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.