Plane & Pilot
Tuesday, May 4, 2010

Analyzing Pilot Performance

The NTSB’s findings on the Colgan Air crash

IMPROPER RESPONSE. NTSB investigators found that the crash of a DHC-8-400 (like the one above) may have been caused by the captain’s faulty reaction to an unexpected stall.
NTSB investigators were able to assemble plenty of data to reconstruct what happened on board the Colgan Air Bombardier DHC-8-400 that crashed at Clarence Center, N.Y., on February 12, 2009. The primary focus of the investigation was the performance of the pilots.

The twin-engine turboprop was en route from Newark, N.J., to Buffalo Niagara International Airport. At 10:17 p.m., it crashed into a house about 5 nm from the airport, killing both pilots, both flight attendants, all 45 passengers and one person in the house. The airplane was in visual meteorological conditions at the time of the accident.

The Safety Board determined that the probable cause of the accident was the captain’s inappropriate response when the airplane’s stall-warning stick shaker activated. There were four contributing factors: (1) the flight crew’s failure to monitor airspeed and recognize instrument cues that airspeed was decaying; (2) the flight crew’s failure to adhere to sterile cockpit procedures; (3) the captain’s failure to effectively manage the flight; (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions. Among the NTSB’s 46 separate findings was that there wasn’t enough ice accumulation to seriously affect the crew’s ability to fly and control the airplane. The Safety Board said that the captain and first officer weren’t adequately trained to deal with an unexpected stall, and found that the airline should have identified the captain as a candidate for remedial training based on his previous performance.

The captain, age 47, held an ATP certificate and a first-class medical. He had received his type rating in the DHC-8 three months before the accident. He had 3,379 hours, with 3,051 in turbine-powered airplanes, according to company records. The first officer, age 24, held a commercial certificate and a first-class medical. Her total time was 2,244 hours, with 774 in turbine-powered airplanes.

NTSB Chairman Deborah A.P. Hersman felt strongly that an additional factor in the probable cause should have been pilot fatigue, but investigators couldn’t determine the extent to which fatigue might have contributed to performance deficiencies. The night before the accident, the captain slept in the company’s crew room, and his sleep was interrupted several times. At the time of the accident, he had been awake for 15 hours. He commuted to work from Tampa, Fla. The night before the accident, the first officer commuted from her home in Seattle, Wash., to Newark. She changed planes in Memphis shortly after midnight, and arrived in Newark at 6:30 a.m. She rested in the crew room for five hours before her work schedule began. She had slept a total of about 8.5 hours: 3.5 hours in a cockpit jump seat while deadheading from Seattle, and the rest in the crew room. Some statements on the cockpit voice recorder (CVR) suggest that the first officer was experiencing symptoms associated with congestion or the onset of a head cold. Also, the CVR recorded the first officer sniffling and sneezing multiple times during the flight.

The cruise portion of flight was uneventful. The captain and first officer chatted a lot. At 9:49:18 p.m., the CVR picked up the captain making a yawning sound. At 9:53:40, the first officer referred to her stuffiness, saying that it “might be easier on my ears if we start going down sooner.” Shortly thereafter, Cleveland Center cleared the flight to descend to 11,000 feet. At 10:03:38, the Cleveland controller told the flight to contact Buffalo Approach Control; the first officer called Buffalo, reporting that they were descending from 12,000 to 11,000 feet with the ATIS. The approach controller said to plan for the ILS approach to runway 23.

At 10:04:16, the captain began the approach briefing. Less than a minute later, the approach controller cleared them down to 6,000 feet. Thirty seconds later, the captain continued the approach briefing. At 10:06:37, the airplane descended through 10,000 feet. From that point on, the pilots should have observed the sterile cockpit rule.


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