Australian report: Avoidable accidents due to low-level flying

by B. N. Sullivan

The Australian Transport Safety Bureau (ATSB) has published the first report in a new series of pilot education documents. The first report focuses on aircraft accidents involving unnecessary and unauthorized low-level flying.

In a press statement that accompanied the release of the Low-level Flying report, the ATSB says:

Between 1999 and 2008, there were 147 fatal accidents in Australia reported to the ATSB involving aerial work, flying training, private, business, sport and recreational flying. Of those fatal accidents, at least six were associated with unauthorised, and unnecessary, low flying. Those six accidents, along with a seventh non-fatal accident, presented here as case studies, were chosen by aviation safety investigators at the ATSB to highlight the inherent dangers of unauthorised low flying and to offer some lessons learnt from each case. It is hoped that these lessons learnt will help pilots make more accurate risk assessments and better decisions before electing to fly at low levels.

At low altitudes, there are many obstacles to avoid and there is a lower margin for error. Recognising the risks and hazards of low-level flying, CASA requires pilots to receive special training and endorsements before they can legally conduct low-level flying. In the accidents below, most of the pilots had neither of these, and none had a legitimate reason to be flying below 500 ft. Some legitimate reasons for flying at low level include aerial stock mustering, crop spraying, and fire fighting operations. For most private pilots, there is generally no reason to fly at low levels, except during takeoff and landing, conducting a forced or precautionary landing, or to avoid adverse weather conditions.

What is sad and unfortunate about the accidents described in the following case studies is that they were all avoidable.

The report is available for download, free of charge, here: Avoidable Accidents, No. 1: Low-level Flying - ATSB (24-page 'pdf' file)

Greek carriers Olympic Air and Aegean Airlines to merge

by B. N. Sullivan

Earlier this week, the Greek carriers Olympic Air and Aegean Airlines announced plans to merge. Following a transition period, the merged airline will use the name and trademarks of Olympic Air, according to a statement released to the press. Olympic Handling and Olympic Engineering will become wholly owned subsidiaries of the new company. The merged company is being billed by the partners as "a national airline champion."

Under the terms of the merger agreement, the main shareholder of Aegean (Vassilakis Group) and the sole shareholder of Olympic Air (Marfin Investment Group) will have equal shares in the consolidated company. The merger must be approved by the European Union, however it is projected that the merger will be completed by late 2010 or early 2011. The new company would be listed on the Athens Stock Exchange.

Aegean Airlines and Olympic Air are Greece's two largest airlines. Aegean currently employs about 2,500 people, while Olympic Air's present work force numbers about 1,300. Another 2,000 are now employed by Olympic Handling, while Olympic engineering has 50 employees. Statements from the companies made no mention of whether any employees would be made redundant by the merger.

Aegean Airlines had planned to join the Star Alliance in June of this year. According to a Financial Times article about the merger, "analysts expect the new entity to take Aegean’s place in the grouping."

Mesa Air Group flight attendants ratify new contract

by B .N. Sullivan

Flight attendants working for Mesa Air Group carriers -- Mesa, Freedom, and Go! -- have ratified a new two-year contract. The new agreement between Mesa Air Group management and the flight attendants' union, the Association of Flight Attendants (AFA-CWA), was reached with the assistance of the U.S. National Mediation Board (NMB).

According to AFA, the agreement includes quality of life improvements such as more favorable work rules, and salary increases. In addition, says AFA, the new contract will serve as a solid foundation for the next round of contract negotiations that will begin in two years.

“Mesa flight attendants have an agreement that recognizes their dedication and professionalism during this challenging time for our airline,” said Brian Manning, AFA-CWA Mesa President. “Mesa Air Group flight attendants believe this agreement provides a framework for working alongside management in rebuilding our airline. This was not our contract of choice, but a contract of necessity at this time. We will be returning to the bargaining table in two years and will expect management to recognize our commitment and contribution to Mesa’s successful reorganization.”

Mesa Air Group filed for Chapter 11 bankruptcy protection earlier this year.

Lufthansa pilot strike slated for next week

by B. N. Sullivan

The pilots at German flag carrier Lufthansa have announced plans to strike after contract talks between the airline's management and the pilots' union, Vereinigung Cockpit (VC), broke down. The pilots intend to strike for four days, beginning Monday, February 22, 2010. VC stated earlier this week that more than 90 per cent of the union membership had voted in favor of striking.

