Thursday, May 28, 2009
So stated a press release that Colgan Airlines released on the first day of the NTSB hearings into Colgan 3407. In an effort to limit the damage to their reputation, Colgan was quite willing to throw their deceased crewmembers under the bus. In the hearings, Colgan management was evasive and defensive, attempting to ward off every suggestion that culpability for this accident might not begin and end with the two individuals not there to defend themselves. In doing so, Colgan management came off looking like rank amateurs.
Nobody can deny the kernel of truth within Colgan's statement. This crew did undoubtedly make a number of serious mistakes, some commonplace and others nearly inexplicable, which compounded on each other and resulted in tragedy. Yet these mistakes did not take place in a vacuum; there were a number of circumstances that may have contributed. In my previous posts I have explored how latent training errors and self-induced distraction may have been factors. Any serious look at this accident must also examine the regional airline industry itself for widespread patterns and trends that helped create the right environment for an accident like this.
At the time of the accident, the Captain had approximately 3300 hours of flight time and the FO had 2300 hours. By most airlines' standards this was an inexperienced crew, but they actually weren't horribly inexperienced compared to some of the crewmembers at the regional airlines. At airlines like Colgan, Pinnacle, and Mesa, in the not-so-distant past one could find 2000-2500 hour new Captains paired with 250 hour newhire First Officers. Worse yet, the Captain might be new to not only the left seat, but the airline and their routes as well; all three of the above companies hired direct-entry Captains. This was because they did not have enough First Officers qualified to upgrade due to a combination of growth, attrition, and their newhires' low flight time. Captain Renslow had 625 hours total time when he was hired at Colgan. First Officer Shaw, with sixteen hundred hours of fair weather flying in mostly single-engine piston aircraft, was actually a "high-timer" for the period in which she was hired.
Colgan testified at the NTSB hearing that a particularly favorite source of pilots is an institution known as Gulfstream Academy; they hired Captain Renslow from there. This "academy" is actually a functioning Part 121 airline in Florida that flies as Continental Connection. Brand-new commercial pilots pay $30,000 to buy a "job" as a First Officer on a Beech 1900 turboprop. Few of Gulfstream's paying passengers have any idea of their crew's extreme inexperience. After 250 hours on the line, these pilots are hired via bridge programs at airlines like Pinnacle and Colgan. They are a management dream: too inexperienced to be hired anywhere else, possessing some airline time to make training go smoother, and willing to work for any wage that's an improvement on paying bucketloads of money for their job.
What these pilots do not have is the experience of taking over the controls from a student who has put the airplane in danger, or having scared themselves straight on a low approach in a decrepit old freighter - or for that matter, having practiced hundreds of successful stall recoveries. Gulfstream portrays this as boring, useless timebuilding to potential enrollees looking for a shortcut, and a certain class of airline management enthusiastically agrees. After all, the modern regional airliner is relatively idiot-proof. If management could hire monkeys to fly them, they would - provided the price of bananas did not go too high.
The noteworthy thing here is that not all airlines stooped to hiring low-time pilots from the likes of Gulfstream. There were plenty of experienced pilots to be had but for a modest price. Despite paycuts and gutted contracts and seniority list stagnation, the major airlines were flooded with resumes from supremely qualified candidates when they began hiring again. It was the regional airlines, with their inferior pay, benefits, schedules, and work rules, who had to settle for pilots with little aviation experience, and a particular class of regional that struggled to fill their classes despite no hiring standards at all.
Here's a real-life example of how Colgan's low pay deprives them of experienced pilots. In the summer of 2007, I briefly considered applying to Colgan. With 4500 total hours and 2200 hours in the Q400, I would have been much more qualified than the average newhire. I chose not to apply because of Colgan's insultingly low pay rates and lack of work rules or union protection, and because the airline's cheapness in compensation bespoke a cheapness in other areas to me.
Training is a perfect example. Like many regional airlines, Colgan has sought to decrease training costs through outsourcing (to FlightSafety), shrinking their training footprint, and allotting a minimum number of hours for Initial Operating Experience (IOE). Colgan's pilots, and those of many regional airlines, are taught by sim instructors who often have never touched the actual airplane, and usually teach for several airlines with differing procedures. Ground instructors may have never flown any airliners! Is it any surprise that Coglan pilots were a little hazy on the significance and proper usage of the Ref Speeds switch? After sim training, Colgan pilots were given 30 hours to complete IOE; any more required approval and invited unwanted scrutiny. That's not very much for inexperienced pilots learning a rather quirky airplane. At Horizon you could go to 50 hours without them batting an eye, and ANA actually requires 70+ hours for their pilots. Sure, you can hammer out the basics in 30 hours, but that doesn't leave much time for a check airman to impart the nuances of the airplane - like, for example, "Be particularly mindful of your airspeed when you put the gear down and the props to 1020, there's a ton of drag and you can get too slow very quickly if you don't pay attention."
