Tuesday, May 19, 2009

Thirty Minutes of Distraction

At 22:16:27.4 EST on February 12th, 2009, the crew of Colgan 3407 experienced a stick shaker activation. They were hardly the first crew to do so; although one wouldn't describe a stick shaker as a common event, it's not unheard of either. A stick shaker is a warning, a clear and unmistakable message to watch thy airspeed lest the ground come up and smite thee. Most crews in this situation heed the warning and take appropriate action, and the only subsequent danger is to their careers. For reasons that will remain unknown to us but possibly include some of those delineated in my previous post, this crew did not take the correct action, and paid the ultimate price.

The fact that the fate of this crew and their passengers was determined by their response to the stick shaker, and the fact that stick shaker activations usually have happier endings, does not mean we should not examine the circumstances that led to the stick shaker activating in the first place. There are more lessons for the average pilot here than there are in the ultimate cause of the accident. Most of us find it very hard indeed to imagine pulling back on the yoke in response to a stall warning, but a great many of us have found ourselves distracted at a critical moment of flight.

If the CVR transcript did not have timestamps, an experienced pilot's first impression upon reading it would be how utterly normal the conversation contained within it was. They talk about the aircraft logbook, reminisce about past flights and old airplanes, discuss upgrades and future career plans, talk about favorite air traffic controllers, and discuss their respective experiences in icing conditions. Even the First Officer's now-famous statement about her lack of previous experience in IMC and icing, taken in its entirety and without interruptions, isn't nearly so scandalous as it's been made out to be:
"Yeah, that's another thing. All the guys— @ came in when we interviewed and he said 'Oh yeah, you'll all be upgraded in six months into the Saab' and blah ba blah ba blah, and I'm thinking, 'You know what? Flying in the northeast, I have sixteen hundred hours. All of that in Phoenix.' How much [actual] time do you think I had, or any in ice? I had more actual time on my first day of IOE than I did in the sixteen hundred hours I had when I came here...I'm not even kidding. The first day! All these guys are complaining, they're saying 'you know how we were supposed to upgrade by now' and they're complaining; I'm thinking, 'You know what? I really wouldn't mind going through a a winter in the northeast before I have to upgrade to captain. I've never seen icing conditions. I've never deiced. I've never seen any— I've never experienced any of that. I don't want to have to experience that and make those kinds of calls.' You know, I'd have freaked out. I'd have like seen this much ice and thought 'Oh my gosh we were going to crash.'...but I'm glad to have seen, oh— you know, now I'm so much more comfortable with it all."
This is the stuff that cruise conversations are made of. This portion of the conversation, however, did not take place at cruise. They were at 4000 feet, and later descending to 2300 feet, on vectors for the approach. Indeed, the last lines of the conversation - from the Captain - were spoken only two and a half minutes prior to stick shaker activation. As even many private pilots know, this is a major violation of FAR 121.542, which states:

(a) No certificate holder shall require, nor may any flight crewmember perform, any duties during a critical phase of flight except those duties required for the safe operation of the aircraft. Duties such as company required calls made for such nonsafety related purposes as ordering galley supplies and confirming passenger connections, announcements made to passengers promoting the air carrier or pointing out sights of interest, and filling out company payroll and related records are not required for the safe operation of the aircraft.

(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft.

(c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight.

One of my commenters in the previous posts noted that nearly all of the conversation below 10,000 feet was at least nominally about icing - which the aircraft was accumulating - and interpreted the FO's statement as being a very passive, beat-around-the-bush way of suggesting to the Captain that she wasn't comfortable with the icing and that he should do something about it or at least reassure her. Perhaps. I personally think that the conversation as a whole was decidedly "nonessential," to use the regulation's wording, but this will no doubt be argued back and forth to exhaustion by the various parties' lawyers.

In his testimony at last week's NTSB hearings, Captain Rory Kay of ALPA's Executive Air Safety Committee pointed out that there is the letter of the regulation, and then there's the intent of the regulation. The intent was clearly to minimize distractions at times when the crew needed to focus on their duties, and there are duties to be completed above 10,000 feet. Some airlines actually call for sterile cockpit below 18,000 feet; Captain Kay noted that he personally also enforces it during any climb or descent. To my mind, the most troubling thing about the Colgan crew's chatter was not that some of it took place below 10,000 feet, but that it was fairly incessant throughout the short flight and it does seem to have impinged upon other things that needed to get done. The descent and approach checklists were both skipped until quite late in the flight, three minutes before the upset as the crew descended to 2300 feet on a base leg for the approach. Both were hammered out in the space of twenty seconds, and one critically important item got glossed over: speed bugs. Even as the crew interrupted a discussion on the perils of icing to do their approach checklist, there was no discussion of what effect that icing would have on their approach speeds. They bugged a speed that was twenty knots too slow.

