Buffalo Crash Likely Pilot Error: Investigators
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Buffalo Crash Likely Pilot Error: Investigators
In other news, it was also reported that the sky is blue, the Pope is Catholic and bears do indeed crap in the woods.
http://www.cbc.ca/world/story/2010/02/0 ... crash.html
Pilot error was the probable cause of an airline crash into a house near Buffalo, N.Y., last year, but the accident's root problems extend far beyond a single event, a federal safety panel said Tuesday.
The head of the National Transportation Safety Board, Deborah Hersman, said the accident casts doubt on whether or not regional airlines are held to the same level of safety as are major airlines, and she promised the board will pursue the issue.
She also criticized the Federal Aviation Administration for taking too long to address safety problems raised by the crash, saying the same issues have turned up before.
"Today is Groundhog Day, and I feel like we are in that movie," Hersman said, referring to the 1993 Bill Murray movie about a Pittsburgh weatherman who repeatedly lives through the same day.
"We have made recommendations time after time after time. They haven't been heeded by the FAA."
The FAA said in a statement that it has driven significant improvements in pilot professionalism, training and background checks in the past year. The agency said it will soon propose new rules to prevent pilot fatigue, further improve training and increase the qualifications required to be an airline pilot.
The three-member board agreed unanimously that an "inappropriate response" by the captain of Continental Connection Flight 3407 to a key piece of safety equipment caused the crash. The board also said an incorrect airspeed entered into the plane's computers by the flight's first officer and the air carrier's inadequate procedures and training for entering airspeeds for freezing weather were contributing factors.
The board discussed issuing more than 20 safety recommendations as a result of the accident.
Hersman praised FAA Administrator Randy Babbitt for initiating regulation changes in response to the crash on Feb. 12, 2009, when the plane dove into a house, killing all 49 people aboard and one man in the house. But Hersman said Babbitt has been unable so far to push reforms "across the finish line" and that congressional action may be needed.
Flight 3407, operated for Continental Airlines by Colgan Air Inc., was approaching Buffalo-Niagara International Airport when the twin-engine Bombardier turboprop experienced an aerodynamic stall and went into a dive. The board said Capt. Marvin Renslow should have been able to recover from the stall but that he did the opposite of what he should have done.
In the final seconds
In the final seconds of the flight, two pieces of safety equipment activated — a stick shaker to alert the crew their plane was nearing a stall and a stick pusher that points a plane's nose down so it can recover speed, investigators said. The correct response to both situations would have been to push forward on the control column to increase speed, they said.
But Renslow pulled back on the stick shaker, investigators said. When the plane stalled and the pusher activated, Renslow again pulled back three times.
"It wasn't a split-second thing," NTSB safety investigator Roger Cox said. "I think there was time to evaluate the situation and initiate a recovery, but I can't give you a number of seconds."
Seventy-five per cent of pilots who had experienced the stick-pusher activation in training also responded by pulling back instead of pushing forward, even though they knew ahead of time to expect a stall, investigators said.
The first officer, Rebecca Shaw, 24, should have stepped in to push the plane's nose down herself when Renslow, 47, responded improperly, but she may not have because she was a relatively inexperienced pilot, investigators said.
Shaw commuted across the country overnight to Newark, N.J., to make Flight 3407. It's not clear how much sleep either pilot received the night before the flight, but investigators said both pilots likely were suffering from fatigue.
Hersman wanted to list fatigue as a contributing factor to the crash. The board's other two members declined, saying it couldn't conclusively be determined if fatigue had impaired the pilots' performance.
Shaw erred at the beginning of the flight by programming an ordinary airspeed into the plane's computer, rather than the higher airspeed needed for freezing weather, investigators said. The plane didn't accumulate enough ice on the wings to stall, but the mix-up on speeds caused the stick shaker to warn of a stall even though one wasn't actually imminent.
Renslow's pull-back response, however, created a stall, the board said.
