Inconceivable
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- Jan 1, 2005
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Memo from MEC Chairman Wake Gordon
Re: Pinnacle flight 3701 accident
Date: June 13, 2005
The NTSB is holding a public hearing beginning today, June 13, regarding this
accident. They have listed as issues: 1 ¡V Aircraft and Engine Certification,
and 2 ¡V Operator and FAA Oversight of Flight Operations and Crew Training.
A Public Hearing is a quasi-legal NTSB proceeding which is intended to gather
additional factual information regarding the accident. This hearing takes place
at NTSB headquarters in Washington DC, and is expected to last three or possibly
four days. As its name implies, it takes place in the public eye, and can be
attended by the public, but the public cannot participate in the hearing itself.
However, ALPA, along with the other interested parties to the investigation
(FAA, Pinnacle Airlines, Bombardier and General Electric) will be key
participants in this hearing. In addition, the news media will certainly be
present and reporting on this event. Streaming video and audio of the hearing
is available on the NTSB website (www.ntsb.gov).
In the NTSB¡¦s own words ¡§The hearing is being held for the purpose of
supplementing the facts, conditions, and circumstances discovered during the
on-scene and continuing investigation. This process will assist the Safety Board
in determining the probable cause of the accident and in making any
recommendations to prevent similar accidents in the future. No determination of
cause [ALPA emphasis] will be rendered during these proceedings.¡¨ In addition,
the Public Hearing marks the point in the investigation process when the
existing body of factual information (known as the ¡¥docket¡¦) becomes
available to the general public.
I will caution you right now that you will become aware of certain facts which
will not reflect well on the accident pilots, on you and your fellow pilots, or
on the Company itself. Your first reaction may very well be to jump to the
defense of any or all of these entities. You may be frustrated by ALPA¡¦s
apparent lack of activity in this regard as well. However, like all NTSB
investigations, this investigation is a process with rules and certain
pre-defined steps, and I can assure you that ALPA is doing its best to ensure
that this is a thorough and balanced investigation. In a few months, ALPA will
be able to publicly discuss the issues and causes of this accident, but in
accordance with NTSB rules, that is not the case just yet.
Obviously, both the Pinnacle MEC and ALPA have a lot at stake in this public
hearing and it is therefore imperative that we maintain our integrity and
professionalism during this difficult period, and that we all abide by the
applicable rules and guidelines. Yes it may be quite frustrating, but in the end
we will all benefit by controlling ourselves a short while longer.
It is also important to present a unified appearance in support of our accident
investigation team, led by Captain Aaron Rose, MEC Central Air Safety Chairman.
The team has been meeting with the various investigative groups since the
accident occurred, while also flying. These members have shown great dedication
to determining and understanding the issues related to the accident.
It is essential that we support our team. Thank you Aaron, from the MEC
The following has been written by the Pinnacle Air Line Pilots Association¡¦s
Air Safety committee to inform the general pilot group about Pinnacle Flight
3701. The information contained in this document has been taken from the NTSB
public docket and consolidated from almost 1,200 pages of reports and interview
transcripts. The information contained herein is factual and contains no
analysis. Determination of probable cause and contributing factors into this
accident will be made by the NTSB at a later date. Our team will prepare a
formal submission to the NTSB that draws conclusions and makes recommendations
to improve safety in the airline and industry, based on what was found during
this investigation.
On October 14, 2004 Pinnacle flight 5668, aircraft N8396A, was scheduled to
operate from Little Rock, Arkansas to Minneapolis, Minnesota as a normal
passenger flight. During the takeoff roll the crew received a R 14th Bleed
overheat message. A low speed abort was conducted and the crew returned to the
gate after consulting with SOC. The passengers were rebooked on other flights
and contract maintenance was called. After a period of time contract
maintenance could not determine the cause of the problem so a Pinnacle
maintenance crew from Memphis drove to Little Rock. Over the course of the
afternoon the R 14th Bleed overheat sensing loop was found to have some chaffing
damage where it passed through a rib in the pylon. The loop was replaced in
accordance with the aircraft maintenance manual and the engine was run for
thirty minutes. Before the aircraft could be returned to service the original
crew deadheaded to their domicile due to duty time constraints.
