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What can a Board learn from a tragedy
Aircraft accidents involving professional crews are rare- but each deserves a careful look by those responsible for the safety of a company’s flight department- asserts Jack Olcott.
Nearly five years have passed since Colgan Air Flight 3407- a deHavilland Dash 8-400 twin-engine turboprop air- craft on a scheduled flight from Newark Liberty International Airport to Buffalo- NY- crashed during the final phase of its night- time approach to landing. Recently- however- additional information about the accident became available as the result of a law suit demanding that a private study for the commuter airline be made public. Previously- the NTSB conducted several days of hearing on the tragedy- which claimed the lives of all 49 people onboard the aircraft and one person on the ground.
Nothing about the aircraft or the weather conditions were deemed suspicious. According to safety experts from the National Transportation Safety Board (NTSB)- the aircraft was capable of coping with the light-to-moderate icing that existed at the time of its approach- which was about 10pm. Until just moments before the twin-turboprop diverged from controlled flight as the result of slowing to its stall speed- all conditions were normal.
Significant- however- was the conduct of the crew—a 47-year-old captain and his 24-year-old co-pilot. Both aviators resided many miles from KEWR. The captain had flown from his home in Florida to Newark the previous evening- and he logged onto a computer at 3am the morning of the flight. Like his co-pilot- who commuted to Flight 3407 the day prior to the trip from her home in Seattle- WA- he was known to have used the crew lounge at KEWR for overnight stays- which was contrary to company policy but apparently not rigidly enforced.
En-route from Newark to Buffalo and during the approach to landing- the two pilots engaged in considerable conversation not directly associated with the flight; so much so that the NTSB felt their performance as a crew was compromised. The Safety Board asserted that the non-professional conversation delayed the completion of approach check lists and violated the requirement for a ‘sterile cockpit’ below 10-000 feet of altitude. [‘Sterile cockpit’ is the term used to denote no conversations or actions below the height of 10-000 feet unrelated to the take- off- departure- approach and landing sequence.]
In essence- the Board claimed the captain failed to effectively manage the flight and allowed a cockpit environment that impeded timely error detection.
In accordance with established procedures for the weather conditions that were present that night in Buffalo- the captain set the aircraft’s reference speed switch for an approach and landing in icing conditions. His co-pilot- however- obtained approach and landing speeds for non-icing conditions and apparently transmitted that information to her captain. The mismatch in approach references resulted in a landing speed that was 13 knots lower than the speed at which the pilot would receive a physical warning of being too slow.
As a result of what the Safety Board suggested was a breakdown in monitoring the flight and maintaining situational awareness- the crew was startled when the autopilot disengaged and the aircraft gyrated in roll and pitch as a consequence of slowing to its stall speed.
The automatic stall warning system activated a nose-down movement of the control column three times - yet the captain failed to input the appropriate control action to recover. In fact- the Board noted that his actions exacerbated the aircraft’s stall condition and prevented the potential recovery. The co-pilot’s action also did nothing to improve the chance of recovery. The twin turboprop rolled onto its back and crashed out of control from an altitude of about 1-000 feet.
There was no specific reason given for why the captain and his co-pilot missed important cues that the aircraft was not properly configured for the approach and that it was approaching a stall.
Fatigue was considered a factor- as well it should considering the lack of quality rest each pilot had before they entered the cockpit. The Board stated that 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 could not be conclusively determined.
The Board also noted that the captain had several failed check rides during his career and that- in its assessment- had not established a good foundation of attitude instrument flying skills during initial training. The Board added that the crew’s employer did not proactively address those issues.
The Message for Boards
Although exceedingly rare- aircraft accidents do happen. Certainly the Airlines- like Business Aviation- pay considerable attention to prevention- such as the need for in-depth screening of potential new hires and active personnel. Initial and recurrent training are also part of the safety culture of professional aviation.
Company flight departments are able to establish rules and procedures that exceed government standards- such as protocols related to rest practices before and after flights. Boards of Directors must apply that unique capability to assure a robust culture of safety.