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Colgan Air 3407; final 7 minutes. | Broken Wing

Colgan Air 3407; final 7 minutes.

Posted on 13. May, 2009 by in Featured

The NTSB hearings continue and Colgan Air executives are currently on the hot seat. It is not going well for them. We now know what happened (inaccordance w/earlier post); the why is next on the list and that will play out via agenda driven debate for years. Below is a summary interwoven with the cockpit voice recorder transcript to give context; analytical comments in bold:

COLGAN 3407 IS ON APPROACH BELOW 10,000 FEDERAL AVIATION REGULATIONS REQUIRE COCKPIT CONVERSATION BE RELATED TO TASK.

22:10:32 — First Officer Rebecca Shaw: Oh yeah, oh it’s lots of ice.
22:10:47 — Captain Marvin Renslow: “Oh yeah, that’s the most I’ve seen, most ice I’ve seen on the leading edges in a long time. In a while, anyway, I should say.

ICE IS ACCUMULATING AT A LIGHT-MODERATE RATE (INCONSEQUENTIAL TO FLIGHT).

22:10:57 — Shaw: Flying in the Northeast, I’ve 1,600 hours. .. I had more actual time on my first day of IOE (initial operating experience) than I did in the 1,600 hours I had when I came here.
22:11:31 — Renslow: But, uh, as a matter of fact I got hired with about 625 hours here.
22:11:37 — Shaw: Oh wow.
22:11:39 — Shaw: That’s not much for, uh, back when you got hired.
22:11:42 — Renslow: No but, uh, out of that .. 250 hours was, uh, part 121 turbine, multi-engine turbine.
22:11:50 — Shaw: Oh that’s right yeah.
22:11:54 — Shaw: No, but all these guys are complaining, they’re saying, you know, how we were supposed to upgrade by now and .. I’m thinking, you know what? I really wouldn’t mind going through a winter in the Northeast before I have to upgrade to captain.
22:12:05 — Shaw: I’ve never seen icing conditions. I’ve never deiced. .. 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’ve freaked out. I’d have, like, seen this much ice and thought, oh my gosh we were going to crash.
22:13:58 — Renslow: Oh yeah, I’m so glad. .. I mean, I would’ve been .. fine. I would have survived it. . We never had to make decisions that I wouldn’t have been able to make but .. now I’m more comfortable.
22:15:59 — Cockpit area microphone (CAM): (sound similar to decrease in engine power).

CAPTAIN (CA) RETARDS POWER TO FLIGHT IDLE; AIRCRAFT BEGINS TO DECELERATE.

22:16:04 — Renslow: Gear down.. loc’s alive.

AIRCRAFT INTERCEPTING FINAL BEARING/COURSE FOR APPROACH.

22:16:06 — CAM (sound similar to landing gear handle movement).

WITH ACCUMULATED ICE, POWER RETARDED TO IDLE AND GEAR DOWN; DECELERATION DEEPENS.

22:16:06 — Buffalo Approach controller (APP): Colgan thirty four zero seven contact tower one two zero point five. have a good night.
22:16:07 — CAM (sound similar to landing gear deployment).
22:16:11 — Shaw: Over to tower you do the same, 3407.

FIRST OFFICER (FO) SWITCHING RADIO FREQUENCY TO TOWER (DISTRACTED).

22:16:14 — Flight Crew Audio Panel (HOT): (sound of two double chimes).
22:16:21 — Shaw: Gear’s down.

FO MONITORING GEAR LIGHTS.

22:16:23 — Renslow: flaps fifteen before landing checklist.

FO DEPLOYING FLAPS READING CHECK LIST. THROTTLES STILL AT IDLE.

22:16:26 — CAM (sound similar to flap handle movement).

DECELERATION IS NOW CRITICAL; AUTO PILOT STILL ON (AGAINST RECOMMENDATION IN ICING) IS TRIMMING INTO STALL.

