NTSB says pilot error caused CO3407 crash

[NIKV69]

http://www.cnn.com/2010/TRAVEL/02/02/co ... tml?hpt=T2 (http://www.cnn.com/2010/TRAVEL/02/02/continental.crash.inquiry/index.html?hpt=T2)

[Mayi757]

Any pilots here who can give more insight on this:

"After the accident, it was revealed that Renslow had failed three pilot tests, known as "check-rides," before joining the airline, but had disclosed only one on job applications. After that, he failed another two check-rides while at Colgan Air"

Common sense tells me his "only" 172 hrs on the type isn't a good reason. He would have still chatted with this young (attractive) fellow pilot and made the wrong input whether he had 300 or 600 hrs on the type.

"At the time of the accident, Renslow had 3,379 hours of flight experience -- 172 hours in the Bombardier Dash 8-Q400."

The simple reason he got so distracted (and she followed) wasn't because of lack of training or experience, but because both were eating s*** and failed to notice the plane was losing speed. Pulled on the control column instead of keeping the nose down, since neither was concentrating 100% on flying.

Ice might not have been "the factor" but it probably didn't help the situation. Wonder if they would have been able to recover had there not been any ice..

I also wonder if Airbus and their computerized philosophy are actually on to something reducing the result of pilot stupidity? Like flirting in a critical phase of flight.

[hiss srq]

To start with Colgan is kind of like the 99 Cent store of regionals. Yeah, you can buy a stir fry pan there but it's not going to be of decent quality and the foods going to taste like crap. Colgan is notorious in the airline pilot circles for being the place all the 300 hour wonders go to get their multi turbine up fast so they can go get a jet job elsewhere. Talking to friends who have flown for both Colgan and other regionals the training diffrence is night and day apparently. I know one of Colgan's most seinor captain's (within the top 10 in company) and he is 26 years old. Milk on the breath so to speak and lives in his parents basement. While the latter part is not so much reflective of Colgan the fact that one of their most seinor pilots is yet to crest age 30 tell's you what kind of a pilot mill that place is.

As sad as the situation is, it is almost entirely caused by the crew's actions or lack there of and in part Colgan's hiring and training practices. It is a shame really. Companies like Colgan, Gulfstream and Great Lakes (BE1900's and E120's) will continue to get the lower level of the commercial rating talent because everyone wants a badge and a quick way to turbine time so they can put a uniform on and walk through the terminal. Companies like Colgan and the practices of regionals in general are why I am leaving aviation all together to complete my college degree and attend med school. The industry is a swamp land from the bottom up. The hiring practices during the mid and latter part of the last decade were redonkulous and the training thanks to companies like Colgan and mickey mouse pilot mills like ATP and Delta Connection Academy has fallen through the floor. Right now the legal mins for an airline job is pretty much 251 with a multi and a commercial rating though most regionals were hireing "competatively" with between 500 and 1500 and 50 to 100 multi with zero turbine time. Alot of the crews at majors and some of the better represented regionals in America that I talk to (and I agree) is that there should be an ATP requirement to fly part 121. That would mean a minimum of 1500TT and age 23 with a written and a checkride. Obivously the mills will adjust but at least with a little luck the pilots applying for 121 jobs will know how to enter a hold, recover a stall and keep their mouth shut below 10K besides "Traffic and checklist chatter". A Senator in South Carolina recently put a bill out that would allow carriers to centerally record CVR script and use it in administrative action against crews. I do not agree with this per see because it would create one more level of stress up front but I understand why some are screaming for it. I wonder how many times a fed was on captain Marvin Renslow's jumpseat previously. Obviously he had checkrides and an IOE for each new type but a little luck, some good weather and some good city pairs and monkeys could probably scrounge by.

Maybe regionals need to instate monitoring systems which more indept observe systems on aircraft like some major's do. At American when you exceed peramiters for a certain phase of flight or configuration there is an automatic print up that goes to dispatch, MX and management pilots in DFW. Maybe this would be a good idea.

Skywest is another carrier that has it right even though they are a regional.
Renslow would not have survived his first recurrency or if he made it that far upgrade school. Skywest does not have a union and their policy as a carrier is that if you fail any one part of a training you are. I have heard stories about F/O's who went to upgrade on their types and failed the ride, the oral or a written and were automaticly fired. Not even the chance to flow back to F/O. If you have the seinority and time in type to upgrade you damn well better know your airplane and your job otherwise you are not worthy of the job is their stance and I agree.

[Mayi757]

While I agree with the above, after 172 hours you should have had enough "on the job training" to get a feel for how the aircraft responds.

The fact they were accumulating ice and on final is not the moment to be chatting. I don't care if Miss Universe is next to me, I'd be paying 120% attention until that plane is back on the ground. Same 'ol routine, complacency, chatting up the chick pilot, and ran a plane full of passengers into the ground.

I would have told that girl it wasn't the time to be worried about the weather, but to pay attention.

[hiss srq]

The captain's inputs were not consistent with pilot training or reaction to a stall warning, but were consistent with surprise and confusion. The captain had a history of failing simulator training sessions.

