The CRASH that Changed US Aviation.

what could cause a flight crew to handle an emergency in almost a complete opposite way to how they have been trained this aircraft tumbled through the dark snow and night it changed the American aviation industry to its core but did it do so for the right reasons stay tuned the story of Colgan Air flight 3407 took its place on the 12th of February 2009. it was a very windy and cold winter day in New York airport and because of the windy weather the airport was suffering from severe ground delays the pilots and crew in this story was originally supposed to operate two more flights before doing flight 3407 to Buffalo Niagara Falls airport but those flights had been canceled due to the weather and long ground delays this meant that the crew now only had to operate two flights instead of four and they were told by the company to report to the airport at a much later time around 1810 in the evening the pilots who were scheduled to operate a flight were both based in Newark New Jersey airport but none of them actually lived in the area they were operating on something called a commuter contract and that meant that they actually lived and spent their off time in completely different cities in the United States but they were expected to fly into their base and start operating from there at the beginning of the roster period it was up to the pilots to ensure that they had gotten enough proper rest before they turned off for Duty and since they were formally based in New York no Hotel accommodation was provided by the company there they would be provided with hotels during their stay at overnight positions throughout their Duty which was typically the majority of the knights and this meant that most pilots who were working on this type of agreement with colganer were either staying in hotels or sharing something called a crash pad that was a small overnight Department with other pilots in order to reduce their costs the crew room that the airline provided in Newark was equipped with nice recliner chairs but Corgan air expressively prohibited pilots from utilizing the crew room for overnight stays but even though that was the case the record shows that the captain in this story who had already been operating flights on the previous day before the accident happened likely did spend the night in the crew room based on observations made by other crew members if you did that because of the nature of how crew rooms work with Crews arriving in departing constantly as well as performing their briefing duties it is unlikely that the captain got much quality rest out the night before the accident the first officer was scheduled to begin her first day of Duty on the 12th of February so she had been traveling from her home in Seattle over to Newark via a stop in Memphis her flight from Seattle had departed at 1951 Pacific Standard time in the evening on the 11th of February and arrived in Memphis at 02 30 Eastern Standard time she had then had to wait for a second cargo aircraft that departed towards Newark at 0 4 18 and arrived two hours later she reportedly slept for most of these two flights and when a crew member asked her what she was going to do until her report time she answered that one of the couches in the newer crew room had her name on it this meant that none of the two pilots who were scheduled to operate flight 3407 received much quality rest before the flight and on top of this the first officer also started showing some symptoms of a light head cold during the day before the flight but she didn't feel that it was bad enough to consider calling in sick the aircraft that the crew was going to operate was a bombardier-8 q400 turboprop aircraft it was a modern high-winged aircraft designed to carry a maximum of 74 passengers and four crew members on the accident day the aircraft was reported to be in full working order with no technical defects it was arriving in New York operated by a different crew at 1854 only 16 minutes before the scheduled departure time of flight 3407. this meant that already from the start the flight was going to be delayed during the briefing the pilot discussed strong winds and the delays expected for departure and they also briefed their cabin crew about these facts the flight time was scheduled to be around 53 minutes over to Buffalo and the weather in Buffalo showed winds from 240 degrees at 15 knots with one and a half mile visibility in light snow showers overcast clouds at around 1500 feet and a temperature around 1 degree Celsius there were also some pilot reports of in-flight icing between 3000 feet and 14 000 feet but the significant weather report they should have had which also showed icing was not included in the brief impact the pilots discussed the weather and they decided that the captain was going to be Pilot Flying for the flight over and the first officer was going to be pilot monitoring now before we go any further here it's also worth talking a little bit about the background and the experience of these two pilots the captain was 47 years old and had a total flying experience of 3379 hours so which 1030 hours was as a captain but he had only flown 111 hours on the q400 he had previously been flying on another turboprop aircraft the sub 340 for the majority of his experience now his training history was a bit spotty to say the least he had failed four different FAA check rights during his training including his first instrument check right his commercial single engine his commercial multi-andian and also his first attempt on the airline transport pilot license and during that last failure he was already flying the sub 340 for Colgan Air in all of these Czech rights he had been approved on the second attempt but on top of this he had also received several trained proficiency and unsatisfactory grades on his recurrent training inside of Corgan air including his initial Captain upgrade check on the sub 340. during his job application to Corgan air he had only advised the company of one of these initial training failures and that's significant because coconair only allowed one failure for the application to go forward if it would have told them about