Distraction likely wasn't the only culprit here. I don't doubt that fatigue - and a possible head cold on the FO's part - made the crew less sharp than they might've been. Reading through the NTSB's post-accident interviews, it is also clear that there was a lack of guidance and training at Colgan concerning the use of deice equipment and appropriate icing speeds. Most of the crewmembers interviewed were vaguely aware that the Ref Speeds switch changed the parameters at which the stall protection system activated, but could not give specifics, and there was no consensus on when exactly it could or should be turned off for landing. Likewise, when asked about when one would use a Vref-ice speed, the answers were varied, few matched Colgan's guidance, and none tied it to the use of the Ref Speeds switch, which in fact decreases stick shaker activation from 12 degrees angle of attack to 8 degrees. All of this was hammered home repeatedly in initial and recurrent training at Horizon; I suspect they had a few stick shaker activations of their own in the Q400's first year or two. It was a deficiency that was clearly not picked up on or acted upon by Colgan management. In fact, less than a month after Colgan 3407, another Colgan crew experienced a stick shaker on approach to Burlington, Vermont. Again, the ref speeds switch was selected to INCR, and they were using non-icing speeds (in this case, they really were well out of icing). This crew wasn't sick or fatigued, and there was no sterile cockpit violation; they actually had a check airman in the jumpseat conducting a line check.

Using non-icing speeds with the ref speeds switch at INCR will not, by itself, set off the stick shaker; it just considerably decreases the margin between Vref and the low speed cue. Unlike the Burlington incident, this was not a case of simply getting a few knots below Vref. In this case, the airplane was level at flight idle and a high-drag configuration from 170 knots down to 126 knots with no interference from the Captain. There are really two possibilities here: that the Captain really was intending to go straight to the Vref of 118 knots and simply called for Flaps 15 too late, or his attention was diverted elsewhere at the time and he didn't see the airspeed get low. I think the latter is more likely than the former: you seldom plan to fly the entire approach at Vref, and looking at the PFD would have made it painfully clear that Vref would put him under the low speed cue without a configuration change. If he wasn't looking at the PFD, though, nobody knows for sure why. You can't blame it directly on the chatter; all conversation had stopped by then. It's clear that he was distracted at a critical moment, though, and there had been a pattern of distraction through the last thirty minutes of the flight. While the violation of sterile cockpit didn't directly cause this accident, I personally think that it was merely one of many holes that lined up at the wrong time (think swiss cheese model).

The only reason I devote an entire post to it is because I do think it's a hole we allow to line up way too often. Most of us, in our most honest moments, will admit that sterile cockpit is not always followed as strictly as it should be. It's generally not willful disobedience, it's usually a matter of letting a few words slip out before remembering that you're below 10,000 feet. The other crewmember will usually reply with a grunt, a few words, or silence, but very rarely with an outright challenge. I've been as guilty of this as anybody. Nobody wants to be known as the "mean Captain" who jumps all over his First Officers for minor slipups. The problem is that not strongly enforcing the rule creates a culture of acceptance. Although the violation might not have been egregious, ignoring it means that when we get two "Chatty Cathy's" flying together, there isn't an cultural taboo that makes them clam up when they should.

From my time jumpseating and from talking about this to fellow pilots, I do think this problem is more acute at the regionals than it is at the majors. The accident record certainly paints that picture. Of the last three regional airline accidents, violation of sterile cockpit was a factor in two, and was also present in the third as one of many manifestations of wildly unprofessional behavior throughout the flight. You have to go back a ways to find a major airline accident in which it was a factor. Why the difference? Some can probably be attributed to differences in age and maturity level, some to the majors' longer stage lengths that provide more time for conversation in cruise. Ultimately, though, I think it's a difference of culture.

The last thirty years have seen a real transformation of the major airlines to where a culture of professionalism prevails. Deviation from standards and regulations is simply not tolerated. The hiring process has changed to emphasize CRM skills and professional attitudes over stick and rudder skills. Management, primarily those in flight operations and training, has helped set the tone by seeking out negative trends and addressing them early on. You do not see this sort of proactive safety culture at all of the regionals, or even at most of them. There is a reason that many major airline pilots will not let their families fly on regional airlines. I myself have prohibited my parents from non-revving on certain carriers.

