rise in altitude; therefore, at 2300’ MSL [about 1650 AGL over Klump, the OM / FAF – where the aircraft went down] – the OAT was likely right at 32 F – meaning icing until descending for approach and landing. Cactus 1452’s report confirms this. Therefore, once again, icing should not have been unexpected by Colgan 3407's crew or a surprise to ATC. Meanwhile ATC’s response to Cactus 1452’s icing pirep [pilot report] is "hold on". While a jet powered aircraft like Cactus 1452 with heated surfaces likely can, a prop booted aircraft like Colgan 3407 may not be able to.

Thus, we have developed the following scenario as our best guess as to how this accident unfolded. Remember – an accident like this is almost never caused by only a few things going wrong.

1. Crew fatigue and /or lax cockpit discipline – most apparent in the “fuzzy” tone of the F/O’s voice and her failure to read back ATC clearances verbatim like the other crews were doing. [Also, compare to the transmissions from the crew of the next Colgan Q400 arriving from EWR about 30 minutes later [on the next recording, beginning at 10:30 p.m. local time / 0330 Z. The “fuzzy” assessment is subjective, and can only be appraised by listening to the transmissions, not reading them. But the lack of readback discipline is not. Moreover, the tone of the radio transmissions may have been a result of ice on the antenna; but if so, that’s information also. In any case, the partial / missed readbacks point most immediately to crew fatigue.

We know that EWR had had delays all day due to strong winds; this flight had departed 2 hours late – meaning the crew had probably been on duty 13 hours or more. We understand that a typical duty day for a Colgan pilot includes flying 7 legs. Assuming 1 hour / leg flying, .5 hour / leg turn around, and 1 hour / day check in time, a 7 leg day would be at least an 11.5 hour duty day. [7 + 3.5 = 1 = 11.5] Such duty is not illegal, but certainly unwise – especially when operational delays extend it to 14 hours.

2. The captain’s lack of assertiveness [shown by his toleration of the f/o’s partial readbacks; compare her transmissions with those of the other aircraft in the area, as well as the next Colgan Q400 from EWR] may have led to flying in ice for over an hour without informing ATC and / or obtaining an exit, altitude change, rerouting, or return to EWR. [Again, note how the JetLink crew on the 10:30 pm local recording handles a potential icing problem.] The captain has been described by other Colgan personnel as “really nice.” Was he too nice for what he had to do? He also does not seem to have considered a low pass over the airport to remove ice prior to an ILS or just diverting to another airport with better weather and / or a longer runway, enabling higher approach speed or delayed flap / landing gear extensions. [As I mentioned, IAG meets these criteria and is only 15 mi. from BUF.] Admittedly, most of these alternatives are overkill and were not necessary; however, they should always be in the crew’s contingency planning arsenal. An altitude change or expedited handling, as Northwest 920 obtained, likely would have done the trick; if not, a low pass would have cost about 5 minutes and broken the dangerous–occurance–chain.

Being night, it’s possible the crew failed to see the ice buildup. Possibly they didn't look. Possibly they assumed the deicing boots were taking care of it. Again, a captain flying in the these conditions must exercise appropriate command authority and have acquired a healthy respect for and awareness of what ice can do – from training and experience. An appropriate and simple action in this situation would have been to ask the first officer or jumpseating captain to view the wing and tail surfaces [if possible] from a cabin window to better assess the icing situation. Without the CVR transcript, we cannot say that the captain failed to do this; however, given his lack of assertiveness in other areas, we would be surprised if he had done so. For if he had, he may well have more actively considered the options listed above, as well as other alternatives. [Note added on 2/22 -- this may not have been possible given that the Q400 is a high wing aircraft, and the wing surface cannot view viewed from the cabin.] But from the transcript and other information, the crew does not seem to have had any awareness of the seriousness of their situation; if they had, they would have acted more appropriately.

Finally, the crew’s lack of assertiveness meant – minimally – failing to ask ATC to vector them for a longer final approach – possibly beginning at Trava. This would have allowed for a much gentler turn [and bank] to intercept and line up with the localizer inbound.

Given the tight turn required by ATC’s vectors close to Klump, the crew may have reduced power and airspeed to slow down to tighten the turn onto final. Thus, power available to heat the props and engine intakes also was reduced. Finally, tightening the turn to capture the localizer may have enticed the crew to increase bank and / or kick the aircraft around with the rudder, putting the aircraft ever closer to an accelerated stall. This is the same scenario most pilots see demonstrated somewhere in their first 10 hours of flight instruction. Unfortunately, they often don’t get to see the resulting spin that ensues [at a safe altitude]. And they can’t experience these events at 1650’ AGL more than once.