Hiring woefully inexperienced pilots and rushing them through training is bad enough; subsequently operating under policies that encourage them to fly sick and/or tired is simply asking for trouble. Unfortunately, many regional airlines including Colgan do just that. It's another side effect of a mentality that stresses cost savings above all else and pretends there are no negative consequences for safety in doing so.
Most regional airlines operate with fewer pilots per airplane than the majors. This is partially a result of differing stage lengths, regulations, and contract work rules, but many regional airlines also intentionally short-staff themselves as far as they can and still maintain schedule integrity. Low-paid regional pilots who are trying to build hours can generally be depended upon to pick up plenty of overtime, after all. The problem is that running so close to the edge means that a few months of high attrition or recruiting difficulties can make the airline severely short-staffed in perpetuity. Pilots suffer the most under these conditions: their schedules get built to the maximum limit, they have fewer days off to recuperate between trips, and even those days are subject to "junior-manning" as desperate crew schedulers force pilots to work on their days off. A few bad months can leave one feeling chronically fatigued. A long or difficult commute only makes things worse.
Many people have correctly noted that it is a pilot's own choice to commute. This is a decision most pilots will make a few times throughout their career, and it's never easy. I chose to leave a city and area I love dearly in order to avoid a notoriously bad commute, but my choice may have been different if Dawn and I had family in Portland, or had kids in school, or if the cost of living in my base was higher. The Seattle-Newark commute has to be one of the worst out there; the FedEx Captain who gave FO Shaw her last ride to work told her as much. Her choice to move to Seattle was apparently sparked as much by financial considerations as personal ones. Ms. Shaw was barely able to make ends meet in Norfolk by holding down a second job as a barista, so New York was clearly out of the question. She and her husband had moved to Seattle to live with her parents, at least initially.
From the multiple yawns noted on the CVR transcripts, it's likely the crew of 3407 was tired. One can understand why: it was after 10pm, they'd both been up very early, and the FO likely had very little quality sleep the night before. Moreover, they'd spent the entire day in the crew room due to a cancelled roundtrip. In my own experience, this is more tiring than actually flying, especially if there's no dark and quiet place to sleep. Most airlines provide such a place near their crewrooms, but not Colgan: they actually left the lights on full-time to discourage pilots from sleeping!
The FAA is quite clear that crewmembers must be fit to fly, and must remove themselves from duty if any condition, including fatigue, would impact their performance. Virtually every airline has a fatigue policy in their contract or FOM. How they actually administer that policy, however, varies widely by airline. At most majors, calling in fatigued is a non-jeopardy event; some even let you use your sick time. At Colgan and many regionals, calling in fatigued results in loss of pay and potential disciplinary action. Fatigue calls are usually tracked and monitored for any "patterns" of fatigue, which is left up to management's discretion and may be a mere two events. Besides the threat of discipline including termination, unscrupulous managers have been known to force fatigued pilots to undergo sleep studies during unpaid time off, or even report them as chronically fatigued to the FAA's aeromedical division. Such scare tactics are meant to cut down on "absenteeism" which threatens schedule integrity at chronically understaffed airlines. The practical effect is that pilots will often just fly tired in all but the worst cases. Most of the time they make it to their destination without incident and the airline can justify their policies as being "safe."
A similar story plays out in the realm of sick call policy. Again, the airlines' policies, ostensibly in place to prevent schedule disruption due to sick time abuse, having a chilling effect on the proper use of sick time as well. To begin with, sick time accrual at many regionals is agonizingly slow. In Colgan's case, it takes a newhire nine months to accrue enough sick time to cover a four-day trip. A newhire already at poverty-level wages can ill afford an unpaid week. Secondly, sick calls are often handled in the same paranoid manner as fatigue calls. Calling in sick at many regionals prompts personal questions from crew schedulers and follow-up calls from chief pilots. If you're unfortunate enough to fall ill on a holiday, around your vacation, or even on a weekend, they'll often demand a doctor's note - procured at your own expense under often-inferior health plans. Mind you, there are many things that a pilot should call in sick for that don't require a visit to the doctor and can usually be handled with rest and OTC medications; FO Shaw's head cold comes to mind. If their policies result in such a marginal pilot deciding to fly, management doesn't seem to mind. At least the schedule gets covered, and it's pretty rare that a sick FO fails to notice her Captain doing something disastrously boneheaded.
