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Occam's Razor and the Colgan Crash

While the simplest explanation is usually the right one, people will search for other answers. In the case of the Buffalo crash, this has presented two distinctly different scenarios, one heroic and one . . . not so.
By Robert Goyer / Published: Jul 14, 2010
image-colgan
Photo: NTSB

I almost never speculate on the cause of a crash early on, but in the case of the crash of Colgan Flight 3407, I weighed in earlier than I ever had before. Within a couple of days, when icing was still seen as a likely cause, it seemed to me that the cause was far simpler, the crew's failure to control the airplane. That is, in fact, what the NTSB, a year later, determined to be the probable cause of the crash.

Here's the text

"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 lowspeed 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."

That seems pretty clear cut, but today there are a number of people who believe that the pilot's pulling back on the stick when the stall came was a result of his reaction to what he perceived as a tailplane icing situation, in which case the usual recovery from stall of lower the nose is the wrong thing to do. Some even say that the captain's actions were exactly the right thing to do but that the icing was too severe for his recovery attempt to succeed.

If you were to apply the Occam's Razor test to this theory, you would discard it almost immediately. According to Occam's Razor, the simplest, most likely explanation, the one that introduces the fewest new assumptions, is usually correct. I'd go further and say that it is almost always correct. That doesn't mean the simplest explanation isn't sometimes a complicated one. In the case of the assassination of President Kennedy, for example, the most likely explanation--what with Oswald's double agent background, the subsequent hit job on him and the high likelihood that shots were fired by someone in addition to Oswald--is that it was some kind of elaborate conspiracy. (Please note that comments focusing on the facts of this case and not the Colgan crash will be deleted.) Other explanations, such as Oswald acting alone, although involving far less complication, are just too far fetched to be believable.

In the case of the Colgan crash, you need to look at the pilot, who had a history of suboptimal performance on his reviews and checkrides throughout his career. Did he suddenly, after having conducted an undisciplined flight up until that point and letting the airspeed deteriorate dangerously, when the chips were down, turn into, as Richard Collins put it, the "ace of the base?" Was he able in that last instant to formulate an out-of-the-box, totally non-standard answer to a loss-of-control scenario based on some theoretical discussion of Dash 8 tailplane icing behavior he'd heard in training years previous?

I don't think so. It's not the simplest answer, nor is it the one that views events as the participants would likely have viewed them.

What happened, Occam says, is that the captain did what countless pilots have done when shocked at the ground suddenly rushing up at them. He pulled back, trying in vain to get the airplane to go in the other direction.

I believe that it was, sadly, just that simple.

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Jerry Lawler's picture

As a retired 747 captain, I feel very strongly that if the "Sterile cockpit" had not been violated, the captain might have paid more attention to flying the airplane rather than having a discussion with the first officer.

dibbelld's picture

I agree with your overall conclusion as to why the aircraft ultimately went out of control as the captain held the yoke back. But it's not THAT simple. Your reference to the classic "ground rushing up" impulse does not explain the captain's initial pull on the yoke in response to the stick shaker activation and autopilot disconnect.

Why would the captain have pulled (incorrectly) on the yoke while at nearly the same time correctly adding a fistful of power?

I think he was startled and confused at the stick shaker activation and autopilot disconnect event, and simply failed to take account of attitude (already nose high), altitude (at or above the assigned altitude) and airspeed (low and decaying). So, why did he pull? I think because in his confusion he saw an indication he was "below" glideslope, when in fact the aircraft had simply not yet intercepted the glideslope. Perhaps he was thinking (incorrectly) that he should "recapture" the glideslope.

Why the startled and confused response? Two reasons: 1) the captain was not paying adequate attention to flying the airplane and 2) the airspeed bugs had been set incorrectly, not having taken into account that the Vref increase/normal switch was in the "increase" position. The airline (Colgan) realized this right away after the flight data recorder was analyzed. They issued a revised operations procedure about a week after the crash, and then another a few weeks later, on this topic.

Does suspected tailplane icing explain what the captain did or did not do? I don't see how it could have. If he was thinking that hard about it, why did he not immediately rule out a tailplane stall when the aircraft exhibited an impressive reserve of pitch authority, even at a decayed airspeed, when it pitched up as he pulled?

Ed Cook's picture

I'm writing this following a lot of great comments that I totally agree with. There is one thing I would like to add. Over the years, many training programs, including airline, have stressed the loss of altitude in stall recovery should be minimum. Many instructors, check airmen, examiners, training center evaluators, FAA inspectors, etc., have insisted that 'zero" altitude loss is ideal or even the "standard". Added to the fact that few turbine powered airplane pilots have actually seen anything more than stall recognition (stick shaker) instead of the full stall, I suggest the 3407 pilot(s) may have done what they were taught. That is to "firewall" the power levers, level the wings, and maintain pitch until the engines pull the airframe out of the stall. This is not the first of this type of air carrier accidents (DC-8 in the 90's), but it may be the last as the FAA is published SAFO 10012 on 7/6/10 that speaks to the reduction of angle of attack and uses the term "minimum loss of altitude".

robert goyer's picture

Great stuff. The sterile cockpit rule is an important one to me, and this accident, better than any other in recent memory, demonstrates how a normal flight can turn deadly in a heartbeat. In the terminal area, we need to be on top of our game. Also, in a situation like this, it's clear in retrospect that the captain needed to be ready to lose altitude to regain control. Did he have enough altitude to recover? Almost certainly. But not after he pulled against the stick shaker. Minimum loss of altitude is still some loss of altitude. We've got to accept that loss. Getting the airplane flying again is job one.

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