Wednesday, February 03, 2010

Tin Kicked

The FAA (aka the Tombstone Agency) has fixed some flaws highlighted by last February's Buffalo, NY crash (which I have posted about here), but has not been able to deal with others.
When the National Transportation Safety Board meets on Tuesday to consider a final report, it will face not simple mechanical fixes, but issues of training, management and professionalism by the pilots. During three days of hearings in May, evidence was presented that the crew on the Colgan Air flight was poorly prepared.
To summarize the NYT, the NTSB cited these factors:
  • Inadequate training and quality control

  • Colgan airlines, operator of the mishap aircraft, apparently did not provide training on in-flight icing. The Captain had failed five checkrides during his flying career, two of which Colgan did not know about.

  • Professionalism.

  • In addition to other violations of the sterile flight deck rule, the First Officer had sent text messages from the flight deck, the latest five minutes before takeoff. The FO was also flying with a bad cold.

  • Fatigue

  • The First Officer had commuted from Seattle the night and morning preceding the mishap flight. "[What] to do about pilots who have a grueling commute before they start work — is not something the F.A.A. is eager to take on. Mr. Babbitt said that “there are so many ways that you can be fatigued; commuting is but a little teeny slice.”

  • Experience

  • First Officers can be hired with as few as 250 flight hours. "After the crash, some officials recommended a 1,500-hour minimum, a position endorsed by the unions for the big carriers."
As straightforward reporting by non-specialists, this NYT effort is not bad. It makes no glaring factual errors, nor does it spin the facts it presents.

But I am a specialist, so I am going to go a little deeper.

From the outset, I am convinced that the only issue germane to this mishap was the crew's failure to observe that airspeed was decaying below Vmin for the configuration. Mishandling the aircraft after the autopilot kicked off because it had reached its pitch trim limit is secondary. Everything else might be noteworthy in a general sense, but serves largely to distract from the problem at hand.

The finding on inadequate in-flight icing training is far less damning than it appears, and I doubt the NTSB has anything to back it up. Airframe icing is one of those basic pilot things. It increases stall speed both by deforming the wing and adding weight, while simultaneously increasing drag. If the NTSB was to conduct a knowledge survey of pilots possessing an instrument flight rules endorsement, the percentage not knowing this would hover somewhere just below nil. In addition, all airline flight operation manuals, by definition, are at least as restrictive with respect to icing as the Federal Aviation Regulations (FARs). It is also worth noting that the crew did not violate any icing FARs.

Quality control is a much more difficult issue. Given that the entire reason 49 people are dead is because the Captain mishandled the airplane, it is hard to suggest busted checkrides did not indicate that he was fundamentally unsuited for the job he was doing. However, the article fails to note, because the authors can't be expected to know, why he busted those checkrides. If he failed them for reasons other than basic airmanship, than the real reason for the crash's sine qua non could still be completely untouched.

IMHO, based on this report, the NTSB is deaf to the screamingly obvious: the reason the crew failed to note the impending stall was because modern Flight Management System (FMS) equipped airplanes are very corrosive to a good instrument cross check, particularly airspeed.

Until flight departments start actively encouraging turning off all the magic when the conditions are permissive, all the checkrides in the world will be no more effective at addressing the fundamental cause of this mishap than dog obedience classes.

Of course, that still leaves busted checkrides as noteworthy in a more general sense. He certainly wouldn't be moving up to the Bigs with his, but the FAA's own rules having nothing to say on this score, and if they did, the jeopardy attached to each check event would inevitably lead to problems in their conduct. So identifying a quality problem doesn't mean there is an easy, or even any, solution.

The lack of professionalism this crew demonstrated is disturbing, but not necessarily in the ways the report discusses.

That the FO was texting five minutes before takeoff isn't even necessarily a violation. On the ground, the sterile cockpit rule applies only when the aircraft is moving. If the crew were in a queue for takeoff at the time the FO sent the text message, doing so would have been completely legal. The report doesn't talk about context, and I'll bet that is because the NTSB didn't, either. With respect to this accident, though, texting before takeoff simply does not matter, any more than driving the wrong way down a motorway depends on not having signaled when pulling away from the curb.

On the other hand, flying with a bad cold could well have contributed to failing to adequately monitoring the aircraft. So far as I know, all airlines award a certain amount of sick leave per year (my airline provides the equivalent of one month flying time per year, which accumulates) so that pilots can largely eliminate health decisions from their checkbook balance.

