Where the Real Blame Lies...

[SEVEN]

For all of you screaming for Regulation change; I have no problem with the FAA tweeking some of the rest, reduced rest, and duty time requirements. That's all fine and dandy. But guess what? Inexperienced pilots will still crash and kill lots of people even with 11 hours of rest. Fatigue is definately real. I and many others have experienced it many times. It can be a factor in crashes. But, pilots have a responsibility, even when tired to complete a flight safely. If a pilot feels that tired/fatigued a sick call is in order. I know that Colgan frowns upon calling in sick. But come on. It's not worth the risk of crashing. This will hopefully be a learning experience for the industry.
Inexperience and crew pairing was huge in this crash. This needs to change and change FAST!

 

[ackattacker]

Which, interestingly enough, is the exact procedure one would use in the event of a tailplane stall.

Agreed. And apparently Colgan was teaching tail-plane stall recovery in ground school. So they have been spring loaded to expect it, especially with icing and just after flap selection.

Of course a tail plane stall does NOT set off the stall warning system. They should have known that. Shoulda coulda woulda.

Clearly that had a lack of situational awareness... no idea the airspeed was so low. So when you say "flaps 15" and all hell breaks loose it's natural to undo what you just did. Not an excuse just an explanation. A lack of airmanship for sure, starting with distraction and not keeping track of the big 3 - attitude, airspeed, position.

I wonder how much time they had with airspeed tape vs. round dial.

 

[Browntothebone]

FAA needs to regulate a mandatory minimum wage, say $40,000 for starting F/O and $100,000 for Captain upgrade. That will bring in the quality applicants.

 

[777forever]

Good point. And consider this:

Regional airlines account for approximately 50 percent of all scheduled airline flights in America.

The NTSB website lists two regional airline accidents over the last 10 years which were flown under 121 and had fatailties associated with pilot error -
COMAIR 5191
Colgan 3407 (let's assume this was for simplicity)

The combined loss of life is approximately 100.

That same database lists three 'major airline' accidents under the same conditions -
American 1420 - Little Rock
American 587 - Bell Harbor NY
Soutwest 1248 - Chicago

The combined loss of life is 277

Sully probably didn't include that in his testimony.

Right on the money bro! Everyone is quick to jump on the lack of experience bandwagon when history has shown these type of crashes occur at all experience levels.

The Turkish Airlines 737 stalled and crashed on final with not 2 but 3 highly experienced crew members on board. And I know the Capt for sure had military training.

A highly experienced CAL 737 Capt got lucky he didn't kill 100+ people when he made the decision to correct for the FO being off centerline with the tiller during the T/O roll. Lawsuits on the way though!

Highly experienced A340 crew made a simple FMS entry error and got lucky they didn't kill 200+ people on T/O in Australia. All they got was a pretty bad tailstrike and a pink slip.

Highly experienced NWA A320 crew just recently tailstriked on landing in Denver so bad the plane is written off. Somehow I think it's gunna end up being pilot error.

I believe the system we have is almost as good as it gets. At the end of the day we have to realize that we are all human and it is virtually impossible to prevent accidents from ever happening. The best we can do is reduce the probability, which I believe the system is doing a excellent job.

 

[BoilerUP]

Inexperienced pilots will still crash and kill lots of people even with 11 hours of rest. Fatigue is definately real. I and many others have experienced it many times. It can be a factor in crashes. But, pilots have a responsibility, even when tired to complete a flight safely. If a pilot feels that tired/fatigued a sick call is in order. I know that Colgan frowns upon calling in sick. But come on. It's not worth the risk of crashing. This will hopefully be a learning experience for the industry.
Inexperience and crew pairing was huge in this crash. This needs to change and change FAST!

While I know what you're saying, history has shown us even highly experienced airline pilots have killed lots of people too...doing things like running out of gas, flying perfectly good airplanes into the ground, not using flaps for takeoff, etc.

Fatigue, experience, working atmosphere - all are contributing factors to fatal accidents...but ultimately the two people sitting in the pointy end are responsible for safety of flight, and complacency (in pilots with 1000 hours or 20,000 hours) kills.

Fate is the hunter...

 

[ackattacker]

Right on the money bro! Everyone is quick to jump on the lack of experience bandwagon when history has shown these type of crashes occur at all experience levels.

The Turkish Airlines 737 stalled and crashed on final with not 2 but 3 highly experienced crew members on board. And I know the Capt for sure had military training.

A highly experienced CAL 737 Capt got lucky he didn't kill 100+ people when he made the decision to correct for the FO being off centerline with the tiller during the T/O roll. Lawsuits on the way though!