22:16:26 — Shaw: uhhh.

CA RECOGNIZES AIRCRAFT IS SLOW AND IN EXTREMIS.

22:16:27 — CAM (sound similar to stick shaker lasting 6.7 seconds).

AIRCRAFT IN PRE-STALL BUFFET.

22:16:27 — HOT (sound similar to autopilot disconnect horn repeats until end of recording).

STICKPUSHER DEACTIVATES AUTO PILOT AND PUSHES STICK FORWARD IN ATTEMPT TO PREVENT STALL.

22:16:27 — CAM (sound of click).

CA DISCONECTS AUTOPILOT.

22:16:31 — CAM (sound similar to increase in engine power).

CA ADVANCES POWER.

22:16:34 — Renslow: Jesus Christ.

AIRCRAFT ENTERS FULL STALL.

22:16:35 — CAM (sound similar to stick shaker lasting until end of recording).

CA PULLS DEEP INTO STALL BY DEFLECTING PITCH CONTROLS IN NOSE UP DIRECTION, WRONG PROCEDURE FOR A WING STALL. AIRCRAFT DEPARTS CONTROLED FLIGHT. FO RAISES FLAPS, WRONG PROCEEDURE FOR WING STALL, PUTTING AIRCRAFT INTO A DEEPER STALL, AIRCRAFT ENTERS UNRECOVERABLE FLAT SPIN.

22:16:37 — Shaw: I put the flaps up.
22:16:40 — CAM (sound of two clicks)
22:16:42 — Renslow: (sound of grunt) (unintelligible) -ther bear.

CA MAINTAINS BACK PRESSURE ON YOKE KEEPING AIRCRAFT IN DEEP STALL ALL THE WAY TO IMPACT.

22:16:45 — Shaw: should the gear up?
22:16:46 — Renslow: gear up oh (expletive).
22:16:50 — CAM (increase in ambient noise).
22:16:51.9 — Renslow: we’re down.
22:16:51.9 — CAM (sound of thump).
22:16:52.0 — Shaw: we’re (sound of scream).

Crew coordination or Crew Resource Management (CRM) was non-existent. At no time did either the CA or FO call out what the emergency was or the procedures to recover. It is evident that by action and lack of a verbal queue, that the FO never noticed the critically slow airspeed (she raised the flaps). Also a possible cause for the incorrect procedures would be neither crew recognizing the actual problem. The CA and FO seemed to be performing procedures for a tail stall, NOT a wing stall, which calls for opposite actions. With the exception of the power going to full; in a tail stall it should go to idle. Confusion was evident do to mixing of recovery procedures. It is probable the CA initially recognized the wing stall and then mis-interpreted the stick pusher as a tail stall (nose drops in tail stall); having never been trained to take a stall to the pusher. However; the low airspeed should have been the controlling condition. Fatigue, lack of CRM and proper training likely contributed to the initial stall and failure of situational awareness in the attempted recovery.

Below is the NTSB simulation based on the flight data recorder (FDR). Note the rapid decay in airspeed (almost 100 knot decay) and the subsequent aft yoke pressure, which lasted throughout the event. The raising of the flaps IMO sealed their fate. Although, had the CA continued to maintain back yoke pressure the result would ultimately have been the same. The real tragedy is there was absolutely nothing wrong with the aircraft. This will continue to unravel as the hearing goes on, and it will make the hiring, training, operation, and regulation of the entire commuter airline industry look bad.

22 Responses to “Colgan Air 3407; final 7 minutes.”

  1. Joe 13 May 2009 at 14:22 #

    This post is not based on all of the factual information available at this point. Several inferences were made, without including the FDR information. Much of what has been written here, with the exception of the CVR transcript, is without the data backing it up and should not be assumed at this point. Please have respect for those who lost their lives by ONLY posting factual information. This post makes me sick at this point in time.

