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Colgan-Buffalo crash...

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Cali, Columbia was a human factors nightmare that demonstrated no matter how much technology enhances safety. Automation can also become a silent killer if not used (monitored) properly.

Agreed, but the point was what I bolded. It was a long error chain combined with human factors that led to the demise of BOTH AA in Columbia as well as Colgan.

Point being, it wasn't just ONE thing led to the crashes. In BOTH cases, garbage in equaled garbage out.
 
1- All this arguing about the flaps is silly. Maybe they would have lost a little more altitude or taken a little longer to recover- that's it. Was it the wrong thing to do, yes- but who gives a ____! Heck, she probably could have shut down an engine and they still could have landed safely had he not done what he did. She committed one BIG error - didnt catch the speed bleeding off and smack him upside the head before he killed them all. Always assume that person next to you is going to screw the pooch at any moment and hope to god that they are doing the same!!

2- Those who argue that CFI experience is irrelevant need look no further than this. A thousand hours of pattern work, slow-flight, and stall practice would have done him a lot of good. A bunch of time in weather with instrument students in an older PA-, C- or BE with no autopilot would probably have been a good thing too...

3- There is little to no opportunity for most pilots starting out to really learn stuff. GA is dying or almost dead. The independent flight schools are dying or dead. The career track is the only way to go. Why instruct, tow banners, traffic watch, etc (if you can even find one of these jobs- and hauling checks is gone) when it is easier to get a RJ job with less time. "The Program" does not teach any deep knowledge of how to fly. It checks the boxes, runs through the curriculum and teaches the procedures. The airlines love these folks because the have an easier time getting through new-hire training and checking off that set of boxes. All is well as long as everything goes according to plan.

There is no ready solution. Heck, most of the instructors at the puppy mills are products of the same institutions. And their instructors were also, and so on. Some of the extra stuff, the weird stuff that isnt in the curriculum and only comes from seeing unexpected stuff happen in airplanes, gets lost with each generation. The highly motivated ones will see that there are gaps, and do the extra effort on their own and be just fine. But for every one of them, there will be many who are lazy or just dont even realize what they are not learning. And the system makes no differentiation between them. This is a situation that is slowly creating a big underlying problem in aviation. At my company, there seem to be more and more CYA memos, tech briefs and SOP changes coming out micro-managing procedures, trying to eliminate the need for actual understanding of what we are doing and the use of actual common sense. It would seem that both are lacking at times (managements performance is another topic altogether). That is in lieu of attempting to increase hiring standards, training standards, or just plain old better "pilot stuff".

That is some ramble-on-when-I-was-a-kid-I-walked-to-school-uphill-both-ways-in-the-snow-stuff, oh well- YMMV

"My mind is aglow with whirling, trasncient nodes of thought, careening through a cosmic vapor of invention"

"Ditto"
 
1- All this arguing about the flaps is silly. Maybe they would have lost a little more altitude or taken a little longer to recover- that's it. Was it the wrong thing to do, yes- but who gives a ____! Heck, she probably could have shut down an engine and they still could have landed safely had he not done what he did. She committed one BIG error - didnt catch the speed bleeding off and smack him upside the head before he killed them all. Always assume that person next to you is going to screw the pooch at any moment and hope to god that they are doing the same!!

2- Those who argue that CFI experience is irrelevant need look no further than this. A thousand hours of pattern work, slow-flight, and stall practice would have done him a lot of good. A bunch of time in weather with instrument students in an older PA-, C- or BE with no autopilot would probably have been a good thing too...

3- There is little to no opportunity for most pilots starting out to really learn stuff. GA is dying or almost dead. The independent flight schools are dying or dead. The career track is the only way to go. Why instruct, tow banners, traffic watch, etc (if you can even find one of these jobs- and hauling checks is gone) when it is easier to get a RJ job with less time. "The Program" does not teach any deep knowledge of how to fly. It checks the boxes, runs through the curriculum and teaches the procedures. The airlines love these folks because the have an easier time getting through new-hire training and checking off that set of boxes. All is well as long as everything goes according to plan.