Don't get me wrong, there are a great many excellent pilots who exhibit the utmost professionalism at the regional airlines. The airlines, however, do not go out of their way to attract and retain these pilots, or give them superior training, or provide them with the support they need to do their jobs well. Nor have they done a stellar job of weeding out weak pilots, or those with poor judgement, or those who simply need more experience. Most of all, they give safety a lot of lip service and always proclaim in to be their first priority, but in reality they seek the highest level of safety that is possible without raising costs.

But I'm getting ahead of myself. There were a lot of holes that lined up in this accident, and some of them were lined up by airline management and their enablers over the past years; they deserve their very own post, which will be my last concerning Colgan 3407. This cannot obscure the fact that there were several holes that were lined up by the crew's own action, and they are holes that all of us who consider ourselves professional pilots must be on our guards against.

18 comments:

Anonymous said...

Very good post! Your blog is quickly becoming a must read. Keep up the good work. On another subject, did you fly yesterday? That runway configuration (22 and 17, depart 12r) is what we'll be using when 12l/30r closes for repair this summer.

LT

Anonymous said...

I think the Captain may not have let a male co-pilot babble on like that. The co-pilot was cute, he was distracted.

Dave said...

Sam - the blog is fantastic. Thanks for taking us inside this world.

I would be very interested in the list of regionals you recommend avoiding...could give you an email to send them to if you want to avoid posting it...

Sam said...

LT - yeah, got to hold over TARGT for a bit. I suspect it's gonna be another fun summer like two years ago when 30L/12R was closed. I wasn't based in MSP at the time but heard about it and saw it from the jumpseat a few times. Ugh.

Anonymous - that's reaching a bit beyond speculation and into the area of character assassination after the guy is dead. A lot of other FO's testified to him being an extremely friendly guy.

Dave - go to airlinepilotcentral.com and look at some of the payscales. There is a pretty direct correlation between those who pay their pilots poorly and those who refuse to spend money on other, more important things. You'll quickly get an idea of which carriers that I refuse to let my parents fly on (and those I avoid myself whenever possible).

In the spirit of full disclosure, I flew on one of them last year because they were the *only* way to get from Denver to Aspen so I could pick up the BMW motorcycle I was getting a killer deal on. I talked to the Captain for a while; he was a greybeard. I was trying to decide whether he just had poor career timing and ended up becoming a lifer at the world's crappiest regional or if was so clueless that he couldn't get hired anywhere else. In the end I took the flight and obviously survived. The reality is that your odds on these carriers are better than surviving your drive to the airport. I prohibit my parents and wife from flying them for my own sake: I couldn't live with myself if anything happened to them when I knew what I know about some of these operators.

mlesser said...

Hey great post.
I dont know about what experience in the USA is, but at least in Australia, most regional and major carriers have pilots that have minimum an ATPL and 500 multi engine command. I guess Australia has such a huge GA market that pilots with experience are easy to come by. I have over 1000 hours and am still very junior in the scheme of work and getting other jobs.

I dont know if im rambling on about unrelated things, but it seems weird to think someone with 1600 hours of flight instructing was allowed in the right seat of a dash 8 in those conditions. I guess with the right training they are as good as anybody, but it seems a but crazy in my eyes.

Anyway good post and i enjoyed reading it, although i dont know a whole lot about the US system or the company involved.

Mike

Sarah said...

'course you meant you held over TRGET.
My house is 2 miles inside SNELL on the 22 approach and with the high south wind I got to enjoy some traffic recently.

Which reminds, me, I've wondered who gets to make up the names for fixes, SIDs and STARs. Some are obvious geographic references but others show some local knowledge and are sometimes pretty funny.

You've got the fauna. SKETR. You've got the sports teams. WILDD, TWOLF. TWINZ Players. KBREW. I like "HRBEK" ( didn't even have to drop vowels for that one ). DOKTR on the way to Mayo. YESUR (?)

Anonymous said...

I like how the ones around Orlando are all disney related

Dave said...

Thanks for the info. Yep, obviously, flying is far and away safe, regardless. Just interesting to see who's not so great.

aviatorpr said...

i hope you aren't taking a stab at RedCo's crj200 operators. excellent pilots who are unfortunately underpaid and deserve a fair contract now!

