crw overrun transcript

[DrunkIrishman]

Which V1 speed was set, Flaps 8 or 20?

 

[Flyer1015]

Yikes. This crew is fried, and the CA sealed his fate with the admission of guilt on the CVR. Not to mention the numerous blatant violations of sterile cockpit. God have mercy on them. They are good people, I'm sure, but after the Colgan crash, everyone is going to come down hard on them. Starting with the FAA.

 

[Stifler's Mom]

Even if he didn't say a word on the CVR, downloading the diagnostics from the airplane would have discovered what happened.

I hope we can all at least learn something from this incident to prevent it from happening in the future.

 

[flygirlqt]

These guys are going to replay this in their minds at least once a day for the rest of their lives. Including the wanton running of their mouths which is going to crucify them both.

 

[svcta]

Even if he didn't say a word on the CVR, downloading the diagnostics from the airplane would have discovered what happened.

Be that as it may, the CA is clearly heard asking for guidance on what his story should be and what he should "admit" to. The thing that concerns me the most about this what happened after the fact. The CA essentially threw away all concern over anything but his own azz. There were things to be done even if neither knew what those things were in that particular case. The first thing Captain Courageous does is phone a friend and ask how to best save his own butt. Not to call the FA and tell her what's up, not to discuss an evac, nothing. The FO is apparently sitting there wondering what he should do and the CA left him to figure it out alone.

All this aside from the fantasy-island conversation about all the neato toys these two want when they grow up, chock full of "like" and even a nice dooooood, "I got so # up on Saturday". What kind of knuckle dragger just decides to throw that in to a conversation like it's some kind of worthwhile accomplishment? I'll bet he listens to a lot of Nickelback in his spare time.

I digress. . . This CAPTAIN had two crew members, tower controllers, and firemen that all needed him to be present and engaged. Not punting away his responsibilities on the cell phone.

 

[Beefy Botham]

deleted.

 

[atlcrjdriver]

From looking at the tech data this a/c reached just over 140kts when he aborted. Once the flaps reached 20 deg the NW actually popped off the grd. Simply put, panic set in once he heard the config warnings. Had he simply continued w/ flaps 8 or after the flaps reached 20 he would have been OK. The one thing that might save him is the immediate action item for T/O config wng is T/O discontinue immediatly. Thus he followed company procedure. Of course, the company NEVER intended for you to reconfig the a/c during T/O roll.

 

[booo]

From looking at the tech data this a/c reached just over 140kts when he aborted. Once the flaps reached 20 deg the NW actually popped off the grd. Simply put, panic set in once he heard the config warnings. Had he simply continued w/ flaps 8 or after the flaps reached 20 he would have been OK. .

The one thing that might save him is the immediate action item for T/O config wng is T/O discontinue immediatly. Thus he followed company procedure. Of course, the company NEVER intended for you to reconfig the a/c during T/O roll.

Nothing should "save" him, except my last point. Somewhere I saw that he was a Check Airman of some level and should have known better than others of the following:

1) He should have known better than to reconfigure on the takeoff roll. F/O calls 80 knots, 1 second later he responds "checked". 5 seconds later someone notices that the flaps are at 8 and not 20 degrees as briefed and selects flaps 20. The runway he was taking off on is up slope with with a hump, no view of the departure end and is relatively short, but barring an engine failure no obstacles to be concerned with, just relatively short, therefore flaps 20. Better than reconfig on the roll,a check airman should have known to just add 12 knots to V1/VR speeds bugged and rotated at that speed or if necessary, gently rotate at the fixed distance markers (last 1000 feet) and ride it out. Non event! In Charlie West if you clear the runway and the EMAS and the (amended) ALS system, you instantly have 400 feet more altitude due to the terrain.

2) As a pilot in the 200,and as a Check Airman, he should have known that he would would get a "config flaps" warning if the flaps were not at 8 or at 20. He made the decision to change configuration, and with 4500+ hours in type he should have known the consequences, "config flaps" while the flaps were in transit.

3) 8 seconds after the F/O calls "V1" we get "config spoilers". He has brought the power levers to flight idle, yet the fuel controllers lag (to protect the engines) have the the engine speed higher than 77.9% (?). The power lever position (flight idle/reverse) sends the spoilers up for the abort but the engines RPM are still above the threshold and give a spurious warning. He should have known not to abort above V1, and especially not on a short runway. 8 Seconds?