the other failures his supplication would have been rejected but there was no formal system in force for the airline to be able to check this information at the time of the accident all of these failures spread out over his initial training and his continued career thus paint the picture of a pilot who was likely somewhat lacking in capacity but there was no indication that this capacity deficit had anything to do with this amount of total flying time that's worth remembering during the transition from the SOB to the q400 the captain had received overall good remarks except for one note from one instructor during his simulated training which said that he had shown the tendency to over correct the aircraft in role when practicing unusual attitudes first officers who had flown with the captain stated that he handled the aircraft and procedures well and they liked flying with him now the first officer was 24 years old at the time of the accident she had flown a total of 2 244 hours of which 774 was on the q400 and prior to starting her work with Colgan Air in 2008 she had been working as a flight instructor she had no failures in her practical FEA flight test except for a theoretical disapproval for her first instructor rating but that had to do with her instructor techniques and not her flying skills her colleagues described her as a very knowledgeable and diligent pilot sometimes even above the average of other first officers with similar experience anyway the two pilots got on really well with each other and like he had plenty of time to get to know each other better as they were waiting to start flying given the cancellation of the first two flights when the aircraft finally arrived the crew walked out to the aircraft and the captain started to set up the cockpit for the flight while the first officer completed the walk around the two cabin crew members started boarding all the 45 passengers who were scheduled for the flight and then they closed the doors and reported that they were ready to go at time 1930 the pilots received their departure clearance from Air Traffic Control and 15 minutes later they requested pushback and engines start but because of the amount of traffic ahead of them they didn't receive clearance to actually start moving until 45 minutes later at time 2030. once they had finally been allowed to push the crew now found themselves as number 20 in the queue for departure this meant that they were facing a very long further ground delay and the pilots spent that time discussing personal things as they were slowly taxiing out it should be mentioned here that the taxi phase is considered a sterile phase of flight and during that time only operational and safety related things should be discussed in the cockpit the sterile phase of flights start when the aircraft initiates the pushback from the gate and then continues until 10 000 feet in the climb it then starts again at 10 000 feet in The Descent until the aircraft is safely parked at the gate for other airlines different limits might apply but the point here is that history has shown that personal discussions during these phases of flight can cause distractions which can be dangerous that's because of the multitude of mode changes configurations ATC Communications and other complexities that happens during those times having said that given the fact that this aircraft was stuck in the queue for almost one hour on the ground I do understand that they had some light chit chat but reading through the CVR transcript there was a lot of conversation going on more than I have seen in any other transcript and unfortunately it likely set the tune for the remainder of the flight during the taxi out the first officer also used her phone to send a text message to her husband and as I have explained in previous videos the use of personal electronic devices is strictly prohibited for similar reasons as I just explained about the sterile phase of light but something that is not prohibited is to press the Subscribe button and to activate the Bell so you don't miss any of my future videos anyway during the taxi out the first officer mentioned that she felt ready for the hotel room and the captain responded that he felt sorry for her she was sneezing and clearing her throat several times showing the onset of that head cold that I mentioned before eventually the aircraft got to the front of the queue and air traffic controlled cleared the aircraft for takeoff the captain announced that he would take control and at time 21-18 he increased the trust and started accelerating down Runway 2-2 now before I tell you the rest of the story I just want to give you this short message from my sponsor who makes it possible for me and my team to create these videos because you know that I'm a huge fan of good non-fictional stories before we go any further I just want to thank today's sponsor curiosity's stream a subscription streaming platform with thousands of documentaries costing less than 20 dollars per year if you like the content on this channel you're probably going to love the shows over on curiosity stream because they cover loads of topics like nature history music sports science technology and yes you guessed it Aviation right now I'm watching an original series called oddly satisfying science hosted by Nick uhas and like the name suggests each episode introduces satisfying experiments designed to blow your mind like explaining how forensic teams extract DNA or how hot air balloons actually work one of the things that I love most about curiosis stream is that they add new shows every week and it's available worldwide for almost every possible device so you'll never run out of new things to watch so go to to curiositystream.com mentorpilot or click on the link here below and start enjoying unlimited access to the world's top documentaries and non-fiction series and since you are coming from my channel they're offering you an amazing deal that will save you 25 off meaning a price of only 14.99 per year that's 1.25 per month now let's continue the story The Climb was largely uneventful and the crew initially adhered to the sterile cockpit rules until the aircraft leveled