There is no ready solution. Heck, most of the instructors at the puppy mills are products of the same institutions. And their instructors were also, and so on. Some of the extra stuff, the weird stuff that isnt in the curriculum and only comes from seeing unexpected stuff happen in airplanes, gets lost with each generation. The highly motivated ones will see that there are gaps, and do the extra effort on their own and be just fine. But for every one of them, there will be many who are lazy or just dont even realize what they are not learning. And the system makes no differentiation between them. This is a situation that is slowly creating a big underlying problem in aviation. At my company, there seem to be more and more CYA memos, tech briefs and SOP changes coming out micro-managing procedures, trying to eliminate the need for actual understanding of what we are doing and the use of actual common sense. It would seem that both are lacking at times (managements performance is another topic altogether). That is in lieu of attempting to increase hiring standards, training standards, or just plain old better "pilot stuff".

That is some ramble-on-when-I-was-a-kid-I-walked-to-school-uphill-both-ways-in-the-snow-stuff, oh well- YMMV

"My mind is aglow with whirling, trasncient nodes of thought, careening through a cosmic vapor of invention"

"Ditto"


I agree...there is value in doing. Being scared in a aircraft as a CFI because I screwed up or let the student go to far had value.

Instead of 10 hours of hasmat training or PRM videos or Security training maybe we should have 10 hours of fly the plane with all the magic sh!t turned off training.
 
More like it's amazing what poor judgement can do to a planeload of people.
When people say judgement, I typically think of aeronautical decision making. ADM didn't cause this, it was loss of SA.

So please try to be accurate when you're being snarky.
 
Exactly

1- All this arguing about the flaps is silly. Maybe they would have lost a little more altitude or taken a little longer to recover- that's it. Was it the wrong thing to do, yes- but who gives a ____! Heck, she probably could have shut down an engine and they still could have landed safely had he not done what he did. She committed one BIG error - didnt catch the speed bleeding off and smack him upside the head before he killed them all. Always assume that person next to you is going to screw the pooch at any moment and hope to god that they are doing the same!!

2- Those who argue that CFI experience is irrelevant need look no further than this. A thousand hours of pattern work, slow-flight, and stall practice would have done him a lot of good. A bunch of time in weather with instrument students in an older PA-, C- or BE with no autopilot would probably have been a good thing too...

3- There is little to no opportunity for most pilots starting out to really learn stuff. GA is dying or almost dead. The independent flight schools are dying or dead. The career track is the only way to go. Why instruct, tow banners, traffic watch, etc (if you can even find one of these jobs- and hauling checks is gone) when it is easier to get a RJ job with less time. "The Program" does not teach any deep knowledge of how to fly. It checks the boxes, runs through the curriculum and teaches the procedures. The airlines love these folks because the have an easier time getting through new-hire training and checking off that set of boxes. All is well as long as everything goes according to plan.

There is no ready solution. Heck, most of the instructors at the puppy mills are products of the same institutions. And their instructors were also, and so on. Some of the extra stuff, the weird stuff that isnt in the curriculum and only comes from seeing unexpected stuff happen in airplanes, gets lost with each generation. The highly motivated ones will see that there are gaps, and do the extra effort on their own and be just fine. But for every one of them, there will be many who are lazy or just dont even realize what they are not learning. And the system makes no differentiation between them. This is a situation that is slowly creating a big underlying problem in aviation. At my company, there seem to be more and more CYA memos, tech briefs and SOP changes coming out micro-managing procedures, trying to eliminate the need for actual understanding of what we are doing and the use of actual common sense. It would seem that both are lacking at times (managements performance is another topic altogether). That is in lieu of attempting to increase hiring standards, training standards, or just plain old better "pilot stuff".

That is some ramble-on-when-I-was-a-kid-I-walked-to-school-uphill-both-ways-in-the-snow-stuff, oh well- YMMV

"My mind is aglow with whirling, trasncient nodes of thought, careening through a cosmic vapor of invention"

"Ditto"

Well stated and matches my observations and experiences.
 