It's easy to vilify regional airline management for this behavior, but the reality is that it is generally borne of financial necessity rather than a perverse hatred of pilots or the pursuit of personal enrichment. Regional airlines live and die by their cost structures because the major airlines they contract with have made it this way. Virtually all regional airline management is cheap; the main difference between them is the degree of their aggressiveness in cutting costs and how vile they're willing to be to their employees. The most foul - i.e., the most cheap - have reaped the most growth in recent years as they lap up contracts with major airlines. In the case of Colgan, this came in the form of 15 Q400's to be flown as Continental Connection.
Now, the major airlines do have certain performance metrics that must be met along with the baseline requirement of low cost - witness Mesa's fall from grace - but otherwise the majors generally leave their regional airline partners to their own devices. They don't concern themselves with hiring practices or minimum experience levels, training programs, or sick and fatigue call policy. They generally are not involved in whatever safety programs the regional airline participates in. In short, by their silence they endorse regional managements' view that penny-pinching in every aspect of the operation doesn't impact safety so long as everything is legal. Of course, when a regional partner suffers a crash, the majors are very quick to point out the actual identity of the carrier involved. It's a convenient about-face after selling the victims a ticket with their name on it and festooning the outsourced airplane with their livery. Those passengers likely expected a mainline standard of safety, but only after an accident does mainline fall all over themselves to explain just how little they had to do with the operation of that flight.
The circle of blame for this unholy situation only expands outward from there. You can include the Congress of 1978 for deregulation, subsequent Congresses for lack of oversight, the FAA for turning a blind eye to the regionals' most abusive practices, pilots for being willing to take such low-paying jobs in hopes of an eventual payoff, and so on. Ultimately, though, what we're seeing is the free market at work. The situation exists because it benefits all of us as a collective group of consumers. Passengers are paying less, in real dollars, than they've ever paid to fly, and they still think they're getting stiffed. Improving safety would require increasing fares, and passengers are utterly unwilling to pay more (if you doubt me, read some of the comments here). While the flying public always make concerned noises about aviation safety, most people know enough basic math to reason that even if the regionals are more dangerous than the majors, the accident rate is still so low that there's a miniscule chance of ever being personally affected. Why spend more money for something that won't affect you? The logic isn't flawed, but it does need to be followed to its ultimate conclusion for real moral clarity on the situation: I am willing to let others die so I can save a few bucks.
As collaborators get the innermost circle of hell to themselves, I've waited to the end of this post to write about one particular group's culpability in creating the environment that fostered this accident: our very own Air Line Pilot's Association. This may come as a surprise to some of you, as I've defended airline unions on this blog before and have noted that I am active within the union. I still maintain that unions are necessary in this industry to guard against management's worst tendancies, but I fully recognize that ALPA has been utterly clueless on the matter of outsourcing and in fact fully cooperated with management in creating the two-tier system we see today when it benefitted them. Having bought into management's stance that regional jet feed was necessary for mainline growth but could not be operated cost-effectively with the payrates that mainline pilots expected, ALPA's mainline MECs declined to fly the first wave of RJs but gladly shared in the revenue they produced. They didn't concern themselves with the question of who would fly those RJs or under what conditions. When regional pilots unionized - often under ALPA - and attempted to better their lot, they got little help from their mainline counterparts. ALPA granted management scope relief after scope relief, but there was never any insistance on requiring that ALPA pilots fly the RJs, or setting a minimum standard contract, or at least insisting on some oversight of the outsourced operation's safety programs. All these things were determined to be the regional pilots' problems, despite the fact that any attempt to solve them, like the Comair strike in 2001, only made mainline shift flying to other, cheaper carriers.
Even after everything that's happened since then, this mindset is still quite prevalent at ALPA. A few months ago I was involved with a group of WidgetCo pilots in a grassroots effort to force their union to at least study the feasability of recapturing 76-seat flying. Just before a meeting of the union's Atlanta council, we were called into a meeting with the MEC chairman. He rejected the idea of recapturing outsourced flying outright, saying it would be too expensive and there would be no benefit for the majority of the membership. He said not to worry about scope, that ALPA was done giving up scope (this was a few days after he had granted scope relief to increase the allowed number of 76 seat airframes!); he then stated that outsourced flying was good for mainline pilots because the low cost flying brought in revenue they shared in. This is coming from the popular union head of the world's largest airline, and a likely future candidate for ALPA's presidency. I left that meeting utterly shaken that ALPA would or could be part of the solution to the mess we're in, at least in its current form.
If anything is going to change, it will likely come through the legislative response that has already begun in response to the Colgan hearings. Randy Babbitt, the FAA's new administrator, is much more favorable to changing duty and rest regulations than previous administrators have been; meanwhile the Senate's Aviation Subcommittee is going to be holding hearings into working conditions and safety at the regional airlines in early June. It'll be interesting to see whether any substantial legislation actually emerges from the process. In the meantime, those of us at the regionals can do our own little bit to keep our airlines safe, whether that means enforcing cockpit discipline, making an active effort to refresh our knowledge of systems and procedures, or standing up to management intimidation when we shouldn't be flying.