off at a cruise altitude of 16 000 feet for their short flights over towards Buffalo during the climb the aircraft entered into clouds and given the temperature outside that also meant icing conditions when that happened the pilots followed the company procedures and switched on the aircraft anti-icing system and as they did so they also likely switched over the ref speed switch to increase in the overhead panel the operation of this switch will play a crucial role in what's about to happen later and to understand it we need to go into a little bit of aerodynamics now in order for Lift to be generated the air needs to flow smoothly over all lift generating surfaces of the aircraft if there is anything disturbing that flow the lift created can be disturbed and lead to control difficulties extra drag and in worst case scenario the aircraft could stall a stall is what happens when the Wing's ability to generate lift drastically reduces and it can happen due to low speed contamination high G loading or a combination of these but what always have to happen for stall to occur is that the critical angle of attack is exceeded so what is the angle of attack well if you look at the wing from the side the center of the wing profile is what we refer to as the wings chord line in order for the wing to generate more lift it needs to increase its angle of attack against the oncoming air and the angle of attack is the angular difference between the oncoming air and that cord line if you have ever put your hand outside of your car window and change the angle of your hand you will have felt the effect that this changing of angle of attack has if there is eyes present on the aircraft wing it might make the wing less effective and therefore the wing could stall at the lower angle of attack than it would if the wing was clean so what does all of this has to do with that switch that I mentioned well the ref speed switch was there to let the aircraft know that it is flying in icing conditions and when that switch is set to increase the stall warning system the stick Shaker would activate at a lower angle of attack to give the pilots an earlier warning of a potential stall it's worth pointing out here that it doesn't actually mean that the wing is stalling it just resets the setting of the warning system and this fact will become very important very soon [Music] once the aircraft was established in Crews the crew continued an almost non-stop conversation about home conditions and company policies plus the cruise phase is not formally a sterile phase of light this was perfectly okay in theory but it's always important to prioritize work even in the cruise to make sure that we don't end up in a situation where important tasks gets pushed forward and increases the workload later on in the flight during the cruise the conversation was only interrupted by occasional yawnings by the crew potentially showing some level of fatigue already but the pilot still seemed alert the captain for example was pointing out Crossing traffic and the first officer who was reviewing the tech log noticed a smaller Mission made by a previous crew before the aircraft reached its program top of the sand the first officer listened into the automatic weather transmission from Buffalo and it confirmed the forecasted weather that they had received earlier the visibility was okay with some snow in the area and light to Gusty winds from the West the captain said that they could probably expect an ILS approach into Runway 2-3 and that they would use flaps 15 for landing but he didn't start his approach briefing at this point instead the first officer filled in the required performance data into their data link system and sent that over to a company called Aero data which would calculate the performance for them when she did this she omitted the part of the message designed to inform aerodyta about the aircraft flying in icing conditions now error data sends the reference speeds and the performance back to the crew and the speeds that they ended up setting was an approach reference speed of 118 knots and a go around reference speed of 114 knots now if she would have told error data of the icing conditions the reference approach speed would have been automatically increased with 20 knots in order to account for the higher stick Shaker onset speed that we discussed before but sadly that wasn't done at time 2156 the first officer told the captain that it might be easier on my ears if they started to descend a little bit earlier and descended a bit slower the captain agreed to this and after having advised their traffic control the crew started descending down to initially 11 000 feet seven minutes later the crew was handed over to the Buffalo approach controller who gave them the local pressure setting and told them to prepare for an eyeless approach into Runway 2-3 at this point as the aircraft was now descending the captain started his approach briefing during the brief the aircraft was clear to descent to six thousand feet and at time 2206 the aircraft descended past 10 000 feet meaning that they were now in a sterile phase of flight again the captain continued his briefing where he also reconfirmed the approach reference speeds again without any discussion about icing or the position of the reference speed switch now there is a possibility that since the crew had activated the ref speed increase much earlier in the flight they might have just forgotten about it the crew were now clear to the center four thousand feet and the captain asked the first officer how her ears were feeling she responded that they were feeling stuffy and popping around time 22-10 the first officer asked the captain if he could see some ice on his side of the windshield and he said that yeah he could the first of Sudan commented that she had a lot of ice on her side and then they both started the conversation about previous experiences they had encountered with icing conversation had nothing to do with the flight that they were actually operating it was more a case of smoking stories in reality later Turf done during the investigation showed that the amount of ice that the aircraft had accumulated at this