ImbracableCrunk
Unregistered Un-User
- Joined
- Feb 5, 2003
- Posts
- 1,481
In the Board Meeting on Feb 2nd the NTSB adopted the following 46 findings, probable cause and 25 recommendations:
Findings:
1. The flight crew was properly certificated and qualified in accordance with applicable Federal regulations.
2. The airplane was properly certified, equipped, and maintained in accordance with Federal regulations.
3. The recovered components showed no evidence of any preimpact structural, engine, or system failures, including no indications of any problems with the airplane’s ice protection system.
4. The air traffic controllers who were responsible for the flight during its approach to Buffalo-Niagara International Airport performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight.
5. This accident was not survivable.
6. The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.
7. The minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane.
8. Explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.
9. The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.
10. The flight crew did not consider the position of the reference speeds switch when the stick shaker activated.
11. The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.
12. The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.
13. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.
14. No evidence indicated that the Q400 was susceptible to a tailplane stall.
15. Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.
16. The Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, that would have facilitated the flight crew’s detection of the developing low-speed situation.
17. An aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker.
18. The captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.
19. The monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills.
20. Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.
21. Specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a pilot-in-command during air carrier operations.
22. Because of the continuing number of accidents involving a breakdown of sterile cockpit discipline, collaborative action by the Federal Aviation Administration and the aviation industry to promptly address this issue is warranted.
23. The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.
24. The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
Findings:
1. The flight crew was properly certificated and qualified in accordance with applicable Federal regulations.
2. The airplane was properly certified, equipped, and maintained in accordance with Federal regulations.
3. The recovered components showed no evidence of any preimpact structural, engine, or system failures, including no indications of any problems with the airplane’s ice protection system.
4. The air traffic controllers who were responsible for the flight during its approach to Buffalo-Niagara International Airport performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight.
5. This accident was not survivable.
6. The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.
7. The minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane.
8. Explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.
9. The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.
10. The flight crew did not consider the position of the reference speeds switch when the stick shaker activated.
11. The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.
12. The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.
13. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.
14. No evidence indicated that the Q400 was susceptible to a tailplane stall.
15. Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.
16. The Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, that would have facilitated the flight crew’s detection of the developing low-speed situation.
17. An aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker.
18. The captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.
19. The monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills.
20. Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.
21. Specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a pilot-in-command during air carrier operations.
22. Because of the continuing number of accidents involving a breakdown of sterile cockpit discipline, collaborative action by the Federal Aviation Administration and the aviation industry to promptly address this issue is warranted.
23. The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.
24. The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
