Pinnacle NTSB Update

[Huck]

1. First off, I better have a dam good reason to climb to 410, and it has nothing to do with aero. It has to do with USEFUL CONSCIOUSNESS. My pop survived an explosive D in a 707 in the seventies, and his description of it scared the crap out of me.

2. I was taught a pretty good climb technique on the RJ by an ex-Pan Am guy: at 10,000, pick a pitch and hold it - I think it was usually 5 deg. Speed would go above profile, then gradually back down, and made for an exceptionally smooth ride. Helps the FA get up and down the aisle with the cart too.

3. In my next life as a freight dog I have spent more hours than I care to admit in the back of pax aircraft, deadheading. NO MATTER what aircraft, I can tell when it's in speed mode, and unless it's a heavy, it is always uncomfortable. The RJ is the worst. Usually it's a guy getting IOE.

4. Reading may be the greatest secret behind the cockpit door (with napping second) but doing it in climb or descent is pretty lame. Too much can happen. That's another holdover from the turboprop days, when we humped in at 220 and pulled cruise power back at the marker. Jets can go FUBAR quicker than anything.

5. I was in the second class in Montreal for ASA back in 1997, and we had a crew (Dennis you out there?) that had a self-induced double flameout at about 8000' on about sim 3. They couldn't get one cranked before they crumped. It was sobering to all of us. That plane needs lots of speed and altitude for relight.

 

[Lear70]

I fear that I've given you guys the wrong impression. I completey understand why you climb in VS. I just don't agree that doing so is as safe, or as efficient as climbing in a speed hold mode.

Sure... climbing in speed mode in the mid-20's and watching the vertical speed go from 1,000 fpm climb to 200 fpm DESCENT just to try to hold the speed is much safer and more efficient, just ask ATC, they love seeing that sh*t.

Speed mode sucks above 10,000.

Getting the shaker in flight? People should get some serious unpaid time off for bullsh*t like that! I had an f/o get the shaker in the flare right before touchdown last week as I was d*mn near yelling at him to quit fu*king around and land and pushing forward on the yoke. Was about to give him a negative mark on the approach and landing portion of the eval sheet but listened as he told me about a captain he had been paired with two or three months back who LIKED TO GET THE SHAKER JUST AS THE MAINS TOUCHED DOWN! With instruction like this from line Captains, it's no wonder so many pilots have screwed up ideas of how to fly the airplane. It's not a fu*king Cessna, people.

 

[SYXDude]

Same goes for the C750, VNAV @ 300/.80-.82 works like a charm.

Same goes for the DorkJet. VNAV at 255/.55 and there isn't a problem.

The DorkJet climbs like a homesick angel but if we want it to go faster in cruise, someone has to get out and help push!

 

[dondk]

about a captain he had been paired with two or three months back who LIKED TO GET THE SHAKER JUST AS THE MAINS TOUCHED DOWN! With instruction like this from line Captains

That Captain has been doing it for better than a year now.. Company/check airman can't catch him and pro standards.. Well a year later and still at it.. speaks for itself.

 

[h25b]

If it is that well known that this idiot is out there doing that crap then somebody needs to go to management before he kills people. Get it stopped NOW!!!

I gotta tell you guys, I am starting to agree with Gulfstream 200. Making me get really nervous about flying on regionals...

 

[TIS]

I have a question that no one else has raised

So I have this question nagging at me – I’ll get to that in a minute.

Not being a CRJ pilot I’m only going to base my comments on my experience. Now, in my experience getting an airplane with turbofan engines up to its maximum altitude at ISA+10 – even at lighter weights - is no simple job. Anyone who’s been up there in an airplane that was barely doing it knows this, and anyone flying for a regional airline doesn’t get to FL 410 often enough to have a natural feel for how their plane’s gonna behave on the way up to a level cruise. So whatever happened, it happened because of a combination of too little air and not enough thought put into the problem.

Now I’ll take aim at my question. The NTSB reports that:

The FDR data show that the computed airspeed did not get above 300 knots and that there was no measured rotation of the engine core.

I’d like to know why not. You see, something no one’s brought up is the loss of pressurization that would have occurred with a double engine failure – particularly at FL 410. At that altitude with no inflow air the cabin would climb rapidly to dangerous altitudes. In short, this is a good occasion to consider some or all of an emergency descent. I’ve never flown a jet that wouldn’t hit 300 knots through about 28,000’ in an emergency descent.

So it seems as though an emergency descent wasn’t underway and it seems as though what might not have been recognized was the link between an emergency descent and getting the engines running again.

That comes from inexperience or complacency, or both.

Surely there is a dual engine flameout procedure for this aircraft. For those who fly this plane, what does it say you need to do? Just as surely, there must also be a loss of pressurization procedure. What does it say?