Fatigue also is not convincing. The FO commuted from Seattle to Newark via Memphis. I don't know if there were any other jumpseaters on her flights, but if there weren't any, or the other jumpseaters were gentlemen, she would have been able to toss the futon (if she was commuting on an MD10 or MD11) on the deck and potentially get at least four hours sleep. Further, by the standards of my typical schedule, there is nothing noteworthy about an all night commute. Fatigue just comes with the territory.

Required experience definitely deserves attention, although this is another problem that is less straightforward than it sounds. In the Bigs, two thousand hours as pilot in command (FO time doesn't count) of a turbine powered aircraft is pretty much the floor. However, that isn't reason to apply the same standard to commuters airlines. Turboprop aircraft are slower, far more forgiving, and don't present anything like the energy management issues that jets do. So 2,000 hours is beyond any reasonable upper bound.

Unfortunately, reasonable and doable experience levels are not necessarily the same thing, particularly now. Why? Checks, as in the kind that most of you don't write many of anymore. Once upon up until about ten years ago, people wrote lots of checks, and they got flown, at night, in single engine planes, to clearing banks. That is how most civilian pilots got enough flight time to get hired at commuters, then move up to the Bigs.

Getting flight time without getting paid for it is extremely expensive — roughly $150 per hour for a complex (i.e., retractable gear, variable pitch prop, IFR capable airplane). Without the gap filler that flying checks used to provide, making the minimum flight time for an FO even 500 hours could well mean that commuter destinations won't get any service because there simply won't be any pilots.

This mishap is extremely frustrating. This crew was undisciplined — blabbing below 10,000 feet is just wrong, and flying with a bad cold (or the Capt allowing the FO to fly in that condition) is no better. Looking at systemic problems, even if they aren't directly related to the crash makes sense. Unfortunately, I am left with the sense that the NTSB never directly addressed the most important reason the airspeed problem went completely undetected: too much magic, too often, takes the human out of the loop.

Which leads to surprised humans.

And corpses by the cord.

7 Comments:

Blogger David said...

Skipper:

The anecdote about checks, pilots and flying time is great. I'll use that in my strategy class as an example of how all the scanning and monitoring in the world can't stop your company from being thrown for a loop by some new effect coming from left field.

February 05, 2010 6:13 AM  
Blogger erp said...

Skipper, I need to comment about flying checks around too. The law of unintended consequences is far reaching and I wonder in how many other ways the basic changes in the way we do business is affecting things we can't predict.

February 05, 2010 6:32 AM  
Blogger Harry Eagar said...

With a little rewriting of the intro, you've got another excellent candidate for an op-ed, Skipper. Try the WSJ, I'd say.

I wonder if there is another difficulty with checks.

I wrote up a story about the crash of a helicopter check ride a few weeks ago. The facts are in dispute, but if the owner of the copter is right, the instructor:

1. Did not select appropriate terrain for the sudden power loss check.

2. Did not begin at sufficient altitude.

3. Did not signal a throttle cutback but shut off the fuel valve.

As we say in the newspaper biz, interesting, if true.

February 05, 2010 9:57 AM  
Blogger dshawindiana said...

Skipper:

I agree with most all of the points you have made in your blog, and thought it was very thoughtful and concise. I would like to brush on a few points though.

1. I just want to make sure it is 100% clear to your readers that Colgan DOES do training on in-flight ice. I think you alluded to this but I want to make sure it is clear. The standard training is actually fairly extensive and includes review during every re-current ground school. At the very least, the training includes the review of the NASA in-flight icing video, which is excellent, and aircraft limitations in icing conditons. I would actually say that it is one of the best, and most in depth parts of their training program. Probably because we spend so much time in the ice in the prop world. The FAA, in my opinion, was actually implying that Colgan should not be teaching about tail plane ice, because supposedly neither the SAAB or the Dash 8 are susceptible to tail stall. I personally disagree as I have felt myself, on the SAAB, the effects of tail ice in heavy icing conditions. As for the Dash 8, call me in a year and I will let you know.

2. Most pilots are building hours these days flight instructing. Although this was not my path, I think teaching is a good way to learn. That being said, that is not always practical in real world 121 flying. The real issue is the amount of time and more specifically, the kind of time. When I was hired at Colgan, I had more multi engine, and solid IFR cross country time, than most of my classmates combined. Although my total time was low, only 600 hours with 450 multi engine, I would like to think it was quality time that was perfect preparation for the turbo prop world. Ice, snow, rain, convective activity, ILS's down to minimums, that is what you need to become experienced. Steep turns every day for a couple years will only get you so far. I think the FAA raising the minimums to get hired in a 121 enviroment is a great idea..... since I already have my job.