Both pilots violated rules against non-essential conversation during flight below 10,000 feet, which likely distracted them at a key moment, the board said.
Colgan's pilot training program was also criticized for not giving Renslow remedial attention despite his failures on several tests of piloting skill and for not emphasizing procedures for recovering from a full stall, including how to respond to the stick pusher.
Colgan said in a statement that the pilots were properly trained in how to recover from a stall.
"We have taken a number of important and specific steps to further enhance all of our training and hiring programs," the statement said.
© The Canadian Press, 2010
http://www.cbc.ca/world/story/2010/02/0 ... crash.html
Pilot error was the probable cause of an airline crash into a house near Buffalo, N.Y., last year, but the accident's root problems extend far beyond a single event, a federal safety panel said Tuesday.
The head of the National Transportation Safety Board, Deborah Hersman, said the accident casts doubt on whether or not regional airlines are held to the same level of safety as are major airlines, and she promised the board will pursue the issue.
She also criticized the Federal Aviation Administration for taking too long to address safety problems raised by the crash, saying the same issues have turned up before.
"Today is Groundhog Day, and I feel like we are in that movie," Hersman said, referring to the 1993 Bill Murray movie about a Pittsburgh weatherman who repeatedly lives through the same day.
"We have made recommendations time after time after time. They haven't been heeded by the FAA."
The FAA said in a statement that it has driven significant improvements in pilot professionalism, training and background checks in the past year. The agency said it will soon propose new rules to prevent pilot fatigue, further improve training and increase the qualifications required to be an airline pilot.
The three-member board agreed unanimously that an "inappropriate response" by the captain of Continental Connection Flight 3407 to a key piece of safety equipment caused the crash. The board also said an incorrect airspeed entered into the plane's computers by the flight's first officer and the air carrier's inadequate procedures and training for entering airspeeds for freezing weather were contributing factors.
The board discussed issuing more than 20 safety recommendations as a result of the accident.
Hersman praised FAA Administrator Randy Babbitt for initiating regulation changes in response to the crash on Feb. 12, 2009, when the plane dove into a house, killing all 49 people aboard and one man in the house. But Hersman said Babbitt has been unable so far to push reforms "across the finish line" and that congressional action may be needed.
Flight 3407, operated for Continental Airlines by Colgan Air Inc., was approaching Buffalo-Niagara International Airport when the twin-engine Bombardier turboprop experienced an aerodynamic stall and went into a dive. The board said Capt. Marvin Renslow should have been able to recover from the stall but that he did the opposite of what he should have done.
In the final seconds
In the final seconds of the flight, two pieces of safety equipment activated — a stick shaker to alert the crew their plane was nearing a stall and a stick pusher that points a plane's nose down so it can recover speed, investigators said. The correct response to both situations would have been to push forward on the control column to increase speed, they said.
But Renslow pulled back on the stick shaker, investigators said. When the plane stalled and the pusher activated, Renslow again pulled back three times.
"It wasn't a split-second thing," NTSB safety investigator Roger Cox said. "I think there was time to evaluate the situation and initiate a recovery, but I can't give you a number of seconds."
Seventy-five per cent of pilots who had experienced the stick-pusher activation in training also responded by pulling back instead of pushing forward, even though they knew ahead of time to expect a stall, investigators said.
The first officer, Rebecca Shaw, 24, should have stepped in to push the plane's nose down herself when Renslow, 47, responded improperly, but she may not have because she was a relatively inexperienced pilot, investigators said.
Shaw commuted across the country overnight to Newark, N.J., to make Flight 3407. It's not clear how much sleep either pilot received the night before the flight, but investigators said both pilots likely were suffering from fatigue.
Hersman wanted to list fatigue as a contributing factor to the crash. The board's other two members declined, saying it couldn't conclusively be determined if fatigue had impaired the pilots' performance.