  2. John Buckley 13 May 2009 at 14:59 #

    The “non essential” nature of the conversation below ten thousand feet seems work and conditions related. Such a conversation should not have had an impact on basic airmanship which appears to be a significant part of the cause. An aware crew could have had a similar conversation with no impact on safety, provided a check list were out, speeds monitored, the aircraft hand flown, etc.

  3. Chip 13 May 2009 at 17:05 #

    Joe;
    The NTSB simulation is very clear and shows all the parameters clearly. Are you saying the NTSB is putting out false information?

  4. Chip 13 May 2009 at 17:07 #

    John;
    No doubt many crews have non-essential conversations at the same point in an approach. But the FAA will key on it. In a recent engine failure event they made a big deal out of a conversation on taxi out.

  5. Ron 14 May 2009 at 00:10 #

    Chip:

    What caused the initial deacceleration of the aircraft leading to the stick shaker activation? The captain may have had some issues, but wouldn’t airspeed coming into final approach be the least of these? I read in a leagal brief that he programmed the wrong inputs into the autopilot and wasn’t taking into account deicing being on. Could you please elaborate on these points?

  6. Rick 14 May 2009 at 06:36 #

    John,
    This airplane was not hand flown. It was on autopilot until the stick pusher engaged. The Capt was not in tune with his plane…and not monitoring airspeed.

  7. Chip 14 May 2009 at 13:22 #

    Ron;
    In icing if you program the computer it adds approx15-20 knots to the bugs (flap/approach speeds). The Q-400 does not have auto throttles so when the throttles were retarded the deceleration started. When flaps 5, gear and then flaps 15 were selected it rapidly slowed. I think that fatigue played a big factor. Until you’ve done 4 or 5 legs with the last leg at night it is hard to realize. Also keep in mind when it is reported that they only flew X-amount of hours, it is the “on duty” time that matters. For example you can be on duty 16 hours but flown only 3-5. One last factor is the older you are the easier you fatigue; at least for me (I’m 50). I try and trade away the 4-5 leg trips, they are tough on old dudes.

    Ricks comment about the auto pilot is a good one. it is recommended NASA/FAA (not required) that you hand fly an approach in icing so you can feel flying characteristics/changes.

  8. Ron 14 May 2009 at 23:21 #

    Chip; so what you’re saying is that in an aircraft *with* auto throttles, the program would have added enough airspeed to account for icing, but in this case, the captain programmed an otherwise *normal* approach speed, failing to take into account the icing conditions? If true, then ice *did* play a role—only insofar as the pilot didn’t compensate for that icing with increased airspeed on approach?

    Thanks again,
    Ron

  9. Chip 15 May 2009 at 08:03 #

    Ron;
    If you watch the NTSB video closely you will see that the indicated air speed (IAS) went below even the normal approach speed. An auto throttle system would have automatically brought the throttles forward to maintain the selected approach speed. The auto pilot was trimming to maintain altitude, thus it was trimming more and more nose up as the aircraft got slower. Trimming into a stall. Leaving the throttles at idle and not noticing the speed decay is what caused the stall. The stick shaker/pusher measures angle of attack (AOA) of the wing. When the airflow begins to break up the system will activate the shaker as a warning. As the stall deepens it then transitions to a pusher, which physically moves the control yoke forward to recover from a stall. The approach airspeeds are set as guidence but are not actual stall speeds; normally they are 1.3 times the stall speed to allow a safety buffer.

  10. Ron 15 May 2009 at 08:44 #

    Thanks. BTW, why do you suspect the FO decided to bring the flaps up, and this was apparently approved by the captain? Did they believe they were in a tail stall and would this be normal procedure? According to NTSB minutes, swift action nose into the stall with power up and flaps down would have averted the disaster, even at so low an altitude.

