Flight Safety - Colgan Air Flight 3407 - Case Study Example

Contents Contents 1 Introduction 2 Events shortly before the crash 2 Causes of the accident 4 Questionable pilot professionalism 5 Ineffective stall training 7 Fatigue 7 Violation of sterile cockpit regulations 9 Conclusion 9 Reference List 11 Introduction On the twelfth day of February 2009, at around 10.17 p.m. eastern time, Colgan Air 3407, a bombardier plane, which was operating as Continental Connection flight 3407, was approaching the Buffalo-Niagara International Airport in New York when it stalled and ultimately crashed into a New York residence in Clarence Center. The airplane was piloted by Marvin Renslow, the Captain and Rebecca Shaw, the First Officer (Stark and Khan, 2010). The crash site was approximately five (5) nautical miles from the airport. Two (2) pilots, including the Captain and the First Officer, two (2) flight attendants, and forty five (45) passengers lost their lives after the crash; and one person was killed by the plane on the ground (James, 2009). The plane got destroyed by a post-crash fire and impact forces. This paper is an in-depth investigation into the probable causes of the crash. Events shortly before the crash The plane, which was a Bombadier Q400, was using a night ILS approach as it maneuvered to intercept the localizer. Engines of the plane were at flight idle and ice had started to build up against the airframe, although it was not a lot. The plane was on autopilot. The plane had been cruising at an airspeed of about 175 knots as it descended but the speed began to decrease as the airplane became dirtied up, and as the captain tried to correct, albeit without increasing power, for a downward altitude excursion. When the airspeed reached 130 knots, the stick-shaker went off and the autopilot became automatically disconnected, which is the procedure required for a stall recovery that is initiated by a pilot (Garrison, 2010). Speculatively, the warning of the impending stall, which was given by the stick-shaker, got the captain by surprise. The warnings were arguably premature because they occurred at an instance when the stick-shaker speed was 20 knots above the usual stick-shaker-triggering speed. This occurred because the plane was equipped with a customizable switch for setting reference speeds when the conditions were icy (Garrison, 2010). The higher speeds mentioned above had actually been selected on the customizable switch. During the investigations that followed the crash, the Board suspected that the captain had forgotten about the fact that higher reference speeds had been selected because of the icy conditions. Apparently, the captain had also lost awareness of rising red bar that was situated on the right hand edge of the airspeed indicator and of the airspeed indicator itself; because the former was giving early warnings that the plane was on its way to a stall. At this point, the aircraft was cruising at an airspeed which had a margin of about 25 knots above the stall. This is however, where things got strange for the captain. After the disconnection of the autopilot, the captain responded by pulling back the control yoke. He perhaps expected the stick-pusher to kick in momentarily after remembering the reset for the reference speeds. However, he did not just maintain the pitch altitude that the plane was in. In approximately four seconds, there was an increase in pitch altitude to about 25 degrees and there was a drop in airspeed to less than 120 knots. Above the flight director, there appeared a red chevron that was pointing downwards, which was an urgent signal for the crew to get the nose down. The plane had rolled to the left, with the captain reacting with near-maximum power, and a right rudder as well as a right-roll command. However, he kept pulling back at the control yoke. Events were unfolding quickly, perhaps too rapidly for the captain to apply training or even thought into his misguided and primitive impulse. Two seconds later, the plane had a pitch altitude of 30 degrees with a speed of about 100 knots (Garrison, 2010). The stick pusher had, to no avail, kicked in. The plane gyrated from left to right; its airspeed had dropped to less than 80 knots with an altitude gain of about 200 feet. Its nose finally fell down through the horizon. At this particular point, the plane had a bank angle of 90 degrees and the first officer made the mistake of raising the flaps, although her mistake had arguably little effect on the outcome of the flight. At this point, she also enquired from the captain if she should raise the gear, to which the captain responded in the affirmative. At this point, the plane made its final gyration after the stall and rolled and sliced into a vertical dive (Garrison, 2010). At about the same time, the captain could be heard from the CVR recorder telling the First Officer that the plane was down, to which the First Officer responded with a scream. The plane crashed on a single-family house where there was a fatality on the ground, and a post-crash fire followed. Causes of the accident The most probably and main cause of the accident was the inappropriate response by the captain to the stick shaker that resulted to a stall, which the plane was unable to recover from. Despite the fact that this could have been the main reason that the accident happened, there were other contributing factors that include the following: The crew of the flight did not adhere to sterile cockpit procedures. The captain did not effectively manage