Colgan 3407 NTSB Animation

[Popeye0537]

I am not condoning moving the flaps, but when she did it the airplane was rolling right through 90 degrees. The aircraft then came back to wing level momentarily. From that moment on if the ailerons were not used just rudder and max power applied while maintaining attitude the result would have been a lot different.

Yes her response to the flaps 15 and the shaker was UHHH. However if you notice right before that she had a hand off to the tower. It appears her head was down for a second as he made his calls she looked up as she selected the flaps and all hell started to break loose.

I wonder if the captains I used to fly with before my furlough that made fun of me for saying speed checks before I moved the flap or gear handle would laugh at me now?

Yes they probably would still laugh at you because the speed did check before she moved the lever to 15*. I wouldn't call for the flaps above speed and if I did, I would preface the call with "on speed". Speed checks is not a call out in your SOP so why do you continue to use it?

I think with her limited time in any aircraft, she thought she was doing the right thing. She move the flap lever and the aircraft stalled...I'm guessing but she might have thought to undo what she did and the aircraft upset might end. In my eyes the CA was asleep at the wheel.

 

[Dubya]

In approx. 15 sec. the speed goes from 180 to below 130 with no addition of power. 50 knots, gear down, 2 flap calls, and no power added. Two PILOTS missed a 50 knot decrease during reconfiguring for landing.

Who's the clown in here trying to use fatigue, commuting, and Colgan's training? GMAFB. This is 101. Looks like the Captain failed 101 AGAIN and killed all those people.

She chose to commute on a red-eye, he CHOSE to commute and sleep in the crew room, they CHOSE to chit chat below 10.

All the factors mentioned are relevent, but they are CLEARLY NOT the cause.


W

 

[Captain X]

One thing I've noticed. Look at the animation at 22:16:27.

CA asked for "flaps 15, landing check." Flaps only made it to 10. At that time, speed hit 130KIAS, stick shaker activated simultaneously with an "uhhh" from the FO.

When she retracted the flaps (unrequested), at 16:36, the speed was 96 KIAS and the pusher was on. Additionally, the aircraft was in a right bank of about 100 degrees. Even though it was unrequested, the retraction was immaterial at this point.

Look at the CA's control inputs. Feet going all over, overcontrolling, the aircraft climbed 200' in the stall. He never "let" the nose go below the horizon. By the time it did, the stall was so aggravated, it was too late to recover.

Yep.

I was thinking the same thing. To everyone bashing the FO and her uncommanded change of configuration, I'm pretty sure she was thinking "I just changed the configuration and the airplane has departed controlled flight." Hence the "Uh..." She was probably just thinking her extension of flaps caused the departure and resetting them would rectify the situation.

I know I've heard that more than once about a departure from controlled flight after a configuration change in my career flying multiple turbine-powered aircraft.

Couple that with their combined limited experience in ice and type as well as her apprehension about the icing conditions (predisposed to thinking you have a situation you don't perhaps) and there are a lot of links in this chain.

But in the end, a loss of situational awareness and instrument scan, caused by any number of factors (duty day, fatigue, illness, stress, etc.) allowed the crew and PIC to miss potential cues that could have broken the chain.

Let's hope their loss, as well as that of the unsuspecting passengers on board, was not in vain.

 

[PURPLEHAZE21]

There is no substitue for Experience......

 

[FO 4 Life]

There is no substitue for Experience......

How much is enough?

Excerpts from a NTSB report

"
As the airplane climbed through 11,700 feet, the captain noted light rime ice accumulating on the windshield wiper blades and about a 1/2-inch-wide area of ice on the left wing. During this time, the crew failed to detect a decaying indicated airspeed due to the ice that was accumulating. As he began to activate the manual deice boot system, he felt a heavy vibration in the airframe and the windscreen immediately turned white with ice. The airplane's nose and left wing dropped and the autopilot disconnected. As he was grabbing the yoke, the clacker sounded (indicating an imminent stall), the stick shaker activated, and the ground proximity warning system emitted a "bank angle" aural warning. Digital Flight Data Recorder (DFDR) data showed that the indicated airspeed went from 144 to 130 KIAS over the 26 seconds before the upset, and that the rate of airspeed decay accelerated in the final 10 seconds before the autopilot disconnected. The airplane departed controlled flight at an indicated airspeed of 130 knots, and before the stall warning activated. The data establishes that the airplane went through a series of roll and pitch excursions, reaching maximum values of 86 degrees left wing down, 140 degrees right wing down, 23 degrees nose up, and 40 degrees nose down before the flight crew recovered control. The data also revealed that about 26 seconds before the stall while the airplane was at a speed of 144 KIAS, the airplane began to experience a likely ice-induced slight rolling anomaly that was counter to the direction of the aileron input. Aileron input from the autopilot arrested this slight rolling motion.