What I’d also be willing to bet is that there is no procedure to address the occurrence of a loss of pressurization due to a double flameout. So what does one do when this occurs? Answer: in the absence of an AFM procedure specifically addressing the problem, the pilot has to stitch the applicable pieces of multiple procedures together in a way that makes sense.

In this case getting to thicker air was the key to getting the pilots breathing better and getting the engines running again, but it seems no one ever figured that out. Someone was focused trying to buy time by optimizing glide instead of focusing on getting back to fairly normal operational conditions (O2 masks off and both the engines running again).

This one’s gonna be pilot error. I don’t believe that anyone here really doubts that for a minute. It will illustrate, in the final analysis, that as pilots, we need to think a few situations through before they happen to us rather than when the pressure is on. It will also illustrate that better knowledge of jet aircraft performance is a direct enhancement to operational safety.

TIS

 

[Mel Sharples]

So I have this question nagging at me – I’ll get to that in a minute.

Excellent post, TIS.

Both your observations and advice are dead on. You make some great points and this post should be mandatory reading.

I especially like what you said about the most likely loss of pressure. Most likely it happened and most likely nobody was ready for it. Very good insight.

 

[efiscompmon]

That comes from inexperience or complacency, or both.

And that is where the company is going to hang this one. The lack of revenue passengers will allow this to be swept under the rug--enabling the role that hiring, training, and procedures may have played in this.

I have met a few bad pilots, but there are alot more deficient ones who simply HAVE NOT BEEN EDUCATED by the operator; usualy due to financial expediency. A number of the posts on this thread will show that.

It will also illustrate that better knowledge of jet aircraft performance is a direct enhancement to operational safety.

Agreed. But when ground school is taught by an ex-ramper with a personality disorder, the majority of the initial cadre pinks in training, check airman billets are handed out on the good old boy system, and management refuses the offers of technical assistance from the world's most experienced operator what can you expect? Where is the knowledge (and discipline) for a 500 hour FO to draw upon?

For those in the know of exact times, any truth to the persistent rumour that this was dispatched part 91 because the crew was "green on green"?

 

[Lear70]

That Captain has been doing it for better than a year now.. Company/check airman can't catch him and pro standards.. Well a year later and still at it.. speaks for itself.

Sounds like it's time for a little "attitude adjustment", Detroit-style, for this particular pilot. I'd like to know who it is, simply so I can have a personal tet a' tet with him.

I've always believed that professional standards should self-disclose any safety issues if they continue to be repeated by the offending individual. Someone like this doesn't deserve the protection of ALPA, they deserve to be thrown out the service door by the F/O as soon as they block in.

 

[Mel Sharples]

But when ground school is taught by an ex-ramper with a personality disorder, the majority of the initial cadre pinks in training, check airman billets are handed out on the good old boy system, and management refuses the offers of technical assistance from the world's most experienced operator what can you expect? Where is the knowledge (and discipline) for a 500 hour FO to draw upon?

This is SO true. Too many companies, major and regional, think that CFI wonderkids can do just as good a job as people who have flown the airplane.

They always say safety has a price. It's incidents like this that show how true that is.

Our company goes out of their way to keep experienced pilots out of the classroom. Granted there are some, but any way you can save a buck. . .

I would love to see Phil T. explain to Jesse's wife and kids that you don't need experience in the classroom.

 

[efiscompmon]

...or the check airman who slams on the brakes on touchdown so hard that unsecured items (jepp binders for example) go flying behind the rudder pedals. Apparently this senior individual believes that the TR's should just be "cracked" because "this plane has good brakes". Hmm. Cycle limited TRs. Wear limited brake pads. Yeah buddy, that's the way to fly!

...or the senior captain (seniority in the teens) who flies ref only, no +5, wind or gust correctons--because it makes for a smoother touchdown

...or the senior captain (single digit seniority) who failed TWO proficiency TRAINING events because he kept confusing Saab calls on the V1 cut and emergency evacuation--this at 6 and 18 months in the airplane.

...or the senior captain who puched back in PIT without fuel and started an engine--then tried to get fuel without opening the cabin door so the company wouldn't know.

...or the former Line Standards manager who improperly aborted a takeoff for a caution, forgot the aborted TO memory items, overheated the brakes and refused to return to the stand--departing with one of the BTMS in the white

...another check airman who thinks getting the clacker in the morning of a high speed (stand up overnight/continuous duty overnight) is a "good thing"--"shows you're trying to get us home"

...the captain who let the A/P line him up for Ry 27 MEM--when ALTS captured at GS intercept he got the shaker because he forgot to add power. Dismissed it as "those who have and those who will".