the flight. The crew of the flight was unable to monitor airspeed relative to the rising position of the low-speed cue. Colgan Air did not have adequate procedures for management and selection of airspeed during approaches in icing conditions. In addition to the aforementioned factors, the National Transportation and Safety Board identified other issues that might have remotely contributed to the accident. Questionable pilot professionalism The captain of the plane had received a number of disapprovals from the Federal Aviation administration, which included the following: On the 1st day of October in 1991, the captain received disapproval for his rating of instrument airplane after he underwent an initial flight check. Among the tasks for which he received disapproval were: compliance with ATC clearance, ATC clearance, omni-directional radio range approach, and instrument cockpit check, very high frequency on partial panel 32 and non-directional beacon (NDB) holding and approach. He however repeated the flight check in 1991 October 25. As he applied for his post in Colgan, the captain explained that “I missed the NDB approach, received additional instruction, then repeated the approach and passed”. This amounted to partial disclosure of his disapprovals during the initial flight test. On the 14th day of May 2002, the captain received disapproval as he underwent an initial flight check with a commercial single-engine airplane. He had flown a Cessna C-177 and got disapprovals for go-arounds, landings, performance maneuvers and take-offs. As he applied for the Colgan job, he did not disclose these disapprovals. He had however repeated the flight check on 25th June 2002 and passed. On the 9th day of April, 2004, the captain received disapproval for his flight certificate for a commercial multi-engine airplane as he performed his initial flight check. He was notified that he needed to repeat the flight portion of the exam for the PA-44 flight test. Although he passed the flight test twenty (20) days later on the 29th day of April, 2004, he did not disclose his initial disapproval to Colgan during recruitment. On the 15th day of October 2007, the captain of the infamous Colgan air 3407 was a First Officer with Colgan. He received disapproval for his initial flight test of Saab 340, on landing and approach. He, however, passed the flight check on the 18th day of October, 2007. From the issues listed above under pilot professionalism, it is clear that the Captain aptitude for the job was questionable. Pilots who had co-piloted planes with him in Colgan gave good remarks about his aptitude after the crash. However, the information presented above shows that he had received disapprovals in a number of his tests, although he always took a second test and passed. Despite the fact that he had failed numerous tests before joining Colgan, he only disclosed a 1991 failed test (Wald, 2009), which was considered by the company to be too early in his career to affect his piloting. After joining Colgan, he also got unsatisfactory grades for planes and activities that he was not used to; including inter alia rejected takeoffs, single-engine landings, etc. It is therefore arguable that from his failure patterns, it could have been predicted that the captain is only able to effectively function under controlled environments and that he would most likely break down if he was required to act under pressure. The NTSB, in its analysis of the accident, identified the captain’s training failures as one of the major factors that led to the accident. The NTSB wrote that “the accident captain’s history of training failures showed that he had demonstrated weaknesses throughout his career with instrument flying skills and had relied heavily on the autopilot to help him stabilize the airplane, which might have contributed to his deficient performance during the accident flight” (“National Transportation and Safety Board”, 2010, p. 89). Ineffective stall training Among the issues that were blamed for the accident was stall training. Specifically, there were concerns that the kind of training that some pilots get is not realistic because of the flight simulators they use, especially when at the edges of the envelope of the flight. In addition, the trainings were deemed to be of misleading quality, especially because they emphasize of the approach to a stall, and not post-stall gyrations and the stall itself. Actually, pilots who undergo their trainings using flight simulators are not conversant with the natural evolution of a stall. The pilots were further misled by the fact that their training identified minimum loss of altitude as one of the main signals of stall recovery. However, as light-aircraft aircraft pilots know, because they sometimes fully stall their planes, the most essential considerations during an impending or actual stall are the airspeed and the attack angle. It is therefore acceptable to undergo significant altitude loss as one avoids getting into a dangerous secondary stall. Fatigue Analysts of the accident believe that both the First Officer and the captain were exhausted before the plane took off. The captain normally slept at 10.00 p.m. and woke up at 9.00 a.m., as reported by his wife. Notably, the accident occurred during this time. The captain also lacked a crash pad in the vicinity of EWR and thus he was forced to use the crew room at Colgan for napping. From his schedule, he had chronically lost sleep and he could not recover easily from that loss. His last activity on the