4) After the fact he has no idea what to do. The F/O talks him into shutting down the engines, no evac plan in state, he goes into CYA mode.

Has he not learned anything in nearly 10000 hours? Or was he brain dead? Fatigued? Yes the F word. They both had a light schedule for the week before, but they both had flown excessive hours in the previous year, and fatigue (CHRONICALLY TIRED) takes a lot longer to recover from than most think.

Bad decisions? YES. Why? Stupid or Fatigued? Your call!

 

[Rally]

I'm confused why did he get config spoilers?

 

[Abernathy]

Looking at the reports, here are some interesting timeline events:

- V1 was called at 16:13:21 and the "sound of engine RPM decreasing" was noted at 16:13:32? What was going on between V1 and 11 whole seconds later when he decided to finally slam the thrust levers back? 11 seconds is a long ass time during a takeoff roll. Sh** I've done entire takeoff rolls that last 11 seconds.

- 80 knots was called at 16:13:10, and 6 seconds later he fumbles with the flaps.

I feel bad for the FO. We're put in a tough position when we see Captains screwing up. Sometimes the bigger call is on the FO--when to intercede.

 

[CX880]

I feel bad for the FO. We're put in a tough position when we see Captains screwing up. Sometimes the bigger call is on the FO--when to intercede.

I think the FO would not have been saved either way. Bottom line, the take off roll should never have started since they didn't do the checklists properly. He could have said "abort abort, flaps not set" to CYA, but even then you never know.

 

[booo]

I'm confused why did he get config spoilers?

It's a glitch in the system. On takeoff, when certain parameters are met (WOW, airspeed, power lever position,...) the airplane thinks it's going to takeoff. Suddenly the throttles are slammed to flight idle and the position of the power levers sends an automatic message for the spoilers to deploy thinking that it's time too abort, dump the lift and maximize braking. Meanwhile, back at the ranch, the fuel controllers are scheduling the fuel (gently) to idle, but there is a "lag" in engine speed (it's jet engine, right?). While the the engines spool down from takeoff setting to below a certain % (77.9?), the computer is confused: The spoilers are up but we still have a lot of power! Oh,no! Send a "config spoilers" message! When the engine speed drops below the trigger RPM the message on the EICAS goes away since the conflict of engine speed/spoiler position is no longer there, leaving the crew with a WTF? moment. But the warning system doesn't have a "never mind, my bad" call out.

 

[beagle pilot]

I feel bad for the FO. We're put in a tough position when we see Captains screwing up. Sometimes the bigger call is on the FO--when to intercede.

True, but in this case it appears the FO not only had ample opportunity to catch and correct errors, but was also part of the problem.

If a Captain is breaking sterile cockpit talking about his car, boat, golf handicap, etc, the FO doesn't have to join in the discussion. He/she could just go "a-hummm" while doing the checklists, rechecking items and monitoring both inside and outside the cockpit. Anyone who has been married for more than five years knows exactly what I mean.

 

[booo]

Looking at the reports, here are some interesting timeline events:

- V1 was called at 16:13:21 and the "sound of engine RPM decreasing" was noted at 16:13:32? What was going on between V1 and 11 whole seconds later when he decided to finally slam the thrust levers back? 11 seconds is a long ass time during a takeoff roll. Sh** I've done entire takeoff rolls that last 11 seconds.

- 80 knots was called at 16:13:10, and 6 seconds later he fumbles with the flaps.

I feel bad for the FO. We're put in a tough position when we see Captains screwing up. Sometimes the bigger call is on the FO--when to intercede.

Not 11 seconds, just (just?) 8 seconds. The "config spoilers" warning was set off when the power levers hit flight idle. "sound of engine RPM decreasing" took three seconds due to the lag in jet engines response.

As for the F/O........he did set the flaps incorrectly. And he may (may!) have violated sterile cockpit. As the non flying pilot he's supposed to be "outside" the cockpit during takeoff. Then the Captain went "rogue" on him and moved the flap handle without telling the F/O. It was the Captains circus from there. The Captain aborts, again without communicating. The F/O was just along for the ride as far as aircraft control. He did have the presence of mind to advise the tower of the abort, so he was still in the game After the fact, the F/O performs admirably, and leads the Captain through the "here and now" issues as the Captain is involved in CYA mode.