Shaw erred at the beginning of the flight by programming an ordinary airspeed into the plane's computer, rather than the higher airspeed needed for freezing weather, investigators said. The plane didn't accumulate enough ice on the wings to stall, but the mix-up on speeds caused the stick shaker to warn of a stall even though one wasn't actually imminent.
Renslow's pull-back response, however, created a stall, the board said.
Both pilots violated rules against non-essential conversation during flight below 10,000 feet, which likely distracted them at a key moment, the board said.
Colgan's pilot training program was also criticized for not giving Renslow remedial attention despite his failures on several tests of piloting skill and for not emphasizing procedures for recovering from a full stall, including how to respond to the stick pusher.
Colgan said in a statement that the pilots were properly trained in how to recover from a stall.
"We have taken a number of important and specific steps to further enhance all of our training and hiring programs," the statement said.
© The Canadian Press, 2010
Re: Buffalo Crash Likely Pilot Error: Investigators
Fotoflyer wrote: Shaw erred at the beginning of the flight by programming an ordinary airspeed into the plane's computer, rather than the higher airspeed needed for freezing weather, investigators said. The plane didn't accumulate enough ice on the wings to stall, but the mix-up on speeds caused the stick shaker to warn of a stall even though one wasn't actually imminent.
Really? Setting speed bugs has an effect on the stall warning system? Somehow I doubt it but any Q4oo guy wanna step in and correct me go ahead I'm not a know it all, I just know that on the plane I fly the speed bugs are merely for reference, so if I added 10 for turbc or windshear or icing, it would have absolutely no effect on the stall warning system.
- Troubleshot
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Re: Buffalo Crash Likely Pilot Error: Investigators
The Q400 has Ice Dectector probes that alert the crew of icing conditions and then inturn they must select the "ref speed" switch to the increase position. Not sure how much the ref speeds increase though.
When selected to the increase position the stall protection system changes its calculations.
The stick-pusher angle is calculated by the Stall Protection Module (2 modules) uses AOA, flap position, mach number, PLA, CLA, and icing status
When selected to the increase position the stall protection system changes its calculations.
The stick-pusher angle is calculated by the Stall Protection Module (2 modules) uses AOA, flap position, mach number, PLA, CLA, and icing status
Last edited by Troubleshot on Wed Feb 03, 2010 7:59 am, edited 2 times in total.
Re: Buffalo Crash Likely Pilot Error: Investigators
I have not flown the Q400, but I would assume the logic is the same as other heavy turboprops I have flown. When you select anti icing on, it changes the threshold in which the stall warning (shaker) will activate. Ergo, you will have two sets of speeds, non-icing, and icing speeds. The icing speeds will be significantly faster than non-icing speeds to account for the fact that the aoa for the shaker will be reduced.
So now if you bug non icing speeds, and have anti-icing selected on, you will be that much closer to the aoa limit for the shaker to activate. IT Does NOT mean you will stall, but you will inadvertently set off the stick shaker by flying the speed bug at the incorrect speed.
If you don't know how to recover from an approach to stall, then the outcome is obvious!
So now if you bug non icing speeds, and have anti-icing selected on, you will be that much closer to the aoa limit for the shaker to activate. IT Does NOT mean you will stall, but you will inadvertently set off the stick shaker by flying the speed bug at the incorrect speed.
If you don't know how to recover from an approach to stall, then the outcome is obvious!
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turbo-prop
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Re: Buffalo Crash Likely Pilot Error: Investigators
If they were in icing conditions the speeds are quite a bit higher then normal so if she read the wrong numbers out then they could've been about 15 to 20 knots slower then they were suppose to be on approach. Your deice boots on the dash aren't like on a king air, they are not flip the switch and boots inflate and deflate once. You turn the boots on and they automatically keep cycling until you turn them off. It takes a lot to stall a dash 8.
