NTSB scrutinizes pilots in Colgan Q400 crash probe

Aviation International News » June 2009
May 26, 2009, 7:57 AM

The pilots of the Colgan Air Bombardier Q400 that crashed on February 12 outside Buffalo, killing 50 people, did not observe the so-called sterile cockpit rule and appeared unprepared to react properly to the aerodynamic stall that led to the accident, according to testimony read last month during the NTSB’s three-day public hearing on the crash.

NTSB hearing officer Lorenda Ward reported that the crew engaged in non-essential conversation while flying below 10,000 feet in violation of FAA rules, including, for example, a three-minute discussion on the first officer’s experience in icing conditions and training. “This conversation occurred just a few minutes before the stick shaker activated and while the crew was executing the approach checklist,” said Ward.

Operating as Continental Connection Flight 3407 from Newark, N.J., to Buffalo Niagara International Airport, the 74-seat turboprop was carrying 45 passengers and four on-duty crewmembers when, after the airplane descended to about 2,300 feet, ATC lost contact with the pilots. FDR data shows that the Q400 pitched up at an angle of 31 degrees, then down to 45 degrees, followed by a 46-degree roll to the left, then a 105-degree roll to the right. The airplane fell the last 800 feet in five seconds, before crashing onto a single house in the suburban town of Clarence Center, N.Y., killing one of the residents.

Although the pilots reported ice accretion on the airplane’s windshield and wings, airplane performance modeling and simulation conducted by the NTSB show that icing had “minimal effect” on the stall speed of the airplane. Information from the airplane’s FDR indicates that the stick shaker activated at 130 knots, a speed consistent with an engaged de-icing system. FDR data further indicates that when the stick shaker activated, the control column experienced a 25-pound pull force, followed by an up elevator deflection and an increase in pitch, angle of attack and g forces.

During the three-day hearing, the NTSB turned much of its attention to fatigue as a possible contributor to the crash. Records indicate that on the day of the accident, the captain logged into the company’s crew scheduling computer system at 3 a.m. and 7:30 a.m., and that the first officer commuted to Newark on an overnight flight and had sent and received text messages on the day of the accident.

Colgan had scheduled the crew to report at 1:30 p.m. on the day of the accident, but high winds at the airport forced the cancellation of the first two flights of the day. Schedules called for Flight 3407 to take off at 7:45 p.m. Although ground crew pushed the airplane back from the gate at 7:45, the crew did not receive taxi clearance until 8:30 p.m., and the tower cleared the flight for takeoff at 9:18 p.m.

During the flight’s climb to 16,000 feet, the crew activated the de-icing systems and left them on throughout the flight. About 40 minutes into the flight, the crew began their descent and at 10:10 p.m. they discussed the build-up of ice on the windshield. At 10:12, the flight received clearance to descend to 2,300 feet and reached that altitude at 10:14. At 10:16 the crew lowered the landing gear, and about 20 seconds later the first officer moved the flaps from 5 to 10 degrees. The stick shaker activated and the autopilot disengaged shortly thereafter. The crew added power to about 75-percent torque and the control column moved aft. That accompanied a pitch-up motion, a left roll, followed by a right roll, during which time the stick pusher activated and the flaps retracted. The airspeed then decreased and after further pitch and roll excursions the airplane pitched down and entered a steep descent from which it did not recover.

Colgan had instituted a fatigue policy before the accident occurred and it covered the policy during indoctrination training. However, according to the testimony, by the date of the accident the airline did not provide specific guidance to its pilots in fatigue management. On April 29 this year Colgan issued an operations bulletin that reiterates its fatigue management policy.

The hearings revealed that the captain had accumulated four FAA certificate disapprovals, three before his hiring at the airline in 2005, including disapprovals for his pilot instrument, commercial pilot initial and his commercial multi-engine rating. He also failed his first evaluation at Colgan for his ATP certificate. The first officer had received one FAA disapproval for her initial flight instructor certificate before she joined Colgan in January last year.

The captain did not mention two of his failed tests on his employment application, according to last month’s testimony. Colgan vice president of administration Mary Finnigan said that if the company knew that he had withheld the information, “he would have been immediately dismissed. That would have been falsifying documentation and it’s not tolerated.”