 

[Abernathy]

You're right about the FO setting the flaps incorrectly (and, in that sense, being responsible for starting this whole process).

As far as sterile cockpit, the simple fact is that it IS there for a reason. Things get missed all the time when I'm sitting next to chatterbox in the left seat and he's busy telling me about why we need a Fair Tax system while I'm trying to run through a T/O brief in my head.

 

[OurMoney1]

The one thing that might save him is the immediate action item for T/O config wng is T/O discontinue immediatly. Thus he followed company procedure. Of course, the company NEVER intended for you to reconfig the a/c during T/O roll.

Nothing should "save" him, except my last point. Somewhere I saw that he was a Check Airman of some level and should have known better than others of the following:

1) He should have known better than to reconfigure on the takeoff roll. F/O calls 80 knots, 1 second later he responds "checked". 5 seconds later someone notices that the flaps are at 8 and not 20 degrees as briefed and selects flaps 20. The runway he was taking off on is up slope with with a hump, no view of the departure end and is relatively short, but barring an engine failure no obstacles to be concerned with, just relatively short, therefore flaps 20. Better than reconfig on the roll,a check airman should have known to just add 12 knots to V1/VR speeds bugged and rotated at that speed or if necessary, gently rotate at the fixed distance markers (last 1000 feet) and ride it out. Non event! In Charlie West if you clear the runway and the EMAS and the (amended) ALS system, you instantly have 400 feet more altitude due to the terrain.

2) As a pilot in the 200,and as a Check Airman, he should have known that he would would get a "config flaps" warning if the flaps were not at 8 or at 20. He made the decision to change configuration, and with 4500+ hours in type he should have known the consequences, "config flaps" while the flaps were in transit.

3) 8 seconds after the F/O calls "V1" we get "config spoilers". He has brought the power levers to flight idle, yet the fuel controllers lag (to protect the engines) have the the engine speed higher than 77.9% (?). The power lever position (flight idle/reverse) sends the spoilers up for the abort but the engines RPM are still above the threshold and give a spurious warning. He should have known not to abort above V1, and especially not on a short runway. 8 Seconds?

4) After the fact he has no idea what to do. The F/O talks him into shutting down the engines, no evac plan in state, he goes into CYA mode.

Has he not learned anything in nearly 10000 hours? Or was he brain dead? Fatigued? Yes the F word. They both had a light schedule for the week before, but they both had flown excessive hours in the previous year, and fatigue (CHRONICALLY TIRED) takes a lot longer to recover from than most think.

Bad decisions? YES. Why? Stupid or Fatigued? Your call!

Your a huge tool.

 

[svcta]

Your a huge tool.

So you're the one.

 

[Spoolingbyu]

flaps do matter. Disregard misconfig? WHAT? WTF.

Again you are using the mentality that it's safer to take it to the sky then to deal with it on the ground, that's what caused this accident. All he had to do was abort but instead he added flaps so they could get out of there and not miss the flow window. If you're on the takeoff roll and you notice that flaps aren't set, doesn't matter if they're 0 or 8, it's an automatic abort. However, if the CA had enough reflex to continue the roll and add flaps then he should have known to disregard flaps misconfig warning and continued. Again the take off phase is not a "set it and forget it" phase of flight, there are different segments which you need to pay attention to the airplane and the roll.

Actually you are disproving your point and proving my point. It IS safer to take to the sky. You know the whole V1, Vr, V2 thingy? V1 is decision speed. After which you have decided to take to the air. Welcome to transport-category aircraft. They went off the end, they didn't crash 10 miles after departing the airport into terrain. He decided to deal with it on the ground (after V1 I should also emphasize) and THAT is what caused the accident.

Here's another refresher at what big boys in transport category airplanes do:

0-80 Abort for any reason. He did not do this.

80-V1 Abort only for a very short list (depending on your company SOP). Instead of aborting, he chose to ***k with the flap handle. If he had initiated the abort in this range, I bet you it's a non-event and they taxi back for another try.

after V1 it is an in-flight emergency. He did initiate the reduction in thrust after V1. This is an abort after V1, and as you can see, the bad decision to stay on the ground sent them off the end.