Captain Jesse Rhodes was hired by Pinnacle Airlines on 2/24/03 as a first
officer. At the time of the accident he had 6900 hours total time, 5055 hours
as pilot in command, 150 hours as pilot in command CRJ and 823 hours second in
command CRJ. He held a first class medical certificate and an Airline Transport
Pilot certificate with type ratings in the CL-65 and BE-1900. His last PC was
conducted on 8/10/04 and was 31 years old.
FAA records show Jesse Rhodes received a notice of disapproval at several points
during his flight training, during his BA-4100 first officer initial and during
his ATP / BE-1900 type rating. All certificates were completed after additional
training. One additional sim session was required during CRJ upgrade training
due to checklist difficulties. There is no history of driver¡¦s license
suspension or revocation or FAA certificate action. Pilots and instructors
interviewed after the accident had favorable comments about his flying abilities
and he had received a letter of commendation for his handling of an emergency at
Gulfstream Airlines. He had not worked or engaged in unusual activity in the 72
hours prior to the accident and the accident flight was his first duty
assignment of the day.
First Officer Peter Richard Cesarz was hired by Pinnacle Airlines on 4/26/04 as
a first officer. At the time of the accident he had 761 hours total time with
222 as SIC in the CRJ. He held a first class medical certificate. His last PC
was conducted 6/27/04.
FAA records show Peter Cesarz received a notice of disapproval during his multi
commercial check ride and passed the next day. There is no history of driver¡¦s
license suspension or revocation or FAA certificate action. Pilots and
instructors interviewed after the accident had favorable comments about his
flying abilities and he had received several favorable letters of recommendation
from former instructors. He had flown a trip on October 11th and 12th, sat home
reserve on October 13th and the accident flight was his first duty assignment of
the day on October 14th.
Tissue specimens from the captain and first officer tested negative for ethanol
and a wide range of drugs, including major drugs of abuse.
Captain Jesse Rhodes and First Officer Peter Cesarz were deadheaded from Detroit
to Little Rock in order to reposition aircraft 8396 to Minneapolis. They
arrived in LIT at approximately 2000L. They blocked out of Little Rock at 2054L
as Flagship 3701. The flight was operated as a FAR 91 flight and dispatch had
issued release paperwork in the same manner done for FAR 121 flights.
The flight route for them was as follows:
FLG3701 CRJ2/F 0434 LIT P0200 330
LIT..COU..ALO.KASPR2.MSP/0145
Airplane Information: Weight and Balance
Operating Empty Weight (OEW) 31,436
Passenger Weight 0
Baggage/Cargo Weight (Manifest) 0
Fuel Weight 8,100
Taxi Fuel Burn 200
Actual Takeoff Weight 39,336
Estimated Fuel Burn to Accident Site 2,200
Takeoff Center of Gravity (CG) 21.6% MAC
Takeoff CG Limits 9.0 ¡V 35.0
Takeoff Stab Trim 6.0
Examination of the FDR data showed portions of the ascent where sharp pitch up
maneuvers occurred. Pitch- up maneuvers were identified at three separate times
between liftoff and the final level off altitude at 41,000 feet. The initial
rotation occurs at 02:21:45, up to a pitch angle of about 6 degrees. Four
seconds later, a larger column deflection to 8 degrees raised the pitch of the
aircraft to 22 degrees, and generated close to 1.8 g¡¦s of vertical
acceleration. A single stick pusher discrete is recorded on the FDR, followed by
a large column deflection towards nose down (-7„a, where ¡V11„a is the limit)
and reduction of pitch angle.
At approximately 02:27:17, while level at 15,000 feet, the autopilot is
disconnected and a pull up is initiated with a column deflection. Over 2.3 g¡¦s
of vertical acceleration is generated as the airplane pitches up to 17 degrees
over the next several seconds. At 02:27:26, a nose down push is initiated,
requiring a calculated 20-pound force in the nose down direction. During this
push, the vertical acceleration drops to close to 0.3 g¡¦s. This is followed by
another pull of about 26 pounds. Approximately 70 seconds later, a rudder
doublet is performed, consisting of a large rudder input to the left, then to
the right. This generates close to 0.16 g¡¦s of lateral acceleration on the
first deflection left, than 0.34 g¡¦s lateral acceleration to the right, than
0.18 g¡¦s back to the left. After these maneuvers, the autopilot is reconnected
at 02:29:27 as the airplane ascends through 22,300 feet.
