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Colgan 3407 Update

jetpig32

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In its continuing investigation into the crash of Colgan Air flight 3407 in Clarence Center, New York, the National Transportation Safety Board has released the following factual information. On February 12, 2009, about 10:17 p.m. Eastern Standard Time (EST), a Colgan Air Inc., Bombardier Dash 8-Q400, N200WQ, d.b.a. Continental Connection flight 3407, crashed during an instrument approach to runway 23 at the Buffalo-Niagara International Airport (BUF), Buffalo, New York. The crash site was approximately 5 nautical miles northeast of the airport in Clarence Center, New York, and mostly confined to one residential house. The 4 crew members and 45 passengers were fatally injured and the airplane was destroyed by impact forces and post crash fire. There was one ground fatality. Night visual meteorological conditions prevailed at the time of the accident. The flight was a Code of Federal Regulations (CFR) Part 121 scheduled passenger flight from Liberty International Airport (EWR), Newark, New Jersey to Buffalo.
The NTSB has voted to conduct a public hearing on this accident. The hearing, which will be held May 12 – 14, 2009 at the NTSB's Board Room and Conference Center in Washington, D.C., will cover a wide range of safety issues including: icing effect on the airplane’s performance, cold weather operations, sterile cockpit rules, crew experience, fatigue management, and stall recovery training. The public hearing is part of the Safety Board’s efforts to develop all appropriate facts for the investigation.
“The tragedy of flight 3407 is the deadliest transportation accident in the United States in more than 7 years,” Acting Chairman Mark V. Rosenker, who will chair the hearing, said. “The circumstances of the crash have raised several issues that go well beyond the widely discussed matter of airframe icing, and we will explore these issues in our investigative fact-finding hearing.”
The hearing will be held “en banc,” meaning that all Members of the NTSB will sit on the Board of Inquiry. Parties that will participate in the hearing will be announced at a later time.
The aircraft wreckage has been moved from the accident site to a secure location for follow-on inspections as may be needed.
A preliminary examination of the airplane systems has revealed no indication of pre-impact system failures or anomalies. Investigators will perform additional examinations on the dual distribution valves installed in the airplane’s de-ice system. The de-ice system removes ice accumulation from the leading edges of the wings, horizontal tail, and vertical tail through the use of pneumatic boots. The dual distribution valves, which transfer air between the main bleed air distribution ducts and the pneumatic boots, were removed from the airplane for the examination.
The airplane maintenance records have been reviewed and no significant findings have been identified at this time.
The ATC group has completed a review of recordings of controller communications with the flight crew during the accident flight and conducted interviews with air traffic controllers on duty at the time of the accident. The group has no further work planned at this time.
Further review of the weather conditions on the night of the accident revealed the presence of variable periods of snow and light to moderate icing during the accident airplane’s approach to the Buffalo airport.
Examination of the FDR data and preliminary evaluation of airplane performance models shows that some ice accumulation was likely present on the airplane prior to the initial upset event, but that the airplane continued to respond as expected to flight control inputs throughout the accident flight. The FDR data also shows that the stall warning and protection system, which includes the stick shaker and stick pusher, activated at an airspeed and angle-of-attack (AOA) consistent with that expected for normal operations when the de-ice protection system is active. The airplane’s stick shaker will normally activate several knots above the actual airplane stall speed in order to provide the flight crew with a sufficient safety margin and time to initiate stall recovery procedures. As a result of ice accumulation on the airframe, an airplane’s stall airspeed increases. To account for this potential increase in stall speed in icing conditions, the Dash 8-Q400’s stall warning system activates at a higher airspeed than normal when the de-ice system is active in-flight to provide the flight crew with adequate stall warning if ice accumulation is present.
Preliminary airplane performance modeling and simulation efforts indicate that icing had a minimal impact on the stall speed of the airplane. The FDR data indicates that the stick shaker activated at 130 knots, which is consistent with the de-ice system being engaged. FDR data further indicate that when the stick shaker activated, there was a 25-pound pull force on the control column, followed by an up elevator deflection and increase in pitch, angle of attack, and Gs. The data indicate a likely separation of the airflow over the wing and ensuing roll two seconds after the stick shaker activated while the aircraft was slowing through 125 knots and while at a flight load of 1.42 Gs. The predicted stall speed at a load factor of 1 G would be about 105 knots. Airplane performance work is continuing.
Since returning from on-scene, the Operations & Human performance group have conducted additional interviews with flight crew members who had recently flown with and/or provided instruction to the accident crew, as well as personnel at Colgan Air responsible for providing training of flight crews and overseeing the management and safety operations at the airline. The group also conducted interviews with FAA personnel responsible for oversight of the Colgan certificate, which included the Principal Operations Inspector (POI) and aircrew program manager for the Dash 8 Q-400. The team has also continued its review of documentation, manuals, and other guidance pertaining to the operation of the Dash 8 Q-400 and training materials provided to the Colgan Air flight crews.
The Operations & Human Performance group continues to investigate and review documentation associated with the flight crew’s flight training history and professional development during their employment at Colgan as well as prior to joining the company.
Post-accident toxicological testing of the flight crew was performed by the FAA Civil Aerospace Medical Institute (CAMI) toxicology lab. Specimens taken from the first officer were negative for alcohol, illicit substances, and a wide range of prescription and over the counter medications. Specimens taken from the captain were negative for alcohol and illicit substances, and positive for diltiazem, a prescription blood pressure medication that had been reported to and approved for his use by the Federal Aviation Administration.
The Safety Board is also examining several other areas potentially related to the accident, including:
  • The circumstances of a recent event involving a Dash 8-Q400, operated by Colgan Air, in which the airplane’s stick shaker activated during approach to the Burlington International Airport (BTV) in Burlington, Vermont. A preliminary review of the FDR data from that flight shows the momentary onset of the stick shaker during the approach phase of flight. The airplane subsequently landed without incident. NTSB investigators have conducted interviews with the pilots and check airman on board this flight and will continue to investigate the incident.
  • Reports of airplane deviations resulting from distortion of the instrument landing system (ILS) signal for runway 23 at BUF. There is an existing Notice to Airmen (NOTAM) related to this distortion condition. To date, investigation into these reports has not revealed any connection to the accident flight.
 