The airplane rolled to 86 degrees left wing down, and then went through a series of roll and pitch
movements. It reached 140 degrees of right roll, and a maximum pitch down angle of 48 degrees. It
rolled to 75 degrees left wing down, and a pitch of 31 degrees nose down. It then rolled to 94
degrees right wing down, followed by a pitch angle to 40 degrees nose down. Starting at 1440, the
altitude and outside air temperature parameters stopped recording valid data for a period of 15
seconds. At 1440:06, the airplane's pitch angle began to increase. It passed through 0 degrees
about 6 seconds later at an airspeed of 219 knots, and a recorded maximum vertical acceleration of
2.5 g's. The pitch reached 23 degrees nose up at 1440:24; the minimum recorded airspeed value of
105 knots occurred 11 seconds later while the airplane was at an altitude of 7,840 feet. The
parameters began to stabilize after this time.

The captain had a total flight time of 6,764.08 hours, with 3,981.87 hours accumulated in Saab 340
airplanes, of which 2,519.46 hours was as the pilot-in-command (PIC). He had a total of 970 hours
of instrument experience and between 1,700 and 1,900 hours of night flight. During the preceding 90
days, 30 days, and 24 hours, he reported that he had flown in both the capacity of PIC and
second-in-command (SIC) approximately 172, 47, and 7 hours, respectively. He added that he had
acquired numerous hours of aerobatic flight time in a Cessna 150 Aerobat airplane."

Anytime, anywhere

 

[flynryan15]

Yes they probably would still laugh at you because the speed did check before she moved the lever to 15*. I wouldn't call for the flaps above speed and if I did, I would preface the call with "on speed". Speed checks is not a call out in your SOP so why do you continue to use it?

I think with her limited time in any aircraft, she thought she was doing the right thing. She move the flap lever and the aircraft stalled...I'm guessing but she might have thought to undo what she did and the aircraft upset might end. In my eyes the CA was asleep at the wheel.

Ummmm look again at the speed before the flaps were selected 15 he was in the red arc. Yes lowering the flaps would lower the stall speed but, he was not making power increases while adding, flaps, gear, and props. Laugh all you want, but in that situation attention to the speed before the final notch of flaps probably would've had her asking about power! I know one thing if you are flying and we are in the red arc your not getting flaps before you bump up the power because at flight idle and already in the red arc they are not lift devices they are drag devices.

 

[ace6453]

I wonder if the captains I used to fly with before my furlough that made fun of me for saying speed checks before I moved the flap or gear handle would laugh at me now?

So you are one of those idiots that make up their own callouts. If it is not a standard callout, then wtf are you doing saying it? Besides she just put them up, no one called for them.

 

[flynryan15]

So you are one of those idiots that make up their own callouts. If it is not a standard callout, then wtf are you doing saying it? Besides she just put them up, no one called for them.

Who the ******************** are you to call me a idiot! I challenge you to show me in a FOM anything prohibiting verbalization and communication. I have done it on PC's and received a positive response from the Check Airman! It is not making up my own callout, it is adding situational awareness. In this very instance it would have brought his attention to the rapid decay of airspeed before the final notch of flaps were selected!

 

[ace6453]

Who the ******************** are you to call me a idiot! I challenge you to show me in a FOM anything prohibiting verbalization and communication. I have done it on PC's and received a positive response from the Check Airman! It is not making up my own callout, it is adding situational awareness. In this very instance it would have brought his attention to the rapid decay of airspeed before the final notch of flaps were selected!

I don't have to show you anything. If it is not a required callout, wtf are you doing saying it. I think everyone checks the speed after flaps are called for before moving the flaps. I think it is a great idea to check the speed, however there is no need to make up your own callout and say it every time. The FP is obviously looking at the airspeed, and you as the PM obviously are too, so why the need to make up a callout? You add to the situational awareness by checking the speed, not saying "speed checks". I never understand people like you who think they have a better way to fly the plane. The company pays you to fly the plane they way they tell you (eg. profiles, callouts), why is that so difficult?

 

[K.V.]

I don't have to show you anything. If it is not a required callout, wtf are you doing saying it. I think everyone checks the speed after flaps are called for before moving the flaps. I think it is a great idea to check the speed, however there is no need to make up your own callout and say it every time. The FP is obviously looking at the airspeed, and you as the PM obviously are too, so why the need to make up a callout? You add to the situational awareness by checking the speed, not saying "speed checks". I never understand people like you who think they have a better way to fly the plane. The company pays you to fly the plane they way they tell you (eg. profiles, callouts), why is that so difficult?

I've read some pretty dumb things on this thread, but you take the cake with this comment. Had the pilot of this aircraft been monitoring his airspeed, there wouldn't have been accident to be discussing right now.

 

[Raskal]

I've read some pretty dumb things on this thread, but you take the cake with this comment. Had the pilot of this aircraft been monitoring his airspeed, there wouldn't have been accident to be discussing right now.