Sam said...

Mike- The crazy thing is that with 1600 hours, the FO was a "high-timer" for Colgan when she was hired.

AviatorPr- If you're referring to the second-to-last paragraph, there are a number of regional airlines it applies to (and some of it applies to my own airline). The description fits the airline you mention as well as any, though. Agree the pilots are underpaid and a fair contract is long overdue, but they do NOT work for an excellent operator.

Sarah- from what I understand, local controllers get to name the fixes. They have some good ones around here.

Anonymous said...

controllers only offer names to the office that actually "builds" the procedures. for this area we use an office in battle creek mi. they are connected to the same office that do the flight inspections (call sign flight check) of navaids, sids/stars and terrain/obstacle clearance.

LT

regular reader said...

Enjoy your blog, but...
"I myself have prohibited my parents from non-revving on certain carriers." is a complete cop out.

Tell us who they are, or report them to the FAA, don´t let us dangle wondering.

Anonymous said...

what does it mean when, in the opening paragraph, you said, "the only subsequent damage is to their careers." implying, that, if indeed a stick shaker does go off, even if the pilots take the appropriate action and avoid disaster, they will still be reprimanded/fired/executed? please elaborate...

Sam said...

Regular Reader - a cop-out, perhaps. My reluctance to be more specific is partially a product of wishing to remain employed in aviation, and partially recognition that my aversion to certain carriers is due to my greater familiarity with them than other airlines. The reality is that statistically, even these airlines are nearly as "safe" as the majors and a great deal safer than various everyday activities, not to mention riskier leisure activities I myself partake in like skiing and motorcycling. Like I said, the reason I prohibit my family from non-revving on them is because I have friends who fly for them and I've heard enough dirty laundry that I'd not be able to live with myself if something did happen to my family on those airlines.

Anonymous 5:16 - It really depends on the circumstances and the airline. If it's something like simply getting a few knots slow and then having a wind gust set the stick shaker off for a second or two, it's likely nothing will come of it even if reported by the pilots. In a case like this, where the crew lost a ton of airspeed in level flight and neither noticed or said anything, there'd likely be consequences. At a few airlines this might involve suspension or firing, but at most, there'd be some retraining in the sim and this training would be more "at risk" than your average proficiency check. The FAA could also get involved, and depending on the circumstances they could take action ranging from a letter in your file to certificate revocation.

One thing that could impact what action is taken is just how the airline became aware of the stick shaker activation. If it's self-reported by the crew through ASAP, they'll likely get off lighter. Doing it on a line check with a check airman in the jumpseat, as was the case in Colgan's BVT incident, is a lot less favorable. Some modern airliners including the JungleBus also "snitch" to the company whenever you exceed certain parameters.

Regular reader said...

I fully understand your position, and am trying very hard to respect it. I certainly respect your right to feed your family above all.

"I have friends who fly for them and I've heard enough dirty laundry that I'd not be able to live with myself if something did happen to my family on those airlines."

I guess the question would be, will you be able to live with yourself if something happened to MY family on those airlines?

I really am not trying to be a pest, and I promise this will be my last comment on the issue.

Really enjoy and appreciate your blog by the way!

Sarah said...

Sam, have to applaud (again) your series on the Colgan 3407 accident. The level of detail and insider insight is most appreciated. Be careful or you'll be called by NTSB or Congress to testify. :)


I have a related question about SOPs. I understand each carrier makes up their own, is that right? In simple private flying we've got our own call outs, but not 2-pilot interlock litany like this 'I Will'. I suppose the manufacturer supplies various checklists, but these procedures seem to be more like "when to run the checklist".

Sam said...

Regular Reader:

Mesa, Pinnacle, Colgan, GoJet, Trans States.

There were a few other airlines I was queasy about in 2007 but their experience levels have jumped significantly since then. My concerns with the above go well beyond pilot experience; I'm primarily concerned with abusive and inept management that wouldn't know a safety culture if it bit them on the bum.

I'll expect you to contribute to my legal defense fund when this comment ends up as Exhibit A in some courtroom.

--Sam

Regular reader said...

Dear Sam,

Thanks, you are a stand-up guy.

I sincerely doubt you will need (or want) my legal help. But if you do, just post it here, and I will come running.

I understand, and I think everyone else will too, that the problems are systematic, NOT with the pilots flying for those carriers.

Thanks again, and go ahead and delete the post if you think it wise.