Finally – the icing on the cake. What if – as Colgan 3407 is turning in sharply to get lined up -- the localizer starts swinging from side to side, making a coupled [autopilot] approach impossible and possibly eliciting even more bank from the crew or autopilot [if still on]. Admittedly, this is speculation. But it is based on clear reports of erroneous localizer readings, as I discussed. Why else would ATC be asking the next flight in about the localizer? Obviously, an inaccurate localizer added to everything else reported would almost guarantee a crash. And even if this hypothesis does not prove to be true, there was more than enough going wrong to lead to an accelerated stall.

In any case, almost to the end, the crew had options. But given fatigue, over scheduling, and pressure to complete an already delayed flight – as well as the expectation that they would break out and shed the ice any second now -- [Been there / done that!], they didn’t opt for a missed approach and retry ice-free from Trava. A diversion for deicing and / or boot inspection to IAG or ROC was also an option. But given the way Colgan Air seems to be pressuring and scheduling their crews – well documented at www.airlinepilotforums.com – we can fully understand the crew’s fatigue and lack of command authority [assertiveness]. Ultimately, then, this accident’s root cause is system [management] induced which led to crew fatigue and lack of command authority. This in turn resulted in an accelerated stall / spin occurrence when turning to final with ice remaining on control surfaces.

Was there asymmetric boot inflation or inadequate / insufficient / ineffective boot operation? There is no way to know this as yet, especially outside the NTSB. But these problems by themselves – properly detected and compensated for – would not have resulted in 50 lives lost. A tail stall? Maybe – in almost 18 years and over 5000 hours of flying I never heard of such a thing. I also never had a serious icing problem – because I never let icing become a problem by staying in it for very long. Nor did I ever have an unintentional stall / spin -- probably because a sadistic CFI scared me to death of them around my third hour of training. [Thank you, thank you!]

In the end, what kind of stall 3407 experienced is immaterial – – it likely was a combination of tail stall and accelerated stall, aggravated and enhanced by ice contamination.. In any case, no stall / spin 1600’ AGL IFR at night with ice is recoverable. We do know that just prior to extending landing gear, 3407‘s ASI was reading 134 K – perilously low for that point in the flying regime. We also know that the ASI’s final reading was about 100 K – meaning the aircraft was stalled. No matter what kind of stall it was, the aircraft was falling, not flying – and likely spinning – when it impacted.

So the bottom line:

From the latest data the NTSB has reported re. the readouts from the FDR, as well as the aircraft’s configuration based on reports from the crash site –

  • pointing 180 degrees from its intended heading
  • neither deep nose burial into the ground nor more than 10’ of forward motion upon impact,
  • airspeed readings of 100 K,
we have to state the boring, not very exciting conclusion:

Due to all the above and possibly aggravated by unreported localizer fluctuations, immediately prior to the crash, the aircraft entered an accelerated stall perhaps combined with a tail stall.

Did the crew’s attempt to recover by overriding the nose lowering mechanism and adding power aggravate or ameliorate the situation? I don’t believe we’ll ever know, nor does it matter. By then the situation was unredeemable, and an unrecoverable fatal flat spin was inevitable.

The root causes of this tragic chain of events, then, were management errors, specifically:

  • overscheduling crews
  • and inadequately training and encouraging the crews to assert themselves as necessary and make command decisions required to ensure safety.

DRAFT TRANSCRIPT OF BUFFALO ATC 2/12/2009 10:00 PM - 10:31:30 PM EST


Not every aircraft is included – mostly just Colgan 3407 [C], Delta 1998 [D], United 246 [U], Cactus 1452 [AW], and Northwest 920 [NW] for illustrative purposes.

THIS IS A DRAFT AND WILL BE PROOFED / REVISED AS TIME ALLOWS PLS. LET ME KNOW IF YOU FIND ANYTHING IN ERROR OR INCOMPLETE..

ATC: = RADIO TRANSMISSION FROM ATC – BUFFALO APPROACH, TOWER, GROUND, OR DEPARTURE

TIMES = APPROXIMATE MINUTES : SECONDS AFTER 10 PM EST.