Lufthansa pilots would like a pay raise, however the main topic of contention in the contract negotiations has to do with job security. In particular, the Lufthansa pilots want well-defined scope clauses in their contract, assuring that the routes they fly are not transferred to Lufthansa's recently acquired subsidiaries, such as Lufthansa Italia and Austrian Airlines, where pilot pay is much lower.

Similar issues have arisen repeatedly in the United States as pilots at mainline legacy carriers see more an more of their work outsourced to smaller regional carriers, which pay their pilots significantly less. It is the view of the pilots that this practice not only threatens their own job security, but ultimately lowers the standard for pilot wages and working conditions across the board.

According to an article about the intended strike on the German news Web site Spiegel.de, the industrial action will affect around 4,500 pilots at Lufthansa, its freight subsidiary Lufthansa Cargo, and budget airline Germanwings, which is wholly owned by Lufthansa.

UPDATE February 22, 2010: The Lufthansa pilots have begun their strike, as announced. Lufthansa management is seeking help from the German courts to halt the strike, which is said to be the largest in German aviation history.

Spiegel.de reports:

The airline's management applied for a court injunction on Monday to try to force the pilots to return to work. A spokeswoman for the airline said the strike was having a disproportionate impact and that the management had a responsibility to prevent damage to the firm, its staff and its shareholders.

The Frankfurt labour court will consider Lufthansa's request at a hearing on Tuesday at 5:30 p.m. CET (4.30 p.m. GMT). Lufthansa is claiming that the strike is in breach of rules governing labor relations, the court said.

UPDATE #2: BBC News is reporting that the Lufthansa pilots have now suspended their strike and have agreed to resume negotiations with the airline's management. There will be "no further action until at least March 9."

FAA slaps American Eagle with multi-million dollar fine for improper repairs

by B. N. Sullivan

A short time ago, the U.S. Federal Aviation Administration (FAA) announced a proposed $2.9 million civil penalty against American Eagle Airlines "for operating more than 1,000 flights using airplanes on which improper repairs were performed on landing gear doors," in violation of an FAA Airworthiness Directive. The airline has 30 days from the receipt of the FAA’s civil penalty letter to respond to the agency.

In a statement to the press, the agency said:

The FAA alleges that between February and May 2008, American Eagle conducted at least 1,178 passenger-carrying flights using four Bombardier jets with main landing gear doors that had not been repaired in accordance with an Airworthiness Directive that became effective in August 2006.

...

Airworthiness Directive 2006-14-05 required operators of certain Bombardier jets to inspect the left and right main landing gear inboard doors for cracks and other damage, including loose or missing fasteners. The directive required operators to remove affected doors and replace them with new or repaired ones, or that the doors be removed and the discrepancy noted in the aircraft’s records.

In this case, American Eagle found such damage on four aircraft. Rather than removing the doors, the airline repaired them while they remained on the planes.

FAA inspectors found that the airline operated at least 961 flights while it was unaware that the situation existed on these aircraft. The FAA further alleges that after the situation was discovered, the airline continued to operate these airplanes on 217 additional flights.

American Eagle subsequently removed the landing gear doors on each of the affected aircraft and repaired them in accordance with the Airworthiness Directive. However, the violations resulted in a proposed civil penalty of $2.9 million.

Commenting on the alleged violations by American Eagle, FAA Administrator Randy Babbitt said, "Following Airworthiness Directives is not optional."

"The FAA does not hesitate to levy fines if maintenance standards are violated. Compliance with mandatory maintenance requirements ensures the highest levels of safety," Babbitt added.

Two pilots perish in Cessna Citation crash in Germany

by B. N. Sullivan

On the evening of February 14, 2010, a Cessna 550B Citation Bravo (registration OK-ACH) crashed in Germany, not far from the Czech border. The aircraft was destroyed; the two pilots, who are believed to have been the only people on board, were killed.

The aircraft, operating as Time Air Flight TIE039C, was en route to Karlstad, Sweden (KSD/ESOK) from Prague (PRG/LKPR), and had just entered German airspace at the time of the accident. According to a preliminary accident description on the Aviation Safety Network, a German air traffic control spokesman reported that the flight was given clearance to climb from FL260 to FL330. The pilot never replied, and the plane then disappeared from radar screens at about 8:20 PM local time.

News reports say that wreckage from the accident aircraft was found in an area of mountainous terrain in Saxony, southeast of Dresden, Germany. UPI.com quoted German officials who said they a body, believed to be that of one of the pilots, was discovered at the crash site. Also found were identification papers for two men, one a Czech, the other a Slovak, although authorities were not certain that the papers belonged to the pilots.