Re: Buffalo Crash Likely Pilot Error: Investigators
The important thing to realize is that the aircraft was not stalled or close to a stall when the shaker went off. The pilot's reaction to the shaker was to pull on the column and accelerate the aircraft into a stall. Then the f/o set the flaps to 0 which made things worse.
Re: Buffalo Crash Likely Pilot Error: Investigators
Thats one thing im surprised they didnt mention, the flaps. During the stick pusher the FO selected flaps to "0" and it wasent called for. The airplane then rolled over and it was too late. They probably mention it on the TSB's full report.
Re: Buffalo Crash Likely Pilot Error: Investigators
75% pulled back with a stick shaker?? Absolutely pathetic! Man oh Man.
King
King
Re: Buffalo Crash Likely Pilot Error: Investigators
here is the ntsb animation at 22:16 they pulled the power to idle put down the flaps/gear/props up and otherwise dirtied up the airplane, and didn't advance power until 29 seconds later, when the stick shaker activated. They screwed the pooch. RIP
http://www.youtube.com/watch?v=vMy8kZ2_ ... re=related
http://www.youtube.com/watch?v=vMy8kZ2_ ... re=related
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wallypilot
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Re: Buffalo Crash Likely Pilot Error: Investigators
very interesting video...
It's hard to believe they both missed the Low Speed Awareness creeping up on the airspeed tape.
It's hard to believe they both missed the Low Speed Awareness creeping up on the airspeed tape.
Re: Buffalo Crash Likely Pilot Error: Investigators
Ok the NTSB ruled out a tail stall.
Does anyone know if the crew had recieved tail stall training.
Pulling back adding power and raising the flaps. Sounds a lot to me like the tail stall recovery procedure NASA demonstrates in the twin otter.
I realize the flap retraction was not commanded (from the Capt) Did the crew hear the wing stall alet and fly the tail stall recovery procedure?
Thoughts?
Does anyone know if the crew had recieved tail stall training.
Pulling back adding power and raising the flaps. Sounds a lot to me like the tail stall recovery procedure NASA demonstrates in the twin otter.
I realize the flap retraction was not commanded (from the Capt) Did the crew hear the wing stall alet and fly the tail stall recovery procedure?
Thoughts?
Re: Buffalo Crash Likely Pilot Error: Investigators
Would you get the stick shaker with a tail stall? This crew was fatigued beyond tired and were in way over their heads at that time of the flight. Lack of situational awareness, lack of appropriate action, all point to flat ass tired. The brain has shut down some very important functions. It is so sad that they will now be roasted and the company can just stand back and point to crew error. What a colosal mistake by the tsb to not include working conditions in the findings.
Re: Buffalo Crash Likely Pilot Error: Investigators
Crash: Colgan DH8D at Buffalo on Feb 12th 2009, impacted home while on approach
By Simon Hradecky, created Wednesday, Feb 3rd 2010 01:28Z, last updated Wednesday, Feb 3rd 2010 01:36Z
In the Board Meeting on Feb 2nd the NTSB adopted the following 46 findings, probable cause and 25 recommendations:
Findings:
1. The flight crew was properly certificated and qualified in accordance with applicable Federal regulations.
2. The airplane was properly certified, equipped, and maintained in accordance with Federal regulations.
3. The recovered components showed no evidence of any preimpact structural, engine, or system failures, including no indications of any problems with the airplane’s ice protection system.
4. The air traffic controllers who were responsible for the flight during its approach to Buffalo-Niagara International Airport performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight.
5. This accident was not survivable.
6. The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.
7. The minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane.
8. Explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.
9. The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.
10. The flight crew did not consider the position of the reference speeds switch when the stick shaker activated.
11. The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.
12. The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.
13. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.
14. No evidence indicated that the Q400 was susceptible to a tailplane stall.
15. Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.
16. The Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, that would have facilitated the flight crew’s detection of the developing low-speed situation.
17. An aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker.
18. The captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.
19. The monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills.
20. Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.
21. Specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a pilot-in-command during air carrier operations.
22. Because of the continuing number of accidents involving a breakdown of sterile cockpit discipline, collaborative action by the Federal Aviation Administration and the aviation industry to promptly address this issue is warranted.
23. The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.
24. The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
25. All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.
26. Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base.
27. Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.
28. The first officer’s illness symptoms did not likely affect her performance directly during the flight.
29. The captain had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.
30. Remedial training and additional oversight for pilots with training deficiencies and failures would help ensure that the pilots have mastered the necessary skills for safe flight.
31. Colgan Air’s electronic pilot training records did not contain sufficient detail for the company or its principal operations inspector to properly analyze the captain’s trend of unsatisfactory performance.
32. Notices of disapproval need to be considered along with other available information about pilot applicants so that air carriers can fully identify those pilots who have a history of unsatisfactory performance.
33. Colgan Air did not use all available sources of information on the flight crew’s qualifications and previous performance to determine the crew’s suitability for work at the company.
34. Colgan Air’s procedures and training at the time of the accident did not specifically require flight crews to cross-check the approach speed bug settings in relation to the reference speeds switch position; such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning.
35. The current air carrier approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall.
36. The circumstances of this and other accidents in which pilots have responded incorrectly to the stick pusher demonstrate the continuing need to train pilots on the actions of the stick pusher and the airplane’s initial response to the pusher.
37. Pilots could have a better understanding of an airplane’s flight characteristics during the post-stall flight regime if realistic, fully developed stall models were incorporated into simulators that are approved for such training.
38. The inclusion of the National Aeronautics and Space Administration icing video in Colgan Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training.
39. The current Federal Aviation Administration surveillance standards for oversight at air carriers undergoing rapid growth and increased complexity of operations do not guarantee that any challenges encountered by the carriers as a result of these changes will be appropriately mitigated.
40. Mandatory flight operational quality assurance programs would enhance flight safety because all operators would have readily available data to identify operational risks and use in developing corrective actions.
41. The viability of flight operational quality assurance programs depends on the confidentiality of the data, which would currently not be guaranteed if operators were required to implement these programs and required to share the data with the Federal Aviation Administration.
42. The systematic monitoring of all available safety data, as part of a flight operational quality assurance program, could provide operators with objective information regarding the manner in which flights are conducted, and a periodic review of this information would enhance flight safety by assisting operators in detecting and correcting deviations from standard operating procedures.
43. Distractions caused by personal portable electronic devices affect flight safety because they can detract from a flight crew’s ability to monitor and cross-check instruments, detect hazards, and avoid errors.
44. The current use of safety alerts for operators to transmit safety-critical information is not effective because oversight and documentation of an operator’s response are not required and critical safety issues may not be effectively addressed.
45. Weather documents missing key weather products or containing products that are no longer valid prevent flight crewmembers from having relevant, readily available weather-related safety information for preflight and in-flight decision-making.
46. Detailed icing definitions that include accretion rates and recommended pilot actions would help pilots more accurately determine the icing conditions to report in airframe icing pilot reports and more effectively respond to those conditions.
Probable Cause:
The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
Recommendations:
As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
1. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers”; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring. (A-10-XX)
2. For all airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121, 135, and 91K, require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. (Supersedes Safety Recommendations A-03-53 and -54)
3. Require that airspeed indicator display systems on all aircraft certified under 14 Code of Federal Regulations Part 25 and equipped with electronic flight instrument systems depict a yellow/amber cautionary band above the low-speed cue or the digits on the airspeed indicator change from white to amber/yellow as the speed approaches the low-speed cue, consistent with Federal Aviation Administration Advisory Circular 25-11A.