When people say judgement, I typically think of aeronautical decision making. ADM didn't cause this, it was loss of SA.

So please try to be accurate when you're being snarky.

If fatigue was indeed the cause, as many on here would aver, then this accident was CAUSED by bad ADM on the part of the crew.

Take your pick (or combination thereof):

Competence - crew
Situational awareness - crew
Decision making - crew
 
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I think the NTSB's conclusions are pretty accurate. They don't mention the flaps, because that is a red herring.

3.2 Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s
failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
 
Well it says Aerodynamical stall!! I'm sure that includes the Capt stall technic that he use and the fo flap selection.... but fatigue oh noooo nooooo they where properly rested I guess!!! :/ Freaking FAA doesn't want to deal with that can of worms.
 
Well it says Aerodynamical stall!! I'm sure that includes the Capt stall technic that he use and the fo flap selection.... but fatigue oh noooo nooooo they where properly rested I guess!!! :/ Freaking FAA doesn't want to deal with that can of worms.

Guess what, we still have crewmembers doing transcontinental commutes to rest a few hours in a hotel/crashpad/crewroom and then do a 12 hr duty day. Anything to spend a few more hours at home.
 
Guess what, we still have crewmembers doing transcontinental commutes to rest a few hours in a hotel/crashpad/crewroom and then do a 12 hr duty day. Anything to spend a few more hours at home.

Oh I believe you!!! I'm a commuter my self...
 
Some guys can handle commuting transcon and do a cracking good job. Others? Yawning all damn day, nodding off, and doing the bare minimum and not giving a darn. It all depends on the person, but I find flying with commuters is not all that great, especially when they feel the need to inform you on leg 1 that they're gonna make the 7:30pm come heck or high water.
 
Well it says Aerodynamical stall!! I'm sure that includes the Capt stall technic that he use and the fo flap selection.... but fatigue oh noooo nooooo they where properly rested I guess!!! :/ Freaking FAA doesn't want to deal with that can of worms.


Since I suffered through your horrid grammer, I felt I had to respond. If memory serves me correctly, the FO commuted in right before the trip. If that's the case, what could improved FAA rest requirements have done to prevent her fatigue?

I'm not saying that FAA rest rules are adequate...in fact, they are LONG overdue for revision. But it would seem that you are upset that the FAA isn't doing something about commuting, which is something NO ONE wants.
 
Hahaha!!!! Good one....

Yes, that was. :-) I misspelled one word whereas your entire post was written by Hooked on Phonics. Anyhow, my question remains unanswered: with respect to your challenge, what could the FAA have done about fatigue on the Colgan flight?
 
Sorry can't let the Captain off the hook on this one.

Posters here are focusing on the day of the flight as the NTSB did, however, I believe think the error chain goes back way farther than that.

This was clearly a pilot who struggles...just good enough to scrape along, but we need to ask should we have pilots like this. Should Colgan have ever hired this pilot? Shouldn't Colgan's training program have caught the weakness. We are too much about checking boxes and giving partial credit. I do not believe I have ever heard of a training record of an active line pilot as bad as this one. It seems he had trouble passing not only every checkride but even recurrent events which are comparatively easy. A bad day once in awhile with 1/2 a dozen busts over a 30 year career, I'll take it! Trouble in EVERY SINGLE EVENT! COME ON! Training departments have become much too accomodating.

As far as what happened at the marker, instructing in Cessna 152's (Stalls are EVENTS in 152s compared to the "was that a stall" stall in Cherokees) I saw MANY students do EXACTLY what this Captain did at the marker and that is FREEZE. He saw the attitud indicator pitch down and he hugged the yoke in his chest all the way to the ground, the whole time disbelieving the fact that the nose wasn't coming up. It sometimes took a sharp jab to the ribs with the elbow to get students to let go of the controls.