Condolences to the families and friends of the two pilots who lost their lives.

MexicanaClick Fokker 100 emergency at Monterrey, Mexico

by B. N. Sullivan

On the evening of February 11, 2010 a MexicanaClick Fokker 100 aircraft (registration XA-SHJ) made an emergency landing at Mariano Escobedo International Airport in Monterrey, Mexico after its main landing gear failed to deploy properly. The crew and passengers evacuated the aircraft on the runway via emergency slides, and one person is said to have sustained minor injuries. According to the company, there were four crew members and 92 passengers on board.

According to a statement on Mexicana's Web site, the aircraft, operating as MexicanaClick Flight QA7222, had been en route to Nuevo Laredo from Mexico City when a "mechanical fault" with the landing gear was detected. The crew chose to divert to Monterrey because of "the length of the runway and the installed capacity of emergency response teams," the company's statement said. The aircraft landed at 8:42 PM local time.

In news photos from the scene, the aircraft appears to be resting on its belly. News media in Mexico are reporting that the airport at Monterrey was closed immediately after the accident, and was expected to remain closed overnight.

[Photo Source]

UPDATE Feb. 12, 2010: This morning, a few more details about this accident have emerged. The Aviation Herald reports that while on approach to Nuevo Laredo, the crew of MexicanaClick Flight QA7222 "received an unsafe gear indication, entered a holding to trouble shoot the problem and after being unable to resolve the problem performed a low approach to have the landing gear inspected which revealed, that both main gear had not extended." After landing on runway 29 at Monterrey, the aircraft " skidded off the runway and came to a stop on soft ground turned around by nearly 180 degrees."

Final report on 2008 British Airways Boeing 777 accident at Heathrow

by B. N. Sullivan

The United Kingdom's Air Accidents Investigation Branch (AAIB) has released the final report on the investigation of the 2008 accident involving a British Airways Boeing 777-236ER (registration number G-YMMM) at London's Heathrow International Airport (LHR). On January 17, 2008, British Airways Flight BA 038 landed short of runway runway 27L at LHR after both of the aircraft's engines failed to respond to throttle inputs while the aircraft was on final approach. The aircraft was arriving at Heathrow on a scheduled flight from Beijing. There were no fatalities or serious injuries among the 136 passengers and 16 crew members on board.

The newly released report, which is lengthy and very complex, includes detailed analyses and 18 safety recommendations. Here is an excerpt from the AAIB's report synopsis, including statements regarding probable cause:

Whilst on approach to London (Heathrow) from Beijing, China, at 720 feet agl, the right engine of G-YMMM ceased responding to autothrottle commands for increased power and instead the power reduced to 1.03 Engine Pressure Ratio (EPR). Seven seconds later the left engine power reduced to 1.02 EPR. This reduction led to a loss of airspeed and the aircraft touching down some 330 m short of the paved surface of Runway 27L at London Heathrow. The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines.

It was determined that this restriction occurred on the right engine at its Fuel Oil Heat Exchanger (FOHE). For the left engine, the investigation concluded that the restriction most likely occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low.

The investigation identified the following probable causal factors that led to the fuel flow restrictions:

1. Accreted ice from within the fuel system1 released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines.
2. Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’.
3. The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below ‑10°C and a fuel flow above flight idle.
4. Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.

Of particular interest to crew members is the section of the report that discusses the actions of the pilots in the final moments of the accident flight. Quoting from the AAIB report:

Final approach

The right engine ceased responding to autothrottle demands 57 seconds before the touchdown and within seconds the crew became aware that there was a problem with the engine thrust control of both engines. This presented the flight crew with a situation that was highly unusual, for which no specific training existed.

The rollback event occurred whilst the aircraft was close to the ground, leaving the crew very little time to react. The commander did make a ‘MAYDAY’ call during this period but he was not able, in the time available, to brief the cabin crew about the emergency or issue a ‘brace brace’ command.

Actions of the co-pilot

The co-pilot initially believed he had disconnected the autopilot at the intended height on the approach in order to carry out a manual landing on Runway 27L. However, as the aircraft descended through 600 ft he became aware of a problem with the engines, indicated by a split in the thrust lever positions. It is likely that, in attempting to understand the sudden and unprecedented problem with which he was presented he was distracted and thus omitted to disconnect the autopilot at this point.