3:50

C: BUFFALO APPROACH COLGAN 3407 12 FOR 11 THOUSAND WITH ROMEO

ATC: COLGAN 3407 BUFFALO APPROACH GOOD EVENING BUFFALO ALTIMETER 2980 PLAN ILS APPROACH RUNWAY 23

C: 2980 AND – AH – ILS 23 COLGAN 3407
4:19

ATC: K – UNITED 246 DESCEND AND MAINTAIN 2 THOUSAND 300

U: DOWN TO 2 THOUSAND 300 UNITED 246

4:38

ATC: COLGAN 3407 PROCEED DIRECT TRAVA

C: [OK – GARBLED]

ATC: UNITED 246 DESCEND AND MAINTAIN 2 THOUSAND 300

U: UNITED 246

4:50

ATC: DELTA 1998 – AH – DESCEND PILOT’S DISCRETION MAINTAIN 6 THOUSAND

D: PILOT’S DISCRETION TO 6 THOUSAND DELTA 1998

4:58

ATC: COLGAN 3407 DESCEND AND MAINTAIN 6 THOUSAND

C: [GARBLED] –07

ATC: UNITED 246 TURN RIGHT HEADING 160

U: RIGHT TURN HEADING 160 UNITED 246

6:30

ATC: UNITED 246 TURN RIGHT HEADING 180

U: 180 UNITED 246

6:50

ATC: UNITED 246 YOU’RE 4 FROM KLUMP TURN RIGHT HEADING 210 MAINTAIN 2 THOUSAND 300 TILL ESTABLISHED LOCALIZER CLEARED ILS APPROACH RUNWAY 23

U: 210 ON THE HEADING 2,300 TILL ESTABLISHED CLEARED ILS RUNWAY 23 UNITED 246
7:55

ATC: UNITED 246 CONTACT TOWER 120.5 HAVE A GOOD NIGHT

U: [CLICK]

8:20

U: BUFFALO TOWER UNITED AH 246 – ILS RUNWAY 23

ATC: UNITED 246 BUFFALO TOWER RUNWAY 23 WIND 260 AT 12 – CLEARED TO LAND

U: CLEARED TO LAND RUNWAY 23 UNITED 246

8:39

ATC: COLGAN 3407 DESCEND AND MAINTAIN 5 THOUSAND

C: 5 THOUSAND COLGAN 3407

9:09

ATC: COLGAN 3407 DESCEND AND MAINTAIN 4000

C: [CLICK]

ATC: DELTA 1998 DESCEND PILOTS DISCRETION MAINTAIN 3 THOUSAND

D: WE’RE. GONNA DO A PRACTICE AUTOLAND OUT OF THIS.

ATC: ROGER

ATC: HEY DELTA 1998 – LET ME JUST AMEND THAT FLIGHT LEVEL [??] – DESCEND AND MAINTAIN 4 THOUSAND

D: ALRIGHT – DESCEND AND MAINTAIN 4 THOUSAND DELTA 1998

ATC: DELTA 1998 TURN RIGHT HEADING 050 [??]

AW: EVENING APPROACH CACTUS 1452 IS WITH YOU WITH ROMEO AT ONE ONE THOU

12:14

ATC: CACTUS 1452 BUFFALO APP GOOD EVENING BUFFALO ALT IS 2980 PROCEED DIRECT

ATC: COLGAN 3407 DESCEND AND MAINTAIN 2 THOUSAND 3 HUNDRED

C: [GARBLED] –- ZERO 7

12:39

ATC: COLGAN 3407 TURN LEFT HEADING 33 ZERO

C: LEFT HEADING 33 ZERO – COLGAN 3407

14:04

15:00

ATC: DELTA 1998 DESCEND AND MAINTAIN 2 THOU 3 HUNDRED

D: 2 THOU 3 HUNDRED DELTA 1998

ATC: CACTUS 1452 DESCEND AND MAINTAIN 4 THOU

AW: CACTUS 1452

ATC: COLGAN 3407 TURN LEFT HEADING 310

C: LEFT HEADING 310 COLGAN 34 ZERO 7

15:08

ATC: [GARBLED] 3407 3 MILES FROM KLUMP TURN LEFT HEADING 260 MAINTAIN 2 THOUSAND 300 TILL ESTABLISHED LOCALIZER – CLEARED ILS APPROACH RUNWAY 23

C: [???? HEADING 2?] SIXTY, 2 THOUSAND 300 TILL ESTABLISHED CLEARED ILS APPROACH RUNWAY 23 34 ZERO 7 [?]

16:02

ATC: COLGAN 3407 CONTACT TOWER 120.5 HAVE A GOOD NIGHT

C: [GARBLED] – THIRTY 4 ZERO 7

17:01

ATC: COLGAN 3407 APPROACH?