Tuesday, May 19, 2009
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:
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.
(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.
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.
Friday, May 15, 2009
"Three thousand for two thousand."
It was a dark night; the landing lights lit up the thick layer of clouds slipping rapidly around us. The plane bobbed rhythmically in light turbulence as we descended at flight idle power. Paul, my First Officer, slid his seat forward and cleared his throat.
"I was talking with what's-his-face the other day, our ALPA communications guy."
I looked over at Paul. "Yeah? What about?"
"Advertising. It occurred to me that we could do a much better job of getting out our message to the general public."
"So why don't we put out some ads that capture people's attention?" Paul continued. "I was reading a magazine the other day, and there was this really brilliant ad. It featured a lovely voluptuous young lady, and she didn't have any clothes on - this was taken from the back, mind you - but this ad was for -."
PPPPPRRRRRBBBBBBBBTTTTTTT! DING DING!
The cockpit erupted into a cacophony of alarm horns and lights as the autopilot disconnected and the yoke began vibrating furiously. I snapped back to the instruments to find the airspeed dangerously low and the torque still at idle. I grabbed the yoke and shoved the power levers forward. "Set power!" I commanded.
It was obvious what had happened, we had leveled off at 2000 feet during the conversation without me noticing and bringing the power back up. Now, with the engines at full power, the airspeed stopped decaying and started creeping back. The stick shaker stopped momentarily.
"Altitude!" Paul called out.
Crap, we had drifted below 1900 feet. I applied some back pressure to the yoke. PPPRRRBBBBTTTT - the stick shaker started up again and the wings began a light burbling back and forth. Ish, don't want that. I eased the back pressure and gingerly nursed the altitude back to 2000 feet. The airspeed finally crept up to a safe number and I started breathing easier.
Fortunately for my career, this incident took place in a SF340 simulator rather than the JungleBus, and my "First Officer" was actually the director of training for a well-known regional airline. This company does stall training completely differently from most airlines, and in the aftermath of Colgan 3407 and Turkish 1951, Paul invited me to fly their jet and turboprop simulators and experience it for myself. We did departure stalls just after departure, approach to landing stalls while approaching for landing, and high altitude stalls at high altitude. A great many stick shaker events in the real world involve distraction at a critical time while on autopilot, so we did the scenario described above. While all of this might seem quite logical to an outsider, it is actually a revolution in the airline world. Moreover, it is done in apparent contravention of the FAA's Practical Test Standards.
In the last few days, a great many pilots - including some of the commenters on my last post - have been asking what in the world could possess a presumably competent airline pilot to pull up in response to a stick shaker - or for that matter, to use 80 to 120 pounds of force to override the stick pusher that might've saved his life. It's the most puzzling aspect of this crash. Even if the crew was relatively inexperienced, it is drummed into pilots from day one that you don't pull up in response to a stall. What could cause an airline pilot to abandon this most elementary of precepts?
Even if the pilot did survive to answer for his actions, I'm not entirely sure that even he could've given a satisfactory answer to the question. Since he is not around, all we - or the NTSB - can do is speculate about some of the possible culprits and do our best to eliminate them as potential causes of future accidents. There are three primary possibilities that have been discussed: 1) the Captain was a poor pilot to begin with; 2) he simply got confused in the heat of the moment; 3) there was some latent defect in his training. These are not mutually exclusive theories, all three could have come into play simultaneously.
By now it has been widely reported that the Captain failed five checkrides in his career. The first was his instrument checkride, back in 1991, on the partial-panel VOR approach and the NDB approach. He disclosed this failure on his application at Colgan. The next two failures, on his Commercial-Single Engine and Commercial-Multi Engine rides, took place in 2002 and 2004 respectively, and were disapproved for a fairly wide range of tasks. He only disclosed the instrument ride failure on his application. At Colgan, he failed a recurrent Proficiency Check as a First Officer and his upgrade/ATP ride. He also had to repeat a small portion of his initial PC as a new FO in the SF340.
There are a great many capable pilots who have a checkride bust or two in their past, but a long string of them raises warning flags. The interesting thing is that when you read through the NTSB Human Performance Group's interviews, everyone describes Captain Renslow as a good, consciencious pilot. Many FOs he flew with described him as above-average. Perhaps it's simply a case of not wishing to speak ill of the dead, but if he really struggled on the line you'd think the NTSB could've found someone who would have told them about it. It's hard to reconcile the popular Captain with all the checkride busts. It's possible that he simply wasn't a good test taker. That's not insignificant for our purposes: falling apart on tests can be a symptom of not coping well with pressure, period.