accident day was at 9.51 p.m and thus at the time of the accident, he had been awake for an approximate 15 hours. This amounts to three (3) hours more than what the NTSB recommends. The Captain’s last known activity before the accident was at 2151 on the date of the accident (Dhavala, n.d.). During a chat with the captain, which lasted throughout the flight until the crash, the First Officer complained about feeling unwell before the plane took off. Towards the end of January in the year 2009, the First Officer had moved from Norfolk Virginia to Seattle with the aim of being close to her family. She was living with her parents and her husband at her parents’ house when the accident happened. In addition, she changed her operational base from the Norfolk International Airport (ORF) to EWR because it was she found it easier to commute to EWR that commuting to ORF (“National Transport and Safety Board”, 2010). Notably, she was commuting to work from Seattle to Newark and was admittedly taking advantage of the sleep opportunities that the flight to work offered. On the accident day, she had taken a flight into EWR through Seattle during which she slept on the flight. She also admitted to taking a 6-hour recliner nap, which is not considered sufficient because a recliner does not offer a comfortable environment for restorative sleep. In the aftermath of the accident, the FAA sought to address fatigue issues related to aviation crew but it did not address the issue of fatigue that comes as a result of commuting resulting in a tired crew in the cockpit. A significantly large number of pilots working for commercial airlines spend many hours before their flights commuting to work (Collins, 2014). During the NTSB investigation into the events leading to the crash of the Colgan Air 3407, the possible contribution of fatigue in the accident was extensively discussed and considered. However, the NTSB concluded that all the evidence that surrounded fatigue as a contributing factor to the crash was circumstantial and thus it was not very persuasive. Violation of sterile cockpit regulations The First Officer and the captain shared an extraneous chat throughout the flight, including chats below 10,000 feet, which is against sterile cockpit regulations. Even after they noticed significant amounts of ice piling up on the wings, the crew chose to ignore the task at hand and continued with their chat, which was unrelated to their job. In addition, the crew did not attempt to carry out checks on their de-icing equipment and other related checks. To prove the distraction that their chat had, although fatigue may have been a contributing factor, the crew was severally interrupted by the ATC and they were not able to quickly or immediately divert attention to it (Dhavala, n.d.). Conclusion It is usually difficult to establish the exact cause of an accident, especially when the pilots involved in the accident are already dead, as it was the case with Colgan Air 3407. However, experts, including the NTSB, established that the main cause of the crash of the Colgan Air 3407 plane was an elementary error committed by the pilot. After the crew of the Colgan Air 3407 got warning of an impending stall in the form of stick shaker activation, the captain committed a mistake so fundamental that one would be tempted to think that he wanted to commit suicide: he pulled back the control yoke and did not release it until the airplane crashed on the ground. Notably, however, there were circumstances that led to the mistake that he committed, including: the crew’s failure to stick to sterile cockpit provisions, the crew’s failure to monitor relative airspeed, Colgan Air’s insufficient procedures for selection of airspeed in conditions of ice and the captain’s inability to manage the flight well. In the end, the NTSB identified the captain’s history of failures during training as a major contributing factor to the accident. In addition to the captain’s training failures, the NTSB identified the absence of external visual cues as a contributing factor as well as the fact that the crew was not aware that the aircraft was close to the ground. The board stated that the captain’s response to the stick shaker activation was contrary to the training that the captain had received and speculated that the captain was in a state of startle and confusion. Reference List Collins, R. (2014). A Double Tragedy: Colgan Air Flight 3407. Retrieved from http://airfactsjournal.com/2014/03/double-tragedy-colgan-air-flight-3407/ Dhavala, L. (n.d.). Continental Connection Flight 3407 accident analysis. Accident Investigation and Accident Reporting. Capt. Mark Dixon. Garrison, P. (2010). Aftermath: The Mystery of Colgan 3407. Retrieved from http://www.flyingmag.com/safety/accident-investigations/aftermath-mystery-colgan-3407 James, F. (2009). Colgan-Buffalo Plane Crash: Errors Began Pre-Flight. Retrieved from http://www.npr.org/sections/thetwo-way/2010/02/colganbuffalo_plane_crash_erro.html National Transport and Safety Board. (2010). Aircraft Accident Report. Retrieved from http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdf Stark, L. & Khan, H. (2010). Pilot Error to Blame for Deadly Flight Accident Last February. Retrieved from http://abcnews.go.com/WN/Travel/ntsb-pilot-error-blame-colgan-air-flight-3407/story?id=9726879 Wald, M. (2009). Pilots Set Up for Fatigue, Officials Say. Retrieved from http://www.nytimes.com/2009/05/14/nyregion/14pilot.html?rref=collection%2Ftimestopic%2FContinental%20Flight%203407&_r=0 Read More