point had little to no effect on its aerodynamics and performance the aircraft performed almost like a clean aircraft would do so icing in itself was likely not an issue at time 2212 at 18 seconds the approach controller cleared the aircraft to descend to 2 300 feet which was the initial approach altitude for the ILS and also to turn onto heading of 330 degrees the first officer read that back the captain set it and then they continued their Lively discussion about icing the aircraft was now getting closer to the ILS and they were still maintaining a speed of about 180 knots on top of that The Descent and approach checklist was still to come something that they should have done much earlier the captain now realized this and asked for the checklist to be completed in the Colgan Air checklist at the time there was no triggers regarding the use of different approach beats due to icing this and the fact that the workload now started to increase meant that none of the pilots spotted the discrepancy between the approach bead that they had selected and the position of the ref speed switch the aircraft now leveled off at 2 300 feet and the Buffalo approach controller asked the crew to turn further left onto heading of three one zero degrees the captain now asked for flaps 5 to be selected and as he was doing that the controller told them to turn further left heading to 600 Degrees and clear them for the eyeless approach for Runway 2-3 the first officer read back the clearance and since they were now less than three miles away from the outer marker of the ILS that's a point on the approach which is quite close to the runway they needed to decelerate quickly in order to establish a stabilized approach speed decelerating is generally not a huge problem for a turbo prop aircraft like the q400 by changing the pitch of the propeller you can increase the drag substantially and that's exactly what the captain now did he reduced the power levers back to almost idle and as he was doing this the approach controller instructed them to contact Buffalo Tower the first officer read this instruction back and that was going to be the last contact Air Traffic Control had with Corgan air flights 3407. the captain now asked for the landing gear to be extended and he moved the propeller condition levers into Max RPM since the speed was now reducing the autopilot applied a bit of back trim to keep the altitude this meant that the angle of attack of the aircraft now started increasing at time 22 16 and 21 seconds the first officer confirmed that the gear was down the airspeed was now around 145 knots reducing and the aircraft was maintaining 2 300 feet waiting to capture the Glide slope if the pilots would have monitored their primary flight displays closely at this point they would have seen how the Barbers polls the low speed indication that shows the onset of a stall warning was creeping higher and higher up their speed indicator but none of the pilots seem to have noticed that the captain now asked for flap 15 to be selected and at the same time an ice detected message appeared on the engine display but it's not clear if anyone actually noticed that this could have served as the last reminder of the reference speed selector switch and its position the first officer move the flap selector to the flaps 10 position where there was a small detent she needed to move the selector through in order to select flap 15 but she never made it to Flat 15. because at time 2216 and 27 seconds the speed had reduced to 135 knots and the angle of attack reached the pre-programmed ice threshold the stick Shaker now suddenly activated and that likely caused an immediate startle to the crew it is important to point out here that the aircraft was not in or even close to a stall at this point the subsequent investigation showed that the ice accumulated on the aircraft at this point did not affect its performance so the only reason that the stick Shaker activated here was because the crew had set the Rev speed selected to increase at the same time as they were trying to decelerate to an approach reference speed which was not set for icing when the stick Shaker sounded the autopilot automatically disconnected as it was supposed to do the cap that reacted to this by pulling back on his controls and also add some but not Max thrust this sudden pull on the control generated an immediate increase of G loading on the wings and when you do that you further increase the angle of attack on the wing bringing it closer to an actual stall this is the reason the first thing that any pilot should do when recognizing an onset of a stall it's to pitch forward to reduce the angle of attack and unload the wings after that you can think of reducing Bank angle or adding thrusts as appropriate but unloading the wing must be the first thing to do this is among the very first thing that you learn in Flight Training and it's drilled into every pilot throughout their career so why did the captain now pull back on the controls the complete opposite to what he had been taught well we will never know all this for sure but it likely had to do with the training that the airline pilots were receiving at the time because during training and checking in the simulator reducing altitude loss during an approach to stall and Recovery maneuver was heavily prioritized if a pilot lost more than 100 feet during the maneuver it could be recorded as a fail on the check ride now we've seen another example of how that could influence the crew that was in the Pinnacle Airlines accident which I also covered in this channel I'll link to that to watch the end of the video but the q400 was also a very capable aircraft and had shown that it could pull itself out of an approaching stall by just adding power and keeping the nose more or less leveled so there is a possibility that this is what went through the mind of the captain as this sudden stick Shake of warning came out of nowhere what actually happened was that his abrupt pull-up maneuver now actually caused the stall that the warning was designed to avoid this stall induced a rapid role initially 45 degrees to the left and then back over towards the right and as