Jet stream down

[JL]

TSB final report

https://www.tsb.gc.ca/eng/rapports-repo ... w0008.html

[FL030]

I'm surprised the TSB report put so much emphasis on wing contamination. The real issue seems to be fiddling with the engines to reduce airspeed at 100 feet above ground instead of just climbing. Scary to see blackhole get another highly experienced pilot.

[pelmet]

I'm surprised the TSB report put so much emphasis on wing contamination. The real issue seems to be fiddling with the engines to reduce airspeed at 100 feet above ground instead of just climbing. Scary to see blackhole get another highly experienced pilot.

What do you say to yourself as a reminder in such a situation? ……….scan, scan, scan. Of course, that might be more for a turn soon after takeoff.

Sound like this pilot stopped flying properly and was participating in non-flying pilot activity. No need to reduce power, just slowly increase pitch.

[5degrees]

I'm surprised the TSB report put so much emphasis on wing contamination. The real issue seems to be fiddling with the engines to reduce airspeed at 100 feet above ground instead of just climbing. Scary to see blackhole get another highly experienced pilot.

Could be because he was concerned with increasing the AOA due to the contamination. All around classic northern ops; deice truck that's been broken for weeks, word of mouth snags, lack of SOP adherence , SMS a farce.

[digits_]

I'm surprised the TSB report put so much emphasis on wing contamination. The real issue seems to be fiddling with the engines to reduce airspeed at 100 feet above ground instead of just climbing. Scary to see blackhole get another highly experienced pilot.

Could be because he was concerned with increasing the AOA due to the contamination. All around classic northern ops; deice truck that's been broken for weeks, word of mouth snags, lack of SOP adherence , SMS a farce.

Perhaps, but is there any realistic situation where the response for a 'check speed' at 100 ft AGL would be to throttle back instead of climbing?

[cncpc]

I'm surprised the TSB report put so much emphasis on wing contamination. The real issue seems to be fiddling with the engines to reduce airspeed at 100 feet above ground instead of just climbing. Scary to see blackhole get another highly experienced pilot.

What do you say to yourself as a reminder in such a situation? ……….scan, scan, scan. Of course, that might be more for a turn soon after takeoff.

Sound like this pilot stopped flying properly. No need to reduce power, just slowly increase pitch.

First off, well done to the TSB. A very good investigation report.

I think the causal chain starts with wing contamination and the captain's solution of higher than normal speed. That is why the emphasis is on wing contamination, for starters. That method is not in conformance with the Regs, and the SOPs, if I remember that part of my quick read of the report. But, I've likely done it, and so have many others.

The accident was not caused by loss of lift, though. In the causal chain, the higher speed led to the gear abnormality. That led to the FO calling for a speed reduction. As Pelmet says, the way to do that is not adjusting power, but increasing pitch. If the snow wasn't gone by then, it never would be. The report notes that is a homemade solution at NWAL for this minor gear problem. Something the crews had cooked up themselves.

I take it that airflow over the gear leg cover as it gets near marrying with the wing in the hole results in the gear up switch not quite activating on that side. So the cover is almost flush with the bottom of the wing, but not quite. I don't think it is a scenario where the leg is hanging down and causing serious drag. That would lead to a more dangerous situation if very bad luck also threw in an engine failure in the same time. But that didn't happen. There was no need to interject immediate speed reduction by adjusting power. I'm not sure if the homemade solution thought there was a need.

The FO called "Descending" a few seconds before impact. What initiated that? Distraction? One of the several forms of somatographic illusion? It certainly is a black hole going off 30 in the middle of the night.

[Eric Janson]

TSB final report

https://www.tsb.gc.ca/eng/rapports-repo ... w0008.html

Once again we see the Normalisation of Deviance. This is a textbook case.

Reducing power at low altitude to reduce airspeed is an extremely bad idea - sadly the results speak for themselves.

[Canoehead]

Once again we see the Normalisation of Deviance. This is a textbook case.

Reducing power at low altitude to reduce airspeed is an extremely bad idea - sadly the results speak for themselves.

100% this.

I'm surprised that an "experienced" pilot would even contemplate this. Especially in a J32... are these not typically known as underpowered airplanes? From an HF point of view, I have questions - some left from the report and others from posts here. We know they flew a perfectly good airplane into the ground (maybe save for an out of rig microswitch on the gear doors) and we know why they did it.