siucavflight

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Thanks for the post, I hate to say it, but sounds like the crew got to slow and stalled the airplane, and the final findings will have little to do with ice as a cause.
 

q100

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Given the 1.42 g, and a 105 kt unaccelerated stall speed, one would expect a stall to occur at just over 124 kts. Sounds like ice not a factor. Sounds like the way the FAA insists upon stalls being demonstrated during PT 121 training is a factor.
 

filejw

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Given the 1.42 g, and a 105 kt unaccelerated stall speed, one would expect a stall to occur at just over 124 kts. Sounds like ice not a factor. Sounds like the way the FAA insists upon stalls being demonstrated during PT 121 training is a
.

And what way would that be???
 

acarpe3448

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And what way would that be???

When we do our stall training at the first sign of a stall we push the nose down. This Captain pulled nose up in a low speed, low power, low altitude situation. Does not look like ice is going to be the cause of this accident.
 

rjacobs

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When we do our stall training at the first sign of a stall we push the nose down. This Captain pulled nose up in a low speed, low power, low altitude situation. Does not look like ice is going to be the cause of this accident.

Never done stalls like that in a jet. I dont think the FAA wants stalls done like that either. I have been taught(2 airlines now) to hold the pitch you have at shaker onset and just drive out of the stall using power(assuming low altitude with power to spare). I have never been taught to lower the nose(unless the pusher does it).
 

q100

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And what way would that be???

I've been through 4 FAA approved Part 121 training programs, including 2 Dash8. All have this in common: In the "approach to stall" maneuver the instructors, check airmen and examiners emphasized the application of full power, and using pitch control to try and maintain altitude or minimize altitude loss (most simplified it to "hold your pitch attitude"). I have a manual stating that the first 2 steps in recovering from an approach to stall are:

1) Apply maximum [power].
2) Adjust pitch as required to maintain altitude or minimize altitude loss.

This method is pretty standard, and the FAA sets and approves the standards...

My two cents: Most important in recovering from a stall is reducing the angle attack. Full power can help as increasing speed will, for a constant pitch, cause a decrease in AofA. However...

Stalls in training are usually hand flown, and not trimmed all the way to stick shaker speed. So the trainee is used to having to hold back pressure to maintain pitch. What would the natural, trained, instinctive reaction be then when the autopilot is kicked off by the stick shaker, trimmed more or less to that speed? I suspect they'd be pulling back, as they are used to doing in training, when in fact the full power being applied is now driving the nose UP to try and maintain the AofA the autopilot had trimmed to when it kicked off. Potentially bad, no?

I'd prefer to see the FAA emphasize, as is the case in primary training, the first priority being to reduce the angle of attack (by some combination of a slight pitch reduction and/or using power to increase speed) and the second priority being minimizing the loss of altitude.