that happened another feature of the aircraft's anti-stalled protection system kicked in the stick pusher a stick Pusher does what the name suggests it pushes the stick forward in order to rapidly reduce the angle of attack if the pilots are not doing so the stick Pusher activates when an actual stall is sentenced which was the case now but instead of allowing nose to be lowered the captain fought against it by applying even more back pressure again the complete opposite of what needed to be done as this was happening the first officer who likely had her hand on the flap selector decided to select the flaps up she did this without any command from the captain and when the speed had dropped to around 100 knots reducing the flaps form part of the recovery procedure but only when the speed had increased enough to allow it and only off the direction of the pilot flying retracting the flaps at this speed and attitude aggravated the situation severely since the flaps are there to increase the lift at low speed again it's hard to know why she did this without any instruction she was likely just as startled by the sudden stick Shaker and upset situation as the captain was and she might just have been trying to help out or she might have regressed back into her old single engine instructor habits some of the situation though was that the crew true lack of situational awareness and crew coordination was now creating a severe opposite situation from nothing the aircraft was flying perfectly well before this and the only thing that had happened was on in reality spurious stick shaky warning the aircraft now rolled over as much as 105 degrees to the right before starting to roll back again towards the left the nose of the aircraft started dropping still with the captain pulling back on the controls as the stick Pusher now activated a second time on the copy voice recorder the captain can be heard grunting from The Strain and pulling against the stick Pusher the roll reached 35 degrees to the left and then rolled back over towards the right again the first officer asked if the captain wanted the gear to be retracted and the captain called out Gear Up dammit the aircraft had now rolled over to 100 degrees right bank and 25 degrees pitched down as the stick Pusher activated a third and final time the combination of all of this meant to start him a very rapid descent from which the crew could not recover the last thing heard on the Coptic voice recorder was the captain stating we're down and then a loud thumping sound as the aircraft impacted a single-family house at time 22 16 and 54 seconds all 49 passengers and crew as well as one person inside of the house perished in the crash the ultimate cause of the accident was found to be the lack of adherence to sterile cockpit procedures by the pilots leading up to their missing important cues of the impending low speed warning the captain's completely inappropriate response to the stick Shaker which actually caused the aerodynamic stall and the first officer's decision to retract the flaps during the offset all led to the accident the investigation team also looked at the training history of the captain and his many failed skill tests and decided that it must be easier for Airlines to access this type of information before hiring a pilot they also concluded that the simulator training that Pilots received regarding approach to stolen recovery had to be improved as well as proper demonstrations of the stick Pusher which was found to be generally poorly understood also it together with some other accidents led to the development of a much more focused upset prevention and Recovery simulator training module which has since become mandatory for all airline pilots other important changes coming out of this accident was more scrutiny of how Airlines allowed Pilots to use commuting contracts and the impact that that could have on their fatigue levels but one thing that was not to mention in the findings or in the recommendations from this accident was the establishment of a minimum amount of flight hours needed to start working as a commercial pilot on the contrary the recommendations pointed more to the importance of good training proper aircraft design and the need to focus on core competencies of Pilots and because of that I find it really interesting that the single biggest lasting Legacy of this accident was the implementation in the United States of the 1500 hour rule this rule with a few exceptions requires Pilots to have a minimum of 1 500 hours of Total time and an Air transport pilot license before they're allowed to operate as a pilot in heavy commercial passenger transport this might sound like a great way to ensure that the pilots are experienced before they're allowed to fly passengers but in reality it does very little to ensure the proper competence of those Pilots remember both of the pilots in this accident had more than 1 500 hours of Total time and the first officer had spent many years as an instructor getting exactly the kind of experience that most pilots in the US now must do in order to reach those 1500 hours in Europe a Cadet can be employed straight out of flight school with as little as 250 hours of Total time provided that they meet strict competence requirements of the airline and that they're able to absorb the training so they can pass the required skill tests the 1500 hour rule has to my knowledge not increase safety in any measurable form but it has helped create a pilot shortage and a lot of financial stress for many new pilots in the United States now check out this really interesting video next or this playlist if you want to binge on more accident videos please consider subscribing to the channel if you like it and join my patreon crew if you want to support my work have an absolutely fantastic day and I'll see you next time bye [Music]

Channel: Mentour Pilot

Views: 1,214,410

Keywords: Colgan air, Q400, bombardier, dash 8, newark, new york, stall, ice, icing, storytelling, true crime, full episodes, investigation, documentary, entertainment, mentour pilot, mentour now, top 10

Id: o6c3ENr_CRM

Length: 30min 57sec (1857 seconds)

Published: Sun Nov 13 2022