5 Lessons from the Buffalo Crash
More than any other crash in recent memory, the tragedy of Continental Connection Flight 3407, which went down on approach to Buffalo killing 49, made me think about how I fly my small airplane. How might the traps that snared the relatively inexperienced crew of that Colgan Air flight be waiting for GA drivers like you and me?
If you haven't read this elsewhere, it's come to the attention of the world that crew of the Q400 (Dash 8) that crashed was sleep challenged, relatively inexperienced and poorly paid. (This last part doesn't sound like a safety issue, but when you look at crew rest and travel factors, you can see that it is.)
The NTSB transcripts of the cockpit voice recorder are absolutely chilling. If you haven't read through them yet, here is a link to the transcript (Buffalo Crash CVR Transcript) . Here, also, is a link to an animation of the last two minutes of the ill-fated flight. (Buffalo Crash Animation) Be forewarned: its' not light reading or viewing. And while the NTSB hasn't issued a final report and its finding of probable cause, the transcript raised numerous questions that the final report will surely address.
How big a causal role did these five factors play in the crash of 3407? I have my ideas about it. But when it comes to examining our own flying, there's no question that there are risk factors exposed by the crash and the subsequent, ongoing, investigation that should give us pause and prompt us to take a minute to reflect on our flying.
5. Training Did the crew of 3407 have sufficient training in their airplane? A Colgan Air official probably answered that indirectly when he was asked whether the crew should have been able to recover from the stick shaker incident: "Yes." was his one word response. But they didn't, and it has been reported widely that the pilot never had stick shaker training in an actual airplane or in the sim. What blind spots do you have for your airplane? Can you do the emergency gear extension procedure in your sleep? Do you know where the extinguisher is and can you get to and activate it without having to puzzle through the process? Do you know how far your airplane glides and how to get the best distance out of a glide in an engine out scenario? Can you fly on the backup gages in the soup? Bottom line: if you're like most pilots, you could probably know your airplane better and be more proficient in it.
4. Fatigue I don't think I've heard anyone argue that the amount or quality of sleep that the Colgan Air pilots had was ideal, never mind adequate. I'd argue that it was insufficient. People who are sleep deprived can do all kinds of things--witness me making coffee in the morning. And flying an airplane is one of those things they can do when they're sleepy. I have a close friend who used to fly corporate in the 70s when rest rules were non-existent or unenforced, and the stories he's told me about schedules--post midnight arrivals with one set of bosses followed by pre-dawn departures with another set--make my hair stand on end. How would he deal with it? He and his co-pilot would swap naps. On more than one occasion they'd both be awakened by a radio call. And I know that I've flown when I've been too tired to be at my best, and I'm not proud of that fact. I did fine, but how would I have handled a complicated emergency? Probably not was well as I could have, and who knows, if that would have been good enough?
3. Preparation Read the transcripts to see just how nonchalant the crew of 3407 appears. They chatted about their commutes, their experience levels, their career plans and their schedules. When it came time to do the approach briefing, they rushed through it as though it were an afterthought. Would something as simple as better advanced planning have prevented the accident? You could make a good argument that it would have.Dick Collins once told me that if on a long flight you think there's nothing to do in the cockpit, nothing to monitor, no information to gather, nothing to prepare for, you're just not paying close enough attention. Good advice.
2. Sterile Cockpit When I was based on the East Coast, I used to fly with friend and collegue Tom Benenson a lot. And I loved our chats while flying. But one day on departure from White Plains (KHPN), a couple hundred feet off the ground, we found ourselves talking about the imporance of a sterile cockpit. The irony was immediately apparent to us, and a good lesson. The crew of 3407 did not maintain a sterile cockpit below 10,000 feet, as the regs require. Would it have made a difference if they had? It's sure a possiblity. The bottom line is, when you're close to the ground, you need to be paying attention.The sterile cockpit policy helps ensure that always happens.
1. Auto Pilot Stalls What was the cause of the crash of Flight 3407? It sure look as though it was the onset of an autopilot stall and a failed recovery from it. Many pilots, I'm certain, don't even know what an autopilot stall is, even those pilots who regularly fly with and use an autopilot. I had to figure it out myself. The first airplane with an autopilot I ever flew was a great little Grumman Tiger. The flying club owner checked me out in it himself. He showed me how to avoid PIO landing accidents in it, he put me through a series of accelerated stalls, and he put me under the hood, too. But he never said word one about how to use the autopilot, never mind about autopilot stalls.
I learned it myself one day when I was climbing out of Bridgeport, CT, (KBDR). I set the vertical speed at a good rate--I forget what it was--one that the airplane could hold down low. Problem was, I was going up to a higher altitude, and as I climbed, I got distracted, with a revised clearance and a new heading. By the time I got that copied down and deciphered, I got a funny feeling. I glanced up at the airspeed indicator, and I was slow, right around best angle of climb airspeed. Had I kept writing for another minute or so, I would have stalled. I saw what was happening, disconnected the autopilot, lowered the nose, and thought, "Hmm, that's a real trap. Wonder why nobody every taught me that?"
The problem is, unless you've got an advanced autopilot, one that knows the airspeed, it will keep flying the airplane for you just as you asked it to do. On approach, a similar thing can happen. You set an altitude, reduce power, and the autopilot will keep flying the airplane for you at the altitude you told it to maintain. If the power's low enough, the airplane will slow down. If there's a stick shaker, that will activate. If there's a pusher, it will push.
And if you're tired, under-trained, not focused and not ready, you're going to be in a tough spot.
By Robert Goyer