Engine power had now reduced to a level at which the aircraft was losing airspeed and it started to descend below the glideslope. As the autopilot had remained engaged it attempted to maintain the ILS glide path by increasing the aircraft’s pitch attitude. This led to a further gradual reduction of airspeed, the initial ‘airspeed low’ master caution and the eventual triggering of the stall warning stick shaker. It was at this stage the co-pilot promptly pushed the control column forward, leading to the disconnect of the autopilot as overriding force was applied to the column to avoid the stall. However, the aircraft was now only 150 ft above the ground and a landing short of the runway surface was inevitable. At this point there was insufficient height available for the aircraft to develop the airspeed needed for a landing flare, to reduce the high rate of descent.

Actions of the commander

The commander, on realising that he was unable to obtain any additional thrust from the engines, attempted to reduce the drag of the aircraft by reducing the flap setting. However, the aircraft was now so close to the ground that there was little time for the beneficial affects of this action to take effect.

The action of reducing the flap setting was prompt and resulted in a reduction of the aerodynamic drag, with a minimal effect on the aircraft stall speed; it moved the point of initial ground contact about 50 m towards the runway threshold. Had the flaps remained at flap 30, the touchdown would have been just before the ILS antenna, but still within the airfield boundary. The effects of contact with the ILS antenna are unknown but such contact would probably have led to more substantial structural damage to the aircraft.

Assessment of flight crew actions - summary

From the available evidence, it is apparent that the flight crew’s preparation and conduct of the flight preceding the engine rollbacks was orderly, and in accordance with the operating company’s standard operating procedures.

On the final approach to land the flight crew were presented with an operational situation, a double-engine rollback at a low height, which was unprecedented. Most importantly at this point, when the stick shaker was alerting them to an impending stall, they kept the aircraft flying and under control so that, at impact, it was wings level and at a moderate pitch attitude. The reduction in flap setting did allow the aircraft to clear the ILS aerial array and, given more height, it would have been more effective.

In analysing the flight crew’s actions during final approach, the first indication of a problem was the thrust lever split. The flight crew did not, at this time, realise that this was associated with the ensuing engine rollback; slight splits in the thrust lever positions are common and manually moving the thrust levers back into alignment is a normal response. The flight crew became fully aware of the problem some 30 seconds before touchdown and at this point the subsequent high rate of descent at impact was inevitable.

The crew’s attention was on monitoring the approach and the external environment and, while the autopilot remained engaged, the crew’s focus was on the developing situation with falling engine thrust and reducing airspeed, and their subsequent attempts to restore power.

In the very limited time available after identification of the problem, the flight crew clearly prioritised their actions and thus did make the ‘MAYDAY MAYDAY MAYDAY’ call, although they were not able to make the ‘brace brace’ call. The initial use of the VHF radio rather than PA system for the cabin evacuation call had no effect on the accident outcome.

Interested readers can download the entire report or any section by visiting this landing page on the AAIB Web site: Report on the accident to Boeing 777-236ER, G-YMMM, at London Heathrow Airport on 17 January 2008

BBC News posted on their Web site an audio file of Air Traffic Control dialogue immediately before and after the crash of British Airways Flight 038.

RELATED: Click here to view all posts about British Airways Flt 038 on Aircrew Buzz.

UPS announces plans for pilot furloughs

by B. N. Sullivan

Hundreds of UPS pilots may be facing furloughs in the near future.  In a press release issued today, the freight carrier announced plans to furlough "at least 300" of its 2,800 pilots.  Plans call for the layoffs to occur in phases, with the first group receiving furlough notices in May of this year.

At the same time, however, the company said it would continue to work with the pilots' union, the Independent Pilots Association, to identify cost-saving measures "that would avert or mitigate the layoffs before they take effect."  According to the UPS press release:

Last June, the IPA identified significant savings through voluntary programs such as pilots taking short- and long-term leaves of absence; military leaves; job sharing; reduction in flight pay guarantees; early retirement, and sick bank contributions. UPS subsequently agreed it would not furlough any pilots in 2009.

The two sides have been working cooperatively ever since to identify additional cost-cutting initiatives that would eliminate the threat of layoffs entirely. Subsequent discussions have failed, however, to identify sufficient operating savings.

"This is a painful decision for our people, but one that is right for the on-going health of our business," said UPS Airlines President Bob Lekites.