4. Issue an advisory circular with guidance on leadership training for upgrading captains at 14 Code of Federal Regulations Part 121, 135, and 91K operators, including methods and techniques for effective leadership; professional standards of conduct; strategies for briefing and debriefing; reinforcement and correction skills; and other knowledge, skills, and abilities that are critical for air carrier operations. (A-10-XX)
5. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide a specific course on leadership training to their upgrading captains that is consistent with the advisory circular requested in Safety Recommendation [2]. (A-10-XX)
6. Develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures, including this accident. Obtain the input of operators and air carrier and general aviation pilot groups in the development and distribution of these guidance materials. (A-10-XX) (Supersedes Safety Recommendation A-07-8 )
7. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to address fatigue risks associated with commuting, including identifying pilots who commute, establishing policy and guidance to mitigate fatigue risks for commuting pilots, using scheduling practices to minimize opportunities for fatigue in commuting pilots, and developing or identifying rest facilities for commuting pilots. (A-10-XX)
8. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to document and retain electronic and/or paper records of pilot training and checking events in sufficient detail so that the carrier and its principal operations inspector can fully assess a pilot’s entire training performance. (A-10-XX)
9. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to include the training records requested in Safety Recommendation [6] as part of the remedial training program requested in Safety Recommendation A-05-14.
10. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide the training records requested in Safety Recommendation [6] to hiring employers to fulfill their requirement under Pilot Records Improvement Act.
11. Develop a process for verifying, validating, auditing, and amending pilot training records at 14 Code of Federal Regulations Part 121, 135, and 91K operators to guarantee the accuracy and completeness of the records. (A-10-XX)
12. Direct all 14 Code of Federal Regulations Part 121, 135, and 91K operators of airplanes equipped with a reference speeds switch or similar device to (1) develop procedures to establish that, during approach and landing, airspeed reference bugs are always matched to the position of the switch and (2) implement specific training to ensure that pilots demonstrate proficiency in this area. (A-10-XX)
13. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators and 14 Code of Federal Regulations Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a reference speeds switch. (A-10-XX)
14. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusher-equipped aircraft to provide their pilots with pusher familiarization simulator training. (A-10-XX) (Supersedes Safety Recommendation A-07-4)
15. Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded. (A-10-XX)
16. Identify which airplanes operated under 14 Code of Federal Regulations Part 121, 135, and 91K are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure in their training manuals and company procedures and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly state this lack of susceptibility and contain no references to tailplane stall recovery procedures. (A-10-XX)
17. Develop more stringent standards for surveillance of 14 Code of Federal Regulations (CFR) Part 121, 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all Federal Aviation Administration regions and 14 CFR Part 142 training centers to provide quality assurance over the operators’ aircrew program designee workforce. (A-10-XX)
18. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) develop and implement flight operational quality assurance programs that collect objective flight data; (2) analyze these data and implement corrective actions to identified systems safety issues; and (3) share the deidentified aggregate data generated through these analyses with other interested parties in the aviation industry through appropriate means. (A-10-XX)
19. Seek specific statutory and/or regulatory authority to protect data that operators share with the Federal Aviation Administration as part of any flight operational quality assurance program. (A-10-XX)
20. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their flight operational quality assurance program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the deidentified aggregate data; and (3) ensure that this information is used for safety-related and not punitive purposes. (A-10-XX)
21. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck. (A-10-XX)
22. Implement a process to document that all 14 Code of Federal Regulations Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the safety alert for operators process or another method. (A-10-XX)
23. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to revise the methodology for programming their adverse weather phenomena reporting and forecasting subsystems so that the subsystem-generated weather document for each flight contains all pertinent weather information, including Airmen’s Meteorological Information, Significant Meteorological Information, and other National Weather Service in-flight weather advisories, and omits weather information that is no longer valid. (A-10-XX)
24. Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91K operators to periodically review the weather documents generated for their carriers to verify that those documents are consistent with the information requested in Safety Recommendation [21] (A-10-XX)
25. Update the definitions for reportable icing intensities in the Aeronautical Information Manual so that the definitions are consistent with the more detailed intensities defined in Advisory Circular 91-74A, “Pilot Guide: Flight in Icing Conditions.” (A-10-XX)
The docket of public documents is available at: http://www.ntsb.gov/Dockets/Aviation/DC ... efault.htm
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CanadianEh
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Re: Buffalo Crash Likely Pilot Error: Investigators
Some excellent recommendations on the NTSB's part... now let's see if the FAA will do anything with them 
Last edited by Widow on Fri Feb 05, 2010 5:19 pm, edited 1 time in total.
