Recommended Viewing.

[alphadog]

Discovery Chanel, Dead Tired Series.Flight 3407, or the connection between pay, fatigue and safety.

[Hiller Highwater]

"the connection between pay, fatigue and safety"

 

With all due respect, fatigue was listed in the NTSB report as a "likley contributing factor". The Captain had about 100 hrs on type and the co-pilot was our equivalent of a 100-hr wonder. The Captain pulled back on the stick when the shaker went and the co-pilot almost immediately raised the flaps. I have seen lots of pilots do similar things in training. I hate being a passenger because you don'[t know whose upfront. But to say this accident is about the connection between pay, fatigue and safety is to way oversimplify a bigger issue. Namely having too many aircraft for the number of qualified pilots. It's going to get worse in choppers too with all the hourly requirements these days.

 

From a report in late 2009:

 

 

Capt. Renslow, 47, joined Colgan in September 2005 after graduating from a pilot-training academy, employment records show. He had a history of flunking check rides -- periodic tests of competency that are also required anytime a pilot begins flying a new type of aircraft. Before joining Colgan, he failed three proficiency checks on general aviation aircraft administered by the FAA, according to investigators and the airline. Colgan's spokesman said the company now believes Capt. Renslow failed to fully disclose that poor performance when applying for a job.

Once at Colgan, he failed in his initial attempt to qualify as a co-pilot on the Beech 1900 aircraft, and also had to redo his check ride to upgrade to captain on the Saab 340 turboprop, according to investigators. Repeated check-ride failures raise red flags, and large carriers rarely keep pilots who require such extensive remedial training, according to numerous industry officials.

Capt. Renslow had about 109 hours of experience flying the Q400 as a captain, an unusually limited amount of time by industry standards. He had started flying the craft only two months earlier.

[alphadog]

You make a point. I'll raise you this: The co pilot , deemed to be tired after having little or no sleep on a crew house couch and having little to no sleep while hitching a ride from Seattle on a cargo plane,was paid 16.000 USD a year, "Less than the average bus driver", could not afford a hotel on that pay to get proper rest. The female co pilot could have saved lives if she wasn't so tired. Unfortunately, the captain and her would have killed anyone flying in a glider with them due to the wrong reaction for the stalling condition they ended up in. Thats where I see the connection.

[Harmonic_Vibe]

I checked out the show and while I like "Mayday" the point of that show is to sell commercials. The guy who has the most to say in the program about the fatigued condition of the Co-pilot is the father of a victim, so he is giving his personal opinion. They are slightly deceitful I think, as they don't identify him as being a private citizen who lost a loved one at the time he is speaking as if he was an expert witness. I feel for him and for anyone that loses someone in an accident of any kind, but I think reading the whole report is necessary to develop a truly informed opinion.

 

http://www.ntsb.gov/doclib/reports/2010/AAR1001.pdf

 

Ultimately, the Captain crashed a perfectly good aircraft into a house and we'll never really know why as some things are speculative. The Co-pilot raised the flaps without being commanded to do so which is what she was used to doing as an instructor in the Piper Archer. The expression "when it hits the fan you sink to the level of your training" comes to mind. I read most of the 299 page report and while fatigue may have been a factor it certainly is not a prime cause from what I can see, nor does the NTSB feel it is.

 

From page 169:

 

 

"The National Transportation Safety Board determines that the probable cause of this

accident was the captain’s inappropriate response to the activation of the stick shaker, which led

to an aerodynamic stall from which the airplane did not recover. Contributing to the accident

were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed

cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s

failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed

selection and management during approaches in icing conditions."

 

Directly from the report about possible fatigue issues:

 

 

"The pilots’ failure to detect the impending onset of the stick shaker and their improper response to the stick shaker could be consistent with the known effects of fatigue. Workload management issues, as well as some minor errors that occurred during the flight (for example, a delayed response to an altitude alert about 2213:21) could also be consistent with fatigue.