Re: Pinnacle flight 3701 accident
Date: June 13, 2005
The NTSB is holding a public hearing beginning today, June 13, regarding this
accident. They have listed as issues: 1 ¡V Aircraft and Engine Certification,
and 2 ¡V Operator and FAA Oversight of Flight Operations and Crew Training.
A Public Hearing is a quasi-legal NTSB proceeding which is intended to gather
additional factual information regarding the accident. This hearing takes place
at NTSB headquarters in Washington DC, and is expected to last three or possibly
four days. As its name implies, it takes place in the public eye, and can be
attended by the public, but the public cannot participate in the hearing itself.
However, ALPA, along with the other interested parties to the investigation
(FAA, Pinnacle Airlines, Bombardier and General Electric) will be key
participants in this hearing. In addition, the news media will certainly be
present and reporting on this event. Streaming video and audio of the hearing
is available on the NTSB website (www.ntsb.gov).
In the NTSB¡¦s own words ¡§The hearing is being held for the purpose of
supplementing the facts, conditions, and circumstances discovered during the
on-scene and continuing investigation. This process will assist the Safety Board
in determining the probable cause of the accident and in making any
recommendations to prevent similar accidents in the future. No determination of
cause [ALPA emphasis] will be rendered during these proceedings.¡¨ In addition,
the Public Hearing marks the point in the investigation process when the
existing body of factual information (known as the ¡¥docket¡¦) becomes
available to the general public.
I will caution you right now that you will become aware of certain facts which
will not reflect well on the accident pilots, on you and your fellow pilots, or
on the Company itself. Your first reaction may very well be to jump to the
defense of any or all of these entities. You may be frustrated by ALPA¡¦s
apparent lack of activity in this regard as well. However, like all NTSB
investigations, this investigation is a process with rules and certain
pre-defined steps, and I can assure you that ALPA is doing its best to ensure
that this is a thorough and balanced investigation. In a few months, ALPA will
be able to publicly discuss the issues and causes of this accident, but in
accordance with NTSB rules, that is not the case just yet.
Obviously, both the Pinnacle MEC and ALPA have a lot at stake in this public
hearing and it is therefore imperative that we maintain our integrity and
professionalism during this difficult period, and that we all abide by the
applicable rules and guidelines. Yes it may be quite frustrating, but in the end
we will all benefit by controlling ourselves a short while longer.
It is also important to present a unified appearance in support of our accident
investigation team, led by Captain Aaron Rose, MEC Central Air Safety Chairman.
The team has been meeting with the various investigative groups since the
accident occurred, while also flying. These members have shown great dedication
to determining and understanding the issues related to the accident.
It is essential that we support our team. Thank you Aaron, from the MEC
The following has been written by the Pinnacle Air Line Pilots Association¡¦s
Air Safety committee to inform the general pilot group about Pinnacle Flight
3701. The information contained in this document has been taken from the NTSB
public docket and consolidated from almost 1,200 pages of reports and interview
transcripts. The information contained herein is factual and contains no
analysis. Determination of probable cause and contributing factors into this
accident will be made by the NTSB at a later date. Our team will prepare a
formal submission to the NTSB that draws conclusions and makes recommendations
to improve safety in the airline and industry, based on what was found during
this investigation.
On October 14, 2004 Pinnacle flight 5668, aircraft N8396A, was scheduled to
operate from Little Rock, Arkansas to Minneapolis, Minnesota as a normal
passenger flight. During the takeoff roll the crew received a R 14th Bleed
overheat message. A low speed abort was conducted and the crew returned to the
gate after consulting with SOC. The passengers were rebooked on other flights
and contract maintenance was called. After a period of time contract
maintenance could not determine the cause of the problem so a Pinnacle
maintenance crew from Memphis drove to Little Rock. Over the course of the
afternoon the R 14th Bleed overheat sensing loop was found to have some chaffing
damage where it passed through a rib in the pylon. The loop was replaced in
accordance with the aircraft maintenance manual and the engine was run for
thirty minutes. Before the aircraft could be returned to service the original
crew deadheaded to their domicile due to duty time constraints.