Highly experienced A340 crew made a simple FMS entry error and got lucky they didn't kill 200+ people on T/O in Australia. All they got was a pretty bad tailstrike and a pink slip.

Highly experienced NWA A320 crew just recently tailstriked on landing in Denver so bad the plane is written off. Somehow I think it's gunna end up being pilot error.

I believe the system we have is almost as good as it gets. At the end of the day we have to realize that we are all human and it is virtually impossible to prevent accidents from ever happening. The best we can do is reduce the probability, which I believe the system is doing a excellent job.

All valid points however I don't believe in saying "well, that's as good as it gets (or good enough), no sense trying to improve the system".

Clearly airline safety can be improved further. And, analyzing the root causes of accidents and correcting for them is a fundamental part of that.

 

[777forever]

All valid points however I don't believe in saying "well, that's as good as it gets (or good enough), no sense trying to improve the system".

Clearly airline safety can be improved further. And, analyzing the root causes of accidents and correcting for them is a fundamental part of that.

Completely agree. I believe we have a very strong foundation for what a safe system should be. It can and will use a little improvements here and there. Like mandatory stickpusher training.

 

[Papa Woody]

American 587 was a bomb.

 

[Flyer1015]

FAA needs to regulate a mandatory minimum wage, say $40,000 for starting F/O and $100,000 for Captain upgrade. That will bring in the quality applicants.

How stupid are you? Since when will the FAA ever cave in to what the NTSB says, when it involves money $$$????????? Sorry, but the ATA and RAA will ensure, through powerful $ lobbying, that the FAA maintain status quo on how things are right now. Expect changes in stall profiles (to probably include all the way to pusher). But do NOT expect changes in long duty days, reduced rest, and fatiguing schedules.

 

[Flyer1015]

American 587 was a bomb.

No, that was pretty much all Molin and rudder smashing to full deflection, left and right, 5 or 6 times before finally snapping.

 

[Abernathy]

How stupid are you? Since when will the FAA ever cave in to what the NTSB says, when it involves money $$$????????? Sorry, but the ATA and RAA will ensure, through powerful $ lobbying, that the FAA maintain status quo on how things are right now. Expect changes in stall profiles (to probably include all the way to pusher). But do NOT expect changes in long duty days, reduced rest, and fatiguing schedules.

Flyer, he's absolutely right. I just posted this very thing on another thread before I read this one. If the gov't wants highly qualified experienced pilots, they're going to have to set an airline pilot minimum wage. Otherwise, all the experienced talent will continue to go to the middle east, asia, etc...

 

[Papa Woody]

No, that was pretty much all Molin and rudder smashing to full deflection, left and right, 5 or 6 times before finally snapping.

What pilot would ever do that under any imaginable circumstances?

 

[Mike man]

American 587 was a bomb.

Uhhh...really? Do you read what you type or just sort of fade in and out?

 

[lionflyer]

Flyer, he's absolutely right. I just posted this very thing on another thread before I read this one. If the gov't wants highly qualified experienced pilots, they're going to have to set an airline pilot minimum wage. Otherwise, all the experienced talent will continue to go to the middle east, asia, etc...

They'll have to re-regulate the industry for that. I don't see it happening.

 

[Abernathy]

They'll have to re-regulate the industry for that. I don't see it happening.

I don't think it's that unlikely that we could see a limited form of regulation resurface.

 

[satpak77]

I think this is all Bush's fault. Because 90% of FI think it is not the pilots fault.

Generation Y at work (no reverse pun intended).

 

[Poahi]

What pilot would ever do that under any imaginable circumstances?

What pilot wouldn't manage airspeed? What pilot would wait on the thrust reversers? What pilot would run out of fuel? What pilot would fly tired? What pilot would fly in to a convective storm? What pilot would take off without a clearance? What pilot would take off without verifying which runway he was on? Pilot error happens at every experience level. That's why the bashing is senseless and building up someone like Sully is counter productive as well.

The heros are the ones you don't see in the news that prevent accidents by avoiding them all together. I've seen regional pilots who rival any major airline pilot and I've seen pilots for the majors who shouldn't be flying anything at all. This type of class warfare isn't going to work. (Well, it might get you a book deal)

 

[Dubya]

Clouds are scary!

Sheeeeeeit. I see clouds coming, turn down my ipod and i'm all like, "what's up cloud full of severe icing beeotch?", and the cloud's like "nothing sir", and i'm like, "that's right beeotch, go make me a chicken pot pie".

