A Very Sobering Transcript

[hiss srq]

I was reading the transcript about the CR2 that crashed in Jefferson a few years back and it is quite soabering to read from a pilots standpoint really. It is hard hitting about why one needs to know the real limits of an airplane. Granted as pilots we all like to have some fun here and there but these guys really did a number and it cost them their lives.


http://www.ntsb.gov/events/2005/Pinnacl ... actual.pdf (http://www.ntsb.gov/events/2005/Pinnacle/exhibits/CVR_Factual.pdf)

[LGA777]

Just got thru reading this transcript over on another site. While I realize these guys where young I was surprised at some of the dialog with ATC such as "we need to go down to 12000, is that cool" ? I also think the word "Dude" was used around 137 times. These guys get my nomination for the Darwin award.

Regards

LGA777

[cancidas]

ron, radio talk aside i too firmly believe that they screwed the pooch with thier flying abilities. in terms of the manner in which they communicate, well that's just normal IMO. i'm sure that hiss will agree, as long as you get the message accross to the other side of the cockpit you're open to say whatever (within reason.) the cockpit is a lot like our office, and most crews, especially when flying with each other will communicate as freinds and not just coworkers.

[USAF Pilot 07]

Reading the transcript, yea it does sound like the crew might not have been the brightest of people, but did they do anything against procedures?

They say their service ceiling was FL410, which they were at. Instrument readings before losing engines weren't completely abnormal, with one pilot saying he had seen similar/more surprising readings before.

So ultimately who is at fault in this incident? Yes the crew failed to operate their aircraft in a safe manner, but did they have any indications that going up to FL410 would lead to double engine failure, ultimately resulting in a crash and their deaths? Should Bombardier, or company procedures, have limited flight that high?

The final part of that transcript is the worst, especially once they realize that they're not going to be able to put the plane down safely and are going into houses...

[moose135]

The NTSB finding on this accident:

http://www.ntsb.gov/Publictn/2007/AAR0701.htm

Among others:
# The pilots' aggressive pitch-up and yaw maneuvers during the ascent and their decision to operate the airplane at its maximum operating altitude (41,000 feet) were made for personal and not operational reasons.

# The flight crew's inappropriate use of the vertical speed mode during the climb was a misuse of automation that allowed the airplane to reach 41,000 feet in a critically low energy state.

# The improper airspeed during the climb demonstrated that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to the published climb capability charts.

# The upset event exposed both engines to inlet airflow disruption conditions that led to engine stalls and a complete loss of engine power.

# The pilots' lack of exposure to high altitude stall recovery techniques contributed to their inappropriate flight control inputs during the upset event.

# The captain did not take the necessary steps to ensure that the first officer achieved the 300-knot or greater airspeed required for the windmill engine restart procedure and then did not demonstrate command authority by taking control of the airplane and accelerating it to at least 300 knots.

# The first officer's limited experience in the airplane might have contributed to the failed windmill restart attempt because he might have been reluctant to command the degree of nose-down attitude that was required to increase the airplane's airspeed to 300 knots.

# Both engines experienced core lock because of the flameout from high power and high altitude, which resulted from the pilot-induced extreme conditions to which the engines were exposed, and the pilots' failure to achieve and maintain the target airspeed of 240 knots, which caused the engine cores to stop rotating; both of these factors were causal to this accident.

# The importance of maintaining a minimum airspeed to keep the engine cores rotating was not communicated to the pilots in airplane flight manuals (AFMs).

# The captain's previous difficulties in checklist management, the situational stress, and the lack of simulator training involving a double engine failure contributed to the flight crew's errors in performing the double engine failure checklist.

# The pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, was a result of their intentional noncompliance with standard operating procedures, and this failure was causal to the accident.

# The pilots' unprofessional operation of the flight was intentional and causal to this accident because the pilots' actions led directly to the upset and their improper reaction to the resulting in-flight emergency exacerbated the situation to the point that they were unable to recover the airplane.

# More scrutiny of regional air carrier pilots during nonrevenue flights would minimize the opportunity for unprofessional behavior to occur.

# Providing additional education to pilots on the importance of professionalism could help reduce the instances of pilots not maintaining cockpit discipline or not adhering to standard operating procedures.

# Line Operations Safety Audit observations can provide operators with increased knowledge about the behavior demonstrated by pilots during line operations.

# All air carriers would benefit from Safety Management System programs because they would require the carriers to incorporate formal system safety methods into the carriers' internal oversight programs.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training; (2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident was 1) the engine core lock condition, which prevented at least one engine from being restarted, and 2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.

[USAF Pilot 07]

Great! Thanks for posting that Moose!

[Nonstop2AUH]

Riveting stuff, not to make this personal since the poor guys lost their lives but the casual attitudes and lack of adherence to SOP make me wonder about the backgrounds of these guys and the sort of training they received.

I know alot of pilots at the regionals come out of academies which often function as sort of 'pilot factories' that have to grind out and place as many graduates as they can in order to make money. Not that it excuses the deficiencies in the airline's own training, but perhaps the mentality at work here was in place long before these guys ever got to Pinnacle, because they seemed to be extraordinarily lacking in judgement.

[PhilDernerJr]

A relaxed cockpit with friendly bantar is one thing, but conversation filled with "dude" and "cool" still shows a level of immaturity.

[hiss srq]

Well than the vasmajority of you would not want to be in the average jet cockpit these days. Granted there are several severe errors in judgement there I do not personally think that the word dude should be brought in as a factor. Casual communication above ten grand is the norm. Below 10 all business or nothing at all. They decided to test the bird out which is not all that uncommon. the facot of the matter is that they were not familiar enough with the airplane in a technichal manner. I go out of my way to learn every possibly quirk of a plane I am flying personally. I like to take it out and run her up in the top limits over a safe area with a check airmen etc etc.... or an instructor so I can feel the plane out and see what works what does not work and all of that. These guys botched it from 13 grand down though severely.