There was plenty of pressure to be had in the last thirty seconds of Colgan 3407. That the stick shaker was a complete surprise is self-evident. We don't know where the Captain's attention was in the moments before stick shaker activation; perhaps looking at the wingtips to see how the deice boots were coping, perhaps around the cockpit to see if anything had been missed during the rushed descent and approach checks. Maybe the long day had got to him and he was simply zoning out. It doesn't really matter; it's very unlikely he had any clue that the stick shaker was coming before it went off. It is difficult to explain to those who have never flown airplanes with stick shakers just how jarring their activation is - even in the sim, much less the real world. The whole idea behind them was to have one signal in the cockpit that is so overpowering and unmistakable that the crew cannot possibly ignore or misinterpret it. Both yokes shake so heavily that you can feel it even if your hands are nowhere near the yoke. Loud clattering noise fills the previously quiet cockpit. The autopilot disconnects with the accompanying lights and aural warnings. In the Q400's case, this is a loud horn that repeats over and over until you acknowledge it by pressing the autopilot disconnect button on the yoke. The Colgan crew never did so - they had their hands full enough already - and that sound must have surely contributed to the chaos and confusion that filled that cockpit in the last 30 seconds.
The sudden cacophony had a clear meaning: do something, now. The Captain indeed reacted very quickly, within half a second. More than a few pilots have suggested that he had tail stalls on the mind. It's possible. He'd just transitioned from an airplane that was known to be susceptible to tail stalls (early models, anyway) and had recently viewed the NASA video on tailplane stalls in recurrent training. The crew had been talking about the icing only a few minutes before. With a tailplane stall, of course, one would not expect to see the stick shaker activate, as that indicates a high aircraft angle of attack and, by extension, a low tailplane AoA. I'm not sure that the distinction would be evident to anyone within the space of a half-second, but by the same token I'm a little skeptical that anyone would think of a tailplane stall within a half second in the first place (much less remember that the corrective action for a tailplane stall is to pull up). It's possible that five or six seconds later the Captain mistook the stick pusher for a tailplane stall (they would feel similar in an aircraft with unpowered flight controls, although not in a Q400) and that's why he fought it. It's very easy to play these parlor games after the fact, having reviewed the NASA video and FAA circulars and discussed among ourselves. At the time, caught by surprise and with little idea of what's going on and events moving far faster than he could really think about them, I rather doubt that the Captain consciously thought about what he was doing, in the same way that the First Officer obviously wasn't thinking about what she was doing when she retracted the flaps in the middle of a stall. Amid the confusion, pure instinct took over.
Why that instinct might involve pulling when new pilots are taught over and over again to push may have its roots in the way that most airlines teach stalls. To begin with, they are not even stall recovery procedures; they are stick shaker recovery procedures. The ATP PTS directs you to recover at the first indication of a stall, which includes the stick shaker. Many pilots will never experience a stick pusher or a real stall in the simulator unless they request it; it was never part of the syllabus at Horizon or NewCo. The maneuver is typically taught and checked well above the ground. The setup is far from realistic: the applicant usually hand-flies and stops trimming well before the stall. The reason to do so is that it makes the recovery easier: the plane won't pitch up when you apply power. The purpose of stall training is really to prepare the student to pass the maneuver on the checkride rather than to prepare them for the possibility of being surprised by a stick shaker on the line.
And this brings us to the most outrageous thing about stall training at many airlines. Applicants are taught to hold their altitude throughout the maneuver. Again, this is due to the Practical Test Standards, which state that an applicant must:
Recover to a reference airspeed, altitude and heading with minimal loss of altitude, airspeed, and heading deviation.
It's entirely possible that the Captain was reacting to the stick shaker exactly as he did in the simulator and simply overreacted a bit with the adrenaline rush. It didn't take that much back pressure to start the abrupt pitch-up after the shaker, only about 25-30 pounds according to the Flight Data Recorder. The fact that the autopilot was engaged right up to the stick shaker meant that the plane was trimmed for the speed at which the autopilot disengaged, which certainly didn't help matters when the Captain shoved the power levers forward during the pitch-up. I don't doubt that he was as surprised as anyone that his reaction to the stick shaker induced a 30 degree pitch up and subsequent stall. It was still a recoverable situation at that point; it was fighting the stick pusher the whole way down and retracting the flaps mid-stall that ultimately doomed the crew. These actions may reasonably be attributed to panic at a situation that had quickly spiraled out of control.
So why did stalls come to be taught this way? I think I see the FAA's original reasoning. A lot of training and checking used to be accomplished in real transport category aircraft, many of which reacted very poorly to full stalls. In the interest of safety, the FAA decreed that recovery be initiated at the very first sign of a stall. Simply increasing one's airspeed from a low number to a high number doesn't seem like a very difficult task, and nobody wants crews to be diving transport category jets at the ground in a low-altitude situation, so the FAA added the language about minimum loss of altitude. Transfer this to the simulator, where the element of danger is removed, and many check airmen began treating it not as a survival maneuver but a proficiency maneuver not much different than steep turns.