Finnigan explained that the company follows the FAA’s Pilot Records Improvement Act, which in 1996 set standards for airlines’ background checks of applicants, including a prohibition against tracking records dating back more than five years. “Are we looking at ways to find out if a pilot falsifies something on his application? Absolutely,” said Finnigan. “However, we would welcome the help of the Board in order to do that.”

Countering some of the reservations expressed about the level of experience and competence of the pilots during the three-day hearing, Colgan vice president of flight operations Harry Mitchel noted that the captain, “from his Q400 training going forward, had 16 months of a very fine track record with successful completion of six training and checking events.”

Mitchel testified that he has “most definitely” considered implementing the recommendations contained in FAA SAFO 06015, which advocates remedial training for pilots with persistent performance deficiencies.

Long Commutes for Pilots
Both pilots were based in Newark. The captain commuted from the Tampa, Fla., area, and arrived in Newark on February 9 at 8 p.m. On February 10 the captain began the first day of a two-day trip at 5:45 a.m.

The first officer, who previously lived and worked out of a base in the Norfolk, Va. area, recently moved to Seattle to live with her parents and had changed her base to Newark. On February 11 she awoke between 9 and 10 a.m. PST and took a jump seat from Seattle to Memphis, Tenn., on a FedEx flight that departed just before 8 p.m. PST. The flight arrived at about 2:30 a.m. EST on February 12; at about 4:20 a.m., the first officer rode a jump seat from Memphis to Newark and arrived at about 6:30 a.m. Before arriving in Newark, she joked that a couch “with her name on it” awaited her in the Colgan crew room, noted NTSB member Debbie Hersman. 

Much of the early questioning during the second day of the hearing centered on Colgan’s pilot commuting and rest policies, which, according to Mitchel, provide for “flexibility” and rely on the good judgment and professionalism of the individuals involved. Mitchel added that the airline and the FAA have begun collaborating “to ensure the interpretation of the regulations is followed.”

Colgan’s pilot handbook states only that the company expects the pilot to report for duty in a timely manner. Although a previous edition of the handbook said that flight crewmembers should not attempt to commute to their base on a scheduled work day, that statement does not appear in the current edition, according to last month’s testimony.

Rest Regulations
Colgan requires its Newark-based crewmembers to provide their own sleeping accommodations, and “sleeping in operations or any crew room in Newark is strictly prohibited and will have severe disciplinary consequences up to and including termination,” stated a memo issued May 24 last year by Colgan’s Newark chief pilot. 

Even though company records indicate that both the captain and first officer acknowledged receipt of the memo, according to last month’s testimony, the NTSB could find no evidence that either crewmember had arranged for accommodations in Newark “and the captain had been reported to stay overnight in the crew room.”
However, at press time it remained unclear exactly where the captain slept the night before the crash.

NTSB investigator Roger Cox also raised the issue of the captain’s experience when he joined Colgan Air in September 2005, by which time he had accumulated only 618 hours total flying time.

“When we looked at pilots with that sort of time, we very much concentrated on what kind of training they had, what experience they had, what airplanes they flew, and Captain Renslow came from a Part 121 carrier [Gulfstream International Airlines],” said Finnigan. “To us it was much more valuable to have 250 hours at a 121 carrier, actually flying the line, doing the job, than a pilot who spends 1,500 hours paying for a [Cessna] 152, flying around the patch just to build up his hours.”

At the time Colgan hired Renslow, the airline required only 600 hours of total flying time and 100 hours of multi-engine experience. It has since raised its standards to 1,000 and 100 hours, respectively.

The focus of questions from Cox then turned to the issue of the notoriously low pay of regional airline first officers and the high cost of living in hub areas such as Newark. According to the NTSB’s investigation, 93 of the 137 Colgan pilots based at Newark commute to their base from various regions of the country, due largely to the high cost of living in the New York metropolitan area.

“What measures does Colgan take to assist and accommodate commuting pilots?” asked Cox.

“Pilots clearly know that when they’re hired with Colgan Air they can be based at any base,” said Finnigan. “We certainly try to help them when they’re trying to find apartments. I believe our crew Web site has areas where people can go on and talk to other crewmembers about places to live, but it is their responsibility to commute in and be fit for duty.”

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