Looking at the Captain's list of endorsements and his total time (not that high for someone flying since the 80s), makes me wonder more; with a 700 hour FO who someone here close to the operation said was "not a good pairing". The report gives the findings and does a good job of reminding pilots (over several pages) that in a 2-crew airplane, someone ALWAYS needs to be flying the airplane (correctly).

There is a discreet line in the Executive Summary that speaks volumes to me.

The investigation also examined factors that may not have been causal or contributing to this occurrence but could pose a risk to the transportation system in the future.

Glad the report is finally out at least, even if I have to read between the lines in the end.

[Old fella]

As anticipated and no doubt expected there is civil litigation ongoing. If it ever gets to court proceedings there will no doubt be a Human Resources element stance presented.

Edit: The 5th and 6th paragraphs from cncpc later post is startling to say the least.

[cncpc]

Once again we see the Normalisation of Deviance. This is a textbook case.

Reducing power at low altitude to reduce airspeed is an extremely bad idea - sadly the results speak for themselves.

100% this.

I'm surprised that an "experienced" pilot would even contemplate this. Especially in a J32... are these not typically known as underpowered airplanes? From an HF point of view, I have questions - some left from the report and others from posts here. We know they flew a perfectly good airplane into the ground (maybe save for an out of rig microswitch on the gear doors) and we know why they did it.

Looking at the Captain's list of endorsements and his total time (not that high for someone flying since the 80s), makes me wonder more; with a 700 hour FO who someone here close to the operation said was "not a good pairing". The report gives the findings and does a good job of reminding pilots (over several pages) that in a 2-crew airplane, someone ALWAYS needs to be flying the airplane (correctly).

There is a discreet line in the Executive Summary that speaks volumes to me.

The investigation also examined factors that may not have been causal or contributing to this occurrence but could pose a risk to the transportation system in the future.

Glad the report is finally out at least, even if I have to read between the lines in the end.

I've taken the time to deep dive into the report. Having done that, as someone who knew the inside story at NWAL, I can say that something isn't right in all of this. I do commend again the investigators, and I understand the boundaries of their remit, but I do believe that all the victims, including the crew, along with the public in Smith and the territories deserve a coroner's inquiry into what the failures were, and to know they have not been and will not be, remedied.

I do want to say that I believe a serious overemphasis is placed generally in our air law on confidentiality of CVR transcripts. I don't know of anywhere else in the mainstream of aviation where this is the case. We've all seen exactly what was being said in the tragic last moments of the Air India 787 accident. It's all there for everybody to see in NTSB reports. It is true that the TSB has provided a non verbatim account of some of the conversations, but I think we would learn more from every word from the time the recording started until it ended. In all accidents where there is an electronic record, CVR, ATC comms, whatever is out there.

So, from the recording portions the report reveals, we understand the factual background of the flight. As I stated early on after this happened, I had no doubt that NWAL did a great job on dealing with the cold weather challenges of dispatching aircraft in extreme cold and in ensuring clean wings for at least beginning of taxi. I do not recall a procedure for dealing with snow that fell on wing and tail surfaces in the time from starting taxi on the ramp to lineups. Sure, it's a pretty sound theory to say that dry, not sticking, snow will blow off as the aircraft picks up speed in the takeoff. It is sound only if the facts are that it IS not sticking, and the clearance will be complete in the first 20 to 30 knots of airspeed. I cannot imagine that the Captain, making 160 knots, thought he couldn't pitch up, instead of reducing power because there was still snow to blow off. I can't imagine that the Captain would have been happy to have the FO interrupt the process with non emergency info about a gear light still red at just over 100 feet. Or, to be told to slow down. Even though this was dealt with in a buck shee fashion by the company, it certainly can't have actually been in some abnormal checklist to be activated at 100 feet. But, the theory out there is that he couldn't pitch up because snow clearing was in process. At 160 knots? He was told by an FO not vocalizing a memory item, but just directing a lowering of airspeed when he should have been monitoring instruments, including the VSI. When he finally got around to that it was too late.

It should be stated that we really don't know why the captain responded to the FO at all for this non standard communication. There was no emergency. Is there CVR data that says the captain says "Can't pitch up. Not sure if the snow is gone. I'll reduce power to get the speed down." It may be this is an interpretation by TSB of the captain's reasoning.