ATC: DELTA 1998 VECTORS GONNA TAKE YOU THROUGH THE LOCALIZER FOR SEQUENCING

D: DELTA 1998 – THANKS

17:22

ATC: COLGAN 3407 BUFFALO

ATC: COLGAN 34 OH 7 – AH – APPROACH?

17:33

ATC: DELTA 1998 – AH – LOOK OUT YOUR RIGHT SIDE ABOUT 5 MILES – FOR A DASH 8 SHOULD BE ABOUT 2300 DO YOU SEE ANYTHING THERE?

D: AH NEGATIVE DELTA 1998 WE’RE JUST IN THE BOTTOMS AND NOTHING ON THE T-CAS

ATC: COLGAN 34 ZERO 7 BUFFALO
[BLOCKED ] APPROACH

ATC: NORTHWEST 920 RADAR CONTACT MAINTAIN 5000

NW: MAINTAIN 5000 AH IF WE COULD WE’D LIKE TO REQUEST A CONTINUOUS CLIMB UP TO 8000 FOR ICE

ATC: NORTHWEST 920 AH CONTINUE TO CLIMB -- CLIMB AND MAINTAIN 8000
NW: UP TO 8000 I’D LIKE TO PUT 1 ZERO THOUSAND OFF AS A FINAL THEN

ATC: NORTHWEST 920 CLIMB AND MAINTAIN 1 ZERO THOUSAND
NW: 1 ZERO THOUSAND NORTHWEST 920 THANKS

ATC: DELTA 1998 TURN LEFT HEADING 360

D: LEFT HEADING 360 DELTA 1998 YOU WANT US TO CLIMB AT ALL?

ATC: BE RIGHT BACK TO YOU SIR

D: OK DELTA 1998 WANT US TO MAINTAIN 2 THOUSAND 3 HUNDRED THEN?

ATC: DELTA 1998 AFFIRMATIVE – DELTA 1998 YOU HAVE VFR CONDITIONS THERE?

D: NEGATIVE WE’RE IMC

ATC: ROGER

20:12

ATC: COLGAN 3407 BUFFALO TOWER HOW DO YOU HEAR?

ATC: F10 ARE YOU ON FREQUENCY?

ATC: THIS IS GROUND YOU NEED TO TALK TO SOMEONE AT LEAST 5 MILES NORTHEAST, OK POSSIBLY CLARENCE, THAT AREA RIGHT THERE, AKRON AREA, EITHER STATE POLICE OR SHERIFF'S DEPARTMENT, I NEED TO FIND IF ANYTHING'S ON THE GROUND. THIS AIRCRAFT WAS 5 MILES OUT AND ALL OF A SUDDEN WE HAVE NO RESPONSE FROM THAT AIRCRAFT

ATC: ALL I CAN TELL IS THERE [WAS] AN AIRCRAFT OVER THE MARKER AND WE’RE NOT TALKING TO HIM NOW

21:04

ATC: DELTA 1998 YOU HAVE ANY ICING WHERE YOU’RE AT?

D: AH WELL WE PICKED IT UP ON THE WAY DOWN I DON’T THINK WE’RE BUILDING ANY MORE HERE BUT FROM ABOUT 6500 DOWN TO ABOUT 3500 MAYBE?

ATC: OK THANK YOU SIR

ATC: DELTA 1998 THERE'S GONNA BE A DELAY I’M GONNA BRING YOU BACK AROUND EXPECT TO HOLD OVER KLUMP

D: ALL RIGHT SO WE’LL HOLD OVER KLUMP DELTA 1998

ATC: DELTA 1998 CLIMB AND MAINTAIN 4 THOUSAND TURN LEFT HEADING 270

D: CLIMB AND MAINTAIN 4000 LEFT TURN 270 DELTA 1998

ATC: [GARBLED] – I’LL HAVE TO GET RIGHT BACK TO YOU APPARENTLY WE HAVE AN EMERGENCY AND I’LL GET BACK TO YOU AS SOON AS I CAN...