You'll find that it is safer to take to the air after 80 for most reasons and obviously mandatory after V1.

I'd say a majority of the other professional pilots in this thread agree and are repeating the same thing I am saying.

It has been mentioned that T/O config warning is an AUTOMATIC abort at PSA. Flaps 0 or boards out? Unflyable. That's why those are automatic. Abort for those at ANY time up to V1.

But is flaps 8 set when 20 should be or 20 when 8 should be set an "automatic" item? I doubt it. This is a question for the PSAers. It doesn't make the airplane unflyable. Take to the air.

Booo makes a great point. Being a check airman, HE SHOULD HAVE KNOWN to just fly to flap 8 Vr and fly away. Add 12 knots or whatever it is and go. Any half-awake PSA FO with 100 hours in the CRJ knows that. It was too late to do anything but.

And CX880 don't scream "short runway 6300 feet blah blah blah" at me. At CRW I'd say on a committed takeoff (which they were by the time he decided to do anything about it) you have a better chance of survival by trimming the weeds off the end runway than flaps 8 accelerate-stop performance in < 6300 feet.

 

[buscap]

All good points, and one to add. That airplane's performance is designed to fly out of that short runway, on one engine.

Now granted, the improper flap configuration negates that planning, but anyone who has flown a hard winged RJ out of there; upon rotation your ability to climb far outweighs your ability to stop.

The nature of v1 must be completely understood in order to comprehend the dangers of trying to stop an aircraft at any speed near it, let alone past it.

If you are gonna have the nads to reinvent the higher than v1 wheel, you'd better have the nads to get that thing in the air.

 

[CX880]

Actually you are disproving your point and proving my point. It IS safer to take to the sky. You know the whole V1, Vr, V2 thingy? V1 is decision speed. After which you have decided to take to the air. Welcome to transport-category aircraft. They went off the end, they didn't crash 10 miles after departing the airport into terrain. He decided to deal with it on the ground (after V1 I should also emphasize) and THAT is what caused the accident.

.

Actually what caused the accident was not aborting rather deciding to continue when he saw that flaps were not set. What happened after V1 is another issue and I'm not saying at that point it's safer to abort than continue.

 

[Spoolingbyu]

Actually what caused the accident was not aborting rather deciding to continue when he saw that flaps were not set. What happened after V1 is another issue and I'm not saying at that point it's safer to abort than continue.

Aborting caused the accident. I don't know how we can all say this any other way.

Continuing would have been fine, but he changed his mind after V1 rolled past. People make mistakes. I will probably dutch oven my old lady tonight, it will be a bad use of CRM. But we are all human.

 

[ASA_Aviator]

Again you are using the mentality that it's safer to take it to the sky then to deal with it on the ground, that's what caused this accident. All he had to do was abort but instead he added flaps so they could get out of there and not miss the flow window. If you're on the takeoff roll and you notice that flaps aren't set, doesn't matter if they're 0 or 8, it's an automatic abort. However, if the CA had enough reflex to continue the roll and add flaps then he should have known to disregard flaps misconfig warning and continued. Again the take off phase is not a "set it and forget it" phase of flight, there are different segments which you need to pay attention to the airplane and the roll.

If you notice prior to 80 knots, I would agree, but after 80 knots with flaps 8, it is safer to continue (If flaps are over than 8 or 20, you will get a config warning well prior to 80 knots). An engine failure is much less likely than some boneheaded move in a >80 or >120 knot abort that gets you killed.

Aborting past V1 is just so counter to our training that it doesn't even merit comment.

The plane will fly with only 8 when it should have 20. In fact, I bet that it happens more than we know.

 

[ASA_Aviator]

Another case of the failed mentality to take to the air then deal with it up there. What they should have done which he obviously recognized after the accident was to abort instead of adding the flaps on the go. Just remember whenever it's getting too comfortable in the cockpit with the other guy/gal, stop for a second and refocus on what you're doing.

This attitude will get you killed someday. Prior to 80, anything. After 80, control issues, fire, and that's it. PRIOR TO V1 ONLY, of course.

 

[Mr Wu]

Jesus they don't even need to investigate this he decided to sit in the cockpit and just talk,

If the lawyer ALPA gets him is any good he will get everything after the CVR CB item on the checklist deemed as inadmissible. WV requires at least one party to a phone call to give their consent or be notified that a call is being recorded. The captain or the guy he called did neither as he had called for the checklist and had a reasonable expectation that it was completed.