Agreed, I have no problem when FO's do the "speed checks" call and I'm occasionally guilty of saying it myself (it was a callout at my previous job). Especially when tired sometimes helping yourself and the other guy out by verbalizing what you're doing is beneficial and can prevent the stupidity we're all occasionally guilty of.

Another example is I'll usually call "anti-ice coming on" so the FO knows what I'm up to when flipping switches outside of normal flows. Is this an official call in the FOM? No. If an FO reached up and turned anything on without letting me know what he's up to am I going to react? Damn straight.

 

[PeanuckleCRJ]

Raskal- well said. That is just good cockpit coordination and communication. He calls for something, I repeat the command back as I'm doing it.... I'm select the engine anti-ice on, I'm calling out that it's coming on.

It's just basic CRM.

 

[Be 23]

ooops

 

[igneousy2]

As far as I can tell it seems many of you are being too hard on the FO for putting the flaps back up. The FAF is the point in time where the PNF is the most task saturated. At a previous 121 carrier I was taught that if you move something and everything gets f-upped...un-f*** it by changing it back. My guess would be that the FO was heads down, sensed something was wrong and looked at the first instrument that you go to which is the Attitude Indicator. She notices that she is rolling through knife edge and retracts the flaps, probably thinking she had an asymetrical flap deployment. It takes a few seconds to go from PNF to FP. Even longer if you're brand spanking new and not 100% confident at what you are looking at.

Although many of the other criticisms are valid, my impression is that the Captain froze and the First Officer was trying to find "A way" all the way to the ground....she just didn't have enough experience to recognize what was going on-quick enough to do anything about it. I do agree with the statment that was made that had she been at the controls this probably would have had a much happier ending.

 

[imacdog]

The captain didn't freeze - he did worse by making the wrong corrective inputs.

 

[Lampshade]

Low airspeed, stick shaker and stick pusher but you think the FO though it was asymmetric flaps?

 

[Crossky]

I have never heard of retracting the flaps during a stall recovery. What kind of plane are you talking about? When you retract the flaps, you effectively increase the wing's angle of attack. This of course is not desirable in a stall recovery. It kinda goes along the same lines as a windshear recovery. Max thrust and don't touch the configuration until you are clear of it.

Can't believe no one corrected your post till now. Please, go read an aerodynamics textbook before commenting on anything technical.

Retracting flaps REDUCES the angle of attack, and extending flaps INCREASES AoA. The Angle of Attack (AoA) is the angle between the relative wind and the chord line of the wing. The chord line is the line between the leading edge and trailing edge. The trailing edge changes when the flaps are extended or retracted. When flaps are extended, the trailing edge lowers relative to the existing chord line, the chord line steepens relative to the relative wind, and the AoA increases.

BTW lift and drag increase with flap extension as well, lift more than drag at first, then drage more than lift as flap extension reaches full.

Also, flaps are always retracted during a stall recovery, if they were extended. This of course has to be done at a safe airpeed and AoA during the recovery procedure.

The FO should have NEVER retracted the flaps until commanded to do so by the CA. The FO should have called out 'AIRSPEED' long before the shaker occured because the CA let it get way too slow. The CA let the plane get way too slow, overcontrolled, and did not perform a proper stall recovery.

peace out.

 

[ultrarunner]

Low airspeed, stick shaker and stick pusher but you think the FO though it was asymmetric flaps?

With all the crap those two were yapping about on the way up from ERW, what on earth makes you think she was AT ALL in the game of acting as an SIC...

$hit, she wasn't thinking at all!

 

[FlyinFife]

The FO should have NEVER retracted the flaps until commanded to do so by the CA. The FO should have called out 'AIRSPEED' long before the shaker occured because the CA let it get way too slow. The CA let the plane get way too slow, overcontrolled, and did not perform a proper stall recovery.

While I don't disagree with anything you have said, I believe the REF & APP speeds were bugged at 114 & 119 (As per the CVR transcript). At my company we don't necessarily have to make an airspeed callout until REF +10. Taking that into account, I don't find it odd that there were not any airspeed callouts.

At the same time, that could explain the FO's "Uhhhhh" comment just as the stick shaker was occuring: she's busy, makes the switch to tower, makes the call, selects the flaps, and looks down at the airspeed just a few seconds too late and sees their airspeed coming up to the red tape which in her mind is not supposed to be there. She says "Uhhhh", the stick shaker goes off, and the rest is history.

That being said, either one of them should have seen the red tape approaching before it got to that point.

 

[LazyLightnin']

With all the crap those two were yapping about on the way up from ERW, what on earth makes you think she was AT ALL in the game of acting as an SIC...

$hit, she wasn't thinking at all!

She wasn't really the one doing the yapping. It was mostly el capitan in the left seat spouting off the entire flight. Most of her comments were "uh huh" and "yeah". As in, "I hear ya, but still don't give a shlt"