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Holly Hegemon's Blog on ILS 23 @ BUF, Safety & Colgan Crash

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This is a copy of an interesting blog post by Holly Hegemon, made more interesting by SWA's memo which now is in the public domain.

(My guess is that her guess is wrong about the NTSB. The New York Times and WSJ are very plugged in to NYC Plaintiff law firms who call the papers hoping for free publicity that results in potential plaintiffs contacting their firms. Under the 1996 Family Assistance Act, the attorneys can't solicit clients for 30 days following the crash. They have a hard time sitting on their hands when there is millions of dollars to be had. The attorneys try everything to circumvent the intent of the law.)

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-- let's talk about what has been going on of late concerning the NTSB and their investigation concerning the actions of the pilot in the crash of Pinnacle/Colgan/Continental Express Flight 3407 last week. If you are like me, you probably did a double take when you read the the Wall Street Journal article yesterday in which the paper reported that "evidence suggests pilot error" as the likely cause of the crash. The New York Times then ran with a story that said that the "crew may have overreacted" after the auto pilot system pointed the plane's nose down to generate speed. No sources were named in either paper's reports.
While officially the NTSB has not publicly made such comments, the assumption would have to be made that someone on the inside of the investigation was feeding both news sources.
Enter a number of our pilot readers.
Here is a "Read Before Fly" announcement that was sent to Southwest Airlines' pilots yesterday. Sound familiar?
Last night more than one pilot sent me a copy. And they weren't all Southwest pilots. Apparently the notice was posted on the PPRUNE site, or at least that is what one American Airlines' pilot wrote me.

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Safety Alert 2009-01 - February 18, 2009

There is a potentially significant hazard concerning the ILS to runway 23 in BUF.
Information has been received indicating it is possible to obtain a significant nose pitch up, in some cases as much as 30 degrees, if the glide slope is allowed to capture before established on centerline. Pilots who are preparing to configure and land have the potential to experience abrupt pitch up, slow airspeed, and approach to stall if conditions present themselves in a certain manner.
This effect is the result of an earthen obstruction close enough to the ILS to affect the integrity of the glide slope signal. This has resulted in the issuance of an advisory given on ATIS which states that "the ILS Glide Slope for runway 23 is unusable beyond 5 degrees right of course." When attempting to intercept the runway 23 ILS from right traffic, the ILS glide slope indication may read full deflection down. Just prior to intercept it may then move up in such as manner as to enable approach mode to capture in such a way as to result in a nose up pitch and loss of airspeed. Southwest Airlines has issued a notice reading: "Until further notice, when executing the KBUF ILS/LOC Runway 23, DO NOT select Approach Mode until established on the localizer inbound."

This issue is being addressed on several levels in an attempt to address procedures, facilities, and communication regarding this matter. If you experience any issues related to this, please file an ASAP form and or call SWAPA Safety at SWAPA toll free 800-969-7972.

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Interesting, eh? Especially because if this is the case, then the pilot could have been doing exactly what he was supposed to have been doing. He was trying to save the aircraft, not stall it. My point in all of this is that no one involved with the NTSB investigation should be "leaking" information to news sources such as that which was obviously leaked for publication in both the New York Times and the Wall Street Journal Wednesday. Especially given this advisory that was just issued to Southwest Airlines' pilots.
 
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Mike man

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I'm not sure anything was leaked...I'm sure it is all speculation by the "expert" aviation reporters at NYT and WSJ.
 

1st Rate

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Let the lawsuits fly. It's too bad that, as usual, there has to be blood before anything is changed or made aware.
 

Redtailer

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Way too much speculation going on. I get the feeling that the WSJ may actually have a source on the inside. Why publish it otherwise and open themselves up to being WAY wrong. Doesn't pass the sniff test.

As for Holly, her scenario doesn't hold water with the already public evidence. The aircraft started losing control either right at or after the gear was down and the flaps lowered.

Ok, how many folks out there flying a turboprop in IMC with icing conditions not doing a visual approach are trying to intercept the localizer with the glideslope captured, have your gear down and flaps more than half way down????? I mean really mentally fly that approach. I can't think of a single scenario that would require that configuration with an ILS at that point in time. It's either extremely unstable to begin with in which case a 360 turn is needed or you are doing something you are not supposed to be.

Holly is way off on this one.
 

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Redtailer:

I don't know. There are plenty of pilots who push APP the minute they are cleared, despite being well outside the FAF. There are numerous airports where the practice will take you below step down fixes and yet pilots do it all the time.

If there is something about this G/S that makes it unusual enough for Southwest to issue a memo on it, then it is well worth my time to consider.
 
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CitationLover

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speculation is bad. i remember everyone thinking they new what the cause of the AA DC-10 crash at ORD was, the ntsb jumped the gun on this too. turns out a forklift and company cheapskating procedures were the problem.
 