ATC: DELTA 1998 AH TURN LEFT HEADING 260 INTERCEPT THE LOCALIZER AND AH YOU CAN MAINTAIN YOUR PRESENT ALTITUDE JUST MAINTAIN 3000 FOR NOW AND I’LL HAVE YOUR APPROACH CLEARANCE FOR YOU WHEN YOU GET A LITTLE CLOSER

D: ALL RIGHT MAINTAIN 3000 GOING TO THE LOCALIZER 23 DELTA 1998

ATC: CACTUS 1452 I WILL BE .... BRINGING YOU BACK AROUND HERE SHORTLY I WILL HAVE APPROACH CLEARANCE FOR YOU IN A WHILE

AW: AH ALL RIGHT WE’RE. PICKING UP RIME ICE HERE FOR A WHILE

ATC: DELTA 1998 YOU CAN DESCEND AT YOUR DISCRETION MAINTAIN 2 THOUSAND 3 HUNDRED

D: OUR DISCRETION 2 THOUSAND 3 HUNDRED DELTA 1998

ATC: CACTUS 1452 TURN RIGHT HEADING 140

AW: CACTUS 1452

23:57

ATC: K – ALL AIRCRAFT THIS FREQUENCY WE DID HAVE A DASH 8 OVER THE MARKER THAT DIDN’T MAKE THE AIRPORT AH HE APPEARS TO BE ABOUT 5 MILES AWAY FROM THE AIRPORT – DELTA 1998 – I’M GONNA BRING YOU IN SIR ON THE APPROACH – AH – IF YOU CAN JUST GIVE ME A PIREP WHEN YOU GET TO 2300 AND IF YOU HAVE ANY PROBLEM WITH THE LOCALIZER OR ANYTHING LET ME KNOW HOWEVER WE’RE SHOWING IT ALL IN THE GREEN HERE

D: WILLCO

24:45

ATC: DELTA 1998 6 MILES FROM KLUMP MAINTAIN 2,300 TILL ESTABLISHED ON THE LOCALIZER CLEARED FOR THE ILS RUNWAY 23

D: ILS 23 AND WE'RE STILL IN THE IMC HERE AT 2300 DELTA 1998
ATC: DO YOU HAVE ANY KIND OF ICING OR ANYTHING THERE?

D: AH IT DOESN’T APPEAR TO BE BUILDING AH AND WE GOT ABOUT HALF – QUARTER INCH – FROM THE DESCENT – HAS REMAINED WITH US THE WHOLE TIME

ATC: THANK YOU

ATC: CACTUS 1452 TURN RIGHT HEADING 220 TO INTERCEPT THE LOCALIZER

AW: CACTUS 1542 RIGHT TURN INTERCEPT THE LOCALIZER AND WE’VE BEEN PICKING UP RIME ICE HERE OH FOR THE LAST – OH – 10 MINUTES

ATC: OK STAND BY ON THE RIME ICE REPORT
AW: [?] BACK – AS SOON AS YOU CAN SIR

ATC: WHO WAS THAT?

AW: 52 SIR AH WE’RE.– BEEN GETTING ICE AH EVER SINCE AH 20 MILES SOUTH OF THE AIRPORT –

ATC: CACTUS 1452 OK AND IF YOU COULD LET ME KNOW WHEN YOU GET OUT OF THE ICING – AND AH AIRCRAFT COMING UP FROM THE SOUTH WAS REPORTING THAT EARLIER –

25:25

ATC: DELTA 1998 IF YOU COULD JUST DISREGARD THE AUTOLAND SIR CONTACT TOWER 120.5 AND LET THEM KNOW IF YOU HAVE ANY VARIATION IN THE LOCALIZER OR ANYTHING

D: OK WE’LL DO IT DELTA 1998

27:05

ATC: ???? ...ANY KIND OF INFORMATION YOU CAN GET, WE'D APPRECIATE IT

27:12

AW: ??? SIR, RIGHT NOW, 2300 SEEMS PRETTY CLEAR HERE
28:05

ATC: CACTUS 14 52, THANKS FOR YOUR HELP, WE APPRECIATE IT, CONTACT TOWER 130.5
28:12

AW: ..5 FOR CACTUS - DID YOU FIND COLGAN?
28:14

ATC: UHHHH! UNFORTUNATELY THEY SAID HE WENT DOWN RIGHT OVER THE MARKER KLUMP

29:17

AW: TOWER, CACTUS 14 52 IS COMING UP ON THE MARKER, WE SAW THE GROUND, YOU GUYS KNOW WHAT’S GOING ON?

29:24

ATC: CACTUS 14 52, BUFFALO TOWER 120.5 RUNWAY 23, YOU ARE CLEARED TO LAND, YES SIR, WE ARE AWARE

29:29

AW: K

AW: CACTUS 1452 AND THE ICE IS STARTING TO COME OFF THE WINDSCREEN NOW

ATC: DELTA 1998 IF ABLE LEFT NEXT TAXIWAY TAXI TO THE RAMP THIS FREQUENCY VIA ALPHA ALPHA ONE

D: ALPHA ALPHA ONE AND WE HAD A LITTLE DEFLECTION AT ABOUT 1 THOUSAND 500 FEET

ATC: YOU SAY IT WAS AT 1 THOUSAND 500 FEET?

