Safety Cause du Jour

Does our government’s response to safety issues sometimes cause more fatalities?

Article appeared in Flying Magazine March, 2017 by Martha King

It is the classic way to screw up an approach in a heavy, fast airplane.  As they approached the outer marker at Buffalo at a higher than normal speed, Captain Marvin Renslow, 47, and First Officer Rebecca Lynne Shaw, 24 had allowed themselves to be distracted by an extended conversation about their previous icing experience compared to their current icing conditions.

This left them with little time to level their Q400 turboprop at glideslope interception altitude and slow down.  About three miles from the outer marker, Captain Renslow quickly reduced power to near flight idle and called for flaps 5 and gear down.  In response, First Officer Shaw selected 5 degrees of flaps, put the gear down, and moved the condition levers to maximum rpm.  As the airplane slowed, Captain Renslow called for flaps 15.  When the autopilot leveled the airplane at glideslope interception altitude it began rolling in nose-up pitch trim to hold altitude, and further increased the nose-up trim as the airspeed slowed.

Continental Connection Bombarder Q400 operated by Colgan Air N196WQ at Baltimore-Washington International Airport. Rudi Riet – originally posted to Flickr as Continental Connection Bombardier Q400

Two things happened next that are hard for a lot of pilots to understand.

First, as the airplane slowed, it appears the pilots had forgotten they were at near-idle power.  Neither pilot mentioned that the pitch attitude of the airplane had increased from three degrees nose-up to nine degrees nose-up, that the numbers on the airplane’s indicated airspeed display had changed from white to red, or any of the other numerous cues the airplane gave them of their deteriorating airspeed.

It is hard to imagine they had leveled off and dirtied up the airplane, and forgotten something so basic as the fact they were practically at idle power.  But an abrupt slowdown creates a common trap for pilots of heavier, faster airplanes.  The process takes long enough that it is very easy to get out of the loop as the autopilot manages things for you.  You can easily forget that you are in a major transition and fail to bring power back in when you should.  In our thirty years of flying jets together, John and I have each made that same mistake and been rescued by our alert copilot.

The second thing that happened may be even harder to understand.  When the pilots were surprised by the stick shaker and autopilot disconnection, in spite of years of training in proper stall recovery and performing multiple approach-to-stall recoveries in airline training, neither pilot responded appropriately.

The captain, who like every other pilot has for years been trained to pitch down and add full power at the first sign of a wing stall, instead pulled back hard on the yoke—a 37-pound pull—and added only partial power.  Meanwhile the first officer, without the captain’s command, raised the flaps, thereby increasing the stall speed.

The result was the crash of Colgan Air 3407 and 50 fatalities.

What could have been going on in the minds of these pilots that interfered with all the years of training each had received?  We’ll never be able to talk with them, so we will never know for sure.  But during their airline training for winter operations the crew had been repeatedly required to watch a NASA-produced video titled “Tailplane Icing.”  Their flight was in icing conditions at the time, and the video describes tailplane stalls, which, when they occur, are caused by ice accumulation on the horizontal stabilizer.  The tailplane stall recovery procedure taught in the video directed pilots to pull back on the control column, reduce flap setting, and, for some aircraft, use only partial power—exactly what this crew did.

Moreover, in spite of the fact that the Q400 they were flying was not susceptible to ice-contaminated tailplane stall (ICTS), there was nothing in the training program that told the crew these recovery actions did not apply to them.  In view of the fact they were required to watch the video multiple times, they can be forgiven for having thought the recovery actions did apply.

The inclusion of this video in airline training programs was part of a zealous “safety cause du jour” push by the FAA.  The sad thing is that very few aircraft in airline service are actually susceptible to ice-contaminated tailplane stalls.  Requiring pilots flying regional airliners to watch this video when it did not apply to their aircraft presented the opportunity to cause more accidents than it prevented (as it appears to have done in this case).

The FAA seems to be acknowledging that their promotion of the NASA video in airline training programs was inappropriate.  In June 2014 the FAA issued a National Policy Notice requiring that the video not be included in the training for crews of aircraft not susceptible to ice-contaminated tailplane stall.  Plus, the FAA recently replaced the icing video with a new one, giving the lame excuse that “Much has occurred since NASA’s original 1998 ice-contaminated tailplane stall video.”  Then they added, “The information in this training video supersedes, supplants, and replaces the instruction in all previous NASA tail stall icing training videos.”

The Colgan Air Flight 3407 crash may not be an isolated case of unintended consequences from inappropriate governmental zeal.  It may, instead, be part of a pattern.

For openers there is the congressional response to the Colgan Air crash requiring all new airline hires, whether captain or first officer, to have 1,500 hours and an ATP.  This response is especially ironic considering the qualifications of both the Colgan Air pilots.  Captain Renslow had 3,379 hours and an ATP.  And First Officer Shaw had 2,244 hours and an SIC type rating in the Q400.  Rather than an increase in safety, the knee-jerk congressional response might have only resulted in an increase in the cost of flying that forces passengers to the significantly higher fatality rate of the highways.

Another recent case of government overzealousness might be the “discovery” that the majority of aviation fatalities are the result of “loss of control.”  This doesn’t seem like much of a revelation to most of us, when the only ways we can think of to crash “in control” are controlled flight into terrain (CFIT) and midair collision.  Recently the FAA has decided that the Colgan Air crash was a “loss of control” type of crash that can be avoided by having pilots be more sensitive to stall warnings.  The new approach is to not require pilots to demonstrate slow flight with the stall warning on—putting us at risk of having a new generation of pilots uncomfortable with flying an aircraft at minimum controllable airspeed.  The result is likely to be fast landings, bounces, gear collapses and runway overruns.

Zeal is a good thing, but when it is combined with governmental power without full consideration of unintended consequences, it can be dangerous.  A slower, more thoughtful response to aviation tragedies could in some cases wind up saving more lives

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