"Companywide, we will continue to evaluate all opportunities and make adjustments as necessary to ensure our company is well-positioned to emerge stronger than ever as the economy continues to recover.  We applaud our pilots for the way they've joined with UPS in trying to tackle this problem and hope we can identify a mutually beneficial outcome," Lekites said.

Ethiopian Airlines Flight 409 flight data recorder recovered

by B. N. Sullivan

There are some new developments regarding the investigation of the crash of Ethiopian Airlines Flight ET 409, the Boeing 737-800 aircraft that was lost shortly after taking off from Beirut on January 25, 2010. Most importantly, the aircraft's flight data recorder (FDR) has been recovered, and has been sent to France for analysis.

Yesterday, Lebanon's Transportation and Public Works Minister Ghazi Aridi announced that a part of the tail section of the aircraft was located by a search vessel in the Mediterranean Sea, off the coast of a Naameh. Mr. Aridi told the press that the newly discovered wreckage, which was found at a depth of about 45 meters (150 ft), was between 10 and 20 meters in length. Early this morning, divers were able to recover the FDR. The cockpit voice recorder (CVR) has been located, but has not yet been recovered.

The remains of eight more victims who were lost in the accident also have been recovered. According to Reuters, 23 bodies have been recovered to date. The crash of Flight ET 409 claimed the lives of 90 people.

Some wreckage from the Ethiopian Airlines plane also was discovered on the shoreline of Syria, near the port city of Latakia. Syrian authorities have said they will hand over the wreckage to the Lebanese authorities.

UPDATE Feb. 10, 2010: FlightGlobal.com is reporting that divers have recovered part of the cockpit voice recorder (CVR) from the Flight ET 409 crash site. Specifically, "the recorder's chassis has been found but the cylindrical memory unit, and its attached locator beacon, are missing."

Lebanese officials say that recovery personnel are continuing to search for the missing parts.

UPDATE Feb. 16, 2010: Lebanese officials announced that the missing memory unit from the Flight ET 409 cockpit voice recorder has now been recovered from the sea by military divers. The device has been sent to France for analysis.

RELATED: Click here to view  all posts about Ethiopian Airlines Flt 409 on Aircrew Buzz.

Republic Airways to shut down Lynx Aviation and furlough crews

by B. N. Sullivan

When Republic Airways acquired Frontier Airlines several months ago, Lynx Aviation -- Frontier's regional turboprop subsidiary -- was a part of the deal. Now Republic has decided to do away with Lynx, shed its fleet of 11 Bombardier Q400 aircraft, and eliminate about 175 jobs.

Republic announced that Lynx Aviation will cease operations by mid-September of this year. Plans call for most of the current Lynx routes to be served in the future by Republic Airlines E-170 and E-190 aircraft, flown by Republic pilots.

Furloughs will begin in April. The Denver Post reports that of Lynx Aviation's 120 pilots and 110 flight attendants, 40 in each group will be retained until September, when remaining Lynx employees will be furloughed. The Denver Post quoted a Republic spokesman who said that Lynx employees will be given the opportunity to continue with Republic or Frontier and will receive priority hiring. Those who don't stay on will be given severance.

FAA asks for input on pilot qualification and training requirements

by B. N. Sullivan

The United States Federal Aviation Administration (FAA) is seeking recommendations to improve pilot qualification and training requirements. The request for input from the public (including pilots) is a part of the FAA’s 'Call to Action', which "aims to strengthen pilot hiring, training and performance, as well as combat fatigue and improve professional standards and discipline at all airlines." The FAA is pursuing both rule changes and voluntary safety enhancements

In the current round, the FAA is seeking comments on basic pilot certification in four key areas:

• Should all pilots who transport passengers be required to hold an Air Transport Pilot (ATP) certificate with the appropriate aircraft category, class and type ratings, which would raise the required flight hours for these pilots to 1,500 hours?
• Should the FAA permit academic credit in lieu of required flight hours or experience?
• Should the FAA establish a new commercial pilot certificate endorsement that would address concerns about the operational experience of newly hired commercial pilots, require additional flight hours and possibly credit academic training?
• Would an air carrier-specific authorization on an existing pilot certificate improve safety?

The FAA announced today that an Advance Notice of Proposed Rulemaking (ANPRM) will be published next week in the Federal Register and will have a 60-day comment period. It is on display today at http://www.faa.gov/regulations_policies/rulemaking/recently_published/.

The FAA will then incorporate the comments into a new proposal that will also be published for public comment.

“Our nation’s airlines should have the best-trained and best-prepared pilots in the cockpit,” said U.S. Transportation Secretary Ray LaHood. “We must build on the current pilot certification system and make it even stronger.”