D: AFFIRMATIVE AH IT WENT ABOUT 1 DOT’S DEFLECTION LEFT AND RIGHT

ATC: ALL RIGHT THANK YOU

ATC: 1452 CLEARED TO LAND PREVIOUS ARRIVING MD 88 REPORTED DEFLECTION IN THE LOCALIZER AT 1500 FEET PLUS OR MINUS 1 DOTS DEFLECTION

AW: K – COPY CONTROL CACTUS 1452

D: YES IT WAS AH ABOUT A 1 DOT’S REFLECTIONS EITHER WAY


--end of transcript--

TO MY FELLOW PILOTS:


For what it’s worth...

1. I'm not in the press or media. I am not a lawyer [nor do I play one on TV.]

2. I have extensive experience as a pro pilot - ATP-ME with all flt and ground instructor ratings, more than 5000 hrs [don't even know how many, really - lost count] - started in the J-3 cub - finished in the B727 - flew for regional airlines in new england [one nasty to us pilots, just like Colgan] and all over for Eastern Airlines. Scratched an a/c once, but never a person - and the a/c was immediately flyable [incident, not accident]. No I don't fly prof. any more, and I have no apologies. These days I prefer sailing, to some extent because it resembles flying, but it's cool in the summer and most of all - if I want to push the limits and mess up, the worst that can happen is I get wet.

3. I was born and bred here in Buffalo - and I'm probably one of the few people in the world who's returned after 30 yrs. [love those air conditioned summers, Canada, and all the lakes!] I did have the opportunity to get up close and personal the other day while they were removing the bodies from Colgan 3407 [don't ask], and while it was not fun, there was nowhere else I wanted to be. And I gasped when they called to tell me a personal and professional colleague had been on that flight.

4. Re. Buffalo - don't come up here if you don't have an out. IAG is about 13 N.M. from BUF ['bout 5 minutes] - with a longer runway. You can land either way if necessary or just fly a low pass. I flew several yrs. in N.E. between EWB, BOS, ACK, MVY, and HYA. Basically it was the airline portrayed in the TV show Wings, except Wings must have been shot in California, given that in Wings the skies were always sunny and for us we had fog or icing more often than not. Also on Wings they show the hero spending most of his time in the coffee shop at ACK - it was a nice coffee shop, 'cept my sked usually was around 20 trips in 12 hours, usually in the fog down to minimums by myself [single pilot auto pilot] - not leaving any coffee shop time cept to drain my tank while they filled the a/c's and get more java to steel me for the next ILS to mins. – especially fun at BOS where ATC was always telling you to keep the speed up [usually above V-le] so the heavy iron behind you wouldn't run you down and ATC wouldn't make you go 'roun'. Something about that horn blaring all the way down the g/s made the pax nervous - never did know why!

This operation gave out cards to the pax saying "landing uncertain" if you can believe - so yes I landed as scheduled more than not - but never if I didn't feel good about it - and I was never questioned for my decisions.

Re. Buffalo? Read my lips: BUFFALO! This is where CNN comes when they need shots of a blizzard on a sunny day in the rest of the US. Ever hear the term LAKE EFFECT? If not, stay away! Lake effect means total snow one minute, clear the next - deal with it! Used to be - even in the jet era, BUF closed for a week or so every winter, and all flights here went in and out of ROC - the airlines truly became bus companies! [One of the commuters I flew for in N.E, made more $ when they bussed folks to JFK than when we flew them. Really!] That doesn't happen much now, but I'm sure any Buffalonian worth the name would rather drive or bus to IAG or ROC every winter than get pulled out of the mud in Clarence. Death is never pretty.

5. We don't need pilots to merely program the autopilot - drone technology has been well developed, and if that's all "pilots" can do, I say replace them and let ATC fly the plane. What we do need is pilots who can make decisions - the right decisions! If you don't always have a plan B, you can't make the right decision. If you're not prepared to divert, you won't! [I remember when we used to say IFR means "I follow roads" and "If you have time to spare, go by air."] The value of a high time airline driver like Sully is not aeronautical skill but rather decision making ability and credibility with management. Can you imagine management daring to question a 20,000 hour pilot like Sully? On the other hand, can you imagine what management would have said to Captain Renslow if he had diverted or returned to EWR?