  11. Chip 15 May 2009 at 09:54 #

    Ron;
    I suspect that the FO thought the tail had stalled. The recovery proceedures for a tail stall are opposite a wing stall. For a tail stall you put up the flaps and pull. Wing you add max power and reduce AOA by pushing to get a fresh bite of air over the wing. The CA countered the pushers initial push down, IMO, then partially due to trim, it (nose) pulled up. In the MD-80 if you counter the pusher it will click off and the aircraft will seek the attitude it is trimed to.

    She did not have concurance with the CA to raise the flaps, she reported it after the fact which actually depened the stall. IMO the nose pitched up rapidly due to light control forces caused by the auto pilot trimming into the stall and ice on the wing. Raising the flaps worsened the stall/pitch. The Q-400 then rolled off nose low, it is counter intuitive to push the nose down for recovery when it is already extremely nose low. It is a tough thing to force yourself to do (unload when the nose is way below the horizon). At my company we do nose high and nose low unusual attitudes. They always include a nose low when the airspeed is also low, you just have to wait until it (airspeed) builds back up.

    Had he called out “we are slow” or “wing stall” her attention possibly would have been drawn back to the airspeed and IMO she would not have raised the flaps. Had she called out “tail stall” and the CA said no it is a wing stall, again the flaps would not have been raised. CRM was a big factor.

    And there was obviously confusion (Fatigue would enter here) on which recovery proceedure applied (power came up, yet he pulled not pushed)ultimately that is why the stall turned into a spin.

    The way to tell the differnce (according to NASA) is if a wing stalls you will feel it in the seat of your pants (buffet) a tail stall comes out of nowhere. That is why they recommend hand flying, so you can feel its onset. Remember a tail (horizontal stabilizer) is an upside down wing; that might make it clearer in your mind why the recovery proceedures are opposite (by pulling back you increase the camber of the tail as if you put flaps on it). Click on the NASA link or go to the FEB page and watch the 3 part video on tail stalls produced by NASA.It is very informative.

  12. Chip 15 May 2009 at 09:57 #

    PS: We do the nose high/low unusual recovery practice in a simulator during training. Just so there is no confusion.

  13. Ron 18 May 2009 at 17:25 #

    Chip, thanks again for all the really helpful insights. Remind me to fly *your* airline next time (LOL). But seriously, I have one or two more observations and if you would bear with me … This is from a CRM/human psychology standpoint. As you say, the CA did not necessarily ‘approve’ the FO’s flaps up decision but was merely reiterating it. So do you think it is possible the FO—in recognizing the captain’s nose up response—*assumed* that he *must* have been responding to a tail stall (correct interpretation/wrong situation) and thus, thought she was properly assisting CA w flaps up? Adding to this dynamic, the CA—not being able to mentally accept a wing stall because 1) it is psychologically difficult to admit you’ve been slacking off and not monitoring the instruments and the speed; and 2) there just *coulnd’t* be a wing stall (in his mind) because he had already taken the proper “corrective” action via deicing—further justifying (again, in his mind) the tail/stall manuever?

    And all of the above is, of course, compounded by lack of CRM as you point out. Does this make sense?

  14. Chip 19 May 2009 at 11:35 #

    Ron;
    I think your scenario is very likely. Remember also they discussed the ice. And the fact that tail ice is a problem with the aircraft the CA had just come off, also entered into the event.

    Once the nose rolled off and pointed toward the ground it is very hard to wait for the airspeed to build back to the point a recovery is possible. All you see is the houses getting bigger and the altimeter un-winding. That is when training is critical; muscle memory the USMC called it.

    When I was with VX-30, I was an IP in the F-4 Phantom. Test Pilot candidates would come from Pax (Navy) and Edwards (USAF) to do Qualitative Evaluations on the Phantom because it had so many “aero-dynamic issues”. Navy F-4’s rarely had a stick and throttles in the back seat (we had one), so for most of the flights I was in the back seat with no controls.

    After a two hour brief we’d launch into the warning area and invaribly they would depart the aircraft (accelerated stall), while pushing the F-4 to it’s limits. The USAF guys were used to the F-16 and the Navy/Marines the F-18, fly by wire, the computer keeps you out of trouble.