I am sure that the management of NWAL were honest and forthright in answering TSB questions. They are very decent people. One of the things I believe they mentioned was that there was there was an absurd tension between the two pilots on the flight deck for this accident. The captain was very unhappy with the FOs performance when they were paired. The FO disparaged the captain to others and stated a belief that he was a better pilot than the captain. When, post accident, someone in Flight Ops was asked why the hell they were ever paired, the response was "We expect them to work that out themselves"

I do believe that this is one of those "factors" the TSB mentions as not directly causal or contributing, but puts the transportation system at risk. I'm not sure it didn't play a role in this awful 15 seconds leading up to the accident, or that it is not consequential to this accident. Certainly pairing incompatible individuals will put our entire air transport system at risk.

I intend to make contact with powers that be in an effort to bring about a coroner's inquest to fully develop a more complete background to the investigation and issues such as the failed substitution of SMS for actual enforcement inspection and much greater demand for Corrective Action plans when irregularities are discovered. There certainly were serious irregularities in some of the things NWAL did.

[digits_]

I can't imagine that the Captain would have been happy to have the FO interrupt the process with non emergency info about a gear light still red at just over 100 feet

Why not? I certainly would want to know if my gear didn't go up when I asked for it. Don't they have something in their SOPs such as "gear up and locked" or "gear up lights out" or something similar? Seems ver appropriate the FO would say that the gear light indications are wrong.

[cncpc]

Read the report, and get back to us.

[digits_]

Read the report, and get back to us.

Wonderful insightful reply.

Yes I read the report.

Just because the captain and/or FO got possibly distracted too much by the failure, doesn't mean the FO should keep the failure of a system to himself.

I'll ask you again: what's the alternative? You want the FO to just go through calls that are incorrect not to distract you? Say nothing and play 20 questions? I'm sure that would be way more distractive than simply pointing out the failure.

What should the FO have done in this situation according to you?

[Dry Guy]

Grab the controls and pull up instead of just calling descending.

[JThornback]

I intend to make contact with powers that be in an effort to bring about a coroner's inquest to fully develop a more complete background to the investigation and issues such as the failed substitution of SMS for actual enforcement inspection and much greater demand for Corrective Action plans when irregularities are discovered. There certainly were serious irregularities in some of the things NWAL did.

Would you mind DMing me cncpc? I haven't posted enough to be able to send a DM myself.

[cncpc]

Some extended comments in the CBC article by the lead investigator.

https://www.cbc.ca/news/canada/north/lo ... -9.7116147

[cncpc]

Read the report, and get back to us.

Wonderful insightful reply.

Yes I read the report.

Just because the captain and/or FO got possibly distracted too much by the failure, doesn't mean the FO should keep the failure of a system to himself.

I'll ask you again: what's the alternative? You want the FO to just go through calls that are incorrect not to distract you? Say nothing and play 20 questions? I'm sure that would be way more distractive than simply pointing out the failure.

What should the FO have done in this situation according to you?

I think this discussion is considerably above your pay grade.

[digits_]

Grab the controls and pull up instead of just calling descending.

Well yes, but that's not the issue I was asking about. I'm trying to find out why a captain would *not* want to know about a gear retraction failure/issue when he calls for gear up. Or how the FO can keep that information to himself without breaking a number of SOPs.

I can see how one could partically blame the FO for not being assertive enough, but the initial gear indication call seems quite by the book to me, based on the limited info in the report.

[oldnbold]

10 seconds of descending before impact is a long time for no one to take corrective action by increasing pitch. The gear not fully retracting isn't critical when you are in such a high area of vulnerability. The PM calls the malfunction and immediately goes back to monitoring the climb. The PF says Roger and climbs to a safe altitude to deal with the malfunction. Especially with the threat of the black hole.

[cncpc]

10 seconds of descending before impact is a long time for no one to take corrective action by increasing pitch. The gear not fully retracting isn't critical when you are in such a high area of vulnerability. The PM calls the malfunction and immediately goes back to monitoring the climb. The PF says Roger and climbs to a safe altitude to deal with the malfunction. Especially with the threat of the black hole.

Concise. Supurb.

[digits_]

10 seconds of descending before impact is a long time for no one to take corrective action by increasing pitch. The gear not fully retracting isn't critical when you are in such a high area of vulnerability. The PM calls the malfunction and immediately goes back to monitoring the climb. The PF says Roger and climbs to a safe altitude to deal with the malfunction. Especially with the threat of the black hole.

The PM/FO did initially that. Called the malfunction, and told the captain to slow down. We know from the report that the captain wanted to fly faster. Was this new 'faster' speed briefed before takeoff? The FO is in a plane with a captain trying to fly fast, with a gear malfunction that now limits the plane to 160kts (google source, 160kts gear operating speed for Jetstream, possibly different for this particular plane). So he tells the captain to slow down, as they are through 145kts and accelerating. This might be conservative, but still a good call. The captain always has the option to ignore it. I just don't agree with the statement that the FO would be pointlessly distracting the captain or interrupting the process. The FO, untill that point, was doing his job.