Many major airlines at least include simulator training to the stick pusher for their pilots, but as far as I know only Paul's regional airline has completely revamped the way they do stall training. They teach their pilots that reducing angle of attack promptly is the most important thing in recovering from a stick shaker, and that this involves both increasing power and lowering pitch to trade some altitude for airspeed. I tried both their method and the traditional method in the sim, and using the new method resulted in far less time spent in the shaker in exchange for altitude loss generally no greater than 200-300 feet (the scenario I described at the beginning of this post was using the traditional recovery method). Just as importantly, this airline trains and checks stick shaker recoveries using the most common scenarios in which real crews have encountered stick shakers: accidental reversion to pitch mode after takeoff, mountain wave at high altitude, leveling off on a non-precision approach, and turning base leg to final approach. Most scenarios involve the autopilot being on and trimming all the way to the low airspeed. They often give students low speed scenarios when they're not expecting them, and make ready use of distraction. In my own case, I knew exactly what Paul was doing when he struck up the conversation about the ad with a naked woman in it, yet I still found myself surprised when the shaker went off. The end result is that if one of their pilots ever finds themselves surprised by a stick shaker at low altitude, it won't be the first time they've had that experience, and they'll have accurate motor memory to call upon for the recovery.
So why haven't more airlines changed the way they train stall recovery? Surprisingly, the FAA isn't standing in the way: they wholeheartedly approved of the changes that Paul introduced to his airline's training program. A lot of it is simply institutional inertia. Until now, few have thought there was a problem that needed addressing. This a symptom of a reactive rather than proactive safety culture at many regional airlines. Another element is cost: many regionals' training programs are all about turning out pilots as quickly and cheaply as possible while maintaining a basic level of competence and safety. When you compare regional airline training syllabi to those at major airlines, you typically see fewer simulator sessions despite having similarly sophisticated aircraft and less experienced pilots. That means that certain things get glossed over, and no "superfluous" training is included. This accident will of course change the way we teach stalls - I fully expect to be using Paul's method next year (and I hope they call it "Paul's method" in recognition of his foresight) - but I do worry that it will take future accidents to expose other weaknesses unless there is a fundamental change in the safety culture at the regional airlines. I'll write more about that in my next post.
Wednesday, May 13, 2009
Most news accounts that I saw focused on the two most sensational elements of the transcript: a statement by the First Officer regarding her inexperience in icing several minutes before the crash, and the crew's last expletives and cries in the moments before impact. Both tidbits are completely irrelevant to the investigation in and of themselves, yet do indirectly offer some clues. The First Officer's statement - that she'd never been in icing before Colgan and was glad to get a winter under her belt before upgrading - was noteworthy mainly in that it was part of a rambling, unceasing conversation that began in cruise and didn't abate until a few miles outside the marker. Put bluntly, sterile cockpit was not observed. The crew will be harshly and universally condemned for this, from the NTSB to the web boards to the lawyers. It is important to note that one cannot point to this conversation as the cause of the accident because most everything was normal while it was ongoing, and the oversight that resulted in the upset took place several minutes after the conversation had ceased. The superfluous chatter may, however, be taken as a symptom of a crew that was not 100% focused on the task at hand.
The last thirty seconds of the CVR, meanwhile, are notable for just how little gets said. Beyond the few exclamatory comments relayed by the press, there are only a few fragments and half-sentences exchanged from the time that it becomes clear that all is not well until impact: "uhhh," "I put the flaps up," "should the gear up?" and "gear up oh #!" It's an indication of how thoroughly surprised and quickly overwhelmed this crew was. There were no standard recovery procedures used, no callouts or coordination, only furious reaction. If the CVR was the only tool at the investigators' disposal, the one and only clue it would provide is a constant noise in the background through the end of the recording: the staccato chatter of a stick shaker.
The Flight Data Recorder (FDR), on the other hand, tells the grim story with an accuracy and clarity that the unfortunate crew never knew. It records in exquisite detail the status and output of every single major sensor and system on the aircraft, 121 parameters in all. The NTSB painstakingly graphed out every pertinent piece of data against various timelines, from the entire flight to the last desperate seconds. Simply thumbing quickly through the graphs gives the very distinct impression that things went south very quickly: the lines go from straight and orderly to severe and chaotic in a manner of seconds. Much closer study of the data contained within, taken alongside the CVR transcript, gives one a very good idea of just what happened on that snowy February night.