Captain DT



THIS IS FROM AN EMAIL A BUD SENT TO ME -- USED TO FLY WITH HIM -- HE'S A FORMER NAVY FIGHTER JOCK, THEN 727 CAPTAIN HERE [WHERE WE FLEW TOGETHER], THEN 747 CAPTAIN ALL OVER THE WORLD -- FOR SOME OF THE BIGGEST FOREIGN CARRIERS.

ENJOY.....

DT:

Judging what I have heard so far, you are right on.

I think 2 turns with ice and a slowing airspeed on each turn as well as the autopilot reaching a limit and clicking off.

Pitch down, one wing stalled and no acro on instruments with people who never trained that way. Engines screaming and it does not take long to hit a house going almost vertical. Most planes wipe out a few houses, not just one!

Every instrument check in the air force has unusual attitude recovery's, which means once a year in the simulator and also in the airplane. Also, the military teaches instrument acrobatics all through your training in all aircraft you fly.

There were 2 ATR crashes in 94 or 95 that I believe were the result of icing where the crew could not recover from an unusual attitude and went in inverted. In 1996 I was a Check airman with --, and all airlines began training unusual attitude recovery for airliners. I was doing all the "upset" training in the 747 simulator, and gave a very gentle profile, and of course never inverted. 90 percent of the Captains, who were all military trained, and many of them by the US military, were incapable or recovering from an unusual attitude. They crashed! It took the full 2 hours to get them to be able to recover the aircraft. The usual comments leveled at me were "you tricked me". Never more than 20 degrees nose up or down and a max of 30 degrees of bank! They would get the recovery so screwed up that every one resulted with a nose low banked turn with the engines at 75 percent until the simulator said "Crash override" and stopped itself before it collapsed the jacks. Every body got trained that year but not very well after that. I am sure that most airlines do not train very well or often in unusual attitude recovery in spite of numerous accidents.

After the JFK Jr. crash I was on a DL jump seat returning to ATL. The Captain gave me a written report of just what he went through. Just reading it was terrifying, as the airplane wound up, and he must have been barfing before he hit the water, not to mention his wife and her sister. The report said that in giving the same circumstances to a group of pilots with even more experience than JFK Jr., they all crashed in much the same way.

It really is a matter of experience and training to be able to handle an unusual attitude. A Delta L-1011 out of LAX got to 135 degrees of bank. The Captain had lost some hydraulic systems, and he rudder rolled it right side up and lived to tell about it. Former military training paid off, for no one at the time was practicing that then. EAL duplicated the problem in L-1011 training that year so everyone would see the problem. But here again it was a one time thing and no further training required.

God forbid an overcorrection on a TCAS maneuver. Hang on and enjoy a real 6 flags ride, assuming you survive it.

Unfortunately, with GPS, great airplanes, and wonderful autopilots, and the total discouragement of hand flying the aircraft, the skill set to actually fly the airplane is being lost. I always hand flew most approaches, unless the airport was down to minimums. I also encouraged F/O's to do the same. My reasoning was that the auto pilot had just flown and proved itself for the last 2, 4, 8, or 15.5 hours but we only were observers and we needed to practice hands on ourselves.

-AL lost 2 Airbus 300-600 aircraft, one in --- and 4 years later in ----. Both accidents were almost identical. VP of flight asked me what I would do.

I told him ground the A300-600 fleet and run all the pilots through the simulator and then the aircraft duplicating that accident. The -AL pilots were going around blaming Airbus for a lousy airplane. To be sure it is. However you do not need to crash it! His concern was they did not have enough airbuses to make up for training losses. I told him to send the Captains to Toulouse, and the French could teach them a proper missed approach in that airplane. Needless to say, it never happened, except the simulator part which did not convince any of their pilots that the airplane would do just what the simulator did.

Captain Bud

THANKS BUD -- I THINK YOU'VE SAID IT ALL!

DT

Sunday, February 8, 2009

US AIRWAYS 1549 DID NOT CRASH SOLELY DUE TO BIRD INGESTION!

Statistically an airliner crashing due to a simultaneous double bird strike is about as likely as being shot down by Martians with ray guns.

It is entirely possible that one engine struck bird[s] and failed, but any experienced flight instructor or professional pilot [and I am both] will tell you the major cause of losing both [of 2] engines on takeoff / climbout is pilot error – usually failing to properly identify which engine has in fact failed and which is still running – and then shutting down the “good” engine instead of securing the “bad.” In addition, there are other crew actions which could easily induce a compressor stall on the remaining “good” engine, resulting in the situation Capt. Sullenburger found himself confronting.