In order to recover from a stall you must have the mental ability to turn off the animal-rote response...think back to your ground school about aerodynamics, and then execute a proper stall recovery. Some people have trouble with this...not everybody should be a Captain of an airliner. Tail-plane stall recovery? NOT A CHANCE...that requires taking TWO steps back and this crew hadn't even taken the first.

As far as the FO - I have to give her props for-if nothing else-she was still fighting in the end. I'm guessing PNF duties at Colgan, like all airlines, tend to get the PNF heads down right about the marker, checklist, fix the box, set tower frequency, what was ground frequency, missed approach altitude was...flaps 15? you got it...Then all hell breaks loose, you get the shaker...Captain fighting the controls....put the flaps back up...no, that didn't work, gear, "should the gear be up?" she was clearly still functioning...looking for the answer. The hope for this flight was with the FO, maybe if she had a little bit more time instructing and/or not been so tired...
 
Sorry can't let the Captain off the hook on this one.

Posters here are focusing on the day of the flight as the NTSB did, however, I believe think the error chain goes back way farther than that.

This was clearly a pilot who struggles...just good enough to scrape along, but we need to ask should we have pilots like this. Should Colgan have ever hired this pilot? Shouldn't Colgan's training program have caught the weakness. We are too much about checking boxes and giving partial credit. I do not believe I have ever heard of a training record of an active line pilot as bad as this one. It seems he had trouble passing not only every checkride but even recurrent events which are comparatively easy. A bad day once in awhile with 1/2 a dozen busts over a 30 year career, I'll take it! Trouble in EVERY SINGLE EVENT! COME ON! Training departments have become much too accomodating.

As far as what happened at the marker, instructing in Cessna 152's (Stalls are EVENTS in 152s compared to the "was that a stall" stall in Cherokees) I saw MANY students do EXACTLY what this Captain did at the marker and that is FREEZE. He saw the attitud indicator pitch down and he hugged the yoke in his chest all the way to the ground, the whole time disbelieving the fact that the nose wasn't coming up. It sometimes took a sharp jab to the ribs with the elbow to get students to let go of the controls.

In order to recover from a stall you must have the mental ability to turn off the animal-rote response...think back to your ground school about aerodynamics, and then execute a proper stall recovery. Some people have trouble with this...not everybody should be a Captain of an airliner. Tail-plane stall recovery? NOT A CHANCE...that requires taking TWO steps back and this crew hadn't even taken the first.

As far as the FO - I have to give her props for-if nothing else-she was still fighting in the end. I'm guessing PNF duties at Colgan, like all airlines, tend to get the PNF heads down right about the marker, checklist, fix the box, set tower frequency, what was ground frequency, missed approach altitude was...flaps 15? you got it...Then all hell breaks loose, you get the shaker...Captain fighting the controls....put the flaps back up...no, that didn't work, gear, "should the gear be up?" she was clearly still functioning...looking for the answer. The hope for this flight was with the FO, maybe if she had a little bit more time instructing and/or not been so tired...

Hey, what the he!! About Cherokee's!!!!!????? You better watch it buddy!!!!:p
 
Here's the problem, Igy. They had been trained in recurrent about the hazards of tail plane icing. You ever experience it? I have.

It happened one day to me in a Convair 580 going into NGU. Blue sky day. However the mighty Queen of the Victor Airways had one fault. Her tail was directly in line with the exhaust out of the engines. As a result,we accreted a bunch of ice on the horizontal stab.

You select landing flaps and the nose pitches violently down. You have to slap the flaps back to 15 degrees, go to radar power and pull for all you're worth to get the beast to climb.

In the Colgan crash, that's almost exactly what the crew THOUGHT THEY HAD. They got slow and the stick pusher activated. Nose pitch over close to the ground and what is your first reaction, especially if tail plane icing is an emphasis item in recurrent?

Max power,flaps 15, pull the nose up. Unfortunately, they didn't have tail plane icing, stalled the airplane and spun in. What did the f/o do immediately? Slapped the flaps to 15. That tells me she thought they had tail plane icing. What did the CA do? Max power and redeefed the nose up. That tells me HE thought he had tail plane icing.