One guy's opinion. Based on speculation. Informed only by knowledge of the Dash8 and how pilots often are trained to fly it.
 
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mynameisjim

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Never done stalls like that in a jet. I dont think the FAA wants stalls done like that either. I have been taught(2 airlines now) to hold the pitch you have at shaker onset and just drive out of the stall using power(assuming low altitude with power to spare). I have never been taught to lower the nose(unless the pusher does it).

That jives with how I have been directed to recover from stalls at three 121 airlines.

I don't agree with it, but that's how they teach it.
 

bailout

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not a case of being right or wrong but it was clear to me from the beginning that ice nor a tail stall was a factor in this crash. it simply didnt make sense with the initial control inputs, airspeeds etc.

and i was taught at three places as stated above by q100. hold pitch or reduce slightly as required, but never to lower the nose as an intial maneuver.
 
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djensen78

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I've been through 4 FAA approved Part 121 training programs, including 2 Dash8. All have this in common: In the "approach to stall" maneuver the instructors, check airmen and examiners emphasized the application of full power, and using pitch control to try and maintain altitude or minimize altitude loss (most simplified it to "hold your pitch attitude"). I have a manual stating that the first 2 steps in recovering from an approach to stall are:

1) Apply maximum [power].
2) Adjust pitch as required to maintain altitude or minimize altitude loss.

This method is pretty standard, and the FAA sets and approves the standards...

My two cents: Most important in recovering from a stall is reducing the angle attack. Full power can help as increasing speed will, for a constant pitch, cause a decrease in AofA. However...

Stalls in training are usually hand flown, and not trimmed all the way to stick shaker speed. So the trainee is used to having to hold back pressure to maintain pitch. What would the natural, trained, instinctive reaction be then when the autopilot is kicked off by the stick shaker, trimmed more or less to that speed? I suspect they'd be pulling back, as they are used to doing in training, when in fact the full power being applied is now driving the nose UP to try and maintain the AofA the autopilot had trimmed to when it kicked off. Potentially bad, no?

I'd prefer to see the FAA emphasize, as is the case in primary training, the first priority being to reduce the angle of attack (by some combination of a slight pitch reduction and/or using power to increase speed) and the second priority being minimizing the loss of altitude.

One guy's opinion. Based on speculation. Informed only by knowledge of the Dash8 and how pilots often are trained to fly it.


I don't know man even in the metro we had to maintain pitch, and power through the stall. For sure don't lower the nose in a swept wing jet. I'm no engineer but I believe it is because of the high lift wing. Even a couple of degrees of pitch down is an extream loss lift. comparing a cessna wing which produces less then a 100 lbs per square foot to a jet which which does around 1500 lbs/sf.
 

q100

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I don't know man even in the metro we had to maintain pitch, and power through the stall. For sure don't lower the nose in a swept wing jet. I'm no engineer but I believe it is because of the high lift wing. Even a couple of degrees of pitch down is an extream loss lift. comparing a cessna wing which produces less then a 100 lbs per square foot to a jet which which does around 1500 lbs/sf.

Not disagreeing. Check the "and/or" in my next to last paragraph.

The first point is that the emphasis should first be on stall recovery/avoidance by reducing AofA (which can be done by adding power to increase speed and maintaining pitch, so long as care is taken not to increase pitch), and secondarily on avoiding altitude loss. Gotta remember - stalls are a function of AofA, not speed.

Secondly, the way training seems to be done is a maneuver, rather than as a recovery from a potentially dangerous situation. In the maneuver, an untrimmed aircraft is hand flown to stick shaker, which then requires much back pressure to maintain attitude/altitude. Perhaps training should include recoveries (no autothrottles or autothrottles off/failed) where speed is allowed to decay in altitude hold mode to stick shaker & then autopilot kicks off.

Food for thought.
 
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pianoman

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I don't know man even in the metro we had to maintain pitch, and power through the stall. For sure don't lower the nose in a swept wing jet. I'm no engineer but I believe it is because of the high lift wing. Even a couple of degrees of pitch down is an extream loss lift. comparing a cessna wing which produces less then a 100 lbs per square foot to a jet which which does around 1500 lbs/sf.