 

[ground_fog]

Just having hours should not qualify as the only experience needed. It's obvious this was caused by a myriad of factors. My Father was an Air Firce Pilot and 30 year Airline Pilot and Captain who flew he 767 in europe for 7 years. Some of his co Piliots had only 1000 hours in a plane and were flying international! However,because of the excellent training they received he viewed them as very competent during even some stressful situations.

Until the pay structure changes, it is what it is. Once a Pilot is hired, however, multiple failed checkrides is certainly a major red flag. The general avaition fails can happen to anybody but once you are in a structured training platform in 121,I know certainly i would consider changing professions after a certain number of failures.

 

[BoilerUP]

I think this is all Bush's fault. Because 90% of FI think it is not the pilots fault.

Generation Y at work (no reverse pun intended).

Everybody here (regardless of their age or the hours in their logbook) knows its the two people in the pointy end's responsibility to fly the f'in airplane and ensure safety of flight...and this crew failed doing just that.

That does not mean, however, that we as an industry and the public as a whole shouldn't examine the underlying problems with the regional airline work culture that disciplines pilots who follow the FARs and call sick when aeromedically deficient, or why highly experienced regional airline pilots leave chasing higher salaries at major airlines.

Cause: pilot error. Contributing factors: a mile long.

 

[Jet41]

The real blame...the crew failed at basic airmanship.

 

[MJ42]

The real blame...the crew failed at basic airmanship.

Correct, and as stated in many posts, pilot error happens to the experienced and inexperienced aviator.

There is a book, "Redefining Airmanship" by Tony Kern, that should be REQUIRED reading for ALL airline pilots. To quote from the book's cover: "know yourself, know your team, know your aircraft, know your environment, know your risk". In most crashes, I'd think one(or more) of these statements are not followed.

Boiler Up, your post #12 concerns me. As stated in post #32, there were no signs of a tail stall. Hopefully, your post was not implying that it may have been a tail stall, albeit the crew may have reacted as if it was.

"Know yourself", were they fit to fly? "Know your team", was proper TEM(threat and error management...the NEW version of CRM) used? "Know your aircraft", did they know Q400 systems adequately(stall system, recovery procedures...)? "Know your environment", did they have enough winter flying experience to recognize signs of a tail stall? "Know your risk", again, TEM. Did they recognize the threats, correct the errors and manage the situation?

Again, this model can be applied to most crashes. My intent is not to criticize or blame the Colgan pilots, however, it is intended to show how we are all vulnerable to these threats. Learning from accidents is crucial to the safety of our industry.

 

[BoilerUP]

Boiler Up, your post #12 concerns me. As stated in post #32, there were no signs of a tail stall. Hopefully, your post was not implying that it may have been a tail stall, albeit the crew may have reacted as if it was.

Why would you be concerned by a statement of fact?

Given the crew's actions, its not unreasonable to deduce that the crew was distracted and as such might have mistakenly believed they were in a tail stall situation once the shaker went off (even though shakers don't account for tail stalls) and they responded accordingly to the wrong diagnosis.

Obviously they were not in a tail stall and their reactions didn't save the aircraft...

 

[MJ42]

Why would you be concerned by a statement of fact?

Given the crew's actions, its not unreasonable to deduce that the crew was distracted and as such might have mistakenly believed they were in a tail stall situation once the shaker went off (even though shakers don't account for tail stalls) and they responded accordingly to the wrong diagnosis.

Obviously they were not in a tail stall and their reactions didn't save the aircraft...

I may have misread your post, but it sounded as if you were implying they were in a tail stall...sorry for reading too much into your statement.

 

[ackattacker]

Proper recovery from a tail stall calls for reducing power. They (he) added power. So if he was trying to recover from a tail stall he was fraking that up too. Just sayin.

IMHO he was reacting instinctively, without thought and his instinct was about what you'd expect from a pre-solo student pilot. Yoke back in his lap, cross controlled. Unforgivable.

There's a reason they don't teach this stuff at the 121 level. You're supposed to know it already, to have spend years teaching it to student pilots. It would be akin spending time teaching you how to plot a course using a VFR chart and an E-6B and doing ground-reference maneuvers.

 

[BoilerUP]

I may have misread your post, but it sounded as if you were implying they were in a tail stall...sorry for reading too much into your statement.

No worries!

At first, I think many people thought this was a tailplane stall...if only because that being the case would make us feel better about the crash, as opposed to the cause being a gross lack of airmanship...

 

[30West]

The real blame...the crew failed at basic airmanship.

Thank you Captain Obvious. The rest of us moved on to the "why" a long time ago. Try and keep up.