...the captain who penetrated a level four over the Gillmore arrival into Memphis at 12000'. Aircraft rolled past 70 degrees, A/P disconnected and he FROZE. Fortunately the FO taught ACM in the Navy. Why did it happen? He had the radar tilt set for a turboprop not a jet and like everyone else at that point (1 year of RJ operation) had received NO radar instruction.

...the jumpseating captain who suggested I have my FO open the service door to inspect the R wing deice with #2 running.

...the captain in the winter of '00/'01 who powered back from the gate after the plane had been deiced in position at the gate.

Just a few things witnessed by myself or my roommates in our time here. There's a whole lot of beatings needed at this airline.

 

[49W]

Hints on the airline? Don't tell me it's mine

 

[efiscompmon]

not unless your massah is on nonconnah.

disregard the green-on-green question. got an answer.

 

[Rottweiller]

So I have this question nagging at me – I’ll get to that in a minute.

Now I’ll take aim at my question. The NTSB reports that:
I’d like to know why not. You see, something no one’s brought up is the loss of pressurization that would have occurred with a double engine failure – particularly at FL 410. At that altitude with no inflow air the cabin would climb rapidly to dangerous altitudes. In short, this is a good occasion to consider some or all of an emergency descent. I’ve never flown a jet that wouldn’t hit 300 knots through about 28,000’ in an emergency descent.

The RJ has 2 out electro-pneumatically controlled outflow valves on the rear bulk head. During normal ops these are controlled by jet pumps from 10th stage bleed air. However they have their own emergency circuit and in the event of a dual loss of 10th stage the valves will automatically close and then be electrically driven open / closed after that. Power is supplied for this from the DC Emergency bus until ADG deploment repowers the AC ESS bus and thus the DC ESS bus.

So it seems as though an emergency descent wasn’t underway and it seems as though what might not have been recognized was the link between an emergency descent and getting the engines running again.

That comes from inexperience or complacency, or both.

Surely there is a dual engine flameout procedure for this aircraft. For those who fly this plane, what does it say you need to do? Just as surely, there must also be a loss of pressurization procedure. What does it say?

Dual flameout:

CONT IGN - ON

Engines continue to run down:
Thrust levers - Both shutoff
ADG manual deploy handle - pull
When ADG power established:
STAB CHAN 2 - Engage
Target airspeed establish - >FL340 M0.7 <FL340 240 KIAS
QRH engine inflight restart procedures.

Windmilling restarts require at least 300 KIAS to get the N2 to turn (on CF34 engines the N2 inlet is not pointed directly into the airflow, but takes air from and upward / outward angle. Military engine design (A10's) to prevent FOD injestion to the N2 stages). As stated in the NTSB report the FDR showed they never got to 300 KIAS and NO N2 rortation was recorded.

What I’d also be willing to bet is that there is no procedure to address the occurrence of a loss of pressurization due to a double flameout. So what does one do when this occurs? Answer: in the absence of an AFM procedure specifically addressing the problem, the pilot has to stitch the applicable pieces of multiple procedures together in a way that makes sense.

Pressurization shouldn't be an issue the cabin bleeds down very slowly, less than a couple hundred feet per minute (see above explanation). If you do get a CABIN ALT message procedure is O2 masks - don 100% flow, crew communication establish.

In this case getting to thicker air was the key to getting the engines better breathing and running engines again, but it seems no one ever figured that out. Someone was focused trying to buy time by optimizing glide instead of focusing on getting back to fairly normal operational conditions (O2 masks off and both the engines running again).

This one’s gonna be pilot error. I don’t believe that anyone here really doubts that for a minute. It will illustrate, in the final analysis, that as pilots, we need to think a few situations through before they happen to us rather than when the pressure is on. It will also illustrate that better knowledge of jet aircraft performance is a direct enhancement to operational safety.

TIS

Sorry to say but I agree with you on the last paragraph it will more than likey be pinned on the crew especially as they failed to restart at least 1 engine and as it seems that procedure wasn't followed as per the QRH.

 

[BluDevAv8r]

I gotta tell you guys, I am starting to agree with Gulfstream 200. Making me get really nervous about flying on regionals...

Are you saying that the same antics don't occur in the corporate/charter world? At the major airline level? Military?

I've certainly heard and read some stories that makes one shake their head in disgust as well. Want to hear about the time my friend was in the jumpseat of a CAL 757 out of LAS and had to remind the FO to set takeoff flaps while they took the runway (checklist was already complete). Or what about the time my buddy was SIC in a Westwind and the Captain ran low on gas, overflew several airports (refusing to stop for fuel), and landed with less than 30 minutes in the tanks (they were ferrying the plane, no pax)?

-Neal