If you are at in a true stall (as in you pulled through the pusher, not just a shaker recovery) you ARE going to have to lower the nose in a swept wing jet to recover, especially at high altitude. (And you may have to give up a hell of a lot of altitude to get it flying again)

Obviously if you are just in the shaker you probably don't need to pitch at the ground full tilt.
 

wmuflyguy

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Stalls in training are usually hand flown, and not trimmed all the way to stick shaker speed. So the trainee is used to having to hold back pressure to maintain pitch. What would the natural, trained, instinctive reaction be then when the autopilot is kicked off by the stick shaker, trimmed more or less to that speed? I suspect they'd be pulling back, as they are used to doing in training, when in fact the full power being applied is now driving the nose UP to try and maintain the AofA the autopilot had trimmed to when it kicked off. Potentially bad, no?

At the place I work the the approach to landing stall is done with the autopilot engaged at first, the onset of the shaker is followed by the A/P disconnecting. When you slam the power forward the aircraft want to pitch down (tail mounted engines, not like the Q400). So you still need to hold back pressure.

The issue I see:

1. In training you know it is coming, not that you shouldn't see it coming in real life, but if you don't it will probably come as a shock to you regardless.

2. I haven't done one of these or any stall other than the high altitude stall demo since initial training in the plane (It jsut isn't part of our AQP apparently).

I'm going to guess that will be changing and be part of our regular AQP evaluation in the near future.
 

Oakum_Boy

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It sounds like a training problem somewhere along the line... This kind of stuff happens when crews are thrown on to the line with minimum training which, incidentally, is what regionals do...
 

HOMER D POE

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so 8 sim sessions and 25 hours of OE is a training problem? usually most checkrides consist of doing one stall and if the CA likes it, that's it. I don't buy a regional slam or God forbid someone bring up windshear recovery training problems at major airlines....
 

Aerosurfer

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If you are at in a true stall (as in you pulled through the pusher, not just a shaker recovery) you ARE going to have to lower the nose in a swept wing jet to recover, especially at high altitude. (And you may have to give up a hell of a lot of altitude to get it flying again)

Obviously if you are just in the shaker you probably don't need to pitch at the ground full tilt.

And thats exactly why you dont push down on a larger aircraft. It is certified to be able to power through the stall with minimum loss. Even so, at 1500 feet, you really dont have any altitude to lose, regardless of what plane you are in. The situation should not have made it as far as it did, by then is seems as though it has proven to be too late
 

wmuflyguy

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And thats exactly why you dont push down on a larger aircraft. It is certified to be able to power through the stall with minimum loss. Even so, at 1500 feet, you really dont have any altitude to lose, regardless of what plane you are in. The situation should not have made it as far as it did, by then is seems as though it has proven to be too late

When the shaker goes off, it is only approaching the critical AOA. Your not stalled and and thus you are not really powering out of a stall. You could concievably get the shaker to go off with full power already in (high altitude and/or slow flight), then your not pwoering through anything and you must lower the nose to make the shaker stop.
 

SpauldingSmails

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When the shaker goes off, it is only approaching the critical AOA. Your not stalled and and thus you are not really powering out of a stall. You could concievably get the shaker to go off with full power already in (high altitude and/or slow flight), then your not pwoering through anything and you must lower the nose to make the shaker stop.

Ding! Ding! Ding!... and so the stick pusher was born.
 

Big Beer Belly

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I've followed this tragedy with interest like most other aviators and am NOT here to start a fight. With today's preliminary findings I am left scratching my head though. As I understand it, the two pilots were engaged in extraneous conversation below 10k (18k per my employer) and were distracted. Understood... not correct, but we've probably all been there.

They allow the aircraft to slow well below bug speed and faced with a stick shaker he/she abruptly pulls back and changes pitch +30 degrees?

If I have the basics correct (and I may be mistaken?)... I'm left scratching my head with the big, "What were they thinking?" Stalls and approach to stalls AND THEIR RECOVERIES!... (trying to be polite here)... are two of the MOST BASIC of all aviation concepts and maneuvers to fly.

49 people lost their lives because two pilots were incapable of recognizing and recovering from one of the most basic of all aviation scenarios? Someone please tell me BBB has this all wrong. :mad: I have NOT paid close attention to all the facts/findings of this accident and may be out to lunch. If so, I'd SINCERELY appreciate a kind response to my lack of knowledge. As of now, when friends ask what happened in this accident, I'm left with the above explanation and I would very much regret maligning the crew (in a generic "pilot error" sense) if another explanation exists. I truly just want to know what happened and figured this forum would probably have the most up to date information.

As with the other recent unfortunate accidents, my sincere condolences to all the families and colleagues of those involved. In the end, we all share the same love for this profession or we wouldn't be here.

Thanks for any info...


BBB
 

Oakum_Boy

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rarely do pilots or airplanes invent new ways to crash. same stuff different day.
 
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