Moreover, it’s a matter of record that the #2 [right] engine had had a compressor stall only 2 days before, and no matter what the NTSB says at this point, that engine may not have been appropriately inspected / tested / repaired. As you can read in the recently issued Canadian air safety advisory, the only inspection method appropriate after a significant compressor stall such as the one 2 days before involves engine removal and disassembly, which was not done.

http://www.tc.gc.ca/CivilAviation/publications/tp185/1-06/Maintenance.htm

And ..... taking off with one marginal engine would dramatically increase the odds that even a single bird strike would have major consequences for both.

Unfortunately, explaining this crash solely or primarily due to bird ingestion shortchanges not only its passenger-victims but air travel safety as well.

But given the NTSB's "statement of facts" in the preliminary report, their investigation can only conclude one way. To wit [from the “fact” section of the NTSB’s preliminary report]:

“On January 15, 2009, at approximately 1530 eastern standard time, US Airways flight 1549, an Airbus Industrie A320-214, N106US, equipped with CFM engines, incurred multiple bird strikes during initial climb, lost thrust to its engines, and ditched in the Hudson River. The flight was a Title 14 CFR Part 121 scheduled domestic passenger flight from New York's La Guardia Airport (LGA) to Charlotte Douglas International Airport (CLT) in Charlotte, North Carolina. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. To date, of the 5 crewmembers, and 150 passengers on board, one serious injury has been reported. A total of twenty-six people were transported to hospitals, including two emergency response personnel. A final injury count is still to be determined.”

What's the problem here? Every statement in the preceding except the italicized is a fact and belongs in the fact section of the report. The italicized is hypothesis – supposedly what the investigation will prove or disprove. NTSB reports are written carefully; if hypothesis is stated as fact at the outset, it will almost certainly be reported as fact in the conclusion
.
I urge you to read the transcripts just released of all communications between ATC [including LGA ground control and clearance delivery] and Cactus [US Airways] 1549. They tell us a lot, but they also raise many questions, especially – but not exclusively – for my fellow professional pilots who took their CRM training seriously, as I did. Here are a few:

1. If you lost all engines on climbout, what would be the first word out of your mouth when contacting ATC?

2. In the case of 1 – what’s the problem with the runways ATC is suggesting? What would you do / say to them?

3. In all your years of flying, how often -- at a busy airport like LGA -- did you forget to call clearance delivery before contacting ground control?

4. If you had a bird strike an engine on an a/c under your command and were about to ditch, why would you try to restart it below 2000’ agl with tas below 250K?

5. If a f/o with minimal experience in type were conducting the t/o from LGA, what would you be doing during the t/o?

6. Are you aware that the engines on US Airways 1549 were putting out 30% n1 [#1] and 10% n1 [#2] all the way down to splashdown? Isn’t it possible that #2 could put out only 10% because it had previously been damaged and / or struck bird[s] 2 days before and had not been properly inspected, tested, or repaired [as above]? And if #2 had been also putting out 30%, how would you assess your chances of landing at an airport vs. risking a splashdown?

7. What does it say about a pilot who does not repeat ATC clearances back to ATC exactly or darn close to how they had been given. Is this nitpicking or have there been severe consequences for not doing so?

8. Upon ditching, what would be a higher priority -- activating the ditching switch or taking the a/c logbook with you off the aircraft?

[For those of you who haven’t seen it, I urge you to watch this textbook video of a bird strike well handled:]

http://www.youtube.com/watch?v=9KhZwsYtNDE

Here are a few more points to consider:

If US Airways 1549 really went down solely due to a double, simultaneous bird strike -- the accident will be considered an "Act of God", with only the birds [and maybe poor God ;-} ] to blame. Since there were no fatalities and only one serious injury [per what I’ve read so far] -- thank God! -- the passengers / victims will not be compensated in any equitable way for the trauma they suffered and the belongings they lost.

However, if there were system deficiencies which made the accident inevitable -- or transformed a fairly common and manageable occurrence [bird strike] into a potential tragedy [again -- pls. watch the above video], then victims can sue for -- and collect -- punitive damages if they have to.

More importantly -- if the only parties responsible are found to be God and the birds, the true cause[s] of this accident will not be addressed or corrected. And sooner or later they will result in a major tragedy instead of a near one.

The point here then is to recognize and address multiple system failures; rather than evaluate individual performances. There’s no doubt that Sully made a great splashdown. The problem, however, is that departing one of the world’s most challenging passenger airports with a marginal engine, an inexperienced f/o, and questionable cockpit discipline made that splashdown virtually inevitable.

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To be continued – expect more detail in the days to come. We welcome thoughtful questions and disagreement and will try to respond appropriately.