Oh, and btw, it takes about 800 to 900 feet to recover from tail plane icing (btdt) which is why we put a caveat in the Convair 580 NATOPS to be fully configured by 1500 ft agl. When it happened to me we were at 1100 feet and recovered about 250 to 300 feet. The houses look REALLY big at that altitude.

Now, I'm not defending the crew. They screwed up. However, given the traing they received, you can see how they could have misdiagnosed the problem they were facing. Think about our "emphasis" items. How many times do YOU see CAs or FOs going uncomfortably below the glide slope due to OUR emphasis items.

It's just food for thought. Go to the FAA website and search tail plane icing and watch their Twin Otter video. This is the video they showed to Colgan guys in recurrent. Perhaps we should cut the crew some slack...
 
There's no way this guy was skilled enough to identify and react to tail plane icing. He couldn't even monitor his airspeed.
 
In the Colgan crash, that's almost exactly what the crew THOUGHT THEY HAD.

There is no evidence to suggest that. This specific possibility was addressed in the NTSB report.

This crew was startled, had no idea what was happening, and reacted poorly to a stalled aircraft relatively close to the ground.
 
There's no way this guy was skilled enough to identify and react to tail plane icing. He couldn't even monitor his airspeed.

You're exactly right. Heck, those two pilots could barely make enough room in their conversation to run the checklists, let-alone have ANY sense of SA....
 
In the Colgan crash, that's almost exactly what the crew THOUGHT THEY HAD. They got slow and the stick pusher activated.

Have you actually seen the NTSB animation? It is nothing remotely close to the situation you described. The stick shaker activated first (obviously) and his immediate reaction was to pull. Then they got the pusher, and he kept pulling.

The nose didn't just pitch over violently by itself until the very end when it actually more like spiraled into the ground.

How it is that you are concluding that they thought it was a tail-plane stall out of this scenario is beyond me. Watch the NTSB animation:

http://www.youtube.com/watch?v=vMy8kZ2_TMs
 
In the Colgan crash, that's almost exactly what the crew THOUGHT THEY HAD. They got slow and the stick pusher activated. Nose pitch over close to the ground and what is your first reaction, especially if tail plane icing is an emphasis item in recurrent?

I just don't follow your reasoning...they got slow...the natural reaction is to pitch down and add power. That is level one. Any profesional pilot, looking at their airspeed indicator, realizing they needed a lot of airspeed right now would have dumped the nose and added power without even thinking about it. This Captain did not misdiagnose the problem...this Captain shut down...he did not make ANY diagnoses, he had NO IDEA what the condition of his aircraft was in. He did not know his aircraft was stalled, he did not think his tail was stalled, he was along for the ride.

I will go out on a limb...I don't know if this has been tested, but I bet if the Captain had merely LET GO of the controls at the pusher the airplane would not have stalled.
 
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He did know enough to push the power fwd. Was it "radar power?' Doesn't look like it.

Every tail icing possibility is usually described occurring when "landing" flaps are selected, i.e. beyond approach flaps. In the demos I've seen it occurs in aircraft selecting flaps beyond 15 or 20º at the approximate moment that the flaps are selected. Recovery is to "undo what you just did." In either case, airspeed is your friend. Increase it, it gets friendlier.

If the captain had lowered the nose, or allowed the wing to unload, to the horizon, it most likely would have recovered if he not yanked it back up. By the time the FO retracted the flaps the aircraft was unrecoverable. She was thinking, sort of. She was not assisting. Neither pilot was communicating. If one would have said "stall" then it might have put them both on the same page.

Then again, if at least one of them was watching the airspeed, then this discussion would be moot.
 
Even suggesting the left seat was concerned about possible tail ice is laughable. This guys history speaks volumes to gross incompetence. The F/O was along for the ride. Alot of innocent people died because someone who should have never been given the privilege to act as PIC slipped through the proverbial cracks.

You guys are beating the hell out of this one.
 

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