“Experience is not measured by flight time alone,” said FAA Administrator Randy Babbitt. “Pilots need to have quality training and experience appropriate to the mission to be ready to handle any situation they encounter.”

Highlights of the NTSB's findings on the Colgan Air accident near Buffalo in February 2009

by B. N. Sullivan

Yesterday the U.S. National Transportation Safety Board (NTSB) released a summary of its findings regarding the February, 2009 crash of a Colgan Air Bombardier DHC-8-400 near Buffalo, NY. The title of the press release that announced the findings read (in capital letters), CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS. Talk about cutting to the chase, right in the title!

Yesterday's report elaborated on the stark title of the press release, with this statement of probable cause:

The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.

Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.

The NTSB summary included a list of 46 individual conclusions. Among the findings:

• The recovered components showed no evidence of any preimpact structural, engine, or system failures, including no indications of any problems with the airplane’s ice protection system.
• The air traffic controllers who were responsible for the flight during its approach to Buffalo-Niagara International Airport performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight.
• This accident was not survivable.
• The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.
• The minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane.

So, no support for those who theorized that icing was the cause of the accident. Instead, the NTSB seems to be saying that pilot error, independent of weather conditions, led to the tragic outcome.

Here's more:

• Explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.
• The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.
• The flight crew did not consider the position of the reference speeds switch when the stick shaker activated.
• The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.
• The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.
• It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.
• No evidence indicated that the Q400 was susceptible to a tailplane stall.
• Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.
• The Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, that would have facilitated the flight crew’s detection of the developing low-speed situation.
• An aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker.
• The captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.

These findings are uniformly damning of the captain and, to a lesser extent, the first officer. But then the NTSB report broadens the focus of responsibility to include Colgan Air, the pilots' employer:

• The monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills.
• Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.
• Specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a pilot-in-command during air carrier operations.
• Because of the continuing number of accidents involving a breakdown of sterile cockpit discipline, collaborative action by the Federal Aviation Administration and the aviation industry to promptly address this issue is warranted.
• The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.

Next, issues related to the role played by pilot fatigue and possible illness are addressed:

• 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 cannot be conclusively determined.
• All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.
• Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base.
• Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.
• The first officer’s illness symptoms did not likely affect her performance directly during the flight.

A number of the NTSB's findings addressed pilot qualificactions and training deficiencies:

• The captain had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.
• Remedial training and additional oversight for pilots with training deficiencies and failures would help ensure that the pilots have mastered the necessary skills for safe flight.
• Colgan Air’s electronic pilot training records did not contain sufficient detail for the company or its principal operations inspector to properly analyze the captain’s trend of unsatisfactory performance.
• Notices of disapproval need to be considered along with other available information about pilot applicants so that air carriers can fully identify those pilots who have a history of unsatisfactory performance.
• Colgan Air did not use all available sources of information on the flight crew’s qualifications and previous performance to determine the crew’s suitability for work at the company.
• Colgan Air’s procedures and training at the time of the accident did not specifically require flight crews to cross-check the approach speed bug settings in relation to the reference speeds switch position; such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning.
• The current air carrier approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall.
• The circumstances of this and other accidents in which pilots have responded incorrectly to the stick pusher demonstrate the continuing need to train pilots on the actions of the stick pusher and the airplane’s initial response to the pusher.
• Pilots could have a better understanding of an airplane’s flight characteristics during the post-stall flight regime if realistic, fully developed stall models were incorporated into simulators that are approved for such training.
• The inclusion of the National Aeronautics and Space Administration icing video in Colgan Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training.

The remaining findings address systemic oversight issues; flight operational quality assurance (FOQA) programs; personal portable electronic devices on the flight deck; the use of safety alerts for operators (SAFOs), and weather data, including information related to icing.

The NTSB summary also includes 25 new recommendations to the Federal Aviation Administration (FAA).

Here is the link to the synopsis of the NTSB report, where you can read all of the findings and safety recommendations arising from the investigation of the Colgan Air Flight 3407 accident: NTSB/AAR-10-01: Summary of Findings

The full final report will be released later this month. When that happens, I will post the link here on Aircrew Buzz.

UPDATE Feb. 25, 2010: The complete final report on the Colgan Air Flight 3407 accident has been released. It is available for download from the NTSB Web site. Here is the link: NTSB Air Accident Report 1001 - 299-page 'pdf' file

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