    When the aircraft would depart and start flopping around; I’d just say over the intercom “I got it, show me your hands”. Eventually the Phantom would point to the ground and start to accelerate back to flying speed. When it had built enough I’d say; “OK, you got it”. Speed is life, once you’ve given it up, it is not always easy or possible to get it back.

  15. Ron 19 May 2009 at 16:25 #

    Thanks again Chip.

    (FYI, the Colgan Air website http://www.colganair.com has divested lots of words to distancing themselves as much as possible from the ill-fated crew; to be expected I guess).

    It will be interesting to read the final NTSB report/recommendations and note what actions the FAA ultimately takes.

    Be safe all,
    Ron

  16. Chip 19 May 2009 at 21:25 #

    Ron;
    Shameful isn’t it: they hired them, they trained them, they scheduled them, their Chief Pilots/Check Airman monitored them and yet now they have never heard of them. Makes you wonder; incompetence or BS?

  17. Ron 20 May 2009 at 09:19 #

    The question of Colgan’s incompetence is a good one. Unfortunately, *competence* is all too often conflated with legality (Colgan: we did everything within FAA guidelines so by definition, we are competent). Of course, they’re not being up front about what they *didn’t do* and when questioned on these issues, use legalese to maneuvre around. For example when asked why CA Renslow wasn’t queried about his past failed check rides, Colgan replied something like “because the FAA doesn’t require a pilot to divulge his past record”. Now that IS BS. Kind of like the drunk fellow who refuses to take a sobriety test when pulled over. Legally, he doesn’t have to, but if sober, why not??

  18. Chip 20 May 2009 at 11:57 #

    Ron;
    I agree and unfortunately the safety lessons that could be learned and passed down will be couched in legalese. By the time it filters to the crews valuble time will be lost.

    That is the reason in the Navy we ran two investigations; one a Saftey investigations the other a JAG (Judge Advocate General). The Safety investigation was seperate and anything said/discovered in it could not be used in the JAG. The JAG determined culpulbility, the Safety investigation cause. It was a good system and we would always get to the bottom of an accident and get the lessons learned to the other crews.

  19. Ron 20 May 2009 at 13:46 #

    Are there any parallels between the Navy system and the NTSB/FAA as two separate entities—i.e., NTSB finds cause and FAA supposedly levels the penalties? (Not sure the politics of the FAA is equivalent to the way Navy would handle things).

  20. Chip 20 May 2009 at 14:58 #

    Ron;
    Yes there are some simularities; however the lawyers will use the NTSB report to sue anyone and everyone. There is no legal seperation. With the Navy system people would talk easily for the safety board but many would clam up during a JAG. Nothing like reading someone their rights to kill an interview. Also the FAA is really there to help the airlines to be successful. Many times they will not act on NTSB recomendations.

  21. Ron 4 June 2009 at 10:39 #

    Chip, if you’re still there: quick question?

    How does an electrical failure (as per Swiss Air, and now, Air France) actually “cause” an aircraft to go down? I mean, if you lose your avionics, you still should have power plant no? Is it that the flight stability becomes unstable, and this causes problems maintaining lift? Thanks again,
    R

  22. Chip 4 June 2009 at 12:45 #

    Ron;
    They are seperate issues. In the Swiss Air case the cockpit was on fire. The heat drove the crew from the cockpit. They had a chance to land but the Captain wanted to perform the checklist. The FAA now stresses get it on the ground in any fire situation.

    With AF, it is a case of fly by wire. To move the flight controls on a fly by wire aircraft you must have electrical power via generators, RAT or battery. In the Hudson river ditching a RAT (Ram Air Turbine) deployed and powered the flight controls. In the case of AF-447 I do not think it was a loss of electricity (see my latest post); the ACARS continued to transmit (thus was powered) through out the event, even after initial break up (IMO).


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