[Canoehead]

The FO, untill that point, was doing his job.

I don't think either pilot was doing their job. The question is "why?".

[Old fella]

The FO, untill that point, was doing his job.

I don't think either pilot was doing their job. The question is "why?".

Dysfunctional crew. The Captain himself had type endorsements on large transport category aircraft up to and including L-1011 so knew the concept of multi crew performance requirements. The report certainly honed on that as it was certainly missing and the company itself knew that issues( ref cncpc posts).

[airway]

A few points copied from the report:

"During the aircraft performance analysis that was completed for the occurrence flight, it was determined that the aircraft was not significantly underperforming due to contaminated critical surfaces."

"The published maximum airspeed at which the aircraft can safely be flown with the landing gear extended (VLE) or being operated (VLO) is 160 KIAS."

"During these maintenance activities, no issues were identified with the operation of the landing gear system’s retraction or extension."

"The investigation determined that there had been an intermittent issue with the left main landing gear unit, in that it did not fully retract when outside temperatures were colder than approximately −20 °C and when the landing gear was under air load at indicated airspeeds exceeding approximately 140 KIAS. However, this information was not found recorded in any of the aircraft’s technical records. The investigation determined that the Jetstream pilots within Northwestern Air Lease had developed an informal procedure to address the issue. According to this informal procedure, the PF increases the pitch angle of the aircraft to bleed off airspeed down to approximately 140 KIAS, at which point the landing gear locks in the retracted position, the landing gear position indicator lights extinguish, and the pilots can then continue the flight as usual."

"Eight seconds later, and at a height of approximately 100 feet above ground level (AGL), the FO observed an abnormal landing gear indication and notified the captain. Two seconds later, the FO called for the captain to reduce the speed; the captain acknowledged, and 2 brief changes in propeller rpm occurred within 6 seconds. During the initial climb, the captain maintained a shallow climb angle and attitude, the aircraft’s speed increased to approximately 165 knots indicated airspeed (KIAS), and the aircraft reached a maximum height of approximately 140 feet AGL (Appendix A, Figure A1). At this point, the aircraft began a shallow descent. Six seconds later, the FO observed that the aircraft was losing altitude and called “Descending”. One second later, the terrain awareness and warning system (TAWS) began to produce an aural alert and, simultaneously, the aircraft impacted trees 0.5 nautical miles (NM) past the end of Runway 30. During this impact, the left-wing structure was compromised, resulting in a fireball. "

The aircraft was cold soaked (-20 C) and multiple tactile tests were done including the captain checking one wing before closing the door. It sounds like all of the snow had blown off before rotation. This is typical for this situation, and I don't think that there is any need to increase your climb speed (other than any increase for icing conditions). If you have any doubts about whether all the snow will blow off early in the takeoff roll, have it removed.

What I would do in this situation (assuming I didn't know about the gear issue), is rotate slightly slower than normal at Vr, but still up to the the normal pitch angle.
Then positive rate, "gear up", FO states "left main gear is red" (or unsafe or in transit), and then in this case "airspeed" (they were 5 knots over the Vlo speed), Capt. states "roger, slowing to 140 (or whatever the safe climb speed is in that configuration, using climb power), "lets climb to 5000 ft and deal with the problem there, I'll target 150 kts once we are level".

.

[Nauclerus]

From the report ...

"The captain was hired by Northwestern Air Lease on 01 December 2022. He obtained his type rating on the Jetstream series 3200 on 22 December 2022. In addition to his Jetstream series 3200 type rating, the captain also held ratings on the Jetstream 3100, Convair 580, Lockheed L-188 Electra, Lockheed L-1011 TriStar, Canadair Regional Jet, and Boeing 737-600, -700, and -800 series aircraft. The captain also held a flight engineer licence with ratings on the Douglas DC-8, the Lockheed L-188 Electra, and the Lockheed L-1011 TriStar."

Odd career progression. Sounds like maybe they started off as an AME/Flight Engineer then progressed to a pilot position. DC-8 and L-1011 sounds like Worldways ? Typed on the B737-600/700/800 sounds like Westjet ? How did they end up in a crappy Jetsteam job flying in the north in the winter after all that ? Has this person's name ever been released in the media yet ? Why the secrecy !?