3. The real story that the media has yet to figure out is that Marvin Renslow went to Gulfstream Academy/Airlines, Which means all he needed was a Commercial Multi Engine License. It takes 4 checkrides to get that, which means he had failed 3 out of 4 checkrides prior to Colgan Air. Someone should have caught that, including Colgan Air. The sad reality is that they did not want to know, they needed "meat in the seat."

4. There were 50 people killed in that crash. 49 on the plane and one on the ground. As a Colgan Captain, I will not allow myself to forget even one of those people. How could I?

Nice work, thank you for the insight.

February 09, 2010 12:59 PM  
Blogger Hey Skipper said...

dshawindiana:

1. I just want to make sure it is 100% clear to your readers that Colgan DOES do training on in-flight ice.

Thanks for the clarification. I presumed Colgan trains the same way the two airlines I have worked do: extensive discussion on anti- / de-icing, anti-ice systems operations and limits, and in flight restrictions. However, neither airline spent even a second talking about the affects of ice accumulation in flight.

I think that is probably due to the nature of hot-air system; clear ice build up behind the leading edge boot doesn’t happen.

Anyway, Colgan gives better training than I credited it for; thanks.

The other thing I should have mentioned, but forgot, is that autopilots give no warning when they reach their pitch trim limit. They just let go, and instantly transfer all the load to the pilot. In this case, he got (if I am thinking this through correctly) and arm-load of nose down

Surprises are bad, and I can’t think of any reason why this kind of surprise exists.

2. Most pilots are building hours these days flight instructing. Although this was not my path, I think teaching is a good way to learn.

Which is a great way to go (particularly if you get to be a CFII); I probably should have mentioned it. However, with one significant means of getting time gone, and another, the military, a shadow of its former self, the supply of guys like you is going to get much smaller. Raising limits to where they should be in an ideal world will likely result in a supply well shy of demand.

The price we pay for meeting that demand may well be the odd crash or two.

I will not allow myself to forget even one of those people. How could I?

Of that thought pros are made.

February 09, 2010 5:00 PM  
Blogger dshawindiana said...

Skipper :

I am so glad you made the point about "The price we will pay for meeting demand will be the odd crash or two.".

So true, I could not have said it better myself. If the public wants to continue to have the cheapest airfares, they will have to come to except that they will not get the most experienced pilots, or a Boeing 777, or even a bag of peanuts and a thank you. It is the reality of modern Common Carriage operations.

Now if you can just get that statement in the New York Times where it needs to be. Once again, great work, thank you.

February 09, 2010 5:43 PM  
Blogger Hey Skipper said...

Harry:

I am not particularly familiar with helo ops.

However, one problem with simulating power loss situations is that the simulation itself involves risk: unseen obstacles; putting yourself much closer to the ground than you would otherwise want to be with an operating engine; and executing the missed approach. When I was flying with the Navy, roughly four people per year died from practicing power loss situations. The airplane itself had suffered fuel control problems when new, but when I got there, the number of aircraft lost due to actual power failure had been zero per year for some time.

Once upon a time I was flying with a friend, and he suggested a simulated power loss shortly after takeoff, so as to show me a semi-hidden place to put it down. After pulling the power to idle, I remembered we also needed carb heat, so I pulled the carb heat knob.

Or so I thought.

When it came time to go around, I pushed up the power, and nothing was there. Why? Because I had inadvertently pulled the identically shaped and adjacently placed mixture knob, thereby turning the engine into a windmill.

We ended up doing an actual forced landing, onto a pasture that was happily both smooth and long enough for us to be able to reuse the airplane.

Anyway, the point here is that simulate power loss situations entail nearly as much risk as the real thing, and deserve a great deal of planning. However, the nature of reality (i.e., nobody expects the engine failure) means simulations end up being pretty ad hoc.

If what you say is true, the instructor gooned up. Just like good lawyers never ask a question to which they don’t already know the answer, good instructor never set up a situation for which they don’t already have an out.

This one did not.

BTW — as with the other op-ed candidate, I haven’t yet been able to wrap myself around shortening it. Writing to length is a real skill, which I don’t have in abundance.

February 09, 2010 6:49 PM  

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