CE750Driver

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Redtailer:

I don't know. There are plenty of pilots who push APP the minute they are cleared, despite being well outside the FAF. There are numerous airports where the practice will take you below step down fixes and yet pilots do it all the time.

If there is something about this G/S that makes it unusual enough for Southwest to issue a memo on it, then it is well worth my time to consider.

Shouldn't be on autopilot, in icing, in a turboprop anyhow. Correct?
 

turn&pull

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The 737--unlike the EMB145 if I remember correctly--will capture a glide-slope and start descending even if it doesn't have a LOC capture.

I think this memo came from Southwest Pilot experiences--relayed up the chain after the accident-- of coming in to Rwy 23 from the North and having the GS capture a false glideslope which obviously then proved erratic.

If I'm not mistaken, the approach plate for 23 even mentions something about glide-slope not reliable 5deg off Loc.

Actually it all seems pretty elementary to me...you don't follow a glideslope signal until you are on the LOC...isn't this Instrument Flying 101?
 

IslandDriver

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The sad thing is CJC was vectored from the south and the accident had nothing to do with all of that. Not Ice...not the ILS......much less complex than all of that...not Instrument 101...flying 101.

I hate to say it...but it is sad........
 

rjacobs

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The sad thing is CJC was vectored from the south and the accident had nothing to do with all of that. Not Ice...not the ILS......much less complex than all of that...not Instrument 101...flying 101.

I hate to say it...but it is sad........

What position do you hold on the AIB to have come up with the cause to the crash?
 

starchkr

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Interesting to hear that any autopilot will capture a G/S "before" it captures a LOC. The Bus will not.

"I don't know. There are plenty of pilots who push APP the minute they are cleared, despite being well outside the FAF. There are numerous airports where the practice will take you below step down fixes and yet pilots do it all the time."

I often push the APP button when a clearance is given, but again, the Bus will not intercept the G/S without the LOC being captured. However it will continue a descent if it is out of managed mode if V/S is selected or Open Descent is selected and the FAF altitude is set no matter how far out you are from the fix.
 
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ReverseSensing

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Interesting to hear that any autopilot will capture a G/S "before" it captures a LOC. The Bus will not.

Neither will the Q400.

And the only Q400 autopilot limitation regarding icing is that it is prohibited in severe icing. The NTSB jumped the gun on trying to imply that there was anything wrong with operating the Q400 in less than severe icing conditions with the autopilot engaged.
 

IslandDriver

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RJACOBS,

I wish I was wrong but trust me...it will come out to be individual pilot error. I am sorry that is all I can say.

Enough Said.....you are right...let the NTSB figure it out.

ID
 

rjacobs

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RJACOBS,

I wish I was wrong but trust me...it will come out to be individual pilot error. I am sorry that is all I can say.

Enough Said.....you are right...let the NTSB figure it out.

ID


If you are actually on one of the various AIB's or are party to the investigation(you are implying you are) you are completely in the wrong even being on here and making statements like this. That is the first rule of being on an AIB or being party to an investigation is to keep your damn trap shut in public, even if you know you figured it out because of a smoking gun. You are just as bad as the media "speculating" you know what happened.
 

IslandDriver

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If you are actually on one of the various AIB's or are party to the investigation(you are implying you are) you are completely in the wrong even being on here and making statements like this. That is the first rule of being on an AIB or being party to an investigation is to keep your damn trap shut in public, even if you know you figured it out because of a smoking gun. You are just as bad as the media "speculating" you know what happened.


I am not on the investigation board. I just do not want CJC to get the blame for this. It is all a tragedy and it will hurt a lot more people that just the people who crashed. It seems like pilot error and pulling down other people for an individaul(s) error is not a good thing. We will never "really" know what happened...we should all look at it, study it, and make sure it never happens in our cockpits.

I was close to many of the people that are involved in the clean up...it will need clean up for a long time. We can all go back and see how it could have been avoided...but that will do no good. We all must learn from it and move on.

You are right...no speculation is good...but that is what we all do here in FI...it is also why I hardly ever write on this...and I will not ever do it again...
 

flyburg

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The 737--unlike the EMB145 if I remember correctly--will capture a glide-slope and start descending even if it doesn't have a LOC capture.

Hi T&P,

The A/P on the 73 will most definitely not capture the GS before loc capture( it will, unlike some other types intercept a GS from above though after LOC capture).

However, depending on intercept angle and closure rate the A/P will go in capture mode quiet early. I believe it's even possible before the loc is alive on the instruments( not sure of that though, we usually have map mode displayed). Indeed, sometimes there will be a NOTAM warning of false glideslope or even false localizer capture beyond a certain localizer coverage. The best way to deal with that is to either use the VOR/LOC mode to capture the LOC and wait until the LOC pointer is centered before pressing APP, the other way ( in case of false loc readings as promulgated by notam) is to use the HDG bug to intercept the loc and then, when it is centered press the APP button.

I think this is what the SWA memo means.

Greetings
 
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