The best place to start is at 22:16:00 Eastern Standard Time, a mere 53.9 seconds before impact. Up to this point, everything is utterly normal so far as aircraft control goes. The Q400 is level at 2400 feet and 180 knots, intercepting the localizer for Runway 23 at Buffalo; the flight has been cleared for the approach. The autopilot is engaged, and the flaps are extended to five degrees (Flaps 5). The Captain is the Pilot Flying and the First Officer is the Pilot Monitoring. The aircraft has a moderate amount of ice on it, but not enough to affect performance significantly. The crew has correctly switched the "Ref Speeds" switch on the ice protection panel to "Increase," which decreases the angle of attack at which the stall protection system activates. During their preparation for the approach, the crew set a V-app speed of 118, which was correct for their weight and configuration but did not include the mandatory 20 knot icing additive. It's a small but important detail that got overlooked during their conversation.
At 22:16:00, the Captain reduced the power levers to flight idle to slow down for landing. A few seconds later he called "gear down, loc's alive" and the FO extended the landing gear and moved the condition levers to their maximum position, 1020 RPM. Both landing gear and flat-pitch propellers on the Q400 are quite draggy, and the rate of deceleration increased. In the next ten seconds, the airspeed decreased from 170 knots to 149, already a fairly slow speed for Flaps 5. At 22:16:21 the FO noted "gear's down," and the Captain immediately called "Flaps 15, before landing checklist."
Perhaps the FO noticed the low speed cue rising menacingly on the Primary Flight Display, because she paused a few seconds before moving the flap handle, only put it to 10 degrees, and began "uhhh...." One second later, the stick shaker began clattering away, almost immediately accompanied by the autopilot disconnect horn. It would continue to blare through the rest of the recording, although it could've been silenced by pushing the autopilot disconnect on the control wheel. At the moment the stick shaker activated, 22:16:27.4, the flaps were moving through 6.7 degrees and the airspeed was 126 knots.
Neither the Captain nor the FO said anything about the stick shaker. In fact, neither pilot said anything at all for a full ten seconds. The Captain did react, however, immediately and decisively. Within half a second, he hauled back on the yoke with almost 30 pounds of force. It was enough to send vertical acceleration from 1G to 1.44G. He subsequently relaxed the back force somewhat, but pitch continued to increase to a maximum of 30 degrees by 22:16:33. Meanwhile, the Captain advanced the power levers to around 70 degrees and left them there; neither he nor the FO seem to have noticed that they weren't at the rating detent, much less the mechanical limits. The Q400's engines can produce up to 130% torque in an emergency, but in this case they never went above 80%.
The Q400 is notorious for its left turning tendencies when power is advanced, and they were magnified by the aircraft's slow speed. As the aircraft pitched up, it also began banking left despite increasing right rudder. By the time the aircraft reached its apex of 2600' feet, it was in a 45 degree bank. The Captain responded with significant right control wheel deflection, which deployed the roll spoilers on the right wing.
We don't know exactly when the stick pusher fired because the FDR only samples it once every four seconds. We know it was active by 22:16:34, and that the Captain responded with renewed stick force of around 40 pounds. The airspeed was now under 100 knots; angle of attack reached 23 degrees. At 22:16:34, the aircraft simultaneously pitched down rapidly and snapped to the right, rolling straight through level and reaching 110 degrees of right bank within seconds. It was at this point that the Captain muttered "Jesus Christ," the first word he spoke since calling for Flaps 15 and the before landing checklist. At the same moment, the First Officer put the flap handle to zero without prompting, and then announced "I put the flaps up." The flaps move slowly on the Q400; they only reached Flaps 0 a few seconds before impact. Its questionable whether the situation was recoverable at this point, but retracting the flaps certainly didn't help matters.
Using full deflection left aileron and rudder, the Captain was actually able to recover from the past-vertical right bank to a shallow left bank. The pitch was bobbling near zero, and the angle of attack fluctuated between 15 and 25 degrees. The stick pusher momentarily stopped firing, and suddenly the control wheel back pressure increased to over sixty pounds. The pusher fired again, and the Captain overrode it for the last 12 seconds with 80 to 120 pounds of force. The plane snapped right past 90 degrees bank again; this time the nose dropped well below the horizon, to about -45 degrees pitch. "Should the gear up?" the FO asked; the CA responded, "gear up oh #."
The crew fought to the end, getting the bank back to around 30 degrees and the pitch to -25 degrees. The airspeed momentarily increased to 160 knots. The angle of attack, though, was still well in excess of 20 degrees and the rate of descent was around 10,000 feet per minute. The crew's last words make it clear that they knew the gig was up a few seconds before the recording ends.