Reason: to remove unneeded quote ;)
Reason: to remove unneeded quote ;)
Re: Buffalo Crash Likely Pilot Error: Investigators
Bombardier says that the Q400 is not susceptible to tail plane stalls. However it was indicated in the report that the captain was previously on the Saab, which is prone to tail stalls. In any case, I doubt that their training would have brought any of this to light.
Re: Buffalo Crash Likely Pilot Error: Investigators
VIDEO http://www.youtube.com/watch?v=vMy8kZ2_ ... re=related
Here's a good animation which includes control inputs, control settings, altitude and airspeed of the Q400 during the final moments.
Interesting to note that the power levers were never fire-walled, if the video correctly indicates.
Here's a good animation which includes control inputs, control settings, altitude and airspeed of the Q400 during the final moments.
Interesting to note that the power levers were never fire-walled, if the video correctly indicates.
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Re: Buffalo Crash Likely Pilot Error: Investigators
Between this incident(which was clearly error) and the CRJ200(same - error) the other year in Lexington, KY as well as other well publized accidents of major commuter airlines, it makes one wonder about flying on such airlines in the US of A.
Flying for me down there will be on AC/WJ/Jazz etc or I won't be going - screw that
Flying for me down there will be on AC/WJ/Jazz etc or I won't be going - screw that
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Re: Buffalo Crash Likely Pilot Error: Investigators
When I find the yoke in my lap, that's usually when I know it's a stall. But if I had an autopilot on, I was tired, I was complacent doing BS ILS approaches and turning off the autopilot in the flare, I'd probably freak out when things were wonky.
BUT I only have 250 hours or so in the log book, so I don't know shit.
I really want to armchair quarterback this one, but I won't.
I'll just make a quotable quote.
"If the autopilot kicks out, no one is flying the plane, and no one WAS flying the plane."
It's lame, and cold, but I get really upset reading on Avcanada week after week about fatalities.
Please excuse my outburst.
-istp
BUT I only have 250 hours or so in the log book, so I don't know shit.
I really want to armchair quarterback this one, but I won't.
I'll just make a quotable quote.
"If the autopilot kicks out, no one is flying the plane, and no one WAS flying the plane."
It's lame, and cold, but I get really upset reading on Avcanada week after week about fatalities.
Please excuse my outburst.
-istp
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crazy_aviator
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Re: Buffalo Crash Likely Pilot Error: Investigators
the cause of the accident was pilot error ,,contributing factor was pilot fatigue ,,,which was PILOT ERROR,,,,,,,NO ONE was forcing the pilot(s) to spend their EXTENDED time off before the flights working or becoming fatigued OR no one was forcing the pilots to IMPROPERLY use their time/resources just before the flight !!! IMHO
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turbo-prop
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Re: Buffalo Crash Likely Pilot Error: Investigators
It is when they have to go out and get a second or third job to survive. Commuting long distances cause $17,000 can't get you a place to sleep where you work. Looking on pilot central pay at Colgan for a 15 year FO is about $28,000. That is pathetic. Any operator in Canada would start an FO with more money than a 15yr FO down there. Not saying you would be in the right seat for 15 years, but even a captain only starts at $36,000. Most of the companies in Canada the FO's start making more than a first year captain.