Earlier in his career the captain had received training on the Saab 340, which is susceptible to tail plane stall and provides a stick pusher. This may have led the captain to believe, the Dash 8 was suscecptible to tail plane stall.

Training at Colgan complied with industry standards but did not require to include training of recovery from a fully developed stall, did not include the element of surprise, autopilot disconnect or the increased stall speed setting (icing).

The civilian pilot certification just states, that a test was passed, however does not take into account the performance during the test or the number of tests failed before passing the test. This allows pilots to receive certification which would be "washed out" in the military pilot selection process and leaves pilots in the system, which are not really capable of being pilots. The investigation was an "eye opener" in that respect.

The crew squandered time and attention in conversation that should have been used to attend operational tasks. The male captain did most of the talking giving the impression, that the flight was just a means to him to talk to the female first officer.

The Dash 8-400's primary flight display does not provide a yellow "low speed" caution above the red "low speed" warning on its airspeed indicator and thus is not consistent with current recommendations and requirements. Crew perceive, that as long as the indicated airspeed is within the "black band", the speed is normal. Therefore if such a caution band had been available on the display, it would have likely raised a "red flag" with the crew.

Colgan's flight crew manuals did not provide any information about the symbology used on the air speed indicator, especially it did not explain the red band and that the stick shaker would activate upon reaching the top of the red band. A board member got the impression from talks with Colgan pilots, that they were not aware, that the red band was fundamentally equal to a barberpole, the airplane should never ever been flown into. The documentation as well as the checklists did not include the Vref switch creating the opportunity for confusion. Colgan actually did not have a full fledged manual to provide for their crew, just an interim manual that showed a lot of deficiencies and is seriously inferior to the de Havilland/Bombardier aircraft operations manual (AOM). The interim manual had been approved by the FAA however.

The Bombardier AOM creates confusion, too, by containing procedures in the landing section, which raise the impression of the airplane being susceptible to tail plane stall. When asked about that paragraph, Bombardier replied that paragraph was left in the AOM in error. The board member voiced the opinion, that the AOM was not thorougly worked through.

In discussing the AOM the board members agreed, that the captain pulling back on the control column would be consistent with the procedures for a tail plane stall and would be consistent with an 8 minutes FAA video about tail plane stall. The captain however did not take enough time to analyse the situation, his reaction therefore is consistent with being startled and confused. The first officer retracting the flaps supports, that the crew was following procedures for a tail plane stall.

Pilots holding ATPLs are not required to obtain or maintain proficiency in full stall recovery. The reason is, that pilots need to demonstrate capability to recover from full stall during their ab initio training. The full flight simulators are not capable of providing fidelity in a full stall scenario. Regulations therefore only require, that recovery from an approach to stall is being demonstrated during simulator training, but do not require to demonstrate a recovery from a fully developed stall.

Sterile cockpit requirements below 10000 feet were violated by the flight crew. Prior to the accident monitoring by FAA had not identified any concern with Colgan in that regards, following the accident the FAA identified several areas of concern. Colgan in the meantime provided their air crew with additional guidance. Pilots (intentionally) diverting from standard operating procedures like the sterile cockpit environment are three times more likely to make additional errors with consequences, studies and previous accidents and incidents have shown. In this flight the conversation clearly took precedence over operational tasks, although the conversation stopped about 2 minutes before the low speed cues appeared. "You do not adhere to standard operating procedures for flights where everything goes smooth, you adhere to standard operating procedures for flight where everything goes sour." The crew had completed all relevant checklists for the phase of flight at the onset of the stick shaker, however were doing some of the checklists late.

Both pilots showed precursors of fatigue. Their sleep prior to the accident had been interrupted and was of poor quality. The accident occured at about the time of the captain's normal bedtime. Witnesses describing the captain's as well as the first officer's usual behaviour and behaviour in the morning of the accident suggest, that both crew may have been fatigued although quantification is impossible. Performance degradation as result of fatigue, short of falling asleep, can however barely be identified. In the accident it is not possible to identify any decision that may have been impaired by fatigue, although the continuous conversation on the flight deck can be seen as result of fatigue. The crew was probably lightly fatigued, but is considered sufficiently fit for the flight. Rest times were up to the choice of the crew members. Colgan however changes procedures and guide lines addressing the issues of fatigue and introduce fatigue management with flight crew. Factors contributing to fatigue of the crew were loss of sleep (sleep deficit), which applies to both crew, and hours of being awake applying to the captain (15 hours awake). The board determined, that the sleep deficit by the captain was between 6 and 12 hours over the period of three days prior to the accident. Counter argument used was however, that the captain was performing a briefing during the approach and was interrupted by ATC, the conversation with ATC taking just shy of a minute. The captain resumed the briefing without "missing a beat". In addition, during the most recent training the instructor observed a tendency to overcontrol the airplane in unusual attitudes by the captain suggesting, that the captain's performance during the accident flight was not degradated but rather matched the captain's core performance.