However, the research and accident data have shown that the errors made by the flight crewmembers, including their failure to monitor airspeed in relation to the position of the lowspeed cue, adhere to standard operating and sterile cockpit procedures, and respond appropriately to the stick shaker, have also been observed in other pilots who were not fatigued."

 

And a big statement not even once suggested in the TV program;

 

 

"It is important to note that, throughout the flight, the pilots were conversational and engaged. Neither pilot acted withdrawn or lethargic or made any statements about being tired or receiving inadequate sleep. Also, the pilots demonstrated good performance during the flight by following sterile cockpit procedures during the takeoff and initial climb."

As for the immediate cause, namely the pilot pulling back on the controls of an aircraft approaching stall:

 

"However, it could not be determined whether the captain had seen a stick pusher demonstration on the Q400. Even if the captain had seen this demonstration, his actions in pulling against the pusher were not consistent with any trained procedure or the basic requirements for recovery from an aerodynamic stall"

 

 

"At the public hearing for this accident, Colgan’s chief Q400 instructor testified that, after the accident, pilots began receiving a demonstration of the stick pusher system during simulator training."

"CVR and FDR data indicated that, when the stick shaker activated, the autopilot disconnected automatically. The captain responded by applying a 37-pound pull force to the control column, which resulted in an airplane-nose-up elevator deflection, and adding power... and airspeed slowed to 125 knots. In addition, the speed at which a stall would occur increased.... Thus, the NTSB concludes that the captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall"

From Gulfstream's training records:

"GIA maintained comprehensive training records for the captain. His training records showed that, even though he completed all entry, training, and operating phases without a failure, the captain had experienced continuing difficulties with aircraft control. For example, during simulator periods 3 and 4, the captain was graded unsatisfactory in “approach to stall – landing configuration,” although he received a satisfactory grade in later sessions. During simulator period 7, the captain’s altitude and airspeed control was unacceptable, and comments included, “airspeed more than 10 knots below Vref + 10. Fly correct airspeed!” “airspeed 10 knots below Vref crossing threshold,” “gear remains up during entire approach,” and “repeated deviation from altitude 200-300 feet.”

There were 46 official Findings in the NTSB report, of which only the following 5 make any mention of fatigue or the copilot's apparent illness:

24. The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.

25. All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.

26. Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base.

27. Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.

28. The first officer’s illness symptoms did not likely affect her performance directly during the flight.

 

The TV program leads you to believe this was a fatigue caused accident. The NTSB concludes fatigue may have been a factor but many other crews have made similar mistakes without any fatigue involvement. The Captain was low time on type, as was the Co-pilot, and had a history throughout his career of not handling a lot of flying exercises very well.

 

Over and over in the program the narrator kept asking "how could a trained crew makes these mistakes?" but anyone that has ever been a training pilot can tell you that absolutely EVERYONE makes mistakes. The whole point of processes and procedures and a lot of the new equipment is to prevent mistakes from causing accidents. From my read (just my opinion) of the report, the Captain probably should never have been a Captain and the FO was too green for the Captain she was paired with. I am willing to bet this type of thing "almost" happens a lot in the small commuter type services. Which is very unfortunate.

 

HV

[tDawe]

Let's not forget the part of the report where the NTSB describes how NEITHER one of them was flying the aircraft at the time of the accident.

 

The aircraft was being flown by the autopilot while both of them sat on their hands and chatted with each other about 1.) how they were both being underpaid for how awesome a pilot they were, and 2.) how neither one of them had ever seen icing conditions as bad as the conditions they were in AT THAT EXACT MOMENT.

 

Neither one of them bothered at any point to check and see what the robot was doing. The aircraft was picking up a ton of ice and pitching up more and more in an effort to maintain altitude. They both botched the stall recovery, but only because they were surprised by a situation that never would have occurred had either of them bothered to pay attention to what they were being paid (albeit not very much) to do.