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crazy_aviator
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Re: Buffalo Crash Likely Pilot Error: Investigators
I agree turboprop, HOWEVER, no one forced the pilot(s) to take that job /conditions or pay !! No one forced the captain to made a tragic and improper reaction to an impending stall,,,however, its possible that he could have put his ego in the box and sought remedial training etc to CORRECT his pilot errors/ability before the accident! She could have ADHERED to CRM / REGULATIONS instead of going along with a flawed culture etc etc etc .... Yes, the industry NOW needs strong re-regulation as one poster admitted , BECAUSE the pilot fraternity will NOT and CANNOT fix the problem by themselves !
Re: Buffalo Crash Likely Pilot Error: Investigators
Rant Switch.....................ON
Canadianeh, there is absolutely NO POINT in quoting huge passages verbatim! Do you think I will read the same thing all over again? What were you thinking? I'm really happy that you are happy, but spare us the pointless quotes.
Ladies and gentlemen, THE STICK-SHAKER IS NOT A STALL! It is telling you that you are in slow flight; the SPS is telling you that you are too close to the stall and if you don't speed up you will next get pusher and THEN you will stall. It is also saying: "Wake up you dork, you are not flying the airplane!" If you get pusher you MUST lower the nose or the resulting stall will be breath-taking if you recover and fatal if you don't.
The correct response to shaker is to firewall it - unless you are in an unusual attitude there is no need to lower the nose but if you do, acceleration will be faster.
Getting a stick pusher in an airliner in normal flight is much much worse than forgetting to put down the gear and if you did it (and survived) and you are not in a simulator, you don't deserve to be a pilot.
WTF did the copilot raise the flaps for? Holy smoking hole, Batman.
If this crew was so tired, sick and generally incompetent that day, they had no right being in the air; look at how their stupid decision killed so many. God help us all if this is a representative crew.
Rant Switch....................OFF
Canadianeh, there is absolutely NO POINT in quoting huge passages verbatim! Do you think I will read the same thing all over again? What were you thinking? I'm really happy that you are happy, but spare us the pointless quotes.
Ladies and gentlemen, THE STICK-SHAKER IS NOT A STALL! It is telling you that you are in slow flight; the SPS is telling you that you are too close to the stall and if you don't speed up you will next get pusher and THEN you will stall. It is also saying: "Wake up you dork, you are not flying the airplane!" If you get pusher you MUST lower the nose or the resulting stall will be breath-taking if you recover and fatal if you don't.
The correct response to shaker is to firewall it - unless you are in an unusual attitude there is no need to lower the nose but if you do, acceleration will be faster.
Getting a stick pusher in an airliner in normal flight is much much worse than forgetting to put down the gear and if you did it (and survived) and you are not in a simulator, you don't deserve to be a pilot.
WTF did the copilot raise the flaps for? Holy smoking hole, Batman.
If this crew was so tired, sick and generally incompetent that day, they had no right being in the air; look at how their stupid decision killed so many. God help us all if this is a representative crew.
Rant Switch....................OFF
"What's it doing now?"
"Fly low and slow and throttle back in the turns."
"Fly low and slow and throttle back in the turns."
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Re: Buffalo Crash Likely Pilot Error: Investigators
Between Rant on............. then Rant off. Your commentary is spot on in the opinion of this old fool!!!!
Re: Buffalo Crash Likely Pilot Error: Investigators
http://www.nydailynews.com/news/nationa ... urges.htmlSen. . Schumer (D-N.Y.) said he will press for requiring pilots to log 1,500 hours of flight time to get a commercial pilot's license. Sen. Kirsten Gillibrand (D-N.Y.) said she will sponsor a Flight 3407 Memorial Act to make NTSB safety recommendations mandatory.
Another really cool Kirsten
Former Advocate for Floatplane Safety
Re: Buffalo Crash Likely Pilot Error: Investigators
+1Old fella wrote:Between Rant on............. then Rant off. Your commentary is spot on in the opinion of this old fool!!!!
Thanks XS for braving your observations .It may save someones life in future