It was 27 seconds from the time the stick shaker went off until impact. When the shaker went off, the airplane was still flying just fine; in fact, the angle of attack was only about 8 degrees. At this point the recovery procedure was fairly straightforward; the Captain practiced it several times quite recently in the simulator. Why he instead reacted by yanking back on the yoke is going to be the cause of a lot of speculation throughout the aviation world, but will never be truly known. Even after the pitch up and subsequent stall, recovery was not out of the question with the right stall recovery technique. Most airlines, however, do not teach stall recovery, and even if Colgan had it is impossible to say whether this crew would have recalled and executed it in time to save the airplane.
This is the easy part of an accident investigation: finding out what happened. Investigating why it happened can be much, much more difficult. This is what the NTSB is focused on now; they'll have plenty to say on the subject, and I'll have a few things to say myself. In the meantime though, this accident provides a reminder of how quickly things can turn bad in our profession. A read through Colgan 3407's CVR transcript should provide more than enough motivation to focus on the matter at hand and leave the distractions at cruise altitude.
Sunday, May 10, 2009
Much of the discussion will likely center around three broad topics: Professionalism and Safety Culture at the Regional Airlines, Training at the Regional Airlines, and Fatigue & Working Conditions at all airlines but particularly the regionals. I have some pretty strong opinions on all of these topics, as anybody who has read my blog for a while knows, and I'll likely be writing more posts on these topics as they relate to Colgan 3407 in the coming weeks. I'd like to talk about them in general terms now, however.
In November of 2007 I wrote a post titled "Are the Regional Airlines Safe?." My conclusion was that yes, statistically speaking they still were, but there were some worrying trends in the industry that, left unaddressed, could cause safety problems down the road. When I wrote the post, one of the most worrying trends was a dramatic decrease in experience levels at the regionals. This trend has since reversed, not due to any management effort to address the root causes of the regionals' inability to attract experienced candidates, but due to the one-two punch of high fuel prices and crashing demand for air travel that has brought the airlines to their knees and sent pilots scrambling for jobs. There are few, if any, first officers with less than 800 hours at the regionals these days. However, the conditions they are working under are as miserable as ever, but now without growth and advancement to soften the blow. The schedules are as fatiguing as ever, and management still insists that there's not a problem, that the few cases of pilot fatigue out there are individual pilots' own fault. The trend towards cheap outsourced maintenance has continued apace. The FAA continues to be irrelevant at best and a hindrance at worse as they myopically nitpick paperwork snafus while doggedly ignoring the things that are actually killing people.
When I wrote that post about regional airline safety, I regarded Pinnacle 3701 as a "Canary in the Coal Mine." That accident was a quintessential regional airline accident. I don't think it could have happened at the today's major airlines. Once upon a time the majors suffered a string of similarly senseless accidents, but they ended up taking the lessons to heart, changed the way they did a lot of things, and ended up with a safety culture where reckless and careless behavior simply isn't tolerated. There were a lot of lessons the regional airlines could've taken from Pinnacle 3701. Nobody really changed anything of importance, though. Maybe two lives and a destroyed airplane and house weren't enough to grab their attention. Maybe it was too easy to write the pilots off as two loose cannons and miss the broader implications of their behavior.
If anything, Pinnacle got worse after 2004. They continued to hire lower and lower time pilots; their upgrade minimums were relaxed several times. Their management got more aggressive and abusive with things like sick call policy and junior manning. Continuous severe understaffing pushed their crewmembers' schedules right up to the legal limit. Pinnacle pilots have been working under an expired contract for four years, their pay frozen while management endlessly stonewalls the union negotiators. I'm not just picking on Pinnacle here, this is a disease that has rapidly spread through the regionals the last five years. The worst offenders are the ones that got all those new 70-90 seaters. The airlines that haven't followed suit in this behavior - the Horizons, ExpressJets, and American Eagles of the world - are shrinking into oblivion. ALPA in its current state is clueless and helpless on its good days, and a collaborator the rest. When I spoke with ALPA's MEC chairman for the world's largest airline, he unblinkingly told me that outsourced regional jets were good for his mainline pilots.
If the warnings of PCL3701 went unheeded, CJC3407 is a much bigger canary that's a lot harder to ignore. These hearings are going to shine a light into some hitherto rather murky corners of the industry. Some of my fellow regional pilots are pretty uncomfortable with that. Yes, I'm aware that all of us will likely come under public scrutiny along with our companies. Yes, this is a bad time to give people another reason not to fly. We really do need to change the way things are done at the regional airlines, though, both for the sake of public safety and for our own profession. This accident needs to be our Tenerife, our Eastern 401, the wakeup call that shows everyone that the way we are doing things is broken. As these hearings progress, I suspect that the industry groups are going to try to make them about the individuals who were involved in this accident. I think the NTSB recognizes, though, that there are industry-wide issues that must be addressed head-on if we don't want another repeat.