Captain Jesse Rhodes was hired by Pinnacle Airlines on 2/24/03 as a first
officer. At the time of the accident he had 6900 hours total time, 5055 hours
as pilot in command, 150 hours as pilot in command CRJ and 823 hours second in
command CRJ. He held a first class medical certificate and an Airline Transport
Pilot certificate with type ratings in the CL-65 and BE-1900. His last PC was
conducted on 8/10/04 and was 31 years old.
FAA records show Jesse Rhodes received a notice of disapproval at several points
during his flight training, during his BA-4100 first officer initial and during
his ATP / BE-1900 type rating. All certificates were completed after additional
training. One additional sim session was required during CRJ upgrade training
due to checklist difficulties. There is no history of driver¡¦s license
suspension or revocation or FAA certificate action. Pilots and instructors
interviewed after the accident had favorable comments about his flying abilities
and he had received a letter of commendation for his handling of an emergency at
Gulfstream Airlines. He had not worked or engaged in unusual activity in the 72
hours prior to the accident and the accident flight was his first duty
assignment of the day.
First Officer Peter Richard Cesarz was hired by Pinnacle Airlines on 4/26/04 as
a first officer. At the time of the accident he had 761 hours total time with
222 as SIC in the CRJ. He held a first class medical certificate. His last PC
was conducted 6/27/04.
FAA records show Peter Cesarz received a notice of disapproval during his multi
commercial check ride and passed the next day. There is no history of driver¡¦s
license suspension or revocation or FAA certificate action. Pilots and
instructors interviewed after the accident had favorable comments about his
flying abilities and he had received several favorable letters of recommendation
from former instructors. He had flown a trip on October 11th and 12th, sat home
reserve on October 13th and the accident flight was his first duty assignment of
the day on October 14th.
Tissue specimens from the captain and first officer tested negative for ethanol
and a wide range of drugs, including major drugs of abuse.
Captain Jesse Rhodes and First Officer Peter Cesarz were deadheaded from Detroit
to Little Rock in order to reposition aircraft 8396 to Minneapolis. They
arrived in LIT at approximately 2000L. They blocked out of Little Rock at 2054L
as Flagship 3701. The flight was operated as a FAR 91 flight and dispatch had
issued release paperwork in the same manner done for FAR 121 flights.
The flight route for them was as follows:
FLG3701 CRJ2/F 0434 LIT P0200 330
LIT..COU..ALO.KASPR2.MSP/0145
Airplane Information: Weight and Balance
Operating Empty Weight (OEW) 31,436
Passenger Weight 0
Baggage/Cargo Weight (Manifest) 0
Fuel Weight 8,100
Taxi Fuel Burn 200
Actual Takeoff Weight 39,336
Estimated Fuel Burn to Accident Site 2,200
Takeoff Center of Gravity (CG) 21.6% MAC
Takeoff CG Limits 9.0 ¡V 35.0
Takeoff Stab Trim 6.0
Examination of the FDR data showed portions of the ascent where sharp pitch up
maneuvers occurred. Pitch- up maneuvers were identified at three separate times
between liftoff and the final level off altitude at 41,000 feet. The initial
rotation occurs at 02:21:45, up to a pitch angle of about 6 degrees. Four
seconds later, a larger column deflection to 8 degrees raised the pitch of the
aircraft to 22 degrees, and generated close to 1.8 g¡¦s of vertical
acceleration. A single stick pusher discrete is recorded on the FDR, followed by
a large column deflection towards nose down (-7„a, where ¡V11„a is the limit)
and reduction of pitch angle.
At approximately 02:27:17, while level at 15,000 feet, the autopilot is
disconnected and a pull up is initiated with a column deflection. Over 2.3 g¡¦s
of vertical acceleration is generated as the airplane pitches up to 17 degrees
over the next several seconds. At 02:27:26, a nose down push is initiated,
requiring a calculated 20-pound force in the nose down direction. During this
push, the vertical acceleration drops to close to 0.3 g¡¦s. This is followed by
another pull of about 26 pounds. Approximately 70 seconds later, a rudder
doublet is performed, consisting of a large rudder input to the left, then to
the right. This generates close to 0.16 g¡¦s of lateral acceleration on the
first deflection left, than 0.34 g¡¦s lateral acceleration to the right, than
0.18 g¡¦s back to the left. After these maneuvers, the autopilot is reconnected
at 02:29:27 as the airplane ascends through 22,300 feet.