 

[Paladin]

No, nothing has changed in 107 years. Fly the plane. When AA departed ORD and the engine departed the plane severing the hydraulics to the leading edge flaps, the F/O flew the "profile". They would have survived if they would have just lowered the nose and gained some speed. Sometimes you have to be creative. Sometimes the company procedures are wrong. See: Risky Business: "Sometimes you have to say 'What the F..."

Not to hijack this thread...but the F/O probably wouln't have flown the profile if there had been a stick shaker installed on the right side...just sayin.

 

[AvroJockey]

I must say...there are a ton of experts here. I think the NTSB should start their investigations with flightinfo.com from now on and stop waisting taxpayer dollars.

Anyways...
There are couple things I picked out from the CVR regarding how insidious threats and errors really are. We should all take this as a lesson learned, because this could have happened to any of us.

1. The call for Flap20 by the Captain was immediately followed with a call from ground. The FO selected the improper flap setting at the exact same moment.

2. I'm not sure what the exact SOPs are for PSA in the CRJ, but it seems the checklist calls are leading the Captain into thinking the flaps are at the proper setting. If the FO is saying the flap setting, the Captain is naturally inclined to interpret that as a confirmation of proper configuration...even if he has to repeat it, and especially after doing these checklists with the excessive repetition of a regional pilot. The dialog of the checklist should never lead with an indication of setting of a critical item.

I'm not saying the crew didn't make mistakes, but those who question professionalism need some reflection. The US is one of a few countries that takes a non-punative approach to it's investigations...I think it's a good system, as we're the leader in aviation safety. I've flown to several countries were they throw the Captain in prison and hide the key until they can prove their innocence. Let's take the former approach, rather than the latter.

 

[AvroJockey]

BTW...
For all we know the Captain could have had visions of Comair 5191 in his head as he was making quick decisions. Regardless the outcome of the investigations (NTSB, and flightinfo.com), this guy and all his passengers get to see another day.:beer:

 

[sniper]

PSA sets flaps after both engines have been started and usually on the taxi out.

PSA needs to re evaluate how their check airman are selected, stop bashing other pilots and look at the mirror.

Sorry but no excuse for such a f---up.

cheers go MU

 

[Long Time Gone]

2. I'm not sure what the exact SOPs are for PSA in the CRJ, but it seems the checklist calls are leading the Captain into thinking the flaps are at the proper setting. If the FO is saying the flap setting, the Captain is naturally inclined to interpret that as a confirmation of proper configuration...even if he has to repeat it, and especially after doing these checklists with the excessive repetition of a regional pilot. The dialog of the checklist should never lead with an indication of setting of a critical item.

However, look at 16 : 09 : 02 --

16 : 09 : 02
HOT-2 takeoff data forty four thousand pounds. flaps eight twenty seven twenty eight thirty four seventy three eighty seven point eight set.

The FO stated that the Flaps were at 8, even though the CA called for Flaps 20. The CA should have verified the Flap setting visually by the EICAS as well as the Flap Handle setting, regardless of what he previously called for.

Also, what exactly is the 5th speed he's referring to? Does PSA climb out at VT+15 instead of V2+15?

BTW, sorry for the way "16 : 09 : 02" is typed. If I wrote it normally, it would look like "16:09:02" and people would think I'm a happy person. I guess just because you put ":" and "0" together, people think you're a happy person.

 

[paulsalem]

HOT-2 takeoff data forty four thousand pounds. flaps eight twenty seven twenty eight thirty four seventy three eighty seven point eight set.

The FO stated that the Flaps were at 8, even though the CA called for Flaps 20. The CA should have verified the Flap setting visually by the EICAS as well as the Flap Handle setting, regardless of what he previously called for.

The procedure was for the FO to read off the data from the ACARS, and the Captain verifies the speeds on the PFD and the flap setting on the EICAS.

Also, what exactly is the 5th speed he's referring to? Does PSA climb out at VT+15 instead of V2+15?

"seven point eight" is the trim setting. Our procedure is to select speed mode after the gear is retracted, and climb out at that to 1,000 above field elevation.